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.

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.

Photo of NTSB Chair Jennifer Homendy and NASA John F. Kennedy Space Center Deputy Director Kelvin Manning

Photo of NTSB Chair Jennifer Homendy and NASA Associate Administrator of the Human Exploration and Operations Mission Directorate, Kathy Lueders

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.