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National Transportation Safety Board Eazardous Materials Special Investigution Report: Cargo Tank Rollover Protection
"Between January and May 1991, the National Transportation Safety Board investigated seven highway accidents in which bulk liquid cargo tanks, Department of Transportation (DOT) specification MC 306 or MC 312, overturned and released hazardous materials through damaged closures or fittings on top of the tanks. In three of the accidents, structural failure of the rollover protection devices for the top fittings resulted in impact damage to the fittings and the release of the cargo; in four of the accidents, the design and configuration of the devices were not adequate to protect and shield the top fittings from external objects or from plowing into the ground As a result of these accidents, the Safety Board conducted a special investigation on c?(g') tank rollover protection. The safety issues discussed in this report are the adequacy of DOT regulations regarding the design and performance of rollover protecti0n devices installed on bulk liquid cargo tanks; the effectiveness of oversight pertaining to the design and construction of the cargo tank; and the adequacy of accident reporting to and data collected by the DOT. Recommendations concerning these issues were made to the Research and Special Programs Administration and to the Federal Highway Administration."
United States. National Transportation Safety Board
1992-02-04
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National Transportation Safety Board Strategic Plan: Fiscal Years 2013 through 2017
From the message section written by chairman Deborah A.P. Hersman: "The NTSB [National Transportation Safety Board] is recognized nationally and internationally for our accident investigation experience, and also for issuing, advancing and closing safety recommendations. For over 40 years, the NTSB has been at the forefront of transportation safety issues. To continue this record, our plan serves as an agenda outlining actions needed to preserve the NTSB's successes and, where appropriate, to bring about positive change. This plan begins with our revised mission and the expansion of our core agency values, to include diversity and inclusion in the workplace. The aim of this plan is to stimulate and promote beneficial change within the transportation community- change that helps fulfill, and is consistent with, our mission and core values."
United States. National Transportation Safety Board
2012-10-01
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NTSB Safer Seas Digest 2016: Lessons Learned From Marine Accident Investigations
"During 2016, the NTSB's [National Transportation Safety Board] work to make marine transportation safer took us to many accident sites and continued in our laboratories in Washington, D.C. The accidents in Safer Seas Digest involved loss of life, injuries, and property damage. The lessons learned in these accidents can prevent such losses in the future if marine stakeholders apply what has been learned. Not only mariners, but management and executives as well, should take these lessons to heart. Safety culture begins at the top; the lessons in Safer Seas Digest should be as important to those in C-suites as they are to those at sea."
United States. National Transportation Safety Board
2016
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Safer Seas Digest 2015: Lessons Learned from Marine Accident Investigations
From the Message from the Chairman: "The National
Transportation Safety
Board [NTSB] investigates accidents in all modes of
transportation, determines probable causes,
and makes safety recommendations as
appropriate. In marine transportation,
NTSB investigators work closely with our
US Coast Guard counterparts to gather facts
and evidence at the scene of an accident.
I would like to thank the men and women of
the Coast Guard not only for their collaborative
investigative work alongside the NTSB, but also
for their work to secure the scenes of accidents,
and for the use of Coast Guard assets on which
we rely in many cases. Once all the relevant
facts have been gathered (both on scene and
afterwards), the NTSB analyzes the information
and publishes accident investigation reports
so that mariners and others know the
circumstances of an accident and what we
recommend to avoid recurrences.
'Safer Seas Digest 2015' is the third
edition of this publication, our 'one-stop
shop' for mariners and others to review
concise summaries of a full year's accident
investigations. Since we first published
'Safer Seas 2013', we have heard that the yearly
digests are used in crew training and safety
meetings both on board and shoreside. Indeed,
safety culture begins at the top; the lessons
of 'Safer Seas Digest' should be of interest
not only at sea, but also in C-suites.
'Safer Seas Digest 2015' represents our
continuing commitment to sharing the lessons
that we learn through our investigations. Many
marine accidents can be prevented when crews
know and respond to safety issues early and
when crews work together effectively in the
event of a crisis."
United States. National Transportation Safety Board
2016
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Railroad Accident Report: Derailment of CN Freight Train U70691-18 With Subsequent Hazardous Materials Release and Fire, Cherry Valley, Illinois, June 19, 2009
"About 8:36 p.m., central daylight time, on Friday, June 19, 2009, eastbound Canadian National Railway Company freight train U70691-18, traveling at 36 mph, derailed at a highway/rail grade crossing in Cherry Valley, Illinois. The train consisted of 2 locomotives and 114 cars, 19 of which derailed. All of the derailed cars were tank cars carrying denatured fuel ethanol, a flammable liquid. Thirteen of the derailed tank cars were breached or lost product and caught fire. At the time of the derailment, several motor vehicles were stopped on either side of the grade crossing waiting for the train to pass. As a result of the fire that erupted after the derailment, a passenger in one of the stopped cars was fatally injured, two passengers in the same car received serious injuries, and five occupants of other cars waiting at the highway/rail crossing were injured. Two responding firefighters also sustained minor injuries. The release of ethanol and the resulting fire prompted a mandatory evacuation of about 600 residences within a 1/2-mile radius of the accident site. Monetary damages were estimated to total $7.9 million."
United States. National Transportation Safety Board
2012-02-14
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Safety Study: Supervisory Control and Data Acquisition (SCADA) in Liquid Pipelines
"In the pipeline industry, Supervisory Control and Data Acquisition (SCADA) systems are used to collect data from pipeline sensors in real time and display these data to humans who monitor the data from remote sites and remotely operate pipeline control equipment. This National Transportation Safety Board study was designed to examine how pipeline companies use SCADA systems to monitor and record operating data and to evaluate the role of SCADA systems in leak detection. The number of hazardous liquid accidents investigated by the Safety Board in which leaks went undetected after indications of a leak on the SCADA interface was the impetus for this study. [...] As a result of this study, the Safety Board issued five recommendations to the Pipeline and Hazardous Materials Safety Administration."
United States. National Transportation Safety Board
2005-11-29
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Special Investigation Report on Emergency Medical Services Operations [January 25, 2006]
"This report discusses safety issues identified during the Safety Board's special investigation of 55 emergency medical services (EMS) aircraft accidents that occurred in the United States between January 2002 and January 2005. Safety issues discussed in this report focus on less stringent requirements for EMS operations conducted without patients on board, a lack of aviation flight risk evaluation programs for EMS operations, a lack of consistent, comprehensive flight dispatch procedures for EMS operations, and no requirements to use technologies such as terrain awareness and warning systems to enhance EMS flight safety. [...]. This special investigation report is not intended to represent a comprehensive statistical analysis of EMS accidents. Because 14 CFR Part 135 operators are not required to maintain flight activity data, such an analysis is not possible. The purpose of this report is to discuss the safety issues identified during the Safety Board's investigation and suggest recommendations that, if implemented, could address these issues. (See appendix C for a list of accidents that were examined during the Board's investigation that might have been prevented by the corrective actions proposed in this report.) The Safety Board also recognizes that the use of EMS aircraft operations involves aspects of public policy (for example, the decision to use EMS aircraft instead of ground transportation, the reimbursement structure of vital services, and the economic competition among EMS operators) that will not be the focus of this report."
United States. National Transportation Safety Board
2006-01-25
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Emergency Evacuation of Commercial Airplanes
"Since its inception, the National Transportation Safety Board has been concerned about the evacuation of commercial airplanes in the event of an emergency. Several accidents investigated by the Safety Board in the last decade that involved emergency evacuations prompted the Safety Board to conduct a study on the evacuation of commercial airplanes. The study described in this report is the first prospective study of emergency evacuation of commercial airplanes. For the study, the Safety Board investigated 46 evacuations that occurred between September 1997 and June 1999 that involved 2,651 passengers. Eighteen different aircraft types were represented in the study. Based on information collected from the passengers, the flight attendants, the flight crews, the air carriers, and the aircraft rescue and firefighting (ARFF) units, the Safety Board examined the following safety issues in the study: (a) certification issues related to airplane evacuation, (b) the effectiveness of evacuation equipment, (c) the adequacy of air carrier and ARFF guidance and procedures related to evacuations, and (d) communication issues related to evacuations. The study also compiled some general statistics on evacuations, including the number of evacuations and the types and number of passenger injuries incurred during evacuations. As a result of the study, the National Transportation Safety Board issued 20 safety recommendations and reiterated 3 safety recommendations to the Federal Aviation Administration."
United States. National Transportation Safety Board
2000-06-27
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Evaluation of U.S. Department of Transportation Efforts in the 1990s to Address Operator Fatigue
"During the 1980s, the National Transportation Safety Board investigated several aviation, highway, and marine accidents that involved operator fatigue. Following completion of these investigations, the Safety Board in 1989 issued three recommendations to the U.S. Department of Transportation (DOT) addressing needed research, education, and revisions to hours-of-service regulations. [...] This report provides an update on the activities and efforts by the DOT and the modal administrations to address operator fatigue and, consequently, the progress that has been made in the past 10 years to implement the actions called for in the three intermodal recommendations and other fatigue-related recommendations. The report also provides some background information on current hours-of-service regulations, fatigue, and the effects of fatigue on transportation safety. As a result of this safety report, the National Transportation Safety Board issued new safety recommendations to the U.S. Department of Transportation, the Federal Aviation Administration, the Federal Highway Administration, the Federal Railroad Administration, the Research and Special Programs Administration, and the United States Coast Guard. The Safety Board also reiterated two recommendations to the Federal Aviation Administration."
United States. National Transportation Safety Board
1999-05
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Risk Factors Associated with Weather-Related General Aviation Accidents
"The goal of this National Transportation Safety Board study was to better understand the risk factors associated with accidents that occur in weather conditions characterized by IMC [instrument meteorological conditions] or poor visibility ("weather-related accidents"). Safety Board air safety investigators collected data from 72 general aviation accidents that occurred between August 2003 and April 2004. When accidents occurred, study managers also contacted pilots of flights that were operating in the vicinity at the time of those accidents for information about their flight activity. A total of 135 nonaccident flights were included in the study. All nonaccident pilots voluntarily consented to interviews and provided information about their flights, their aircraft, and details about their training, experience, and demographics. Additionally, the Federal Aviation Administration provided information about pilots. practical and written test results and their previous accident/incident involvement. Statistical analyses were used to determine the relationships between study variables and accident/nonaccident status and to identify variables that could be linked to an increased risk of weather-related general aviation accident involvement. The analysis revealed several pilot- and flightrelated factors associated with increased risk of accident involvement. The safety issues discussed in this report include: 1) pilot age and training-related differences, 2) pilot testing, accident, and incident history, and 3) pilot weather briefing sources and methods. Safety recommendations concerning these issues were made to the Federal Aviation Administration."
United States. National Transportation Safety Board
2005-09-07
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Current Procedures for Collecting and Reporting U.S. General Aviation Accident and Activity Data
"Unlike Part 121 and scheduled Part 135 air carriers, general aviation operators and on-demand Part 135 operators (air taxis) are not required to report actual flight activity data to DOT [Department of Transportation]. Instead, the Federal Aviation Administration (FAA) uses its annual General Aviation and Air Taxi Activity (GAATA) Survey to query a sample of registered aircraft owners, either through the Internet or by mail. The National Transportation Safety Board and others rely on GAATA Survey activity estimates to calculate accident rates and statistics that form the basis for assessing general aviation safety in the United States. Congress, government agencies, the aviation industry, and other researchers frequently cite accident rates when evaluating the need for safety initiatives. Valid activity data are necessary to compare the accident rates for different aircraft types and types of operations, to establish baseline measures that can be used to identify and track accident trends, and to assess the effectiveness of safety improvement efforts. Because of a critical need for accurate activity measures, and the perception of possible problems with current general aviation activity estimates, the Safety Board analyzed several general aviation exposure measures to determine the relationship of trends over time. The results of that analysis are included in this report. One existing recommendation to the FAA is superseded in this report, two new recommendations are issued, and two existing recommendations are reiterated."
United States. National Transportation Safety Board
2005-04-29
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Public Aircraft Safety
This National Transportation Board safety study examined public aircraft safety. The report includes accident and exposure data, accident rates, accident characteristics, an analysis and recommendations, and appendixes. "'Public aircraft' are aircraft operated for the purpose of fulfilling a government function that meet certain conditions specified under Title 49 United States Code, Section 40102(a)(37). [...] For this study, the Safety Board identified 341 public aircraft accidents that occurred during the years 1993.2000. Using activity data from the Federal Aviation Administration (FAA) (for the period 1996.1999), the Board calculated an accident rate of 3.66 accidents per 100,000 flight hours for nonmilitary, nonintelligence public aircraft. Using activity data from the General Services Administration (also for the period 1996. 1999), the Board calculated an accident rate of 4.58 per 100,000 flight hours for nonmilitary, nonintelligence Federal aircraft."
United States. National Transportation Safety Board
2001-10-23
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We Are All Safer: NTSB-Inspired Improvements in Transportation Safety
"The National Transportation Safety Board (NTSB) was established by Congress in 1967 to investigate and determine the causes of accidents in all modes of transportation. Since then, the Safety Board has investigated more than 110,000 aviation accidents and thousands of railroad, marine, highway, and pipeline accidents. The Board is recognized as one of the world's premier independent accident investigation agencies because of the expertise it has accumulated in more than three decades of experience. [...] Every time you travel in an airplane, a school bus, a train, a boat, and even your own automobile, you are protected by safety measures resulting from Safety Board recommendations. This publication summarizes many of these Safety Board - inspired improvements."
United States. National Transportation Safety Board
1998-07
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Safety Report: Survivability of Accidents Involving Part 121 U.S. Air Carrier Operations,1983 through 2000
The National Transportation Safety Board frequently receives inquiries from the general public and Government agencies concerning the survivability of airplane accidents. Although the Safety Board's Annual Review of Aircraft Accident Data for U.S. Air Carrier Operations summarizes the degree of occupant injury by aircraft damage, the annual publication has not, in the past, analyzed the issue of survivability in detail. Therefore, the purpose of this safety report is to examine aircraft occupant survivability for air carrier operations in the United States. The Safety Board examined only air carrier operations performed under Title 14 Code of Federal Regulations Part 121 because the majority of the Board's survival factors investigations are conducted in connection with accidents involving Part 121
carriers. Therefore, more survivability data are available for Part 121 operations than are available for Part 135 and Part 91 (general aviation) operations. This report also examines cause-of-death information for the most serious of the Part 121 accidents; that is, those accidents involving fire, at least one serious injury or fatality, and either substantial aircraft damage or complete destruction.
United States. National Transportation Safety Board
2001-03
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National Transportation Safety Board: Lessons Learned and Lives Saved: 1967-2007
"To help mark the NTSB's 40th anniversary, this report highlights some of the thousands of transportation safety improvements that have resulted from NTSB accident investigations and recommendations. Accidents have been prevented, lives saved and injuries reduced because of NTSB-inspired safety advances in all modes of transportation: aviation, highway, marine, railroad and pipeline. This reports also gives a brief history of the Safety Board, its responsibilities, and the legislation that created it, that strengthened its independence, and that has expanded its safety role over the years. This report includes information on the 'Most Wanted List.' The list focuses on additional safety advances the Safety Board strongly believes are needed to further increase transportation safety. The report also lists noteworthy Safety Board public forums and meetings, and a list of Board Members, 1967 through the present."
United States. National Transportation Safety Board
2007
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American Airlines Flight 77 FDR Report
"In support of the Federal Bureau of Investigation's (FBI's) investigation into the terrorist act of American Airlines Flight 77, which crashed into the Pentagon in Arlington, Virginia, on September 11, 2001, the NTSB Vehicle Recorders Division received the following solid state flight data recorder (SSFDR) on September 14, 2001: Recorder Manufacturer/Model: Loral Fairchild Model F-2100. The SSFDR was examined upon receipt. The recorder displayed evidence of impact, fire, and smoke damage."
United States. National Transportation Safety Board
2002-01-31
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Flight Path Study - United Airlines 93
"This document provides a brief description of the flight path of the aircraft based on information obtained from various sources of recorded radar of the subject aircraft both before and after the hijacking events. Information from the Flight Data Recorder (FDR) recovered on scene is also used to develop the
description. Flight paths are overlaid onto maps of the area, and time histories
of altitude data are presented."
United States. National Transportation Safety Board
2002-02-19
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Study of Autopilot, Navigation Equipment, and Fuel Consumption Activity Based on United Airlines Flight 93 and American Airlines Fiight 77: Digital Flight Data Recorder Information
"This document describes information obtained from the Digital Flight Data Recorders (DFDRs) of the subject aircraft concerning the use of the airplane autoflight and navigation systems both before and after the hijacking events, and presents fuel on board calculations based on the DFDR fuel flow data."
United States. National Transportation Safety Board
Bower, Daniel W.; O'Callaghan, John
2002-02-13
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Recorded Radar Data Study: American Airlines Flight 11, United Airlines Flight 175, American Airlines Flight 77, United Airlines Flight 93
"This document describes information obtained from various sources of
recorded radar of the subject aircraft both before and after the hijacking events, and a general overview of the time correlation of the data for all four aircraft with other data sources. Time synchronized ground tracks of the hijacked aircraft are presented."
United States. National Transportation Safety Board
Bower, Daniel R.
2002-02-15
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Air Traffic Control Recording - United Airlines Flight 93
"On September 11, 2001 Untied Airlines Flight 93, a Boeing 767 crashed near Shanksville, PA. A certified analog copy of air traffic control (ATC) transmissions recorded on September 11, 2001 at various tower, departure, and Air Route Traffic Control Center (ARTCC) positions along the route of flight was sent to the audio laboratory of the National Transportation Safety Board. These recordings were used to create an audio track and text transcript of the aircraft-ground communications from takeoff to accident time."
United States. National Transportation Safety Board
2001-12-21
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United Airlines Flight 93 FDR Report
"In support of the Federal Bureau of Investigation's (FBI's) investigation into the terrorist act of United Airlines Flight 93, which crashed in Shanksville, Pennsylvania, on September 11, 2001, the NTSB Vehicle Recorders Division received the following solid state flight data recorder (SSFDR) on September 13, 2001: Recorder Manufacturer/Model: Allied Signal SSFDR. The SSFDR was examined upon receipt. The recorder displayed evidence of impact damage. The memory board was removed and also showed signs of impact damage."
United States. National Transportation Safety Board
2002-02-15
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Air Traffic Control Recording - American Airlines Flight 11
"On September 11, 2001 American Airlines Flight 11, a Boeing 767 crashed into Tower 1 of the World Trade Center in New York City, New York. A certified analog copy of air traffic control (ATC) transmissions recorded on September 11, 2001 at various tower, departure, and Air Route Traffic Control Center (ARTCC) positions along the route of flight was sent to the audio laboratory of the National Transportation Safety Board. These recordings were used to create an audio track and text transcript of the aircraft-ground communications from takeoff to accident time."
United States. National Transportation Safety Board
2001-12-21
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Air Traffic Control Recording - American Airlines Flight 77
"On September 11, 2001 American Airlines Flight 77, a Boeing 767 crashed into the Pentagon in Arlington, VA. A certified analog copy of air traffic control (ATC) transmissions recorded on September 11, 2001 at various tower, departure, and Air Route Traffic Control Center (ARTCC) positions along the route of flight was sent to the audio laboratory of the National Transportation Safety Board. These recordings were used to create an audio track and text transcript of the aircraft-ground communications from takeoff to accident time."
United States. National Transportation Safety Board
2001-12-21
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Flight Path Study-American Airlines Flight 11
"This document provides a brief description of the flight path of the aircraft based on information obtained from various sources of recorded radar of the subject aircraft both before and after the hijacking events. Flight paths are overlaid onto maps of the area, and time histories of altitude data are presented."
United States. National Transportation Safety Board
2002-02-19
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Air Traffic Control Recording - United Airlines Flight 175
"On September 11, 2001 Untied Airlines Flight 175, a Boeing 767 crashed into Tower 2 of the World Trade Center in New York City, New York. A certified analog copy of air traffic control (ATC) transmissions recorded on September 11, 2001 at various tower, departure, and Air Route Traffic Control Center (ARTCC) positions along the route of flight was sent to the audio laboratory of the National Transportation Safety Board. These recordings were used to create an audio track and text transcript of the aircraft-ground communications from takeoff to accident time."
United States. National Transportation Safety Board
2001-12-21
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National Transportation Safety Board Fiscal Year 2010 and 2009 Performance and Accountability Report
"This Performance and Accountability Report (PAR) for fiscal year (FY) 2010 and 2009provides the National Transportation Safety Board (NTSB) financial and performance information that enables the President, Congress, and the American people to assess the agency's performance as provided by the requirements of the following legislation: (1) Accountability of Tax Dollars Act of 2002 (2) Government Management Reform Act of 1994 (3) Government Performance and Results Act (GPRA) of 1993 (4) Chief Financial Officers Act of 1990 (5) Federal Manager's Financial Integrity Act (FMFIA) of 1982 (6) Office of Management and Budget (OMB) Circular A-136 This report compares performance results to the agency's strategic and performance goals. The NTSB's Strategic Plan and annual PARs are available on the NTSB's website at . The NTSB welcomes feedback on the form and content of this report. This report is organized as follows: 1. 'Letter from the Chairman': This includes an assessment of the reliability and completeness of the financial and performance information presented in the report and a statement of assurance of the agency's management controls as required by the FMFIA. 2. 'Management's Discussion and Analysis (MD&A)': This section provides an overview of the financial and performance information contained in the Performance and Financial Sections and Appendices. The MD&A includes an overview of the NTSB organization, highlights of the agency's performance goals and results, the current status of systems and internal control weaknesses, and other pertinent information, such as the progress being made by the NTSB in the President's Management Agenda. 3. 'Performance Section': This section provides annual performance information as required by OMB Circular A-11 and the GPRA and includes a detailed discussion and analysis of the agency's performance in FY 2010. It also includes information about past results of key performance measures. 4. 'Financial Section': This section contains detail on the NTSB's finances in FY 2009. The OIG Quality Control Report, the Independent Auditor's Report, followed by the NTSB Chief Financial Officer's (CFO) Response to Auditor's Report; the agency's audited financial statements, footnotes, and notes to the financial statements."
United States. National Transportation Safety Board
2010-11-10
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National Transportation Safety Board (NTSB) [website]
The NTSB is an independent Federal agency that investigates every civil aviation accident in the United States and significant accidents in the other modes of transportation, conducts special investigations and safety studies, and issues safety recommendations to prevent future accidents. Safety Board investigators are on call 24 hours a day, 365 days a year.
United States. National Transportation Safety Board
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Flight Path Study - United Airlines 175
"This document provides a brief description of the flight path of the aircraft based on information obtained from various sources of recorded radar of the subject aircraft both before and after the hijacking events. Flight paths are overlaid onto maps of the area, and time histories of altitude are presented."
United States. National Transportation Safety Board
2002-02-19
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Flight Path Study-American Airlines Flight 77
"This document provides a brief description of the flight path of the aircraft based on information obtained from various sources of recorded radar of the subject aircraft both before and after the hijacking events. Information from the Flight Data Recorder (FDR) recovered on scene is also used to develop the description. Flight paths are overlaid onto maps of the area, and time histories of altitude are presented."
United States. National Transportation Safety Board
2002-02-19
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Marine Accident Report: Sinking of the Recreations Sailing Vessel Morning Dew at the Entrance to the Harbor of Charleston, South Carolina
"The major safety issues identified in this investigation are the adequacy of the reasoning and decisionmaking of the operator; the fatigue and hypothermia suffered by the operator; the adequacy of the reasoning and decision-making of U.S. Coast Guard Group Charleston's watchstanders; the adequacy of Coast Guard Group Charleston's personnel, equipment, and procedures for responding to an emergency; and the role of the Coast Guard in providing factual information for safety investigations."
United States. National Transportation Safety Board
1997-12-29
