Personal Locator Beacons Improve the Chance of Rescue at Sea

By Morgan Turrell, Director of the Office of Marine Safety

New Year’s Eve is a time of celebration and remembrance. Three years ago, on December 31, 2019, as the new year was being rung in across the lower 48 states, a tragedy was playing out in icy Alaskan waters. The fishing vessel Scandies Rose, with seven crew members aboard, encountered severe icing conditions and high winds and waves as it transited from Kodiak to fishing grounds in the Bering Sea. The crabber tried to make it to Sutwik Island to shelter from the storm; however, because of the weight of the topside ice that had accumulated on the vessel and the force of the winds and waves, the Scandies Rose capsized and sank before reaching safety.

Two crewmembers managed to climb out of the capsized ship and swim to a life raft, where they were tossed about for 4 hours in 50‑mph freezing winds and 30-foot seas. Search-and-rescue (SAR) operations, hampered by the poor weather conditions and unsure of the survivors’ location, struggled to find them. Eventually, a Coast Guard helicopter rescued the two crewmembers, but the remaining five were never found.

Our investigation into this accident found that the Scandies Rose’s emergency position indicating radio beacon (EPIRB) failed to provide a position after crewmembers were forced to abandon the vessel. The crew was left without a means of communicating with SAR personnel, who, going off the EPIRB information, were searching in the wrong area. As a result of this situation, we reiterated a 2017 recommendation (M‑17-45) to require mariners to have personal locator beacons (PLBs). This recommendation asks the Coast Guard to require that all personnel employed on vessels in coastal, Great Lakes, and ocean service be provided with a PLB. Unfortunately, this recommendation is still open.

Rescue helicopter search area for Scandies Rose based off position passed in error. (Courtesy: Coast Guard)

A PLB is a personal electronic device that transmits a survivor’s location on or in the water to the Search and Rescue Satellite-Aided Tracking system during an emergency. It’s designed to be carried in a person’s life vest (or elsewhere on their body) and manually activated when the wearer is in distress. PLBs continuously update a survivor’s location.

The Scandies Rose is one of several notable marine casualties the NTSB has investigated in the last 5 years involving mariners lost at sea in which PLBs could have made a difference. These casualties highlight the critical safety need for PLBs to aid in SAR operations at sea. We’ve been recommending that all mariners use PLBs since our investigation of the October 2015 sinking of the cargo ship El Faro, which sank in the Atlantic Ocean about 40 nautical miles northeast of Acklins and Crooked Island, Bahamas, after sailing directly into the path of Hurricane Joaquin. The entire crew of 33 aboard perished.

Three days after the El Faro’s sinking, searchers spotted the remains of one El Faro crewmember in an immersion suit. It’s unclear when the crewmember perished or if any other crewmembers were able to abandon ship; however, had that crewmember, or any others who were able to evacuate, been equipped with a PLB, searchers would have had the essential information to focus rescue efforts. We concluded then that equipping all people onboard a vessel with a PLB would enhance their chances of survival, and, in 2017, we issued safety recommendation M-17-45.

Since the sinking of the El Faro and the Scandies Rose, we have investigated two other marine tragedies that continue to highlight the need for PLBs.

• On November 23, 2020, the Coast Guard received a distress signal about 27 miles from Provincetown, Massachusetts, from the EPIRB registered to the Emmy Rose, an 82-foot-long commercial fishing vessel with four crewmembers aboard. The Coast Guard recovered the EPIRB, but none of the crewmembers were located and are presumed dead. The investigation showed that if any crewmembers had been able to evacuate the vessel, they would have been able to survive up to 22.5 hours in the water with an immersion suit. It’s unlikely that the crew had PLBs; however, had they been able to activate a PLB after abandoning the vessel, SAR crews may have been able to find them.

• On April 13, 2021, the liftboat SEACOR Power capsized off the coast of Port Fourchon, Louisiana, in a severe thunderstorm. Six crewmembers were rescued by the Coast Guard and Good Samaritan vessels, and the bodies of six other fatally injured crewmembers were recovered. Seven crewmembers were never found and are presumed dead. None of the survivors rescued had PLBs or similar satellite emergency notification devices (SENDs), which use commercial satellite systems, nor did they know of anyone else on board who did.

Other marine investigations we’ve conducted have shown how PLBs and SENDs, when voluntarily incorporated into marine operations, likely saved lives. For example, our investigation of the November 10, 2021, fire aboard the fishing vessel Blue Dragon found that SAR controllers were able to correlate location data from multiple emergency beacons. Similarly, our investigation of the July 23, 2016, sinking of the commercial fishing vessel Ambition found that use of the vessel’s SEND prompted an immediate response from the commercial response center when the Coast Guard did not receive the captain’s mayday call.

PLBs are now widely available, relatively inexpensive, and remarkably accurate. Models typically cost $300–$400, and most offer GPS location functionality that can provide SAR operations with a continuously updated location of each person to within 300 feet. PLBs can be equipped with an integrated automatic identification system (AIS) “Man Overboard” alert that, in addition to satellite GPS location, transmits AIS signals for local assistance from nearby vessels.

The NTSB has been advocating for PLBs for many years now. The Coast Guard should require them, but the marine industry doesn’t have to—and shouldn’t—wait for a Coast Guard requirement to make PLBs a common piece of safety equipment on commercial vessels.

This New Year, as we reflect on the third anniversary of the tragic Scandies Rose sinking, we ask mariners and marine operations to make it their new year’s resolution to invest in their crews’ safety by providing PLBs. Without a doubt, a PLB can avoid turning an unfortunate accident or incident into a tragedy on the seas.

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For more information on our marine casualty investigations, visit our Office of Marine Safety investigative reports webpage. Also, check out these resources on PLB use from the National Oceanic and Atmospheric Administration (NOAA) and the Federal Communications Commission. Note that for any PLB, mariners should read the manufacturer’s instructions for specific guidance on use and register the device with NOAA prior to use.

Taking Stock: The IRF Caribbean Regional Congress at 10

By Nicholas Worrell, Chief, NTSB Safety Advocacy Division

The year 2012 seems not so long ago in some ways, but in other ways, it seems like another age. That was the year of the first International Road Federation (IRF) Caribbean Regional Congress during the UN’s Decade of Action on Road Safety. The group focused that year on halving the yearly toll of 1.25 million road traffic deaths around the world.

Sadly, it has only gotten worse. The annual toll of road violence victims is now up to 1.35 million per year. In a word, we failed to change things, and real people paid the price worldwide. These losses are spread across every region of the world, including the sun-splashed apparent paradise of the Caribbean.

For the loved ones of 1.35 million people a year now, there’s someone they want to call out to or share a joke with, perhaps even someone whose phone number they began to dial before realizing again the eternal disconnect of their loss. For some loved ones, there are weddings or graduations forever relegated to a hypothetical, never-to-be-realized future. Perhaps young children still look for some of those lost before they remember again the intolerable fact of their absence. And of course, some of those lost are young children themselves.

None of these losses are necessary or unavoidable. None is acceptable.

I have participated in most of the ten Caribbean regional congresses, both as a representative of the NTSB and as a Bajan by birth (a native of Barbados.) The 10th IRF Caribbean Regional Congress addressed the twin challenges of road safety and climate-resilient infrastructure. As Deputy Prime Minister of Barbados & Minister of Transport, Works and Water Resources of Barbados Santia O. Bradshaw said in her opening address, “natural hazards can reverse years of development by continuous destruction of infrastructural, economic and social capital.”

A high-level meeting was called for, and last week’s Congress fit the bill.

The Ministerial Session

As IRF Senior Vice Chairman Dr. Bill Sowell said on June 8, “The extraordinary turnout today tells us that momentum for ambitious and coordinated action in the region is growing.” The ministerial session that I mediated that morning reinforced his statement.

During the ministerial session, I helped facilitate a dialogue among the ministers, media, and audience members about the intersecting concerns of development, climate change, and road safety—and these ministers brought their A game. Ninety minutes flew by as they described how responses to today’s challenges can result in lives saved tomorrow, if their nations, and ours, act.

Road Safety Leadership – A Safe System Approach to Zero Road Deaths for the Caribbean

“Leadership,” as James C. Maxwell said, “is influence, nothing more, nothing less.” Later that day, I participated on the Safety Leadership panel. I shared with the delegates how the NTSB works to influence the transportation community to take the safe way forward, and I had plenty to share.

Other delegates often touched on the Safe System Approach to preventing traffic injuries and fatalities, and they appreciated that the same approach was embraced by the NTSB, which is lauded internationally as the gold standard of crash investigations and transportation safety studies.

During this leadership session, delegates committed to coming together in a coalition of Caribbean nations and territories to meet quarterly instead of annually.

A Challenging Farewell

On Friday, June 10, I delivered capnote remarks to the final plenary session to help close out the regional Congress. I recounted what author Jim Rohn calls “the law of diminishing intent” – the principle that the longer you wait to take action, the less likely you are to take action.

I touched on the five pillars of the Safe System Approach, and the connectedness we all share to the lives that we will save. I touched on resilience in the face of the pandemic and of climate change, and I talked about the urgency I feel to take intentional, immediate action. But the audience hardly needed my encouragement!

By the end of the IRF’s 10th Caribbean Regional Congress, commitments had been made to take the following steps:

• Ministers have agreed to form a coalition that will meet quarterly for continued discussions around road safety in the region.
• Ministers promised to collaborate on financial endeavors for road safety projects in the region (one of the biggest concerns in the region).
• The IRF committed to finding support for the region.
• Delegates agreed to place a greater commitment on data sharing.
• Leaders and delegates committed to intentional efforts around road safety by acting now and showing results next year.

After 10 years, this Congress—like the global road safety community, and the safety community here in the United States—is ready for some wins. It will take a sustained effort to achieve success, and a change of safety culture among all of us. But it can be done.

I thank my hosts at last week’s 10th IRF Caribbean Regional Congress for the opportunity to see this awareness taking hold throughout the Caribbean region.

Episode 48: James Anderson

In this episode of Behind-the-Scene @ NTSB, we have a conversation with James Anderson, the Audio Visual Communication Specialist in the NTSB Office of Safety Recommendations and Communications and the Producer of the NTSB podcast. James shares how he got interested in audio and video production, his career path to the NTSB, and some notable projects he’s worked on at the agency.

You can view the video James produced about the NTSB investigation of the Sinking of US cargo Vessel El Faro, on our YouTube channel.

To learn more about the work of the NTSB visit our YouTube channel.

Subscribe to the podcast on Apple Podcasts, Stitcher or your favorite podcast platform.

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

Remembering Air Florida Flight 90 and the Progress Towards Eliminating Airline Icing Accidents

By Jeff Marcus, Chief, NTSB Safety Recommendations Division

Forty years ago, on Jan. 13, 1982, a Boeing 737 jetliner crashed into Washington, DC’s 14th Street Bridge and plunged into the freezing Potomac River after departing National Airport during a snowstorm. The crash killed 73 of the 79 people aboard the airplane and 4 people in cars on the bridge; 4 others on the bridge were injured. A total of five passengers and a flight attendant escaped the airplane into the freezing, ice-filled Potomac River and clung to wreckage.

About 20 minutes after the crash, a National Park Service helicopter arrived. Showing remarkable flying skills, the pilot and paramedic worked so close to the water that at times the helicopter’s skids dipped beneath the surface. They managed to pull four of the survivors to shore. As a fifth survivor lost her grip on the helicopter’s lifeline, Lenny Skutnik—one of hundreds of bystanders—dove into the icy water and brought her to the riverbank.

(A U.S. Park Police helicopter pulls two people from the wreckage of an Air Florida jetliner that crashed into the Potomac River when it hit a bridge after taking off from National Airport in Washington, D.C., on Jan. 13, 1982. Photo by Charles Pereira, Associated Press)

A sixth survivor of the impact had taken the lifeline and flotation rings from the helicopter and passed them to others. When the helicopter returned for him, he was gone. The 14th Street Bridge is today named in honor of that passenger, Arland D. Williams.

NTSB investigators found that after traveling almost half a mile farther down the runway than was typical for a normal takeoff, the airplane lifted off and attained a maximum altitude of only about 350 feet before crashing into the bridge, which was less than a mile from the end of the runway. While the airplane was on its takeoff roll, the first officer remarked several times, “that don’t seem right, does it? Ah, that’s not right. That don’t seem right.” The captain did not respond.

The NTSB’s investigation identified numerous errors related to safely flying in snowy and icy conditions.

• Though the outside temperature was well below freezing and snow was falling, the crew did not activate the engine anti-ice system that prevents sensors in the engines from freezing and giving incorrect engine power readings. Although the pilots set the engines to the correct power setting, the NTSB’s analysis showed the engines were actually operating with substantially less power than was needed.
• After leaving the gate, the aircraft waited in a taxi line with many other aircraft for 49 minutes before reaching the takeoff runway. The pilot decided not to return to the gate for reapplication of deicing, fearing that the flight’s departure would be even further delayed. More snow and ice accumulated on the wings during that period.
• While waiting in line to take off, the pilots decided to maneuver closely behind a DC‑9 that was taxiing just ahead of them, mistakenly believing that the heat from the DC-9’s engines would melt the snow and ice that had accumulated on flight 90’s wings. This action, which went specifically against flight-manual recommendations for an icing situation, contributed to the icing on the Air Florida jet. The exhaust gases from the DC-9 turned the snow into a slush mixture that froze on the wings and the engine.
•  Although the crew was aware of the ice and snow on the wings, they decided to take off.

Air Florida flight 90 was just one of numerous airframe-icing-related crashes we’ve investigated. Between 1982 and 1997, we investigated eight fatal accidents of aircraft flown by professional flight crews that encountered icing conditions. Other professionally crewed flights were among the numerous icing accidents we investigated through April 2011, when the final report on such an accident was issued. These crashes killed 265 people. Similar problems were found by the Canadian Transportation Safety Board where two accidents in 1985 and 1989 killed 280 passengers and crew.

As a result of these accidents, we’ve issued several recommendations covering a variety of topics, including the following:

• Deicing fluid properties
• The number of minutes after which a plane can safety take off after being deiced
• Airport congestion and the time needed for air traffic control clearance, which can delay takeoff beyond when deicing fluid is effective
• The importance of deicing engine instruments that are used to set the proper engine power
• Prolonged autopilot use in icing conditions can mask developing problems with controllability until it is too late to avoid a crash
• Icing on swept wing aircraft (including most airliners) can cause an airplane to pitch up uncontrollably, leading to a stall
• Small amounts of ice on an airplane wing (comparable to the roughness of sandpaper) disrupt airflow and reduce the airplane wing’s ability to hold up the airplane
• FAA certification standard revisions for airplanes approved to fly in icing conditions
• Increasing stall speed in icing conditions

Because the NTSB identified airframe icing as a significant threat to aviation safety, it was on our Most Wanted List of Transportation Safety Improvements for 14 years.

After researching how ice forms on airplane wings in flight, and how that ice affects airplane performance, the FAA revised the standards for airplanes certified for flight in icing conditions. Pilot training and flight procedures were improved, and more attention was paid to minimizing the time between deicing and taking off.

Although the NTSB still investigates aviation accidents involving icing, the numbers are down drastically. We have not investigated a fatal icing-related crash involving a professional flight crew since the February 16, 2005, crash of a Cessna Citation 560 in Pueblo, Colorado.

At the NTSB, we draw knowledge from tragedy to improve the safety of all. The knowledge gained from our investigations of icing accidents, such as Air Florida flight 90, identified the actions needed to improve the safety of everyone who flies.

Let’s Stop Going the Wrong Way

By Robert Molloy, PhD, Director, NTSB Office of Highway Safety

If you’re driving down a divided highway and see headlights coming right at you, or hear screeching tires and see cars and trucks swerving to get out of your way, it’s probably an indication you’re heading in the wrong direction. Another indicator may be the large signs that read “Wrong Way” and “Do Not Enter.” The signs are always there, yet, unfortunately, they can go unnoticed, with catastrophic results.

“Do Not Enter” and “Wrong Way” signs posted on an exit ramp (Source: New York State DOT)

The NTSB has a long history of investigating collisions involving vehicles traveling the wrong way on high-speed divided highways. Wrong-way crashes occur relatively infrequently, but they are much more likely to result in fatal and serious injuries than any other type of highway crash.

In December 2012, we released a special investigation report looking at the causal factors involved in wrong-way crashes. In that report, we issued 16 safety recommendations aimed at prevention, many of which are still open, awaiting action by highway safety regulatory agencies, automotive industry groups, and states.

As we strive toward safety, we must look at what the trends and data are telling us. Are we heading in the right direction regarding wrong-way crashes? Today, the AAA Foundation for Traffic Safety released a research brief examining fatal wrong-way crashes. It contained alarming statistics that should be a flashing “Wrong Way” warning sign to all of us. The trendline for these crashes is clearly moving in the wrong direction.

The AAA’s analysis shows that, between 2010 and 2018, there were 3,885 deaths resulting from wrong-way driving crashes—an average of 430 deaths per year. This is a 19-percent increase over the 360 fatalities per year found in our analysis of 2004 to 2009 crash data. In total, we have lost a staggering 6,024 precious lives in wrong-way crashes in just 15 years—an unacceptable loss of life, especially when these types of crashes are preventable.

Like our earlier report, AAA’s research found that alcohol impairment plays a large role in wrong‑way crashes. Over 60 percent of wrong-way drivers in fatal crashes are impaired. In May 2013, we published Reaching Zero: Actions to Eliminate Alcohol-Impaired Driving, which includes a comprehensive list of safety recommendations to help eliminate alcohol‑impaired driving. Specific prevention strategies needed to reduce wrong-way crashes include the following:

• Increase high-visibility impaired-driving enforcement, including sobriety checkpoints and saturation patrols, in areas where wrong-way driving movements are most prevalent.
• Accelerate the development of in-vehicle alcohol-detection technologies.
• Require the use of alcohol ignition interlock devices for all individuals convicted of driving-while-impaired offenses.
• Reduce the per-se blood alcohol concentration (BAC) limit to 0.05 or lower for all drivers. Lowering the BAC has been shown to provide a broad deterrent effect.

AAA research also found that older drivers are more at risk of wrong-way driving than their younger counterparts. The NTSB has open recommendations to the states calling on them to develop a comprehensive highway safety program for older drivers that incorporates, at a minimum, the elements of the National Highway Traffic Safety Administration’s Highway Safety Program Guideline No. 13—Older Driver Safety. A successful program includes driver licensing and medical review of at-risk drivers, education for the medical and law enforcement community, and improved roadway design for older driver safety.

The NTSB, AAA, and others have developed a roadmap for preventing wrong-way crashes. It’s about time we do a U-turn and start heading in the right direction. I applaud the AAA Foundation for Traffic Safety for this recent research. We can’t ignore the flashing warning sign that we are going the wrong way toward preventing deadly wrong-way crashes on our highways.