How Tragedy Led to Trust: National Aviation History Month

By Jeff Marcus, Chief, NTSB Safety Recommendations Division

From the Wright brothers’ first flight on December 17, 1903, to today, aviation has made remarkable progress. The affordability, speed, capacity, comfort, and, most importantly, safety of flight have all improved to the point that flying is one of the safest modes of transportation.

But that safety has been hard won. In honor of National Aviation History Month, let’s reflect on how the  aviation industry and Congressional action have evolved to further transportation safety.

The Early Days of Flying

Although most people are familiar with the Wright brothers, who did the research and development that produced the first airplane, many are unfamiliar with other important visionaries, such as Otto Lilienthal and Samuel Langley.

Otto Lilienthal with glider, 1895
Photo credit: Library of Congress

Karl Wilhelm “Otto” Lilienthal was a German pioneer of aviation who made the first successful flights with gliders, making the idea of a heavier-than-air machine a reality. His flight attempts in 1891 are seen as the beginning of human flight. Lilienthal made over 2,000 flights in self-designed gliders until his death on August 9, 1896, when he was unable to regain control after his glider stalled. Falling from about 50 ft, he broke his neck and died the next day. At the time of his death, Lilienthal’s total lifetime flying time was about 5 hours. The Wright brothers later cited Lilienthal’s death as the point when their serious interest in flight research began.

Samuel Langley’s Experimental Tandem Biplane on the Potomac River, 1896
Photo credit: Library of Congress

Another early aviation pioneer was Samuel Langley. In addition to being an American aviation innovator, Langley was the third secretary of the Smithsonian Institution. His first aviation success came on May 6, 1896, when his unpiloted, steam-powered, fixed-wing aircraft, weighing 25 pounds, made two flights—one 2,300 ft and the other 3,300 ft—after a catapult launch from a boat on the Potomac River. He followed that on November 11, 1896, with an improved aircraft model that flew more than 5,000 feet. In 1898, based on the success of his models, Langley received grants of $50,000 from the War Department and $20,000 from the Smithsonian to develop a piloted airplane.

Langley gave up on the project after two crashes on take-off on October 7 and December 8, 1903 (just a few days before the Wright brothers’ successful flight). The Smithsonian displayed Langley’s device as the first human-carrying airplane in the world capable of sustained free flight, triggering a decades-long feud with Orville Wright.

The first aviation fatality in a powered aircraft crash came on September 17, 1908, when, during a demonstration flight for the War Department in hopes of getting a military contract for their invention, Orville Wright crashed his aircraft, injured himself, and killed his passenger, Signal Corp Lieutenant Thomas Selfridge.

Lt. Selfridge & Mr. Wright stepping into the Wright airplane at Ft. Myer, 9/17/1908
Photo credit: Library of Congress

The Wright Flyer flew four circles around Fort Myer at an altitude of 150 feet. Halfway through the fifth, the right propeller broke, creating a vibration. The damaged propeller hit a guy-wire bracing the rear vertical rudder. The wire tore out of its fastening allowing the rudder to swivel to the horizontal sending the Flyer into a nosedive.

Wright cut the engine and glided to about 75 feet, but then the aircraft descended nose-down into the ground. Wright and Selfridge were thrown forward, and Selfridge struck one of the wooden uprights of the framework, fracturing the base of his skull. He died 3 hours later without regaining consciousness. Wright suffered severe injuries and was hospitalized for 7 weeks.

Despite the setback, aviation continued to develop worldwide, and on January 1, 1914, the St. Petersburg-Tampa Airboat Line became the world’s first scheduled airline. The airline provided service between St. Petersburg, Florida, and neighboring Tampa—a distance of about 23 miles with a travel time of 23 minutes (compared to 2 hours by boat). A one-way fare was $5.00 (approximately $130 in 2020 dollars), and flights rarely exceeded an altitude of 5 feet. The service terminated on May 5, 1914.

The Birth of Commercial Aviation

During the 1920s, airlines began to offer regular commercial air service. The were 24 fatal commercial airline crashes over 1926 and 1927, 16 in 1928. In 1929, which remains the worst year on record, there were 51 fatal crashes, about 1 for every 1,000,000 miles flown. In today’s world, this rate would result in 7,000 fatal airline accidents per year, or about 20 every day.

Partly in reaction to this accident rate, Congress passed the Air Commerce Act, which President Calvin Coolidge signed into law on May 20, 1926. The act established federal control over civil aviation by making the secretary of commerce responsible for improving air commerce by designating and establishing airways; establishing, operating, and maintaining aids to air navigation (but not airports); sponsoring and conducting research and development to improve such aids; licensing pilots; issuing airworthiness certificates for aircraft and major aircraft components; and investigating accidents.

On March 31, 1931, a Fokker F-10A operated by Transcontinental and Western Air (which evolved to become TWA) crashed near Bazaar, Kansas, after the wooden structure of one wing failed in flight. The crash killed eight people, including Notre Dame football coach Knute Rockne. The investigation found that the wooden wing became moist over time, causing the glue connecting the wing to the body to weaken, allowing the wing to separate. At the time, the investigation was publicly criticized for its secret nature. This crash brought about significant changes in the airplane industry, and was of cultural significance, given the death of Rockne and the public perception of aircraft safety. This accident, which killed a well-known public figure and the secretive nature of the investigation brought public attention to learning from accident investigations to prevent such disasters in the future. The intense public interest forced the Department of Commerce to make the results of aircraft accident investigations more transparent.

The investigation of the Bazaar, Kansas, crash resulted in a public expectation that the US government would objectively investigate crashes and publicly release its findings. In 1934, the Air Commerce Act was amended to require that reports on probable causes of fatal aircraft crashes be made public and banned the use of such reports and related evidence in court proceedings.

On May 6, 1935, a Douglas DC-2 operated by TWA crashed near Atlanta, Missouri. Its pilots were trying to make an emergency landing before their fuel ran out. The crash killed five, including Senator Bronson M. Cutting of New Mexico. Public debate and criticism over the cause of the accident showed the need for an independent investigative body.

Investigators from the Bureau of Air Commerce concluded that several factors led to the crash, including communications malfunctions, darkness, inaccurate weather forecasts, worsening weather at the destination airport, and errors in judgment, both from the airline dispatchers and the flight crew. They also found TWA in violation of several aviation regulations. Senator Cutting’s death drove Congress to investigate the Bureau of Air Commerce’s management of civil aviation. Senator Royal S. Copeland established a special subcommittee that harshly criticized the bureau in a report. Partly as a result, in 1938, President Franklin Roosevelt signed the Civil Aeronautics Act of 1938, which transferred federal responsibilities for nonmilitary aviation from the Bureau of Air Commerce to a new, independent agency: the Civil Aeronautics Authority.

Focus on Safety

On June 30, 1940, the Civil Aeronautic Authority was split into the Civil Aeronautics Administration (CAA) and the Civil Aeronautics Board (CAB). The CAA area of responsibility was air traffic control, safety programs, and airway development. The CAB focused on safety rulemaking, accident investigation, and economic regulation of the airlines.

During the 1950s, airline travel expanded. A midair collision on June 30, 1956, between a TWA Super Constellation and a United Air Lines DC-7 over the Grand Canyon killed all 128 occupants of the two airplanes. The collision occurred while the airliners were flying under visual flight rules in uncongested airspace. The accident showed that, even though US air traffic had more than doubled since the end of World War II, little had been done to expand the air traffic control system or to increase safeguards against midair collisions. This accident led directly to the Federal Aviation Act of 1958, which President Dwight Eisenhower signed on August 23, 1958. The law created the Federal Aviation Agency and led to the creation of the air traffic control system as we know it today.

Air traffic control booth with staff at Washington National Airport, Arlington, Virginia, 1958
Photo credit: Library of Congress

On October 15, 1966, President Lyndon Johnson signed the Department of Transportation (DOT) Act, which created the new cabinet-level department with five major agencies, including the Federal Aviation Administration. The DOT Act also created, within the DOT, an independent National Transportation Safety Board (NTSB) with authority to investigate accidents in all modes of transportation. The new DOT began operations on April 1, 1967.

President Lyndon Johnson signs the Department of Transportation Act
that created the NTSB, 1966
Source: NTSB.gov

In 1974, Congress made the NTSB completely independent of the DOT with the Independent Safety Board Act of 1974, which also prohibits the use of any portion of an NTSB report as evidence in a lawsuit related to matters discussed in the report and, with few restrictive exceptions, bars discovery, admittance into evidence, and public release of transcripts or recordings of a “cockpit or surface vehicle . . . voice or video recorder,” if not made public by the NTSB. In 1996, the Aviation Disaster Family Assistance Act expanded the role of the NTSB to include coordinating victim and family assistance following a major aviation accident.

The history of aviation, and the remarkable safety enjoyed today, are the result of the detailed aviation accident investigations throughout the years. And that work continues at the NTSB today, because we know that, from tragedy, we draw knowledge to improve the safety of us all.

Jeff Marcus, Chief of the Safety Recommendations Division, is retiring from federal service on December 29 after 43 years.

Rail Tank Car Safety Ten Years after Lac‑Mégantic

By Paul Stancil, NTSB Senior Hazardous Materials Accident Investigator

I wonder what Don Ross, the Transportation Safety Board of Canada (TSB) investigator-in-charge, might have said to commemorate the 10th anniversary of the train derailment that occurred in Lac‑Mégantic, Quebec: a tragedy that claimed 47 lives, forced about 2,000 people to evacuate, and destroyed 40 buildings and 53 vehicles. It was my somber privilege to lead a team of NTSB investigators to that devastating accident scene to assist the TSB.      

Sadly, Don passed in 2019. But I am certain that he would have expressed gratitude for the dedication and personal sacrifices of his team members who, despite the massive scale of the task before them, organized quickly to get the job done. And I know he’d talk about how the appreciation and trust offered by families of the victims kept them going.

I wish I were visiting the accident scene with my friend Don to reflect on the enormous impact of this event. I’d tell him that he and his team didn’t just set the standard for how investigations of this magnitude should be done; the lessons they uncovered are still saving lives across Canada and the United States.

Lac-Mégantic town center, July 7, 2013. Courtesy: Transportation Safety Board of Canada.

What Happened

The events that led to this derailment began on July 5, 2013, at 10:50 p.m. local time, when Montreal, Maine & Atlantic Railway (MMA) freight train MMA-002 enroute from Montréal, Quebec, to Saint John, New Brunswick, Canada, via Brownville Junction, Maine, came to rest at a crew change point near Nantes, Quebec. The track had a descending grade toward the town of Lac-Mégantic. The train was carrying volatile Bakken petroleum crude oil, a flammable liquid, that originated from New Town, North Dakota, destined for an oil refinery in Saint John, New Brunswick. The train was composed of five head-end locomotives, a special‑purpose caboose equipped to remotely control the locomotives, one loaded boxcar used as a buffer car, and 72 DOT-111 general service tank cars.  

The train was operated by a single locomotive engineer, who left the lead locomotive idling after setting hand brakes on the locomotive consist and buffer car (seven cars in total). The locomotive engineer reported to the MMA rail traffic controller located in Bangor, Maine, that he had experienced mechanical difficulty with the lead locomotive throughout the trip and excessive smoke was coming from the engine. The engineer and rail traffic controller agreed the condition would likely settle on its own and the performance issues could be dealt with the next morning. The locomotive engineer then departed the area, leaving the idling lead locomotive and train unattended on the mainline track.

About 11:40 p.m., a local resident reported a fire on the idling locomotive. The fire department responded, and the MMA dispatched an employee to assist the fire department personnel. About midnight, the responders activated the emergency fuel cut-off switch to shut down the locomotive and extinguished the fire. The fire department and MMA personnel then departed the location, leaving the train unattended.

With no locomotive running, the air in the train’s brake system slowly began to deplete, resulting in a reduction in the retarding force holding the train in place. Shortly before 1:00 a.m. on July 6, 2013, the unattended train started to move, and it gathered speed, rolling uncontrolled for 7.2 miles down the descending grade into Lac‑Mégantic. The train reached a speed of about 65 mph as it entered the center of Lac‑Mégantic, where 63 loaded crude oil tank cars derailed on a curve and caught fire.  

To this day, the Lac-Mégantic derailment remains the worst dangerous goods railroading disaster in Canadian history. At least 60 of the 63 derailed DOT-111 tank cars released about 1.6 million gallons of crude oil. Some of the spilled oil ignited immediately and engulfed the derailed tank cars, resulting in cascading fires and explosions. More than 26,000 gallons of the released crude oil entered Mégantic Lake and the Chaudière River. The fire wasn’t extinguished until around noon on July 7, 2013.

Rail Car Safety at the Forefront

I was preparing for an NTSB investigative hearing on another derailment with hazardous material release when I first learned about Lac‑Mégantic. Before we knew the details, I found myself hoping that the Lac-Mégantic train was not composed of many DOT-111 tank cars.

Based on our own experience with train derailments going back to the 1990s, my NTSB colleagues and I knew that this type of tank car performed poorly in an accident. Between 2007 and 2012, alone, there were several derailments with major flammable liquids releases and fires involving DOT-111 tank cars.

• New Brighton, Pennsylvania: 23 derailed DOT-111 cars lost over 485,000 gallons of denatured ethanol on October 20, 2006.
• Cherry Valley, Illinois: 19 DOT-111 tank cars carrying ethanol derailed on June 19, 2009, killing one person and injuring seven others who were stopped in automobiles at a grade crossing. We concluded that enhanced tank head and shell puncture-resistance systems such as head shields, tank jackets, and increased shell thicknesses could have significantly reduced the severity of the accident.
• Arcadia, Ohio: 33 derailed DOT-111 tank cars released about 786,000 gallons of ethanol on February 6, 2011.
• Tiskilwa, Illinois: 10 DOT-111 tank cars derailed, resulting in fire, energetic rupture of several tank cars, and the release of 162,000 gallons of ethanol on October 7, 2011.
• Columbus, Ohio: Three derailed DOT-111 tank cars released about 53,000 gallons of ethanol on July 11, 2012; one of the derailed tank cars experienced energetic rupture.
• Plevna, Montana: Five of 18 derailed DOT-111 tank cars carrying ethanol caught fire on August 5, 2012, resulting in explosions.

Sadly, the degree of urgency for immediate regulatory action following these accidents was not commensurate with the potential for harm.

Recognizing the growing problem, however, the Association of American Railroads (AAR) Tank Car Committee had begun an effort in July 2009 to improve the accident survivability of DOT-111 tank cars transporting petroleum crude oil, ethanol, and ethanol/gasoline mixtures. Thus, in the absence of any new federal regulatory requirements, builders began producing new “CPC-1232” tank cars that used thicker steel for greater tank head and shell strength.

Several days after the Lac-Mégantic derailment, our worst fears at the NTSB were confirmed: all 63 of the derailed tank cars were DOT‑111s.

An Incredible Partnership

Given our history of safety recommendations citing safety deficiencies in DOT-111 tank cars and our newly acquired ability to laser scan tank cars, the TSB soon reached out to the NTSB to assist in its investigation. That is how I came to lead a team of five NTSB investigators to Lac-Mégantic, where we helped examine the derailed tank cars. A sixth NTSB investigator deployed to the oil shipment’s point of origin in North Dakota.

As a result of our collaborative examination of the derailed tank cars, we found that the train was solely composed of “legacy” DOT‑111s that incorporated basic 1950s technology for general service. The TSB determined that 94% of the derailed cars were breached in some way. Further, more than half of the shell-breaching damages were equal in size to the car’s diameter, which resulted in massive instant loss of product.

NTSB investigators adjust laser scanning equipment next to a damaged tank car in Lac-Mégantic, July 25, 2013.

During this investigation, we also discovered that railroads were not required to conduct analyses to ensure safe transport routes for flammable liquids, a requirement that did apply to other high-hazard materials.

Because the MMA had not ensured response resources would be available to remove a potential crude oil discharge of this size, Canadian authorities were left to complete the cleanup. We found a loophole in US federal regulations that established a comprehensive oil spill response planning threshold for a single tank size that was greater than any currently in use. In other words, had this derailment occurred in the United States, the rail carrier’s lack of oil-spill planning would have required the federal government to initiate removal actions using the Oil Spill Liability Trust Fund to pay for the costs.

Finally, the shipper in North Dakota had incorrectly classified the crude oil as a Packing Group III material, meaning it presented the lowest degree of danger in transportation. However, TSB’s testing found that the crude oil should have been assigned to the more hazardous Packing Group II. Not only could misclassification affect the type of tank car used to ship the hazardous material; it also could have affected other safety provisions, such as outage requirements, operational controls, and safety and security planning for the train. The misclassification also could have hampered emergency responders’ ability to correctly understand the hazards associated with a shipment.

Impact on Tank Car Design

In January 2014, the TSB and the NTSB, in unprecedented action, jointly issued safety recommendations to remedy deficiencies that impacted the safety of rail operations both in Canada and the United States. Our recommendations were coordinated in recognition of the cross-border nature of hazardous materials rail shipments. This approach proved to be a call to action for improving the safety of operating freight trains that later came to be known as high-hazard flammable trains. Our combined voice was also beneficial for eliminating confusion about what had to be done.

Within 2 months of the Lac-Mégantic accident, the Pipeline and Hazardous Materials Safety Administration (PHMSA) addressed four of our safety recommendations dealing with improving tank car standards and improving the availability of hazardous materials information to emergency responders.[1] Other freight rail safety improvements soon followed.

• January 2014: Transport Canada proposes a new standard for DOT-111 tank cars that included thicker steel, top fittings protection, and head shields.
• April 2014: Transport Canada orders the least crash-resistant DOT-111 tank cars removed from service; the NTSB holds a Rail Safety Forum on the Transportation of Crude Oil and Ethanol in response to the 16 significant derailments in the United States and Canada which, combined, were responsible for 48 deaths and 281 derailed DOT-111 tank cars that released 2.8 million gallons of crude oil and 2 million gallons of ethanol.
• August 2014: Citing Lac-Mégantic as justification, PHMSA considers a new specification DOT-117 tank car, which, among other things, would be required to have a thicker shell than the CPC-1232 tank car, full head shields, and tank jackets with thermal protection system.[2]
• Early 2015: A spate of fiery derailments fuels public outcry over so-called “bomb trains.”
• April 2015: the NTSB recommends that all new and existing tank cars used to transport flammable liquids be equipped with thermal protection systems and appropriately sized pressure relief devices. We also recommended an aggressive milestone schedule for replacement or retrofitting legacy DOT-111 and CPC-1232 tank cars and a publicly available reporting system for its progress.
• May 2015: PHMSA imposes restrictions on high-hazard flammable trains, ensures proper classification of unrefined petroleum products, and codifies new tank car design standards for DOT-117 tank cars. Transport Canada harmonizes Canadian regulations to reflect the new tank car design standards.
• December 2015: President Obama signs the Fixing America’s Surface Transportation Act of 2015 (FAST Act) into law, which instructs the Secretary of Transportation to make specific regulatory amendments to tank car design standards and establishes a phase-out schedule.
• August 2016: PHMSA codifies the FAST Act mandates by requiring newly manufactured DOT-117 and retrofitted tank cars meeting DOT specification 117R to be equipped with a thermal protection blanket and top fittings protection.

The Work Ahead

According to the latest AAR figures, more than 92,900 tank cars in the North American fleet meet DOT-117 specifications, while about 33,600 total DOT-111 and CPC-1232 tank cars remain to be retrofitted or phased out of flammable liquids service.[3]

As we have watched the flammable liquids fleet transition away from DOT-111 tank cars in recent years, there have been fewer derailments of high-hazard flammable trains. Although declining accident numbers could certainly be due to a significant decrease in petroleum crude oil shipments since 2014, a steady volume of ethanol continues to fill between 300,000 and 400,000 carloads per year.

However, thanks in large part to increased puncture resistance, service equipment protection, and thermal protection systems, there has not been a single death or serious injury, nor a single instance of energetic fireball release or boiling liquid expanding vapor explosion (BLEVE) involving a derailed specification DOT-117 tank car transporting flammable liquids. The Lac-Mégantic investigation has remained the cornerstone for these safety improvements.

Nevertheless, there continue to be incidents and near-misses; more work is needed to improve rail tank car safety. For example, recent derailments have revealed vulnerabilities in the thermal performance of gasket materials, hinged and bolted manways, and service equipment. This includes the following four derailments with hazmat release that the NTSB is currently investigating:

• The January 8, 2022, derailment of a high-hazard flammable train in Oklaunion, Texas, in which 28 derailed DOT-117J tank cars released almost 602,000 gallons of ethanol, largely due thermal damage of manway gaskets and other service equipment.
• The February 3, 2023, train derailment with hazardous material release and fires that occurred in East Palestine, Ohio, in which a mixed freight train derailed 11 tank cars carrying hazardous materials, including three DOT-111 tank cars that were punctured and released flammable and combustible materials that ignited. The resulting thermal damage to other tank cars carrying vinyl chloride prompted a controversial vent-and-burn action that released toxic combustion products into the surrounding community.
• The March 30, 2023, derailment of a mixed freight train in Raymond, Minnesota, including 10 DOT-117J tank cars carrying ethanol, some of which was released from two punctured tank cars and ignited and caused thermal damage to manway gaskets in other tank cars.  
• The June 24, 2023, freight train derailment in Reed Point, Montana, in which nine DOT-111 tank cars carrying hazardous materials derailed from a bridge and came to rest in the Yellowstone River, where they released molten sulfur and asphalt petroleum liquid into the river.

Thinking back on those lost in the Lac-Mégantic tragedy, I can’t help but remember something Don once told me: “I think it is fair to say that no one can be fully prepared for this.” That may be true, yet Don and the TSB team more than rose to meet the occasion. And we are all safer for it.

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[1] Safety Recommendations R-12-5, R-12-6, R-12-7, and R-07-4 (reiterated).  

[2] 79 Federal Register 45016 (August 1, 2014)   

[3] North American Flammable Liquid Tank Car Fleet: Status Report, 4th Quarter 2022, (Association of American Railroads, April 2023).

Commemorating Air Crash Victims and Honoring Families, Every Day

By Elias Kontanis, Chief, Transportation Disaster Assistance Division

Last year, for the first time, the international aviation community observed February 20th as the International Day Commemorating Air Crash Victims and Families. This year, on the second annual observance, we join in reflecting on the lives lost in aviation accidents as well as on the vigilance needed to ensure safety remains the priority in aviation.

As important as it is to commemorate, it is imperative that we also commit—commit to ensuring our programs effectively address the concerns of accident survivors and families and provide the information and support needed after tragedy happens.

The NTSB conducts its investigations with the goal of preventing future accidents. We do this work so that no other families must experience the painful loss or injury of loved ones due to transportation accidents. Our objective is, first and foremost, accident prevention. We maintain a steadfast commitment to this because we believe that the only acceptable number of deaths and serious injuries in all modes of transportation is zero.

With our commitment to transportation safety, we also have a commitment to support families by offering information about the NTSB’s investigative process, addressing their questions about the specific accident investigation involving their loved ones, and offering information about other services that may be available. The NTSB’s family assistance team does this every day, not only for aviation accidents but for all transportation accidents involving fatalities investigated by the NTSB. In 2022, our seven-member team provided support for 868 investigations, interacting with 3,480 accident survivors and family members.

The NTSB’s commitment to supporting transportation accident survivors and their family members is long-standing, spanning over 25 years. In that time, we have established some basic yet enduring principles:

• An independent and transparent safety investigation, with a focus on enhancing safety and not assigning blame or liability, is essential to the success of family assistance. Transparency and honesty fosters confidence.
• Rapport and credibility must be established with family members by communicating realistic expectations about the investigation and other aspects of the response. This includes clearly and appropriately communicating limits to the information and services available.
• A well-designed family assistance plan should be flexible and scalable. Rigid constructs break when they encounter an unanticipated force, but when the plan is flexible, it will bend and spring back to its original form when a stressor is applied.
• The entity responsible for coordinating the response should use a unified command concept of operations, enabling organizations to work together without giving up authority, responsibility, or accountability.
• A comprehensive response requires collaboration from multiple government agencies and nongovernmental organizations. Participating entities should focus on the fundamental concerns of families within the boundaries of their mandate and capabilities.

The International Civil Aviation Organization (ICAO) has spearheaded several initiatives to promote these principles among contracting states (that is, countries) by developing a 3-day course designed to provide governments, aircraft and airport operators, and other stakeholders the foundational knowledge to develop family assistance plans. Most recently, the European Civil Aviation Conference and the ICAO European and North Atlantic Regional Office have also jointly organized a workshop on assistance to aircraft accident victims and their families, which is scheduled for February 20, 2023, in Milan, Italy. This workshop will bring together representatives from several countries, family associations, and other stakeholders to share best practices.

Family assistance needs to be an organizational priority, ingrained in the culture and mindset of an entity engaging in this work. More than regulations, policies, standard operating procedures, or checklists, family assistance is about listening to and learning from those affected by disaster. Ultimately, family assistance is about caring for our fellow human beings and treating them with dignity and compassion, the same way we would expect to be treated when faced with an unexpected injury or loss of a loved one.

We stand with our international colleagues in honor of this solemn day, commemorating the lives lost and the families who faced such unimaginable tragedy, and we will not forget our commitments to them in the work we do.

40 Years Later, The Marine Electric Sinking Remembered

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.

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.