Improving Transportation Safety Through Accident Investigation. Vernon S. Ellingstad Office of Research & Engineering
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1 Improving Transportation Safety Through Accident Investigation Vernon S. Ellingstad Office of Research & Engineering
2 Mission The NTSB is an independent federal agency charged to: Determine the probable cause of transportation accidents, Make recommendations to prevent their recurrence, 2!
3 The NTSB is responsible for investigating: All U.S. civil aviation accidents. Selected Highway accidents. " Major Railroad accidents. " Major Pipeline accidents. " Major marine accidents. " Transportation accidents involving the release of hazardous materials. 3!
4 The Party System " Federal Regulatory Agencies (FAA, FHWA, NHTSA, FRA, USCG) " State/Local Regulatory and Enforcement Agencies. " Operator/Carrier " Vehicle Manufacturer " Operator Union 4!
5 Investigative Groups " Led by NTSB specialist " Party representatives who are technically qualified " Develop the factual evidence in the investigation. " Analysis performed by NTSB staff. 5!
6 I-35W Bridge Collapse Minneapolis, MN August 1, 2007
7 7!
8 Scope of the Accident " 111 vehicles on bridge when it collapsed " 145 people transported to 12 area hospitals " 13 victims fatalities " NTSB on-scene Aug 1 Nov 9. 8!
9 Parties to the Investigation " Federal Highway Administration " Minnesota Department of Transportation (+ Tech Support) " Jacobs Engineering " Progressive Contractors Inc. " (Support from 93 other agencies) 9!
10 Investigative Groups " Highway Factors & Bridge Construction " Bridge Design " Witness " Survival / Emergency Response " Mapping / Evidence Collection " Video and Photogrammetry Analysis " Structural Investigation " Computer Modeling " Transportation Disaster Assistance 10!
11 Video Evidence South North Pre-Collapse 11!
12 Video Evidence South North L11W Collapse Video - Frame #1 12!
13 Video Evidence South North L11W Collapse Video - Frame #3 13!
14 Video Evidence South North Collapse Video - Frame #11 14!
15 15! Source: FHWA
16 Fracture and Deformation North U10W Upper chord Lower chords U10E 16! Upper chord
17 Initial Tension Fracture U10 West L9/U10W Up North 17!
18 Loads at Time of Accident Orange and red shading: exceeds yield stress 18!
19 Probable Cause.... The inadequate load capacity of the U10 gusset plates, due to a design error by the bridge design firm... Contributing to the design error was the failure of the design firm s quality control procedures and inadequate design review by Federal and State transportation officials. Also contributing was the generally accepted practice of not giving proper attention to gusset plates in inspections and load ratings of steel truss bridges. 19!
20 Safety Recommendations "Four recommendations to FHWA (including an emergency recommendation issued early in the investigation) "Six recommendations to AASHTO 20!
21 Collision of Metrolink Train 111 with Union Pacific Train LOF Chatsworth, CA September 12, 2008
22 Metrolink Train UP Train 22!
23 Parties to the Investigation " Federal Railroad Administration " California Public Utilities Commission " Los Angeles Fire and Rescue " Los Angeles Police Department " Metrolink " Connex " Mass Electric Construction Company " Union Pacific Railroad (UP) " United Transportation Union " Brotherhood of Locomotive Engineers & Trainmen " Bombardier Inc. (Passenger Car manufacturer) 23!
24 " Mechanical " Track " Signals " Rail Operations " Survival Factors 24! Investigative Groups " Human Performance " Crashworthiness " Recorders (Also supported by Transportation Disaster Assistance Group)
25 Safety Issues " Cell phone use by train crews " Lack of a positive train control system on the Metrolink rail system. "Performance of the signal system. 25!
26 Metrolink Engineer's Text Messages On-Duty Off-Duty On-Duty 26!
27 27!
28 Signal Aspects from CP Bernson to CP Davis 28!
29 Probable Cause... the failure of the Metrolink engineer to respond to the red signal because he was... text messaging.. Contributing was the lack of a positive train control system... 29!
30 Recommendations " Two to the FRA (The U.S. Congress acted to require Positive Train Control in response to this accident) 30!
31 Motorcoach Overturn Mexican Hat, Utah January 6, 2008
32 32!
33 Parties to the Investigation " Utah Highway Patrol " Utah Department of Transportation " Federal Motor Carrier Safety Administration " Motor Coach Industries " Busco, Inc. (dba Arrow Stage Lines) " San Juan County, Utah 33!
34 Investigative Groups "Survival Factors "Motor Carriers "Human Performance "Vehicle Factors / Vehicle Performance "Highway Factors "Vehicle Recorders "Biomechanics & Medical "Material Failure Analysis "Transportation Disaster Assistance 34!
35 Safety Issues " Driver fatigue and excessive speed " Hours-of-service violations and motor carrier trip planning " Motorcoach occupant protection " Emergency medical notification and response with regard to large buses traveling on rural roads 35!
36 DriveCam II System " Forward view " Audio " Forward/lateral acceleration " Interior view 36! "No hands, steering wheel "20 seconds (10 before crash)
37 Vehicle Speed Video forward view Plotted position 37!
38 Emergency Response - Ejections - Not ejected - Ejected 38!
39 LDS Hospital (360 miles) University Hospital and Primary ChildrenÕ s Hospital (360 miles) Allen Memorial Hospital (117 miles) San Juan Hospital (75 St.miles) MaryÕ s Hospital (169 miles) Blanding Family Practice (43 miles) Accident Location Sage Memorial Hospital (120 miles) Flagstaff Medical Center (190 miles) San Juan Regional MC (130 miles) Chinle Healthcare Facility (115 miles) Kayenta Medical Clinic (45 miles) Banner Good Samaritan Hospital (340 miles)
40 Probable Cause.. Driver s diminished alertness due to inadequate sleep.. excessive speed on downhill mountain grade.. Contributing to severity was the lack of... motorcoach occupant protection.. 40!
41 Safety Recommendations " To the Federal Interagency Committee on EMS " To Utah Bureau of EMS " To Federal Highway Admin. " To AASHTO " To American Bus Association & Arrow Stage Lines 41!
42 Colgan Air Flight 3407 Clarence Center, NY Board Meeting DCA09MA027 February 12, 2009
43 43!
44 Parties to the Investigation " Federal Aviation Administration " Colgan Air, Inc. " Air Line Pilots Association " National Air Traffic Controllers Association " United Steelworkers Union Attendants) (Flight 44!
45 Investigative Groups " Operations " Air Traffic Control " Meteorology " Aircraft Structures " Aircraft Systems " Flight Recorders (FDR & CVR) " Aircraft Performance " Human Performance " Maintenance Records 45!
46 Accredited Representatives " Transportation Safety Board Canada "Transport Canada "Bombardier "Pratt & Whitney Canada " Air Accidents Investigation Branch United Kingdom "Dowty Propellers 46!
47 History of Flight " Snow and light-to-moderate icing expected en route " Captain set reference speeds switch for icing conditions. " Speed slowed, triggering stick shaker and stick pusher. " Pilot fought stick pusher airplane stalled and crashed. 47!
48 48!
49 Cues of Slowing Airspeed Airspeed information on primary flight displays " Pilots must ensure airspeed remains above low-speed cue Airspeed Display Trend arrow Indicated airspeed Low-speed cue 49!
50 Probable Cause " Captain s inappropriate response to.. stick shaker.. led to aerodynamic stall... " Contributing: "Failure to monitor air speed.. "Failure to adhere to sterile cockpit rules.. 50!
51 Recommendations " 25 recommendations to the FAA " Reiterated 3 additional recommendations previously made to the FAA 51!
52 Improving Transportation Safety Through Accident Investigation
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