Category Archives: Transportation History

Two-years Later: Conception Tragedy Still a Reminder that More Should Be Done to Improve Passenger Vessel Safety

By Chair Jennifer Homendy

Two years ago today, a preventable tragedy became one of the worst maritime events in US history.

At about 3:14 a.m. on September 2, 2019, the U.S. Coast Guard (USCG) received a distress call from the Conception, a 75-foot-long small passenger vessel operated by Truth Aquatics, Inc.

Preaccident photograph of the Conception (Source: http://www.seawaysboats.net)

The Labor Day fire began in the early morning hours, as five crewmembers slept in their upper-deck crew berthing. Two decks below, thirty-three passengers and one crewmember slept in the bunkroom. A crewmember on the upper deck, awakened by a noise, noticed a glow from the aft main deck and alerted the remaining four crewmembers that there was a fire on board. Then the captain radioed the 3:14 a.m. distress message to the USCG before evacuating the smoke-filled wheelhouse.

Crewmembers tried to get to the bunk room through the main deck salon but were blocked by fire and smoke. Unable to reach the bunkroom, they jumped overboard. Two of them re-boarded the vessel at its stern but were once again blocked by smoke and fire. Ultimately, the five crewmembers who had been sleeping on the upper deck survived. Two were treated for injuries. But tragically, the 33 passengers and one crewmember who had been asleep below deck in the bunkroom lost their lives in the fire.

Small passenger vessel Conception at sunrise prior to sinking (Source: VCFD)

Along with a multidisciplinary NTSB team, including marine safety investigators and specialists from the NTSB Transportation Disaster Assistance (TDA) and Media Relations divisions, I launched to my first maritime investigation as a Board Member. During my time on-scene, I met with the families of those on-board the vessel and gave them the only promise we at NTSB have to give, that we would find out what caused the fire aboard the Conception, in hopes of finding ways to prevent similar suffering for other families.

Our investigators, along with the USCG, the Federal Bureau of Investigation (FBI), and the Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) were carefully recovering wreckage. They examined a similar vessel to help learn how it was built, and how escape might have been thwarted for so many. While we conducted our safety investigation, a parallel criminal investigation was underway.

Yet despite difficult circumstances and the limited evidence left after the fire, the NTSB was able to identify critical safety issues, determine the probable cause, and make important safety recommendations. If implemented, these recommendations will help prevent a similar tragedy from happening again.

NTSB investigators found that the Conception had no smoke detectors anywhere in the main deck salon where the fire likely started. But incredibly, there are no passenger vessel regulations requiring smoke detection in all accommodation spaces. The vessel was also required to have a roving patrol to guard against and raise alarm in case of a fire or other emergencies, but there was no evidence that such a safeguard was in place, and the USCG has difficulty enforcing such an important requirement aboard small passenger vessels.

Furthermore, small passenger vessel construction regulations for means of escape did not ensure that both escape paths from the sleeping compartment exited to different spaces. On the Conception, the only emergency routes from the passenger accommodations exited into the same space, which was fully engulfed in fire.

Finally, our investigation highlighted yet another company with ineffective safety oversight. When the Board met to deliberate the report on the tragedy on October 20, 2020, we determined that the probable cause of the fire on board the small passenger vessel Conception was the failure of Truth Aquatics, Inc., to provide effective oversight of its vessel and crewmember operations, including requirements to ensure that a roving patrol was maintained, which allowed a fire of unknown cause to grow, undetected, in the vicinity of the aft salon on the main deck. Contributing to the undetected growth of the fire was the lack of a USCG regulatory requirement for smoke detection in all accommodation spaces. Contributing to the high loss of life were the inadequate emergency escape arrangements from the vessel’s bunkroom, as both exited into a compartment that was engulfed in fire, thereby preventing escape.

The NTSB reiterated its Safety Recommendation (M-12-3) to the USCG to require all operators of U.S.-flag passenger vessels to implement safety management systems (SMS) considering the characteristics, methods of operation, and nature of service of these vessels, and, with respect to ferries, the sizes of the ferry systems within which the vessels operate. An SMS is an enormously powerful tool which helps a safety critical company identify hazards and mitigate risks.

Additionally, we issued seven new safety recommendations to the USCG to:

  • require new and existing small passenger vessels to be equipped with smoke detectors in all accommodation spaces, which are interconnected so that when one detector alarms, the remaining detectors also alarm.
  • develop and implement inspection procedures to ensure vessel operators are conducting roving patrols when required.
  • require a secondary means of escape into different exits from overnight accommodations that emerge into different spaces than the primary exit, and that those routes are not obstructed.

While these regulatory changes may take time, the NTSB also recommended that industry groups such as the Passenger Vessel Association act voluntarily to install smoke detectors and improve emergency egress routes. Finally, we recommended that the company that operated the Conception implement an SMS to improve safety practices and minimize risk.

The Conception investigation report is an excellent example of the NTSB’s ability to complete investigations in a timely manner, resulting in effective common-sense safety recommendations. It is now up to the USCG and industry to make these essential changes to improve safety and prevent the horrendous loss of life we saw two years ago on Labor Day weekend. The NTSB added Improve Passenger and Fishing Vessel Safety to its Most Wanted List in 2021 and will actively advocate to ensure these safety recommendations are implemented.

Comair 5191 Crash Led to Air Traffic Control Changes

By Jeff Marcus, Chief, NTSB Safety Recommendations Division

Fifteen years ago today, on August 27, 2006, Comair flight 5191, a Bombardier CL-600-2B19, lined up on the wrong runway and crashed during takeoff from Blue Grass Airport, Lexington, Kentucky (LEX), killing 49 people, including the captain and flight attendant. The first officer, who was seriously injured, was the only survivor. This investigation led to several improvements that furthered safety for all air travelers.

What Happened

The flight crew was instructed to take off from runway 22, a 7,000-foot-long air carrier runway. Instead, they lined up the airplane on runway 26, a 3,500-foot-long general aviation runway, and began the takeoff roll without cross-checking and verifying that the airplane was on the correct runway before takeoff.

Because runway 26 was too short for the takeoff, the airplane ran off the end of the runway, became momentarily airborne, and crashed into the airport perimeter fence, trees, and terrain. The airplane was destroyed by impact forces and postcrash fire.

What We Found

The NTSB investigation determined that there were adequate cues on the airport surface and resources were available in the cockpit to allow the flight crew to successfully navigate from the air carrier ramp to the runway 22 threshold. The flight crew believed that they were taking off on runway 22, even though it was dark when flight 5191 tried to take off and runway 26 was unlighted. We determined the crash was due to:

  • the flight crewmembers’ failure to use available cues and aids to identify the airplane’s location on the airport surface during taxi, and
  • their failure to cross-check and verify that the airplane was on the correct runway before takeoff.

We also found that the flight crew was engaged in nonpertinent conversation during taxi, resulting in a loss of positional awareness, contributing to the accident. This is a violation of the FAA’s sterile cockpit rule, which bans nonpertinent conversation in critical phases of flight. (As awareness of distraction spread to other modes of transportation—and to distraction by other means—the sterile cockpit rule began to be seen as a forerunner of later anti-distraction measures.)

Our Recommendations

Although, the probable cause pointed to flight crew actions, our recommended changes covered all aspects of the aviation industry. We not only recommended improving flight crew procedures, but also recommended that moving map displays be required in cockpits to improve situational awareness to help prevent similar accidents in the future.

In addition, we saw other aspects of the aviation industry that could be improved to help prevent similar accidents: improving air traffic control practices and procedures.

Also contributing to the crash was the Federal Aviation Administration’s (FAA) failure to require that all runway crossings be authorized only by specific air traffic control clearances. In this case, the air traffic controller on duty, like the pilots, had the ability to head off the accident, if he was alert and aware of the flight’s surface movements.

But the tower controller who could see the airplane on the airport surface did not detect the flight crew’s lining up to take off on the wrong runway. Instead of monitoring the airplane’s departure, he was not looking inside the control tower while he performed a lower-priority administrative task that could have waited until after transferring responsibility for the airplane.

The controller’s duty times, and sleep patterns indicated that he was most likely experiencing fatigue at the time of the accident. However, his routine practices did not consistently include the monitoring of takeoff. What’s more, the FAA’s policies and procedures at the time were not optimized to prioritize controller monitoring of aircraft surface operations over administrative tasks.

Lessons Learned

Followers of aviation safety know that the loss of Comair flight 5191 was an accident that brought a focus on preventing fatigue in air traffic controllers. The NTSB recommended, and the FAA implemented, numerous measures improving air traffic control practices and procedures. These included fatigue management programs, training, and, together with the National Air Traffic Controllers Association, working to improve scheduling practices.

Many other recommendations which came out of the tragedy were implemented, advancing crew resource management and airport surface painting and markings, and prohibiting the issuance of a takeoff clearance during an airplane’s taxi to its departure runway until after the airplane has crossed all intersecting runways.

Because the NTSB’s mission is to improve safety, not to punish, finding a human error was by no means the end of the investigation. Instead, the actions of the flight crew were only the beginning. What conditions led to the human error? Was there anything that could have been done to capture the error? Were there other errors in other parts of the transportation system that allowed the crash to transpire? What could prevent the next crash?

The result is that revisions have been made to ensure that the same set of circumstances at play in LEX during the early morning of August 27, 2006, will not lead to another fatal accident.

Learn More

Aviation Accident Report: Attempted Takeoff from Wrong Runway Comair Flight 5191, Lexington, KY, August 27, 2006

Aviation Investigation Docket: Attempted Takeoff from Wrong Runway Comair Flight 5191, Lexington, KY, August 2006

Episode 42: TWA Flight 800

In this episode of Behind-the-Scene @NTSB, NTSB Managing Director, Sharon Bryson and Frank Hilldrup, Chief Technical Advisor for International Affairs, NTSB Office of Aviation Safety, talk about the July 17, 1996, TWA flight 800 accident.  We discuss what happened, the findings and safety recommendations that came out of the investigation, its tremendous impact on aviation safety, how the Aviation Disaster Family Assistance Act of 1996 led to the establishment of NTSB’s disaster assistance program, and the decommissioning of the TWA flight 800 reconstruction.

The NTSB final report for the TWA flight 800 in-flight breakup mentioned in this episode and the NTSB docket for investigation is also available on our website.

To learn more about the NTSB Transportation Disaster Assistance (TDA) Program, visit our TDA web page.     

To learn more about the NTSB Most Wanted List (MWL), visit our MWL web page. You can also access the MWL archive  on our website.

Information about upcoming NTSB virtual training courses are available on our Training Center web page.                                                               

Get the latest episode on Apple Podcasts , on Google PlayStitcher, or your favorite podcast platform.

And find more ways to listen here: https://www.blubrry.com/behind_the_scene_ntsb/

Twelve Years After Colgan 3407, FAA Still Hasn’t Implemented Pilot Records Database

By Chairman Robert Sumwalt

I grew up in the South, and people sometimes say we do things slowly in that part of the country. Whether there’s any validity to that claim, I can’t say with certainty. What I can say with great certainty, however, is that speed isn’t an attribute commonly associated with the Federal Aviation Administration (FAA), an agency within the US Department of Transportation. Below is a sad, but true, example of the glacial pace of the FAA’s rulemaking processes—even in the wake of a congressional mandate to get something done. Perhaps the new secretary of transportation can give a needed boost to this untenable situation.   

On this date 12 years ago—February 12, 2009—while on approach to the Buffalo‑Niagara International Airport in New York, Colgan Air flight 3407, a Bombardier Q-400 turboprop, plunged from the sky. Fifty lives were lost, including that of a man who died when the turboprop crashed into his home.

The NTSB’s year-long investigation revealed that, as the airplane slowed on approach, the captain became startled by the activation of the aircraft’s stall warning system. In response to something that should have been easily dealt with, the captain inappropriately manipulated the elevator controls, forcing the aircraft into its fateful dive. Our investigation found that the captain had a history of piloting performance deficiencies, including having failed several flight tests. Possibly more troubling, he concealed these performance deficiencies from Colgan when he applied for employment.

The Colgan crash was the deadliest US airline disaster in the past 19 years.

In response to this tragedy, the NTSB issued safety recommendations to the FAA to strengthen the way airlines ascertain a pilot applicant’s background, including requiring previous employers to disclose training records and records of any previous failures.

Congress took note of these recommendations and included them in a bill signed into law in August 2010. This law required the FAA to establish a pilot records database (PRD), and stipulated that “before allowing an individual to begin service as a pilot, an air carrier shall access and evaluate . . .  information pertaining to the individual from the pilot records database.” Items required to be entered into the PRD, and considered by hiring airlines, included “training, qualifications, proficiency, or professional competence of the individual, including comments and evaluations made by a check airman . . . any disciplinary action taken with respect to the individual that was not subsequently overturned; and any release from employment or resignation, termination, or disqualification with respect to employment.” Congress appropriated $6 million per year for the next 4 years to help facilitate creation of the PRD—a total of $24 million.

The FAA’s response reminds me of my college’s football team—they get off to a good start, but after scoring on the opening drive, they have difficulty executing for the rest of the game.

In early 2011, the FAA established an aviation rulemaking committee (ARC) to develop recommendations on the best way to implement the PRD. Despite the ARC completing its work and issuing a report to the FAA in July 2011—just 6 months after being tasked with developing recommendations—it wasn’t until September 2015 that the FAA began a phased approach to implementing the PRD.

By July 2016, Congress had become impatient with the FAA’s lack of progress. After all, it had been 6 years since the FAA was required to create the PRD, and there was still no appreciable progress. Congress gave the FAA a new deadline: it mandated the PRD be in place by April 30, 2017.

Unfortunately, April 30, 2017, came and went. Still no PRD. Meanwhile, 40 days after that deadline, a young pilot applied for employment at Atlas Air and was hired shortly thereafter. As with the Colgan Air captain, this pilot concealed his history of performance deficiencies, which deprived Atlas Air the opportunity to fully evaluate his aptitude and competency as a pilot. He struggled with training at Atlas, but after failing his check ride, he was retrained and passed. Tragically, on February 23, 2019, on what should have been a routine cargo flight from Miami to Houston, this pilot, like the Colgan Air captain, encountered something that startled him. He overreacted and put the Boeing 767 into a fatal dive. The commonalities between the Colgan Air crash and the Atlas Air crash are striking: Both pilots had a record of poor performance prior to their employment, both pilots concealed that information when applying for airline employment, and both pilots misapplied the flight controls following events they weren’t expecting. Events that should have been easily corrected. Events that, tragically, led to their aircraft plunging to the ground.

Neither of these sad events was an isolated case. Including these two crashes, the NTSB has investigated 11 air carrier accidents over 3 decades in which pilots with a history of unsatisfactory performance were hired by an airline and then were later involved in an accident attributed to their poor piloting performance.

After years of foot dragging, last March, the FAA provided its first visible indication of moving forward with the PRD, publishing a notice of proposed rulemaking (NPRM) to give the public a glimpse of what the proposed rule may look like—10 years after Congress initially mandated it, and 3 years after the April 2017 deadline that Congress eventually imposed.

The NPRM indicated that the PRD should be implemented sometime this year; however, the NPRM also proposes allowing a 2-year phase-in period. This puts complete implementation somewhere around a 2023 timeframe, assuming this proposed timeline holds. If that’s the case, we will finally have the PRD 14 years after the Colgan Air disaster, 13 years after Congress mandated it, 5 years after the deadline imposed by Congress, and 4 years after the Atlas Air crash.

A crash is a tragedy. It’s even more tragic to see a similar crash happen again and again and not have the regulatory agency responsible for safeguarding the skies take corrective action in a reasonable timeframe. We’re past the point of reasonable, and the traveling public deserves better.

We Can Do Big Things. Just Look at Positive Train Control

By Member Jennifer Homendy

After 50 years of investigation, advocacy, and persistence by the NTSB, positive train control (PTC) is now a reality across the country!

This video highlights the NTSB’s more than 50 year effort in investigating PTC-preventable accidents and advocacy for this life-saving technology.

PTC systems use GPS and other technology to prevent certain train collisions and derailments. It could have been lifesaving in the 154 rail accidents that have killed more than 300 people, and injured more than 6,800 passengers, crewmembers, and track workers in major accidents stretching across the nation, from Darien, Connecticut, in 1969, to Chatsworth, California, in 2008, to Philadelphia, Pennsylvania, in 2015, and DuPont, Washington, in 2017.

But let’s step back and marvel at this real achievement—and the effort it took. Safety improvements are never easy or quick. It took more than 50 years of advocacy by the NTSB and historic action by Congress to make PTC a reality. For many of these years, the NTSB was a lonely voice for safety, pushing for PTC despite opposition from railroads over the price tag and technological hurdles.

I know how tough the battle was because I was there. As staff director for the House subcommittee charged with overseeing rail safety, I played a role in ensuring that any effort to move legislation forward to improve rail safety included the NTSB’s recommendation to implement PTC. When I got to the NTSB, one of my priorities was to ensure that mandate was implemented.

It truly is remarkable in Washington to keep such clear focus on PTC across so many administrations, through so many changes in Congress and at the NTSB.

Earlier this month, I had the honor of moderating a panel of current and former NTSB leaders and staff who recalled the long, bumpy road to PTC implementation. NTSB Chairman Robert Sumwalt and former agency heads Chris Hart, Debbie Hersman, and Jim Hall recalled their own contributions and noted how remarkable the agency’s sheer persistence was in a time of short attention spans and quickly changing priorities.

It was so uplifting to hear their personal reflections of their time on the Board fighting for PTC, and their continued commitment to the agency and its critical safety mission. But it was the staff panel that really defined persistence. Generations of rail investigators and other staff worked every one of the 154 PTC-preventable accidents over the decades, launching to horrific crash scenes only to discover similarities pointing to the same solution: PTC. They spent holidays working. Missed birthdays and anniversaries. Completed their important jobs regardless of on-scene obstacles and personal priorities.

Recording of the January 14, 2021, NTSB live‑streamed discussion about Positive Train Control implementation.

The public doesn’t often see what goes on behind the scenes at accident investigations, after investigations are completed when recommendations need to be implemented, and the tremendous work required to keep those recommendations at the forefront of discussions to improve safety. As stated in the first panel, board members come and go, but it’s the staff that keep these critical safety issues alive. It was truly remarkable and heartwarming to hear their reflections of the agency’s work and how that work has impacted public safety, as well as how it affected them personally. I hope it gave the public a sense of what it takes to stay focused on an issue for five full decades.

Was it worth it? You bet. PTC will save lives.

Other safety improvements have also taken many years to implement. Midair collisions were dramatically reduced by the Traffic Alert and Collision Avoidance System (TCAS). That took decades to put in place. Airliner fuel-tank inerting systems, which addressed fuel tank explosions like the one that brought down TWA Flight 800 in 1996, also took years. And let’s not forget about the long fight for airbags and seat belts in passenger vehicles. All these transportation safety improvements were strongly and relentlessly advocated for by the NTSB.

We can do big things in America. We can save more lives on our rails, in the sky, in communities where pipelines are located, on the water, and on the highway. But major safety improvements like PTC take time, money and, perhaps most of all, incredible perseverance.