06_境外及港澳台调查报告_part11.md

06_境外及港澳台调查报告 · 整合分片 part11

本片含 51 份报告。

FD07309 ｜ 2005_美国_NTSB_HAR0701_Motorcoach_Fire_on_Interstate_45_During_Hurricane_Rita_Evacu.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2005 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

highway Motorcoach Fire on Interstate 45 During Hurricane Rita Evacuation Near Wilmer, Texas September 23, 2005 ACCIDENT REPORT NTSB/HAR-07/01 PB2007-916202 National Transportation Safety Board

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Highway Accident Report Motorcoach Fire on Interstate 45 During Hurricane Rita Evacuation Near Wilmer, Texas September 23, 2005 NTSB/HAR-07/01 PB2007-916202 National Transportation Safety Board Notation 7774C 490 L’Enfant Plaza, S.W. Adopted February 21, 2007 Washington, D.C. 20594

National Transportation Safety Board. 2007. Motorcoach Fire on Interstate 45 During Hurricane Rita Evacuation Near Wilmer, Texas, September 23, 2005. Highway Accident Report NTSB/HAR-07/01. Washington, DC. Abstract: On September 23, 2005, a 1998 Motor Coach Industries, Inc. (MCI), 54-passenger motorcoach, operated by Global Limo Inc., of Pharr, Texas, was traveling northbound on Interstate 45 (I-45) near Wilmer, Texas. The motorcoach, en route from Bellaire to Dallas, Texas, as part of the evacuation in anticipation of Hurricane Rita, was carrying 44 assisted living facility residents and nursing staff. The trip had begun about 3:00 p.m. on September 22. Fifteen hours later, about 6:00 a.m. on the following day, a motorist noticed that the right-rear tire hub was glowing red and alerted the motorcoach driver, who stopped in the left traffic lane and then proceeded to the right shoulder of I-45 near milepost 269.5. The driver and nursing staff exited the motorcoach and observed flames emanating from the right-rear wheel well. As they initiated an evacuation of the motorcoach, with assistance from passersby, heavy smoke and fire quickly engulfed the entire vehicle. Twenty-three passengers were fatally injured. Of the 21 passengers who escaped, 2 were seriously injured and 19 received minor injuries; the motorcoach driver also received minor injuries. Major safety issues identified in this investigation include vehicle fire reporting and inconsistent data within Federal accident databases, the ineffective compliance review program of the Federal Motor Carrier Safety Administration (FMCSA), emergency egress from motorcoaches, fire resistance of motorcoach materials and designs, manufacturer maintenance information on wheel bearing components, transportation of partially pressurized aluminum cylinders, and emergency transportation of persons with special needs. As a result of this accident investigation, the Safety Board makes recommendations to the FMCSA, the National Highway Traffic Safety Administration, the Pipeline and Hazardous Materials Safety Administration, the Fraternal Order of Police, the International Association of Chiefs of Police, the International Association of Fire Chiefs, the International Association of Fire Fighters, the National Association of State EMS Officials, the National Sheriffs’ Association, the National Volunteer Fire Council, MCI and other motorcoach manufacturers, the United Motorcoach Association, and the American Bus Association. The Safety Board reiterates two recommendations to the U.S. Department of Transportation. The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Web at http://www.ntsb.gov. Other information about available publications also may be obtained from the Web site or by contacting: National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (800) 877-6799 or (202) 314-6551 Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2007-916202 from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605-6000

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

iii Highway Accident Report Contents Acronyms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Preaccident Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Accident Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Motorcoach Evacuation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Driver Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Certification and Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Duty Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Vehicle Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Tag Axle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Vehicle Ownership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Vehicle Fires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Motorcoach Fire Data Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Volpe National Transportation Systems Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Tire Fires and Fire Suppression Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Highway Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Traffic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Operations Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Global Limo Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Federal Motor Carrier Safety Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Nursing Home Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Bus Brokers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Oxygen Cylinders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Toxicological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Other Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Commercial Vehicle Inspections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Motorcoach Tire Fire Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Federal Railroad Administration Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Motorcoach Fires and Research Studies in Germany and Finland . . . . . . . . . . . . . . . . 41 DOT Evacuation Research Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Federal Motor Vehicle Safety Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Emergency Evacuation of Persons With Special Needs . . . . . . . . . . . . . . . . . . . . . . . . . 44 Federal Evaluation of Catastrophic Hurricane Evacuation Plan . . . . . . . . . . . . . . . . . . 47 GAO Report on Disaster Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Lessons Learned From Federal Response to Hurricane Katrina . . . . . . . . . . . . . . . . . . 49

Contents iv Highway Accident Report Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Accident Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Heat Source and Fire Ignition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Motorcoach and Bus Fire Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Fire Propagation Into Fuel Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Fire Propagation Into Passenger Compartment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Tire Fires and Fire Suppression Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Vehicle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Bus Brokers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Federal Motor Carrier Safety Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Survival . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Motorcoach Emergency Egress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Evacuation Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Emergency Exit Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Oxygen Cylinders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Emergency Evacuation of Persons With Special Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 New Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Reiterated Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Appendixes A: Investigation and Public Hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 B: Global Limo Inc. Federal Motor Carrier Safety      Administration Compliance Reviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 C: Federal Motor Carrier Safety Administration Safety Program . . . . . . . . . . 117 D: Excerpts From Federal Motor Carrier Safety Regulations . . . . . . . . . . . . . 119 E: Excerpts From Federal Railroad Administration Testimony . . . . . . . . . . . . 128 F: Emergency Evacuation of Special Needs Populations: Major      Federal Studies Since Hurricanes Katrina and Rita . . . . . . . . . . . . . . . . . . . . . 131

v Highway Accident Report Acronyms and Abbreviations AASHTO American Association of State Highway and Transportation Officials ABS antilock brake system ADA Americans With Disabilities Act ANSI American National Standards Institute ASTM American Society for Testing and Materials CAPRI Compliance Analysis and Performance Review Information System CDL commercial driver’s license CFR Code of Federal Regulations CGA Compressed Gas Association CMS Centers for Medicare and Medicaid Services (HHS) CSA Comprehensive Safety Analysis 2010 Initiative CUSA Coach USA, LLC CVSA Commercial Vehicle Safety Alliance DDEC Detroit Diesel Electronic Controls DHS U.S. Department of Homeland Security DOT U.S. Department of Transportation DVIR driver vehicle inspection report ECM electronic control module EMS emergency medical services ESF emergency support function (NRP) F Fahrenheit FAA Federal Aviation Administration FARS Fatality Analysis Reporting System (NHTSA) FEMA Federal Emergency Management Agency FHWA Federal Highway Administration FM Farm-to-Market FMCSA Federal Motor Carrier Safety Administration FMCSRs Federal Motor Carrier Safety Regulations FMVSS Federal Motor Vehicle Safety Standard FOP Fraternal Order of Police FR Federal Register FRA Federal Railroad Administration GAO U.S. Government Accountability Office

Acronyms and Abbreviations vi Highway Accident Report GES General Estimates System (NHTSA) HHS U.S. Department of Health and Human Services HM hazardous materials HMR Hazardous Materials Regulations HVAC heating, ventilating, and air conditioning I-45 Interstate 45 IACP International Association of Chiefs of Police IAFC International Association of Fire Chiefs IAFF International Association of Fire Fighters ISS inspection selection system MCI Motor Coach Industries, Inc. MCMIS Motor Carrier Management Information System (FMCSA) MCT MCT Charter Tours MP milepost NASEMSO National Association of State EMS Officials NDMS National Disaster Medical System NFIRS National Fire Incident Reporting System (NFPA) NFPA National Fire Protection Association NHTSA National Highway Traffic Safety Administration NIST National Institute of Standards and Technology NPRM Notice of Proposed Rulemaking NRP National Response Plan NSA National Sheriffs’ Association NVFC National Volunteer Fire Council OOS out-of-service PHMSA Pipeline and Hazardous Materials Safety Administration psig pounds per square inch gage PVC polyvinyl chloride SafeStat Safety Status Measurement System (FMCSA) SAFETEA-LU Safe, Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for Users SEA safety evaluation area (FMCSA) TBPC Texas Building and Procurement Commission TxDOT Texas Department of Transportation TxDPS Texas Department of Public Safety UL Underwriters Laboratories Inc. VIN vehicle identification number

vii Highway Accident Report Executive Summary On September 23, 2005, a 1998 Motor Coach Industries, Inc. (MCI), 54-passenger motorcoach, operated by Global Limo Inc., of Pharr, Texas, was traveling northbound on Interstate 45 (I-45) near Wilmer, Texas. The motorcoach, en route from Bellaire to Dallas, Texas, as part of the evacuation in anticipation of Hurricane Rita, was carrying 44 assisted living facility residents and nursing staff. The trip had begun about 3:00 p.m. on September 22. Fifteen hours later, about 6:00 a.m. on the following day, a motorist noticed that the right-rear tire hub was glowing red and alerted the motorcoach driver, who stopped in the left traffic lane and then proceeded to the right shoulder of I-45 near milepost 269.5. The driver and nursing staff exited the motorcoach and observed flames emanating from the right-rear wheel well. As they initiated an evacuation of the motorcoach, with assistance from passersby, heavy smoke and fire quickly engulfed the entire vehicle. Twenty-three passengers were fatally injured. Of the 21 passengers who escaped, 2 were seriously injured and 19 received minor injuries; the motorcoach driver also received minor injuries. The National Transportation Safety Board determines that the probable cause of the accident was insufficient lubrication in the right-side tag axle wheel bearing assembly of the motorcoach, resulting in increased temperatures and subsequent failed wheel bearings, which led to ignition of the tire and the catastrophic fire. Global Limo Inc. had failed to conduct proper vehicle maintenance, to do pretrip inspections, and to complete posttrip driver vehicle inspection reports, thereby allowing the insufficient wheel bearing lubrication to go undetected. Contributing to the accident was the Federal Motor Carrier Safety Administration’s ineffective compliance review system, which resulted in inadequate safety oversight of passenger motor carriers. Contributing to the rapid propagation and severity of the fire and subsequent loss of life was the lack of motorcoach fire-retardant construction materials adjacent to the wheel well. Also contributing to the severity of the accident was the limited ability of passengers with special needs to evacuate the motorcoach. The following safety issues were identified in this investigation: • Vehicle fire reporting and inconsistent data within Federal accident databases, • Federal Motor Carrier Safety Administration’s ineffective compliance review program, • Emergency egress from motorcoaches, • Fire resistance of motorcoach materials and designs, • Manufacturer maintenance information on wheel bearing components, • Transportation of partially pressurized aluminum cylinders, and • Emergency transportation of persons with special needs.

viii Highway Accident Report As a result of this accident investigation, the Safety Board makes recommendations to the Federal Motor Carrier Safety Administration, the National Highway Traffic Safety Administration, the Pipeline and Hazardous Materials Safety Administration, the Fraternal Order of Police, the International Association of Chiefs of Police, the International Association of Fire Chiefs, the International Association of Fire Fighters, the National Association of State EMS Officials, the National Sheriffs’ Association, the National Volunteer Fire Council, Motor Coach Industries, Inc., and other motorcoach manufacturers, the United Motorcoach Association, and the American Bus Association. The Safety Board reiterates two recommendations to the U.S. Department of Transportation. Executive Summary

1 Highway Accident Report Factual Information Preaccident Events On September 20, 2005, the Governor of Texas issued a proclamation of an imminent hurricane threat and urged residents living in coastal areas to evacuate prior to landfall by Hurricane Rita.1 On September 21, the mayor of Galveston, Texas, issued a mandatory evacuation order for the coastal city and surrounding areas. Also on that day, staff at the Brighton Gardens of Bellaire (Brighton Gardens) senior assisted living center, located in a Houston suburb approximately 50 miles inland from Galveston (and within the projected path of the hurricane), began the process of evacuating residents to two facilities in Dallas and Arlington, Texas. Brighton Gardens was operated by Sunrise Senior Living Services, Inc. (Sunrise), headquartered in McLean, Virginia. Sunrise contacted the BusBank2 and negotiated a contract to transport residents from Bellaire to Dallas, an expected 4-hour trip, beginning about 9:00 a.m. on September 22.3 The BusBank contracted with Global Limo Inc. (Global) to provide two motorcoaches4 for evacuation of the Brighton Gardens residents and nursing staff. On September 22, the President of the United States issued a Declaration of Emergency for the State of Texas because Hurricane Rita was expected to make landfall near Galveston on September 24. Accident Narrative On September 22, 2005, the accident motorcoach driver departed Pharr, Texas, about 5:00 a.m., drove approximately 360 miles, and arrived at Brighton Gardens in Bellaire about 11:00 a.m. While Brighton Gardens staff prepared residents for the evacuation, the driver napped in the vehicle for about 2 hours. About 1:30 p.m., 37 assisted living facility residents, 6 nursing staff, and 1 staff parent were loaded into the motorcoach. Firefighters assisted in boarding passengers with special needs, a process that 1  Hurricane Rita was one of the strongest storms on record for the Atlantic Basin. By the afternoon of September 21, 2005, Rita had reached category 5 strength on the Saffir–Simpson scale, with winds of 165 mph. The storm brought hurricane-strength winds more than 150 miles inland and caused significant damage along the coast. Rita made landfall along the Texas–Louisiana border early on September 24 as a category 3 storm with sustained winds of 120 mph. See , November 8, 2006. 2  According to the BusBank website, the company is a “group and event transportation specialist.” See , September 20, 2006. 3  Unless otherwise indicated, all times in this report are central daylight time. 4  The contract requested two motorcoaches. The second motorcoach, transporting 16 ambulatory passengers, departed Brighton Gardens about 6:00 p.m. on September 22, 2005. It arrived at its destination about 9:30 a.m. on the following day.

Factual Information 2 Highway Accident Report took 1.5 to 2 hours. In addition, Brighton Gardens staff loaded 22 wheelchairs, 5 walkers, and 18 medical oxygen cylinders5 into the luggage compartments. According to the 37-year-old motorcoach driver, he departed Brighton Gardens between 3:00 and 3:30 p.m. When he attempted to head north on Interstate 45 (I-45), he found it to be closed. Alternatively, he traveled east on Interstate 610 to U.S. Route 59 north, then headed west on State Highway 105. About 4:00 p.m., the nursing staff asked the driver to pull over so they could retrieve two full oxygen cylinders for the passengers who needed oxygen. The driver stated that the vehicle entered I-45 about 7:00 p.m. and exited at Huntsville, Texas, to refuel. Ten minutes after returning to the interstate, the driver was asked by the nursing staff to pull over so they could retrieve an additional four full oxygen cylinders; the driver then continued north on I-45. (See figure 1.) On September 23, the accident motorcoach was still traveling north on I-45 about 3:15 a.m. when, just prior to the Farm-to-Market (FM) 1126 overpass, near exit 239, the right-side tag axle wheel locked and began to produce 1,500 feet of dragging tire marks on the roadway. The driver said that he then heard the right-rear tire blow out, and he pulled off the roadway near the FM 1126 entrance ramp, which was about 400 feet from the location of the tire blowout. The driver exited the motorcoach and checked the tire. He saw that the right tag axle tire was flat, returned to the vehicle, and continued driving north to try and find a suitable location to pull off for a tire change. The driver operated the vehicle a total of 6,800 feet from the initial tire lockup to the location where he pulled over on the right shoulder, partially blocking the right lane and impeding traffic. The Navarro County Sheriff’s Office received a cellular telephone call at 3:22 a.m. from a nurse passenger, who reported the flat tire and requested assistance. A Rice Police Department officer was dispatched; a tow truck mechanic was delayed 1 hour because of heavy evacuation-related traffic. By 4:30 a.m., the towing service arrived on scene. The mechanic removed the flat tire and replaced it with the spare, estimating that the entire tire change took less than 5 minutes; the motorcoach driver had already placed the spare tire next to the flat tire, and he subsequently placed the flat tire in the spare compartment. Once the tire was changed, the Rice police officer advised the driver and the mechanic to drive their vehicles to the next exit to complete payment. About 4:40 a.m., just off exit 242, the nursing supervisor paid the service repair bill. According to the mechanic, he was unaware of the long tire marks leading to the location where he replaced the flat tire. He also reported that he did not see anything unusual about the tire and wheel and that he and the driver did not have any discussion regarding the vehicle while he was changing the tire. The motorcoach driver reentered I-45 about 5:00 a.m. and continued north. Less than 1 hour later, about 2,100 feet south of the Mars Road exit, a motorist also traveling north on I-45 noticed that the right-rear wheel of the motorcoach was glowing red hot, with sparks emanating from the wheel. The motorcoach was traveling in the left lane. The motorist maneuvered his vehicle in front of the motorcoach and slowed down until the motorcoach came to a stop. He exited his vehicle and approached the driver’s window to tell him that the right-rear wheel was glowing orange-red. The motorist later told Safety 5  Because two residents required medical oxygen, two of the cylinders were loaded into the seating area.

Figure 1. Regional map and accident motorcoach evacuation route. N Not to scale Wilmer Rice (tire change) Bellaire (starting point) Conroe 45 59 610 Houston Dallas MP 269.5 (accident location) Dallas Houston 45 TEXAS Factual Information 3 Highway Accident Report

Factual Information 4 Highway Accident Report Board investigators that he was unsure whether the motorcoach driver understood him because the driver never responded verbally. The motorist then returned to his vehicle and drove away. The supervising nurse reported hearing the motorist approach the motorcoach driver and report a problem with the right-rear wheel. The driver began to move the motorcoach across the crowded lanes of travel and pulled off onto the right shoulder north of the Mars Road exit, at milepost (MP) 269.5. (See figure 2.) Figure 2. Accident scene diagram. N 32-inch concrete barrier Gouge marks End of tire marks Motorcoach Burned area Beginning of tire marks Motorcoach stopped by motorist Mars Road Exit 269 MP 269.5 400' 200' 100' 300' 500' Scale 0'

Factual Information 5 Highway Accident Report The driver, nurse supervisor, and another nurse exited the motorcoach and observed the right-rear wheel well on fire. As the driver began trying to extinguish the flames with his shirt and by throwing dirt and grass, the nurses immediately went back into the vehicle and urged the passengers to quickly exit. As the nursing staff was evacuating the nonambulatory passengers, the driver had reentered the motorcoach and attempted to unlatch the fire extinguisher from its bracket under the right (passenger)-side second row seat. He was unable to unlatch it and reported opening a roof hatch vent instead; he tried opening a few windows on the driver’s side but said that they would not stay open. About 6:07 a.m., Dallas County and the city of Wilmer dispatchers received a 911 call reporting the fire. Two Wilmer Police Department officers had arrived on scene by 6:12 a.m., and one officer, along with motorists who had stopped to help, entered the motorcoach to help the nonambulatory passengers evacuate. Witnesses interviewed by the Safety Board reported trying unsuccessfully to pry open the motorcoach windows from outside; two passersby broke the glass in two windows, but they were unable to rescue anyone through the broken windows. (See figure 3.) Figure 3. Damaged motorcoach on I-45 following fire. At the time of the accident, local media were in the vicinity filming the heavy interstate traffic. In addition to a photograph provided by a witness (see figure 4), KTVT television, a CBS affiliate in Dallas–Fort Worth, provided the Safety Board with a video of the motorcoach fire, with elapsed time recorded in the upper left corner of the images. The Safety Board constructed the following sequence of events from the images: • About 6:08 a.m., approximately 3 minutes after the motorcoach pulled onto the right shoulder of I-45 (the 911 call was placed at 6:07 a.m.), fire is visible from the rear on the right side of the vehicle. (See figure 5.)

Factual Information 6 Highway Accident Report • Less than 15 seconds later, the entire rear of the vehicle is engulfed in flames. • An intense burst of fire is visible about 3 minutes later. (See figure 6.) • By 6:15 a.m., 6.5 minutes into the video, the motorcoach is almost completely engulfed in flames. (See figure 7.) Figure 4. Motorcoach tire on fire, witness photo from I-45 frontage road. (Courtesy of Dallas County Sheriff’s Office) Figure 5. Video image 1 of accident motorcoach. (Courtesy of KTVT, Dallas–Fort Worth)

Figure 6. Video image 2 of accident motorcoach. (Courtesy of KTVT, Dallas–Fort Worth) Figure 7. Video image 3 of accident motorcoach. (Courtesy of KTVT, Dallas–Fort Worth) Factual Information 7 Highway Accident Report

Factual Information 8 Highway Accident Report Emergency Response The second Wilmer police officer who had arrived on scene about 6:12 a.m. began to direct traffic away from the burning vehicle. By 6:15 a.m., two deputies from the Dallas County Sheriff’s Office arrived on scene; fire within the motorcoach prevented them from entering the vehicle to assist in the passenger evacuation. The Wilmer and Hutchins Fire Departments arrived on scene from opposite directions by 6:24 a.m. and reported that the motorcoach was completely engulfed in flames. Thirteen local emergency service agencies responded to the fire, along with nine ambulances from four agencies and a private ambulance service. A grass fire had occurred approximately 3.2 miles south (near exit 266) of the site of the motorcoach fire, in the median between the northbound and southbound lanes. This fire was reported to the Ferris Volunteer Fire Department at 6:04 a.m., approximately 3 minutes prior to the 911 call reporting the motorcoach fire. The Safety Board examined the location of the grass fire and recovered two metal objects similar in appearance to objects removed from the accident motorcoach tag axle wheel and hub assembly during a Safety Board postaccident inspection.6 The Safety Board interviewed several of the first responders and dispatchers, who reported some delays in emergency response to the motorcoach fire. Interviewees stated: the initial 911 calls reported the vehicle fire location north of the actual accident site; hurricane evacuation traffic was extremely congested; the Wilmer Fire Department was staffed with only two firefighter/emergency medical technician personnel at night; and the Wilmer dispatch office had only one dispatcher on duty, who handled all incoming and outgoing emergency calls, including the dispatching of personnel and equipment. Subsequently, on March 15, 2006, the city of Wilmer dispatch office installed two four- channel CD loggers with digital voice recorders to handle 911 calls. Injuries Twenty-three passengers died in the motorcoach fire. According to medical examiner autopsy reports from the Southwestern Institute of Forensic Sciences in Dallas, Texas, the causes of death were smoke inhalation and thermal injuries. Six nursing staff personnel, 1 parent of a nursing staff member, and 14 passengers escaped. Of these survivors, 2 passengers were seriously7 injured, and 19, along with the driver, sustained minor injuries. The driver and 14 passengers were transported to two local hospitals for treatment of smoke inhalation, an arm fracture, minor lacerations, contusions, and burns. (See table 1.) 6  These objects were examined by the Safety Board metallurgy laboratory and determined to be rollers from the accident motorcoach right-side tag axle outer wheel bearing. 7  One passenger sustained a right arm fracture, and one passenger was hospitalized with a second- degree facial burn and smoke inhalation injury.

Factual Information 9 Highway Accident Report Table 1. Injuries. Motorcoach Evacuation Most of the 37 patient-passengers had moderate-to-severe mobility or cognitive impairments8 and were not able to evacuate during the fire without assistance. Twenty- two passengers had occupied nursing facility beds at Brighton Gardens, at least 13 of who did not walk at all, and 5 required extensive assistance to walk; 7 of these passengers had “moderately impaired” decision-making skills.9 Of the 15 passengers who had not occupied nursing facility beds, 9 required a walker or wheelchair for ambulation, and 4 were diagnosed or described as having dementia, forgetfulness, or hysteria. According to the nursing staff on board the motorcoach, many of the passengers refused to evacuate, did not understand the urgency of escaping the approaching fire, or actively fought efforts to physically move them from the motorcoach. Of the 14 passengers who evacuated, many had to be pulled, pushed, or dragged out the front loading door by nurses or rescuers. The 23 passengers who died in the fire ranged from 68 to 100 years old. Eighteen individuals were found still seated, and 5 were found in the center aisle. One of these passengers had reportedly been seated in row 10 and was found near the front of the motorcoach in the aisle adjacent to row 1. (See figure 8.10) InjuryA Motorcoach driver Motorcoach passengers Staff and parent Total Fatal 0 23 0 23 Serious 0 2 0 2 Minor 1 12 7 20 None 0 0 0 0 Total 1 37 7 45 ATitle 49 Code of Federal Regulations (CFR) 830.2 defines fatal injury as any injury that results in death within 30 days of the accident. It defines serious injury as an injury that requires hospitalization for more than 48 hours, commencing within 7 days of the date of injury; results in a fracture of any bone (except simple fractures of fingers, toes, or nose); causes severe hemorrhages, or nerve, muscle, or tendon damage; involves any internal organ; or involves second- or third-degree burns, or any burn affecting more than 5 percent of the body surface. 8 Based on State and federally required Minimum Data Set reports and State-required Individual Service Plans. 9 These patients required reminders, cues, and supervision in decision-making. 10 The seating chart shown in figure 8 is based on interviews with nursing staff and patients; it may not depict the exact seating locations immediately prior to the fire.

Figure 8. Passenger seating chart and postfire injury information. M - 78 : Minor M - 76 : Minor F - 81 : Minor M - 81 : Serious F - 94 : Fatal *F - 59 : Minor **F - 79 : Minor *F - 50 : Minor F - 87 : Fatal M - 78 : Minor *F - 57 : Minor F - 84 : Minor F - 87 : Minor F - 93 : Fatal F - 100 : Fatal F - 85 : Fatal F - 92 : Fatal *F - 42 : Minor F - 84 : Minor M - 37 : Minor F - 77 : Fatal F - 91 : Fatal F - 80 : Fatal *F - 51 : Minor *F - 55 : Minor F - 84 : Fatal F - 79 : Fatal M - 86 : Fatal F - 89 : Fatal M - 89 : Fatal SAMPLE F = FEMALE M = MALE # = AGE +International Civil Aviation Organization +INJURY LEVEL AGE GENDER F - 14 : Minor Source: NTSB F - 79 : Fatal F - 91 : Fatal F - 92 : Fatal F - 78 : Minor M - 93 : Minor M - 90 : Fatal M - 79 : Fatal M - 74 : Fatal M - 78 : Fatal M - 68 : Minor F - 68 : Fatal F - 84 : Serious M - 92 : Fatal F - 87 : Minor F - 99 : Minor 3 1 2 4 5 6 7 8 9 10 11 12 13 14

• Indicates Nursing Staff

** Indicates Nursing Staff Parent Factual Information 10 Highway Accident Report

Factual Information 11 Highway Accident Report The Safety Board interviewed the nursing staff regarding evacuation of the motorcoach. The nursing supervisor reported that when she informed the staff they needed to get the passengers off the motorcoach, she and other nursing team members and even bystanders began assisting passengers. She did not recall anyone opening windows during the evacuation, and other nursing staff reported not being able to open the side windows because they could not see the latches. The nursing staff reported that the flames began entering the motorcoach through the last window on the right side and spread to the newspapers that had been placed on the windows to help shade the interior during the day. Several of the passengers who were able to walk and understood the need to evacuate waited at the front loading door for assistance down the steps. The Safety Board also interviewed emergency responders and passersby who stopped to aid in the rescue of passengers. The interviewees explained that almost as soon as they observed the fire in the wheel well of the motorcoach and pulled over to assist, thick black smoke began to accumulate inside the vehicle and could be seen coming out the front door. The Wilmer Police Department received notification of the fire at 6:08 a.m. An officer arrived on scene within 1–2 minutes and observed flames already past the wheel well area and moving up the side of the motorcoach, smoke pouring out the front door, and the rear windows covered by flames and smoke. He assisted in evacuating one person seated in the first row and then assisted in evacuating several more, by which time smoke was present from the ceiling to the floor level, and fire debris was falling from the ceiling. A passerby explained that when he and a coworker stopped to help, the smoke made him sick after one rescue attempt inside the motorcoach, and he instead tried to reach inside through an open window to pull out a passenger. His coworker stated that he was able to rescue two passengers but then had to stop because the smoke was too thick to reenter the motorcoach, and he instead tried to open a window. Another passerby stated that he had made up to four trips into the front of the motorcoach to assist passengers in evacuating, but then it became too smoky to proceed beyond the first several rows of seats, and he had to crawl back to the front door to escape. A fourth passerby stated that he pulled over to assist at the same time as the police officer, but he moved only about 10 feet into the motorcoach before he had to retreat because of the smoke. The interviewees reported hearing several “explosions” from the rear of the motorcoach and then ceased rescue attempts. Damage The body panels below the side windows and above and below the floor line of the accident motorcoach were constructed of fiberglass-reinforced plastic,11 except for the painted aluminum baggage door panels. The fire destroyed the majority of the fiberglass 11  Motor Coach Industries, Inc., MCI 102E Series Maintenance Manual (Schaumburg, IL: MCI, 1997) 3A-1.

Factual Information 12 Highway Accident Report body; the chassis steel frame, rear engine compartment, and aluminum cargo compartment doors were intact. Only the tubular frame structure remained from the base of the windows upward toward the roof. Two fiberglass-covered access panels were located under the motorcoach in the wheel well area. The rearmost cover panel was consumed by fire, and the forward cover was charred. Fire consumed the flexible thermoplastic fuel line tubing from the engine compartment to less than 1 foot from the fuel tank, in addition to most of the combustible materials12 in the wheel well area. The windshield and all side window glass were missing. According to witness statements, the windshield right pane and several windows along both sides of the motorcoach were broken out by some of the bystanders who assisted in the evacuation effort. The interior of the motorcoach was destroyed by fire. The fire consumed all nonsteel seating materials and combustible component sections, in addition to the plywood and vinyl center aisle flooring in the rear of the compartment above the service tunnel. The heating, ventilating, and air conditioning (HVAC) system was largely destroyed by fire. The recirculation duct in the right-rear wheel area was missing, and sections of the aluminum return ducts were destroyed and missing; adjoining parts showed signs of severe heat exposure. The missing sections had been located above the wheel well areas on both sides of the coach. Driver Information Certification and Experience The 37-year-old motorcoach driver held a country of Mexico licencia Federal de Conductor (commercial driver’s license [CDL]) permitting him to transport passengers in Mexico.13 The driver’s license was issued on September 2, 1998, with an expiration date of September 2, 2006.14 The driver had first received a Mexican CDL on September 2, 1988. During an interview with the Safety Board, the driver said, through an interpreter, that he began working for his family’s motorcoach service in Mexico as a mechanic helper. He eventually began driving motorcoaches on trips within Mexico and between Mexico and the United States. The driver had begun his recent employment with Global in February 2005.15 12  These items included six tires, six air bags used for load leveling, mud flaps, six bump stops, and bushings on the stabilizer bar and torque rods. 13  This endorsement is similar to the U.S. CDL class “B” passenger endorsement. 14  The Mexican CDL is issued for 10 years; the driver is required to renew the license and provide a valid medical certificate every 2 years during that period. The accident driver’s license was issued in 1998; it showed an embossed “04,” indicating that the license required the 2-year renewal by September 2, 2006. The plastic license packet is embossed over the appropriate expiration year to certify that the license is valid. 15  Previous to his current employment, the driver had worked for Global temporarily from February 2002–August 2003.

Factual Information 13 Highway Accident Report The back of the Mexican license contains an area for the driver to respond with a “yes” or “no” for diabetes, hypertension, and corrective lenses. The driver had indicated negative responses on his license; when interviewed by the Safety Board,16 he stated that he did have type 2 diabetes.17 The driver reported that he had been under the care of a doctor in Monterrey, Nuevo Leon, and that his wife picked up his oral diabetes prescription in Mexico. During a postaccident examination of the motorcoach contents, an opened container of metformin tablets was found in the driver’s belongings.18 On March 7, 2005, Global had referred the driver to a physician in the United States for a U.S. Department of Transportation (DOT) medical examination. The examining physician refused to issue a U.S. medical certificate because the driver had been diagnosed with type 2 diabetes in 1998. The physician wrote on the medical examination form that the driver “needs to show proof of diabetic control” before he could be certified fit for duty. He then issued the driver a prescription for diabetes medical testing. The accident driver did not report for the medical tests. According to the Dallas County Sheriff’s Office, in an accident supplemental report dated October 5, 2005, the motorcoach driver did not possess a Texas driver’s license. The driver had been living in Pharr, Texas, since February 2005, 7 months prior to the date of the accident. According to Texas Transportation Code 521.029, a new resident moving into Texas, who has a valid CDL from his home State or country, has 30 days after entry to secure a Texas CDL. Applicants must visit a local Texas Driver License Office and present proof of identity, social security number, and vehicle registration and liability insurance, if applicable; submit the required forms and fee; pass the vision exam; and surrender the valid out-of-State license (CDL).19 According to the Federal Motor Carrier Safety Administration (FMCSA), CDLs issued by the United Mexican States meet established U.S. standards, and all Mexican drivers operating in the United States must have an appropriate license from their country.20 On September 23 and 25, 2005, and April 5, 2006, the Safety Board conducted three interviews with the accident motorcoach driver using Spanish–English interpreters provided by the Texas Department of Public Safety (TxDPS), because the driver was unable to converse in English.21 16  This interview took place on September 25, 2005, in Dallas, Texas. The Safety Board did not obtain copies of the driver’s medical records from Mexico to verify his statements regarding medical care. 17  According to 49 CFR 391.41(b)(3), a person is physically qualified to drive a commercial motor vehicle if he or she has no established medical history or clinical diagnosis of diabetes mellitus that requires insulin. 18  Metformin, an oral antidiabetic medication, is sold in Mexico as metformina. 19  See , December 11, 2006. 20  See , January 16, 2007. 21  A nursing staff member spoke limited Spanish and was able to communicate with the driver.

Factual Information 14 Highway Accident Report Prior to the accident, on February 12, 2005, the driver had been pulled over for a roadside inspection while driving a commercial vehicle (motorcoach) on Interstate 10 in Harris County, Texas. The inspector noted (as a discrepancy) on the roadside inspection report that the driver was non-English-speaking.22 Title 49 CFR 391.11(b) defines the qualifications for commercial vehicle drivers, specifying the requirement that the driver “can read and speak the English language sufficiently to converse with the general public, to understand highway traffic signs and signals in the English language, to respond to official inquires, and to make entries on reports and records.” Duty Status The following information was provided to the Safety Board by the motorcoach driver during three postaccident interviews. The driver awoke about 8:00 a.m. on September 21 and reported for work at 9:30 a.m. He changed the air conditioning filters on the accident motorcoach and was informed by his employer that he would be on call for a possible Federal Emergency Management Agency (FEMA) transportation charter. The driver said that he went shopping with his wife at 10:30 a.m. and returned home by 2:30 p.m. He was called by his employer at 5:00 p.m. and told to report to Bellaire, Texas, by noon on September 22 for an evacuation charter of elderly persons from a nursing home to Dallas. The driver went to work, fueled the motorcoach, ran an errand, and returned home by 7:30 p.m. He went to bed between 9:30 and 10:00 p.m. On September 22, the driver awoke at 4:30 a.m. and departed Pharr, Texas, about 5:00 a.m. He arrived at Brighton Gardens in Bellaire at 11:00 a.m. The driver then took a 2-hour nap in the motorcoach and awoke when the nursing staff began loading the passengers around 1:30 p.m. The driver departed the nursing home between 3:00 and 3:30 p.m. He continued driving for over 15 hours, in heavy evacuation traffic, until the fire occurred about 6:00 a.m. the following morning. (See figure 9.23) The FMCSA, in 49 CFR 395.5, requires that no motor carrier shall permit or require any driver to drive a passenger-carrying commercial motor vehicle, nor shall any such driver drive a passenger-carrying commercial motor vehicle: (a)(1) more than 10 hours following 8 consecutive hours off duty; or (a)(2) for any period after having been on duty 15 hours following 8 consecutive hours off duty. Title 49 CFR 395.1 guidance states that, under 395.1(b)(2), in case of any emergency, a driver may complete his/her run without being in violation of the provisions of the regulations in this part, if such run reasonably could have been completed absent the emergency. The Governor of Texas issued a proclamation on September 23, 2005, exempting the hours-of-service violations for all carriers and drivers involved in, and caught in, the hurricane evacuation. 22  The FMCSA requires that a discrepancy noted on the inspection report be corrected by the motor carrier within 15 days (49 CFR 396.9(d)). The owner of Global stated to the Safety Board that he did not furnish the FMCSA with documentation of correction to discrepancies noted during roadside inspections, as required. 23  This 72-hour history is based on the three interviews with the accident driver and interviews with Brighton Gardens staff.

Figure 9. Motorcoach driver’s 72-hour history.

DAYLIGHT NIGHT 0600 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000 2100 2200 2300 2400 0100 0200 0300 0400 0500

9/19

9/20

9/21

9/22

9/23

Driving

Sleeping

On Duty/Not Driving

Time of Incident

Factual Information 15 Highway Accident Report Vehicle Information The 1998 54-passenger Motor Coach Industries, Inc. (MCI), model 102EL3 “Renaissance” motorcoach was 45 feet long. It was equipped with a Detroit Diesel Corporation Series 60, 6-cylinder electronically controlled diesel engine and a Detroit Diesel Electronic Controls (DDEC)24 IV electronic control module (ECM). The ECM was damaged by the fire, which destroyed the recorded information. The motorcoach had an Allison Transmission model B-500R automatic transmission. A repair invoice for the motorcoach, dated September 14, 2005—9 days before the accident—showed an odometer reading of 505,608 kilometers25 (313,477 miles). The fire destroyed the odometer. The motorcoach was equipped with three ArvinMeritor-manufactured axles: the front or steering axle, the second or drive axle, and the tag axle. The motorcoach had air brakes at all six wheel positions. The brakes were D-LISA air disc brakes, also manufactured by ArvinMeritor, while the six-channel antilock brake system (ABS) was manufactured by Meritor WABCO. Seven windows were located along each side of the motorcoach. The windows were double-glazed safety glass; the exterior pane was tempered safety glass, and the interior pane was laminated safety glass. Six windows on each side were designed for emergency egress. Interlocking extrusions at the top frame provided hinge action for the

24  The DDEC IV ECM is capable of recording vehicle speed, brake application, engine rpm, and other information for more than 1 minute prior to a final stop of the vehicle. 25  The odometer recorded kilometers because this vehicle was originally built for, and owned by, a Canadian company.

Factual Information 16 Highway Accident Report window sash assembly. The motorcoach was equipped with a 5-pound dry chemical ABC26 fire extinguisher, as required by 49 CFR 393.95.27 The motorcoach fuel tank was located aft of the luggage compartment and forward of the (rear) wheel well area. Two flexible thermoplastic fuel lines served as the supply and return paths from the fuel tank to the engine compartment. The fuel lines were made of Synflex composite fuel tubing, which is a flexible thermoplastic product with a nylon liner. The fuel lines, along with the power steering and coolant lines, ran within a centerline trench located between the left- and right-rear wheel wells, beneath the passenger cabin floor. Each fuel line is a nonreinforced seamless tube, designed and tested for use with noncrimp barbed fittings and rated for use with diesel fuel at a temperature range of –50º to +250º Fahrenheit (F). The motorcoach seats consisted of upholstery-covered, foam-padded backs and cushions over steel seat frames. The floor was 0.5-inch-thick plywood with a 0.1-inch- thick vinyl covering. Overhead luggage racks were constructed of aluminum, acrylonitrile butadiene styrene, and polyvinyl chloride (PVC) extruded handles. The ceiling at the front and rear window areas was fiberglass-reinforced plastic, and the main ceiling was Xorel FR28 over acrylonitrile butadiene styrene. The HVAC system was symmetrical along the centerline of the motorcoach. The return ducts were located at floor level, spanning the length of the vehicle; vent grills drew air into the return ducts. Tag Axle The third axle is mounted to the frame of the motorcoach by means of an adjustable air suspension system. This auxiliary weight-bearing axle is commonly referred to as the tag axle. A hub affixed to both the left and right sides of the outer axle assembly serves as the interface, allowing the wheels to rotate. (See figure 10.) In vehicles equipped with a disc brake rotor, such as the accident motorcoach, the brake rotor is also mounted on the hub. At the Safety Board public hearing on this accident, on August 8–9, 2006, in Washington, D.C. (see appendix A),29 a chief engineer with Timken Company (a bearing manufacturer) explained that a vehicle’s wheel bearings have three functions: to allow rotation with minimum friction (between wheel assembly parts), to carry the vehicle load 26  A class A fire involves ordinary combustibles, such as wood, paper, cloth, rubber, and many plastics; a class B fire involves flammable liquids, oils, greases, tars, oil-based paints, and flammable gases; and a class C fire involves energized electrical equipment. A multipurpose dry chemical ABC fire extinguisher covers these types of fires and works by blanketing the fuel (burning materials) and interrupting the chemical chain reaction at the fuel’s surface. To a lesser extent, it dilutes the oxygen content of the air around the fire and absorbs heat. See , October 23, 2006. 27  A power unit that is not used to transport hazardous materials (HM) must be equipped with either a fire extinguisher having an Underwriters Laboratories Inc. (UL) rating of 5 B:C or greater, or two fire extinguishers, each with a UL rating of 4 B:C or greater. 28  Xorel FR is a fabric woven from polyethylene and treated with a fire retardant. 29  “Motorcoach Accident and Selected Federal Motor Carrier Safety Administration Oversight Issues, Wilmer, Texas.” The Safety Board may hold a public hearing as part of its investigation into an accident to supplement the factual record. Technical experts are called as witnesses to testify, and Board investigative staff and designated representatives from the parties to the investigation ask questions to obtain additional factual information. A hearing is not intended to analyze factual information for cause.

Factual Information 17 Highway Accident Report or transfer the load (the weight of the motorcoach), and to concentrically position and align rotating and stationary components within the hub and wheel assembly. The wheel bearing rollers are evenly spaced and held within a circular wheel bearing cage, both of which are located inside a wheel bearing cup. The inner wheel bearing cup is fixed on the axle spindle (see figure 11), and the outer bearing cup is pressed into the hub. The inner cup remains stationary while the outer cup rotates with the hub and wheel. Figure 10. Simplified hub and wheel diagram. Tire Wheel Hub Figure 11. Hub and wheel bearing diagram. Axle spindle Rotor Oil seal Inner bearing Inner bearing cup Hub Outer bearing cup Outer bearing Hubcap Lockwasher Oil fill plug Gasket

Factual Information 18 Highway Accident Report The accident motorcoach had oil bath bearings; in this type of wheel bearing configuration, the individual bearing components are partially immersed in an oil lubricant (rather than being “packed” with grease) contained in a sealed reservoir within the wheel and hub. Oil is distributed to the bearings and throughout the reservoir cavity only when the vehicle is in motion. This distribution of oil provides both lubrication and cooling to the bearing rollers. A wheel bearing seal keeps the lubricant inside the bearing and the contamination outside. The hubcap,30 the outer component on the axle assembly, contains a sight glass and filler plug and also functions as part of the reservoir for the wheel lubrication fluid. A mechanic or driver uses the sight glass to check the lubrication oil level for the wheel bearings. Oil is added by removing the filler plug. A wheel bearing may fail prematurely as a result of loss of lubrication, contamination of lubricant, improper wheel bearing adjustment, or incorrect adjustment during servicing or installation of new bearings. The most common reason for loss of lubrication is a worn-out or defective wheel seal; other causes may be a defective gasket between the hubcap and hub or a missing or improperly secured filler cap. According to MCI, other than checking oil lubrication levels using the sight glass, oil leaks from wheel seals in the tag axle can be observed only from underneath the motorcoach because the wheel is mounted to the vehicle with its convex center facing outside.31 The MCI maintenance manual for the accident motorcoach specifies that the wheel bearing lubricating oil levels should be checked daily, and oil should be added if it is not visible at the sight glass level mark.32 The manual provides additional instructions for maintenance of wheel bearings, including specific warnings in text boxes to exercise caution when providing vehicle maintenance. (See figure 12.) During a Safety Board interview, the motorcoach driver stated that he knew how wheel bearings were lubricated, though he had never lubricated them himself and had never checked the wheel bearing oil level on any motorcoach. Vehicle Ownership The accident motorcoach was titled (and registered) in British Columbia, Canada, to the owners of R&J McMynn Leasing (McMynn). MCT Charter Tours (MCT), of Beltsville, Maryland, leased the accident motorcoach. According to McMynn, the lessee is responsible for all vehicle repairs and maintenance, and the lease requires maintenance at specific mileage intervals. The lease also prohibits the sublease of the vehicle without authorization. MCT subleased the motorcoach to Global in May 2005; according to McMynn, the company was unaware of the sublease. U.S. Customs documents indicate that the motorcoach entered the United States from Canada near Buffalo, New York, on May 28, 2005. The motorcoach was not registered in the United States at the time of the accident, though registration was required. 30  According to MCI, this model of motorcoach is originally equipped with aluminum hubcaps on the tag axle; on the accident motorcoach, the 3R hubcap was aluminum, and the 3L hubcap was steel. 31  The concave outside wheel mounting is common for steer axles in trucks and motorcoaches and for the tag axle in all motorcoaches. 32  MCI 102E Series Maintenance Manual.

Figure 12. Example of MCI maintenance manual warning text box. Coach wheels weigh more than 200 lbs (90 kg.) To avoid injury, use extreme care when removing them. WARNING Factual Information 19 Highway Accident Report During a Safety Board interview with Global’s owner on September 26, 2005, he stated that he had an insurance card (required) for the accident motorcoach and that it did undergo a commercial vehicle inspection on June 9, 2005, at Valley Volvo in Pharr, Texas. The owner reported that he used a 144-hour temporary permit33 for the motorcoach during its operation in Louisiana in post-Katrina relief efforts, as well as during the Brighton Gardens evacuation trip from Bellaire to Dallas. The permit had expired during the post-Katrina relief operations in Louisiana. According to the motorcoach driver, who had driven the same vehicle in Louisiana, he removed a tag (license plate) from another Global vehicle and attached it to the accident motorcoach34 to avoid being stopped for an expired registration. Accident Motorcoach Maintenance. The following maintenance information is available for the accident vehicle beginning in May 2005 with the sublease arrangement between MCT and Global. The owner of Global said that he does not have a mechanic or brake inspector on staff full-time and that he normally takes his vehicles to a dealership or service center for repairs. About 3 weeks prior to the accident, he had hired a mechanic to perform oil changes, minor repairs, and belt changes, but the mechanic worked only part- time on Saturdays. Global did not have a brake inspector qualification file for the mechanic, as required by 49 CFR 396.25. The motorcoach had undergone preventative maintenance35 August 8–12, 2005, at Valley Volvo, in Pharr, Texas. According to the mechanic who performed the maintenance, he checked the oil level in the hubs and checked for oil around the wheels but did not find any leaks. 33  The Texas 144-hour permit specifies: “this permit is issued to vehicles owned by residents of the United States, Mexico, or Canada subject to registration by the State of Texas and which are not authorized to travel on the public roads of the State for lack of registration.” 34  Postaccident, inside a luggage compartment, police found a Texas temporary license plate, expiring September 8, 2005, with a vehicle identification number (VIN) matching the accident motorcoach VIN. 35  The preventative maintenance included oil change and filter, fuel filter change, check of air cleaner, greasing of fittings, and check of rear differential oil level and other fluid levels, in addition to a transmission fluid and filter change, winterization and repair of radiator, and compressor head gasket repair.

Factual Information 20 Highway Accident Report The FMCSA requires motor carriers to ensure that every driver prepare a written driver vehicle inspection report (DVIR) at the completion of each day on each vehicle operated and further requires that the report list any defects noted during operation of the vehicle.36 When interviewed by the Safety Board on September 26, 2005, Global’s owner stated that he paid drivers by the mile and did not pay them to conduct pretrip or posttrip vehicle inspections. Postaccident Inspection of Tag Axle. During the Safety Board’s postaccident investigation, the left and right tag axle wheel components were inspected because the fire had originated in the right-side tag axle wheel well. The left-side tag third (3L) axle wheel, hub, and brake assembly and other related components were examined. The rubber fill cap or fill plug, where oil is put into the hub cavity to lubricate the wheel bearings, was missing, and a significant amount of water was found in the hub cavity. The 3L wheel bearing hub cavity was low on lubricant, with only residual traces of oil on the bearing elements, though the bearings were intact, in good condition, and did not show signs of wear or excessive heat. The 3L ABS tone ring component and adjoining axle torque plate were encrusted with oil, which, along with the low oil level in the hub cavity, is an indication of oil leaking from the wheel seal. At the Safety Board public hearing, the senior technical advisor for MCI said that inspection of the accident motorcoach left tag axle knuckle and torque plate showed that they were heavily coated in oil and dirt, indicating “that there had been at least for some considerable period of time, a fairly heavy oil leak.” The inspection revealed that the right-side tag axle (3R) aluminum hubcap melted during the fire; several small fragments were still present around the hubcap mounting bolts. (Aluminum melts at approximately 1,150º F.) The 3R tire was burned, and no rubber remained. The 3R brake rotor was skewed outward and was in contact with the torque plate and the brake caliper housing. Normally, the brake rotor does not make contact with either of these components. This abnormal contact caused grinding marks on the underside of the caliper housing, as well as on the torque plate and brake rotor. Additionally, the brake pad retaining clips, which are normally round, had flat spots from contact with the rotor; the 3R outside brake pad was worn more on the top, and the 3R inside pad was worn heavier at the bottom, consistent with wear from the displaced and tilted rotor. As originally installed, the outer wheel bearing contains 19 rollers evenly spaced and held within a bearing cage. (See figure 13.) Inspection of the 3R wheel bearing revealed four flattened rollers in the hub. Two other flattened rollers were found in the area of the grass fire, near MP 266. The inner wheel bearing, as originally installed, contained 17 rollers. Eight or nine rollers were discovered fused together, two other rollers were found severely flattened, and the bearing cage was destroyed. (See figure 14.) The inner wheel seal was destroyed. According to a chief engineer with Timken Company, the 36  In accordance with 49 CFR 396.11, the DVIR shall cover at least the following parts and accessories: service brakes, including trailer brake connections; parking (hand) brake; steering mechanism; lighting devices and reflectors; tires; horn; windshield wipers; rear vision mirrors; coupling devices; wheels and rims; and emergency equipment. The report shall identify the vehicle and list any defect or deficiency discovered by or reported to the driver that would affect safe operation of the vehicle or result in its mechanical breakdown.

Factual Information 21 Highway Accident Report strength of wheel bearing roller material is a function of temperature. At a temperature as low as 1,000º F, the roller material can begin to lose metal strength. Further, the amount of roller deformation is dependent on the loading (weight) from the motorcoach and the length of time the roller is exposed to this weight and increased temperatures. Figure 13. Left tag axle outer wheel bearing assembly. Figure 14. Damaged right tag axle spindle and inner bearings.

Factual Information 22 Highway Accident Report Vehicle Fires Motorcoach Fire Data Sources During the investigation of this accident, the Safety Board compiled data in an attempt to examine the scope of motorcoach fires in the United States. The Safety Board examined two insurance company databases and two passenger motor carrier company reports for vehicle fire information. In addition, the Safety Board gathered motorcoach and bus fire data from several sources, including Federal accident reporting databases such as the National Highway Traffic Safety Administration (NHTSA) Fatality Analysis Reporting System (FARS)37 and General Estimates System (GES) and other sources, including the FMCSA Motor Carrier Management Information System38 (MCMIS) and the National Fire Protection Association (NFPA) vehicle fire database. Vehicle reporting requirements for each source (MCMIS, FARS, GES, and the National Fire Incident Reporting System [NFIRS]) are different and do not allow the correlation of comprehensive and statistically accurate data on motorcoach fires. Each DOT agency defines “bus” and “motorcoach” differently for data collection and analysis, and this terminology is also different in the NFIRS database. The Federal Motor Carrier Safety Regulations (FMCSRs) and the vehicle classification in the MCMIS database define a bus in two ways: as any motor vehicle, including taxicabs, designed, constructed, or used for the transportation of passengers (49 CFR 390.5) and as any vehicle designed to carry more than 15 passengers, including the driver (49 CFR 393.5). NHTSA’s FARS database uses five body type classifications for buses: intercity/cross-country bus, school bus, transit bus, other bus, and unknown bus. The FARS and GES databases are populated with police-reported accident data.39 The FMCSA reports40 that FARS data from 1994–2004 include 24 motorcoach fires with fatalities; GES data from 1995–2003 include two motorcoach accidents that involved fires. The FMCSA also reports that its MCMIS data from 1995–2005 include 265 motorcoach fires, of which 4 involved fatalities, 49 involved injuries, and 212 involved property damage. On March 2, 2006, the then-FMCSA Administrator, during 37  FARS was established in 1975 and contains data on fatal traffic accidents in the 50 States, the District of Columbia, and Puerto Rico. To be included in FARS, an accident must involve a motor vehicle traveling on a road open to the public and result in the death of a person within 30 days. 38  The MCMIS is a database of motor carrier census information, inspections, accidents, and enforcement history. 39  Police agencies use the American National Standards Institute (ANSI) definitions of motor vehicle accidents and traffic accidents. ANSI defines a motor vehicle accident as a transport accident that involves a motor vehicle in transport and a traffic accident as a road vehicle accident in which the unstabilized situation originates on a trafficway or a harmful event occurs on a trafficway. American National Standards Institute, Manual on Classification of Motor Vehicle Traffic Accidents, ANSI D16.1-1996 (Washington, DC: ANSI, 1996) Sections 2.4.12 and 2.4.18. 40  U.S. Department of Transportation, Research and Innovative Technology Administration, Volpe National Transportation Systems Center, Motorcoach Fire Safety Analysis Work Plan, Project No. CV702 (Cambridge, MA: Volpe National Transportation Systems Center, 2006) 1.

Factual Information 23 Highway Accident Report testimony to the House Committee on Transportation and Infrastructure Subcommittee on Highways, Transit, and Pipelines, explained that bus fires have been found to be a chronic problem throughout the entire industry.41 During the Safety Board’s public hearing, the NFPA’s manager of fire analysis services stated that the NFIRS data from 1999–2003 indicated an average of 2,200 bus fires each year (including transit42 and school buses), or about 6 per day. A National Interstate Insurance Company representative testified that insurance data from 2003–2006 showed 74 bus fire claims, including school buses, transit buses, and motorcoaches. A Lancer Insurance Company representative reported 220 bus fire claims from 1998–2005. During the week of October 23, 2006, the Safety Board had access to additional information on 80 of these claims (29 wheel/tire fires, 37 engine fires, and 14 other).43 Of the 29 wheel/tire fires, 5 were wheel bearing failures. Two large self-insured passenger carrier companies volunteered information to the Safety Board regarding their experiences with vehicle fires. From 2004–2005, one company reported 24 motorcoach fires (6 axle/wheel, 14 engine compartment, 1 brake system, 2 tire, and 1 battery); the other company reported 49 motorcoach fires from January 2004–April 2005 (9 wheel bearing, 12 turbocharger, 14 electrical system, 11 brake system, and 3 fuel system). Volpe National Transportation Systems Center The Volpe National Transportation Systems Center (Volpe Center) is conducting a motorcoach fire safety analysis for the FMCSA.44 The objectives of the study are • To gather information on the causes, frequency, and severity of motorcoach fires and to identify ways to prevent, reduce, or mitigate their severity and frequency, • To investigate and qualitatively assess fire suppression systems and their adequacy based on the type and location of fire, • To assess the adequacy of current motorcoach operational inspection practices (both daily and periodic) as they relate to detecting and remedying situations that may lead to a fire, 41  See , May 4, 2006. 42  A transit bus is a vehicle that frequently loads and unloads passengers and operates primarily in local, scheduled route service at lower-than-highway speeds. These buses are manufactured with space and accommodations, such as support bars or hand-hold straps, for standing passengers. 43  Following the public hearing, Lancer invited the Safety Board to review a portion of its claim files for fire data. 44  Motor Coach Fire Safety Analysis Work Plan.

Factual Information 24 Highway Accident Report • To consider and recommend fire prevention and mitigation techniques, to include revisions to both inspection and maintenance procedures, use of active fire suppression systems, use of passive systems to mitigate fire spread and release of toxic gases, and methods to facilitate the exit of passengers and drivers, and • To set up a database for a broad population of motorcoach fires, identifying the characteristics and outcomes of incidents; the operational, usage, maintenance, and inspection characteristics of vehicles; and the correlating contributing and mitigating factors. The Volpe Center expects to complete the final report in March 2007. Tire Fires and Fire Suppression Systems At the public hearing on this accident, the manager of the product analysis department of Bridgestone Americas Holding, Inc. (Firestone),45 stated that little information is available in the public domain about whole tire autoignition temperatures, and Firestone’s limited testing indicates that the tire temperature would approach 800º F before autoignition. He further stated that when a tire is subjected to an increasing amount of heat, approaching 350º–400º F, its rubber begins to break down and the tire does not maintain the desired material properties for adhesion, strength, or tear resistance. As long as the heat cycle continues, the tire will accelerate toward failure. The vehicle fire suppression systems product manager with Amerex Corporation reported that rubber burns very hot, and modern tires generally have a steel cord that retains heat. In addition, the metal mass from the wheel itself (axles and brakes) retains heat, which can cause a reflash, even if the fire on the rubber portion of the wheel assembly is extinguished. He further added that if the sidewall is compromised as a tire burns, it is quite likely that the inside of the tire will get fresh air, and the tire will burn on both the outside and the inside. A fire extinguisher agent applied to the exterior of the tire may never reach the interior and will not fully extinguish the fire. Automatic fire detection and suppression systems for engine compartment and electrical equipment fires have been installed on some transit and intercity motorcoaches.46 According to the senior technical advisor for MCI, the number of motorcoaches being sold with fire suppression systems has increased.47 Generally, these systems, typically located in the engine compartment, employ spot heat detectors and a fire suppression agent distribution network with individual nozzles. The systems are not designed to protect against and extinguish a tire fire. 45  Bridgestone Americas Holding, Inc., is the parent corporation to Bridgestone Firestone North American Tire, LLC, and other subsidiaries that manufacture tires in North America. 46  For example, New Jersey Transit has been using fire detection and suppression systems in its fleet since 1994. 47  In 2005, MCI also introduced the SmarTire pressure temperature monitoring system as an option for its motorcoaches. Although not a suppression system, it aids in the identification of high temperatures.

Factual Information 25 Highway Accident Report The vice president of Daecher Consulting Group stated at the public hearing that some types of fires severely affect a motorcoach. He explained that engine fire suppression systems “tend to work fairly well in terms of recognizing the fire, controlling it.” However, he stated that “there is no way” motorcoach equipment will have any effect in putting out a tire fire or a fire that originates in a wheel well. He added that motorcoaches “go up very quickly” as a fire propagates. The vehicle fire suppression systems product manager with Amerex Corporation explained that vehicle fires are of an “uncontrollable nature,” and the purpose of a suppression system is to delay or prevent the spread of a fire to give the occupants a reasonable amount of time to escape. He added that “the current thinking on tire fire protection, instead of extinguishment, is to prevent ignition, working toward a heat monitoring system that will give a prewarning to a driver in the event of elevated heat in one or more wheel wells.” In July 2006, the FMCSA announced its fiscal year 2006 research grants program, as specified in the Safe, Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for Users (SAFETEA-LU), Section 5513(a), and provided funding of $1.4 million for a roadside thermal imaging inspection system project. As reported in 71 Federal Register (FR) 42438–42439, the project uses a thermal imaging inspection system that leverages state-of-the-art thermal imaging technology, integrated with signature recognition software, providing the capability to identify, in real-time, faults and failures in tires, brakes, and bearings mounted on commercial motor vehicles. The objectives of the demonstration project are to employ the system in a field environment (such as along an interstate) to further assess its capability of identifying faults in tires, brakes, and bearings mounted on commercial motor vehicles; to establish the probability of failure; and to develop and integrate a predictive tool to identify an impending tire, brake, or wheel bearing failure and provide a timeframe in which the failure may occur. In September 2006, the FMCSA awarded a grant for the demonstration project to the International Electronic Machine Corporation of New York; the period of performance is expected to be 24 months. Highway Information General The motorcoach fire occurred on I-45 north, approximately 1,000 feet north of the exit ramp to Mars Road, at MP 269.5, near Wilmer, Texas. I-45 is classified as a rural principal arterial road; it is a divided, straight, and level six-lane concrete roadway. Each travel lane is 12 feet wide, and the lanes are separated by broken white retroreflective lines on the road surface. A solid yellow retroreflective line delineates

Factual Information 26 Highway Accident Report the inner edge of the roadway. A 24-foot-wide concrete median with a permanent 32- inch-high median barrier separates the northbound and southbound lanes. A solid white retroreflective line delineates the outer edge of the roadway from the 10-foot-wide outer shoulder and the 12-foot-wide inner shoulder. The posted speed limit in the vicinity of the fire location was 60 mph. Traffic According to records of the Texas Department of Transportation (TxDOT),48 the most recent traffic count in the vicinity of the accident was 44,000 vehicles per day in

1. During evacuation in advance of Hurricane Rita, TxDOT instituted contra-flow

lanes49 on I-45 north of Houston in anticipation of the estimated 2 million evacuees traveling to other locations for safety. “Contra-flow” converted all lanes of I-45 to northbound-only travel. On September 22, 2005, all lanes on I-45 from Conroe to Fairfield, Texas (90 miles), were designated one-way northbound. The contra-flow lanes did not extend as far north as the location of the motorcoach fire, at MP 269.5. Witnesses reported that traffic in the vicinity of the accident was moving freely, with vehicles traveling northbound at 40–50 mph. Table 2 shows a chronology of the date, time, and limits of the one-way northbound operation for I-45. Table 2. Contra-flow history on I-45 during Hurricane Rita evacuation. Operations Information Global Limo Inc. According to the FMCSA registration, Global was an authorized interstate for-hire passenger motor carrier50 headquartered in the State of Texas. At the time of the accident, Global operated with four motorcoaches (not including the accident motorcoach) and six drivers. According to Global’s owner, the company was established in 1980; the FMCSA 48 TxDOT records from 1998–2001 indicate that 201 accidents occurred within 5 miles of the site of the motorcoach fire. The accidents (overturn, hit motor vehicle, pedestrian, parked car, animal, and fixed object) resulted in 6 fatalities and 190 injuries. 49 Reverse-flow operation on a divided highway is termed “contra-flow.” American Association of State Highway and Transportation Officials, A Policy on Geometric Design of Highways and Streets (Washington, DC: AASHTO, 2004) 492. Date (2005) Time I-45 traffic lane operation Sept 22 12:00 noon TxDOT working to improve traffic flow from Houston 2:00 p.m. All lanes from Conroe to Fairfield, Texas (90 miles), routed one-way northbound Sept 23 6:07 a.m. Time of motorcoach fire 50 DOT No. 1031282.

Factual Information 27 Highway Accident Report records show that interstate operating authority was granted to Global on June 30, 1987. The owner changed the company name from Global Tours and Charters to Global Limo Inc. on November 20, 2003. Company History. Global’s inspection selection system (ISS) value51 was 92, falling in the ISS-2 “inspection recommended” range of values. For the 2 years prior to the accident (September 23, 2003–September 23, 2005), Global’s drivers had been subjected to eight roadside inspections, which showed serious violations of the FMCSRs and resulted in four drivers being placed out of service (OOS); thus, the company’s OOS rate was 50 percent (the 2005 national OOS rate was 6.6 percent).52 The accident driver himself had undergone three roadside inspections53 prior to September 23 and had been placed out of service in two of the three inspections. The four drivers were cited for multiple violations,54 which included: • Failing to retain record of duty status (also known as a driver’s log) for the previous 7 days (OOS), • Failing to maintain current record of duty status (OOS), • Failing to meet CDL restrictions (OOS), • Failing to show required information for total hours (violation), and • Failing to have an English-speaking driver (violation). Also during the 2 years prior to the accident, four of Global’s vehicles were subjected to roadside inspections, and vehicle defects55 were found. None of Global’s vehicles were placed out of service during this period (the 2005 national OOS rate was 23.4 percent). Compliance Reviews. On April 10, 2002, the TxDPS conducted an intrastate educational review of Global; this review is similar to the FMCSA compliance review. At the time of the review, the State of Texas did not issue safety ratings to intrastate carriers; it began doing so in early 2004.56 (The FMCSA is the only agency that issues safety ratings to interstate carriers.) 51  The FMCSA’s ISS program is designed to aid roadside inspectors in selecting vehicles for individual inspection. Inspections are optional for carriers with inspection values from 50–74; carriers with inspection values less than 50 are not considered for inspection under normal circumstances. 52  According to the FMCSA, the fiscal year 2004 OOS rate for commercial bus drivers was 5.1 percent, and the OOS rate for commercial buses was 9.5 percent. 53  February 12, March 1, and August 19, 2005. 54  A “violation” is a violation of the FMCSRs found during the inspection and recorded. A serious violation results in an OOS order because the violation must be corrected before the affected driver or vehicle can return to service. 55  These defects included inoperable tail lamp, no required vehicle markings, no fire extinguisher, insufficient tire tread depth on steer axle, inoperable marker lamp, defective brake warning device, operating a commercial motor vehicle without a periodic inspection, and damaged windshield. 56  The TxDPS issues OOS orders to carriers that are rated “unsatisfactory.” Shutdown orders are issued after 60 days for passenger carriers and HM carriers and after 75 days for property carriers.

Factual Information 28 Highway Accident Report The TxDPS procedures used in the safety review process mirror the FMCSA compliance review process. The educational review of Global listed the following deficiencies: • No drug and alcohol testing program, • No driver background investigation, • No driver employment application, • No driver record inquiry, • Failure to require driver to make a record of duty status, • Failure to require form and manner on driver’s log, • Failure to maintain vehicle inspection and maintenance records, and • Failure to maintain evidence of brake inspector qualifications. The April 2002 educational review resulted in five specific recommendations for compliance in the areas of driver qualifications, driver logs, and vehicle maintenance. Global was directed to notify the TxDPS of its actions to comply with the FMCSRs. The narrative section of the review included additional comments describing the discrepancies in each area. The reviewing TxDPS officer recommended compliance monitoring of Global and a followup review. The followup review did not take place. The FMCSA conducted an on-site compliance review of Global on February 6, 2004, noting seven violations of 49 CFR Parts 382, 391, 395, and 396.57 (See appendix B for a list of these violations.) The FMCSA issued a satisfactory rating to Global on February 12, 2004. Following this review, Global’s vehicles and drivers underwent seven roadside inspections prior to the accident, which resulted in three driver OOS violations (the accident driver accounted for two of the three) of the FMCSRs for logbook and duty status. After the accident, the FMCSA conducted another compliance review of Global, which included inspection of Global’s four remaining motorcoaches. Two of the motorcoaches were placed out of service, resulting in a 50 percent OOS rate. The national OOS rate in 2005 was 23.4 percent. The FMCSA issued an unsatisfactory rating to Global on October 7, 2005, stating that the compliance review uncovered violations of the FMCSRs (49 CFR Parts 382, 391, 395, and 396) “so widespread as to demonstrate a continuing and flagrant disregard for compliance” and a management philosophy “indifferent” to motor carrier safety. Table 3 summarizes the violations common to both compliance reviews. (See appendix B for a full list of the violations found in each compliance review.) 57   Prior to 2004, the FMCSA reported that Global had been identified as a category B carrier within the Safety Status Measurement System (SafeStat), which is used to identify and prioritize carriers for FMCSA safety improvement and enforcement programs, such as compliance reviews. SafeStat places carriers in categories A–H, with “A” as the lowest safety fitness assessment. At the time of the accident, Global had been categorized as an “E” carrier, which indicated that the company had a driver safety evaluation area (SEA) value of 75 or greater (Global’s value was 96.96) and all other SEA values were less than 75. (See appendix C for more details on SafeStat values.)

Factual Information 29 Highway Accident Report Table 3. Global compliance review violations, February 2004 and October 2005. In Global’s postaccident compliance review, the FMCSA declared that the company presented an “imminent hazard” to public safety and issued an operations OOS order on October 7, 2005. The FMCSA had determined that the violations detected in the compliance review both individually and cumulatively were likely to result in serious injury or death to Global’s drivers and the motoring public. The OOS order was based on determinations that Global’s vehicles were mechanically unsafe due to lack of vehicle maintenance, inspections, and repairs and that the company failed to comply with Federal regulations on drug and alcohol testing, driver qualifications, and hours of service. Federal Motor Carrier Safety Administration General. The FMCSA was established as a separate administration within the DOT on January 1, 2000, pursuant to the Motor Carrier Safety Improvement Act of 1999. Its primary mission is to reduce accidents, injuries, and fatalities involving large trucks and buses. According to the FMCSA, the agency develops and enforces data-driven regulations and uses safety information systems to focus on higher risk carriers. The FMCSA requires a motor carrier to have management controls that comply with applicable safety requirements and uses a rating formula to determine a motor carrier’s safety fitness. The FMCSA mission is primarily accomplished through on-site compliance reviews and roadside program inspections of a carrier’s vehicles and drivers. Compliance Reviews. The FMCSA standards require a motor carrier to have adequate controls in place to ensure compliance with the FMCSRs. In accordance with 49 CFR Part 385, appendix B, one step in the safety rating process is an FMCSA- conducted compliance review. (See appendix D for more details.) During a compliance review, the FMCSA uses the computer program CAPRI58 to organize and record compliance information and determine the proposed safety rating.59 The compliance review applies six factors (general, driver, operational, vehicle, hazardous materials [HM], and accident rate) to determine the degree to which a carrier complies with the FMCSRs and meets the Federal safety fitness standard. Within each factor, the FMCSR violation Feb 6, 2004 Oct 7, 2005 CFR Failure to provide drivers with drug and alcohol policies X X 49 CFR 382.601(a) Failure to have persons trained for reasonable suspicion testing X X 49 CFR 382.603 False reports of records of duty status X X 49 CFR 395.8(e) Failure to maintain a note relating to annual review of driver’s driving record X X 49 CFR 391.51(b)(5) 58 Compliance Analysis and Performance Review Information System. 59 The compliance review itself is conducted at the carrier’s business location; the actual safety rating is determined and issued by the FMCSA headquarters in Washington, D.C.

Factual Information 30 Highway Accident Report FMCSRs are rated as either acute60 or critical61 regulations, in accordance with 49 CFR Part 385, appendix B II(b); the carrier’s noncompliance results in an assessment of one point for that factor.62 According to the FMCSA, noncompliance with acute regulations and patterns of noncompliance with critical regulations are quantitatively linked to inadequate safety management controls and usually higher-than-average accident rates.63 (On May 28, 1997, the FMCSA published a request for comments on a change to the safety fitness ratings in appendix B to Part 385 and made it an interim measure. In November 1997, the appendix was made an interim final rule pertaining to the compliance review process.64) Once the compliance review is finished and violations or deficiencies (the number of acute or critical regulations not complied with by the carrier) are tallied, a safety rating is computed for each applicable factor. As defined below, each factor is rated “satisfactory,” “conditional,” or “unsatisfactory,” except the accident factor, which is rated either “satisfactory” or “unsatisfactory”: • A satisfactory rating indicates that the carrier has not violated any acute regulations or shown a pattern of noncompliance with critical regulations. • A conditional rating indicates that the carrier has violated one acute regulation or has a pattern of noncompliance with critical regulations. • An unsatisfactory rating indicates that the carrier has violated two or more acute regulations or has a pattern of noncompliance with two or more critical regulations. According to the FMCSA, an accident rate below 1.5 per million miles is considered satisfactory; anything higher is rated “unsatisfactory.”65 The ratings for all six factors are given equal weight and entered into a rating table. Table 4 summarizes the FMCSA rating process. 60  Acute violations of the FMCSRs (or HM regulations) are defined as those that demand immediate corrective action, such as requiring or permitting the operation of an OOS vehicle before repairs are made, regardless of the motor carrier’s overall safety posture. 61  Critical violations indicate deficiencies in the motor carrier’s management controls, such as requiring or permitting a driver to drive after having been on duty for 15 hours (49 CFR 396.9(c)(2)). 62  Two points are assessed for noncompliance with a “critical” regulation in 49 CFR Part 395 for hours of service. 63  See , December 13, 2006. 64  By this interim final rule, the Federal Highway Administration (FHWA) publishes its safety fitness rating methodology as appendix B to 49 CFR Part 385 to be used as an interim measure until a notice of proposed rulemaking (NPRM) becomes final (Docket No. MC-94-22 changed to FHWA-97-2252). See 62 FR 28807. 65  The rating for the accident factor is based on the number of recordable accidents in relation to the carrier’s annual mileage for the 12 months leading to the compliance review. The FMCSA defines a recordable accident as an occurrence involving a commercial motor vehicle operating on a public road in interstate or intrastate commerce that results in a fatality, a bodily injury, or a vehicle incurring disabling damage that requires it to be towed from the scene (49 CFR 390.5). The accident threshold for a satisfactory rating is 1.7 per million miles for carriers operating within 100 air miles of their home terminal (49 CFR Part 385, appendix B, (B) accident factor (d)).

Factual Information 31 Highway Accident Report Table 4. Motor carrier safety ratings. The rating table establishes the motor carrier’s overall final safety rating: satisfactory, conditional, or unsatisfactory. A safety rating is issued to a motor carrier within 30 days of the completion of a compliance review. When the FMCSA issues a proposed safety rating of unsatisfactory, it is a notice to the motor carrier that the FMCSA has made a preliminary determination that it is “unfit” to continue operating in interstate commerce and that the prohibitions in 49 CFR 385.13 will be imposed after 45 days for passenger-carrying operations, if necessary safety improvements are not made. According to 49 CFR 385.13(a), an owner or operator receiving notice of a proposed unsatisfactory safety rating from the FMCSA must improve that rating to conditional or satisfactory within 45 days of the date of notice. Owners or operators who fail to improve their ratings within this 45-day period are prohibited from operating in interstate commerce beginning on the 46th day following the date of the rating notice and may not reestablish interstate operations until they become fit for such transportation. (See appendix C for more information.) According to the FMCSA, 910,866 motor carriers were operating in the United States in calendar year 2005, and the agency conducted compliance reviews on 8,097 carriers. Table 5 shows the results of these reviews. Overall, of 61,924 violations discovered during the 8,097 compliance reviews, 53,064 were noncritical and nonacute and are not used to rate the carrier. In September 2005 and again in June 2006, the Safety Board met with the FMCSA to discuss FMCSA plans for evaluating the compliance review process as part of the Comprehensive Safety Analysis (CSA) 2010 Initiative. According to the FMCSA, the CSA 2010 Initiative is an effort to evaluate the effectiveness of current Federal safety compliance and enforcement programs, such as compliance reviews and roadside inspections, and to identify better methods of achieving an accident-free environment. The FMCSA indicated that the evaluation is still in its early stages, no conclusions have been reached, and it is too soon to speculate on what specific changes may be made in the safety rating process. Full implementation of any changes proposed by the initiative is not expected until 2010. No. of factors with unsatisfactory ratings No. of factors with conditional ratings Safety rating 0 2 or less Satisfactory 0 More than 2 Conditional 1 2 or less Conditional 1 More than 2 Unsatisfactory 2 or more 0 Unsatisfactory

Factual Information 32 Highway Accident Report Table 5. FMCSA compliance review data, 2005. The FMCSA has posted on its website information explaining the CSA 2010 Initiative.66 According to the posting, the initiative is “a comprehensive review and analysis of FMCSA’s current commercial motor vehicle safety compliance and enforcement programs.” The FMCSA’s objective is to develop and deploy a new operational model to identify drivers and operators that pose safety problems and to intervene to address those problems.67 The FMCSA acknowledges that the present compliance review program is resource-intensive and reaches only a small percentage of motor carriers68 and that increased attention needs to be given to commercial vehicle drivers. Roadside Inspection. According to the FMCSA, in this program, qualified safety inspectors carry out roadside inspections in accordance with the North American Standard Inspection Program Guidelines, which were developed by the Commercial Vehicle Safety Alliance (CVSA) and the FMCSA. The ISS-2 “value” based on safety is derived from a carrier’s roadside inspections and accident history. According to the program, vehicles with an inspection value of 75–100 (maximum value is 100) should be inspected.69 During roadside inspections,70 an inspector examines commercial motor vehicles and their drivers to determine whether they meet the FMCSRs. Under the North American Standard inspection criteria, a leaking wheel seal alone is not an OOS item; it is an OOS item if the hubcap is missing or broken, allowing an open view into the hub assembly, or if the wheel is smoking due to bearing failure.71 Serious violations found during roadside Safety rating No. of reviewsA Percent of total reviews Satisfactory 5,234 64.6 Conditional 2,117 26.1 Unsatisfactory 531 6.6 Not rated 215 2.7 Total 8,097 100 ASee MCMIS March 31, 2006, snapshot, , October 20, 2006. 66 See , December 12, 2006. 67 See , December 12, 2006. 68 In calendar year 2005, less than 1 percent of the 910,866 registered motor carriers underwent compliance reviews (8,097 reviews conducted). 69 Inspections are optional for carriers with inspection values from 50–74; carriers with inspection values less than 50 are not considered for inspection under normal circumstances. 70 Most roadside inspections are conducted by States through the FMCSA-administered grant Motor Carrier Safety Assistance Program. 71 Commercial Vehicle Safety Alliance, North American Standard Inspection Program Guidelines, Out-of-Service Criteria, sections 12.i(1), (2) (Washington, DC: CVSA, 2005).

Factual Information 33 Highway Accident Report inspections result in the issuance of driver or vehicle OOS orders; these violations must be corrected before the affected driver or vehicle can return to service. According to the FMCSA, 3,022,286 roadside inspections were conducted in 2005;72 2,960,849 driver inspections resulted in 195,667 driver OOS violations, and 2,198,718 vehicle inspections resulted in 513,439 vehicle OOS orders. Nursing Home Information The Brighton Gardens senior assisted living center, located in Bellaire, Texas, offers assisted living services, nursing and rehabilitation services, and hospice care. Sunrise operates more than 420 senior living communities in 37 States, the District of Columbia, Canada, the United Kingdom, and Germany, with a combined resident capacity of 52,000. Sunrise offers at-home assisted living, independent living, assisted living, Alzheimer’s care, and nursing and rehabilitative care.73 During the public hearing for this accident, Sunrise officials stated that the company had originally planned to use a shelter-in-place strategy at Brighton Gardens during the Hurricane Rita emergency. Sunrise made the decision to evacuate in the evening hours of September 21, 2005, at the urging of the Bellaire fire marshal. Those residents who could not be accommodated locally were to be transferred to facilities in Arlington and Dallas, Texas. Several Sunrise nursing home and assisted living facilities in the Gulf region required evacuation in advance of Hurricane Katrina, which made landfall in New Orleans, Louisiana, on August 29, 2005. During those preparations, Sunrise had contacted BusBank to secure motorcoach transportation to evacuate residents in two coastal Louisiana communities. According to Sunrise representatives at the public hearing, the company did not encounter any problems with the buses provided by BusBank.74 Sunrise owned small wheelchair-accessible shuttle buses that were normally used for short day trips but were not equipped with restrooms. After watching media coverage of the heavy evacuation traffic, which showed evacuee vehicles running out of gasoline, Sunrise representatives made the decision to charter a diesel-powered motorcoach with restrooms because of the number of residents being evacuated and the anticipated 4-hour drive to Dallas. The Sunrise vice president for sales and marketing and the vice president for operations contacted BusBank on September 21 to arrange transportation for the Brighton Gardens residents. BusBank first informed Sunrise that it did not have any motorcoach 72  These inspections included 2,309,258 trucks and 71,464 buses. See , November 27, 2006. 73  See , September 13, 2006. 74  Global Limo Inc. was not the passenger carrier provided by BusBank for the Hurricane Katrina contract.

Factual Information 34 Highway Accident Report operators available to provide charter evacuation services because FEMA had contracted approximately 275 motorcoaches for posthurricane operations. Shortly thereafter, BusBank informed Sunrise that it found two motorcoaches to transport Brighton Gardens residents from Bellaire to Dallas. According to Sunrise, it was not given the name of the motorcoach operator. The accident motorcoach, which carried 37 residents, was staffed with 3 nurses and 3 nurses’ aides (and 1 parent of a nurse). Global’s second motorcoach completed the trip as outlined in the contract and trip itinerary; it transported 16 ambulatory passengers and arrived at its destination on the morning of September 23. Brighton Gardens is a licensed facility and did have a preparedness plan. 75 At the time of the Hurricane Rita evacuation,76 the Sunrise Senior Living plan, titled Preparing the Community for a Complete Evacuation, stated, “If the evacuation is decided: Transportation arrangements will be confirmed.” There were no other written procedures for arranging transportation for residents. Bus Brokers A bus broker is an entity or business that arranges bus or motorcoach transportation between a client and a passenger motor carrier for a fee. Bus brokers are not required to obtain a DOT registration or operating authority from the FMCSA. An FMCSA official testified at the public hearing that the agency does not have the authority to regulate brokers for motor carriers of passengers. In addition, on September 15, 2006, the FMCSA informed the Safety Board that 49 United States Code 13506(a)(14) exempts the Secretary of Transportation from jurisdiction over brokers for motor carriers of passengers. According to the FMCSA, the statute does give the DOT authority to require brokers for motor carriers of passengers to maintain a bond or insurance as needed to protect passengers and carriers dealing with such brokers. The DOT, like the ICC before it, has not imposed an insurance requirement because, without the ability to register these brokers, the agency has no way to identify passenger brokers that are operating and monitor their compliance with an insurance requirement. 75  “Under current Texas law, only licensed facilities are required to maintain a written emergency preparedness and response plan; however, the law does not address the quality or currentness of a licensed facility’s plan. Unlicensed facilities are not required by law to maintain an evacuation plan.” State of Texas, Governor’s Task Force on Evacuation Transportation and Logistics (Austin, TX: Office of the Governor, February 14, 2006) 5. 76  Sunrise followed its written disaster plan in making evacuation arrangements. A section on “Hurricane Preparedness” included guidance covering such issues as keeping medical records and identification with evacuees; maintaining adequate supplies of food, medication, and other medical necessities; and securing the evacuated property.

Factual Information 35 Highway Accident Report Global Charter Services, Ltd,77 doing business as The BusBank,78 is a Delaware corporation headquartered in Chicago, Illinois. BusBank was one of the vendors used by FEMA during the Hurricane Katrina evacuations. The BusBank website describes the corporation as transportation and event specialists with local knowledge of bus availability, bus quality, the best routes, and seasonal events that impact bus transportation in hundreds of markets—thousands of cities—across North America. . . . Working with independent operators rather than owning buses, we maintain the flexibility to create customized group transportation solutions that fit the specific needs of the customer and situation. BusBank maintains a registry of motorcoach companies and contacts them to arrange charters when needed. When a company agrees to the charter contract, the operator is given the itinerary and completes the trip. The group requesting the charter pays BusBank, which then pays the motorcoach company for its transportation services. According to BusBank, the agreement requires that the motorcoach operator’s drivers be properly licensed. The carrier must comply with all applicable Federal, State, and local laws and regulations. Global did not have a formal contract with BusBank; its registration information was taken via telephone 1 year before the accident, and it had completed one prior charter for BusBank. Oxygen Cylinders The director of risk management for Sunrise stated in a Safety Board interview that Brighton Gardens employees placed medical oxygen79 cylinders both inside the passenger compartment and inside the luggage bay during passenger loading of the motorcoach. Initially, two cylinders were hooked up to nasal canulas80 and used to provide medical oxygen to two passengers inside the motorcoach. Fifteen cylinders, contained in metal racks, were placed in the luggage bay in the lower portion of the coach, along with passenger wheelchairs. During the trip, the oxygen within the cylinders in the passenger compartment was depleted, and the nursing staff requested that the driver pull over to retrieve additional cylinders from the luggage bay. 77  Global Limo Inc., the operator of the accident motorcoach, and Global Charter Services, Ltd, are two distinct and separate commercial entities. 78  See , December 1, 2006. 79  Oxygen is an atmospheric gas. It is transported as a compressed or liquefied gas; it is not flammable but supports and enhances combustion. An oxygen-enriched atmosphere lowers the ignition temperatures of certain combustible materials and increases the intensity of a fire. Oxygen is also reactive with combustible materials and can cause a fire. Title 49 CFR Subchapter C 172.101 classifies oxygen as a nonflammable compressed gas, and 173.301(a) requires oxygen to be shipped in DOT specification cylinders. 80  A canula is a tube inserted into the nasal cavity to administer medical oxygen.

Factual Information 36 Highway Accident Report During the Safety Board’s postaccident inspection, 18 cylinders,81 or parts thereof, were found in the cargo and passenger areas of the motorcoach; 15 cylinders were aluminum, and 3 were steel. Seven cylinders found in the luggage bay had limited fire damage. All 11 cylinders found inside the passenger compartment showed fire damage; 5 were extensively damaged and had been found near the rear of the motorcoach. Of these five, the pressure-relief plated brass medical post valves on three aluminum cylinders were intact; two of these cylinders had evidence of melting, and one had fractured and burst just below the cylinder neck.82 According to the manufacturer of one of these cylinders, aluminum melts at 1,020º–1,206º F and loses its strength at temperatures well below this range. A fully pressurized aluminum cylinder would maintain its integrity for only minutes at temperatures of about 600º F. These cylinders are designed to hold large quantities of gas by compressing it into a small volume, which results in high levels of pressure. When a cylinder fails, the rapid expansion of the compressed gas creates a pressure surge that radiates from the container and can carry along portions of the cylinder as projectiles. The Safety Board examined the three aluminum cylinders to determine how the structural failure occurred. According to the manufacturer of several plated brass valves found on the accident motorcoach, the typical pressure relief device installed on this type of valve includes a burst disk83 set to actuate at 3,025–3,360 pounds per square inch gage (psig). These pressure relief devices are designed to open to relieve pressure within the cylinder before an exposure to high temperatures can cause the cylinder to fail.84 Examination of the three valves at the Safety Board’s laboratory revealed that one burst disk had actuated as designed, and two had not.85 One of the two that had not actuated was on the cylinder that had fractured and burst. The disks within these cylinders were examined, and no defects were found. The Safety Board studied the effect of heating aluminum cylinders containing various quantities of oxygen, from fully charged at 2,015 psig to minimally charged at 500 psig. The study revealed that the pressure-relief device on a fully charged cylinder 81  The director of risk management was unable to explain why an additional cylinder was found in the motorcoach postfire. 82  Two other melted cylinders were found without the valves attached. One had holes melted through on the top head, and the other was only a base with attached resolidified aluminum. 83  A burst disk is a pressure-actuated device used to prevent the pressure in a normally charged cylinder from rising above a predetermined maximum, thereby preventing rupture of the cylinder when subjected to high temperatures. 84  Fire tests performed for the Compressed Gas Association (CGA) to establish standards for these pressure relief devices proved that they operated as designed when the cylinders were fully charged with gas. In accordance with 49 CFR Subchapter C and the CGA S-1.1 standard, these are the minimum requirements for pressure relief devices considered to be appropriate for use on cylinders with capacities of 1,000 pounds of water or less; 49 CFR 173.301(f) requires that pressure relief devices be sized, selected, and tested in accordance with the CGA S1.1 standard and that they be capable of preventing rupture of a normally filled cylinder when subjected to a fire test conducted in accordance with the CGA C-14 standard. 85  In all, the plated brass medical post valves were still installed on 16 of the 18 recovered cylinders. Each cylinder was examined to determine whether the pressure relief device had actuated as designed.

Factual Information 37 Highway Accident Report actuates, relieving its internal pressure before failure, at temperatures of 260º–315º F. However, it was also determined that the exposure of an aluminum cylinder with less than 78 percent of its original quantity of gas (about 1,570 psig at room temperature) to temperatures exceeding 400º F reduces the strength of the aluminum to a point where the cylinder structurally fails before the pressure within the cylinder is great enough to activate the burst disk. It was also found that as the quantity of gas in the cylinder decreases, the temperature required to increase the internal pressure above the rupture pressure of the burst disk increases. Federal HM regulations in 49 CFR Subchapter C 171.8 define materials of trade as those materials carried on a motor vehicle to protect the health and safety of the motor vehicle operator or passengers; section 173.6 states that when materials of trade (such as the medical oxygen cylinders) are transported by a motor vehicle, they are not subject to DOT shipping requirements, with certain provisions. On September 26, 2005, 3 days after the accident, the Pipeline and Hazardous Materials Safety Administration (PHMSA) issued guidance for the safe transportation of medical oxygen for personal use on buses and trains. This guidance was updated and rereleased on June 30, 2006.86 It suggests, in part, that the number of cylinders to be transported in a vehicle be limited to the extent practicable and, except in emergency situations, that bus or train operators consider limiting the number of passengers who require medical oxygen. The guidance specifies that each cylinder be equipped with a valve protection cap and be secured away from sources of heat or potential sparks. PHMSA also suggests that the total weight of oxygen cylinders permitted in a bus cargo compartment not exceed 99 pounds, though a carrier may elect to transport up to 440 pounds in the cargo compartment if the oxygen is required for passenger health or safety. When a new cylinder design or technology is developed, manufacturers apply to the DOT for a special permit87 to use the new technology. Prior to 1981, aluminum cylinders were manufactured, tested, inspected, and placed on the market as exempt from DOT regulations, which applied to steel cylinders. In 1981, aluminum exemption cylinders became subject to 49 CFR 178.46, specification 3AL seamless aluminum cylinders. Meteorological Information The Lancaster Airport in Lancaster, Texas, about 4 miles west of the accident site, was the closest official weather-observing system. At 6:03 a.m. on September 23, 2005, it reported visibility unrestricted at 10 statute miles, a temperature of 72º F, and scattered clouds above 9,500 feet. 86  U.S. Department of Transportation, Pipeline and Hazardous Materials Safety Administration, Guidance for the Safe Transportation of Medical Oxygen for Personal Use on Buses and Trains (Washington, DC: PHMSA, 2006). 87  The Hazardous Materials Safety and Security Reauthorization Act of 2005 (Public Law 109-59), Stat. 1144 (August 10, 2005), amended the Federal HM transportation law by changing the term “exemption” to “special permit.”

Factual Information 38 Highway Accident Report Toxicological Information Toxicological specimens were not collected from the accident motorcoach driver. According to 49 CFR 382.303, the employer of a driver of a commercial motor vehicle operated on a public road in commerce is required to conduct alcohol and controlled substance testing on that driver if the vehicle is involved in a fatal accident.88 Global did not test the driver postaccident for alcohol or illicit drugs. When interviewed by the Safety Board, the Dallas County Sheriff’s officer who responded to the fire stated that he lacked reasonable suspicion of intoxication to require the driver to submit to toxicological testing. 89 Other Information Commercial Vehicle Inspections According to Global’s owner, the accident motorcoach underwent a commercial vehicle inspection for the State of Texas on June 9, 2005, at Valley Volvo in Pharr, Texas. In Texas, the inspection of motor vehicles, including motorcoaches, is conducted in State- approved privately owned and operated garages, inspection-only facilities, and vehicle repair facilities,90 which are designated by the TxDPS under the Texas Vehicle Inspection Act.91 Under 49 CFR 396.17, the FMCSA requires that “every commercial vehicle shall be inspected as required . . . the inspection shall include, at a minimum, the parts and accessories set forth in appendix G of subchapter B.”92 88  Title 49 CFR 390.5 defines an accident as an occurrence involving a commercial motor vehicle operating on a highway in interstate or intrastate commerce that results in: “(i) a fatality; (ii) bodily injury to a person who, as a result of the injury, immediately receives medical treatment away from the scene of the accident; or (iii) one or more motor vehicles incurring disabling damage as a result of the accident, requiring the motor vehicle(s) to be transported away from the scene by a tow truck or other motor vehicle.” 89  Texas Transportation Code 724.012(b) states that: “[a] peace officer shall require the taking of a specimen of the person’s breath or blood if: (1) the officer arrests the person for an offense under Chapter 49, Penal Code, involving the operation of a motor vehicle or a watercraft; (2) the person was the operator of a motor vehicle or a watercraft involved in an accident that the officer reasonably believes occurred as a result of the offense; (3) at the time of the arrest the officer reasonably believes that a person has died or will die as a direct result of the accident; and (4) the person refuses the officer’s request to submit to the taking of a specimen voluntarily.” 90  According to 49 CFR 396.23, a vehicle meets Federal requirements if inspected under a mandatory State inspection program, such as the State of Texas vehicle inspection program. 91  All inspection-authorized facilities are required to operate according to the Rules and Regulations Manual for the Operation of Official Vehicle Inspection Stations, which is issued and maintained by the TxDPS. Texas Transportation Code, “Compulsory Inspection of Vehicles,” chapter 548. 92  As specified in 49 CFR 396.17(f), vehicles passing roadside or periodic inspections performed under the auspices of any State government or equivalent jurisdiction or the FMCSA, and meeting the minimum standards contained in appendix G of this subchapter, are considered to have met the requirements of an annual inspection for a period of 12 months commencing from the last day of the month in which the inspection was performed, except as provided in 396.23(b)(1).

Factual Information 39 Highway Accident Report Title 49 CFR Parts 393 and 396 set forth FMCSR guidelines pertaining to commercial vehicle tires, wheels, and lubrication. (See appendix D.) In appendix G of subchapter B,93 the FMCSRs list the minimum periodic inspection standards for commercial motor vehicles. According to the standards, “a vehicle does not pass an inspection if it has several defects or deficiencies for tires.” Wheel bearings or wheel seal leaks are not specifically addressed. Title 49 CFR 396.3 specifies that every motor carrier shall systemically inspect, repair, and maintain, or cause to be systematically inspected, repaired, and maintained, all motor vehicles subject to its control.94 Parts and accessories are to be kept in safe and proper operating condition at all times, including “those specified in Part 393 of this subchapter and any additional parts and accessories” that may affect safety of operation, “including but not limited to, frame and frame assemblies, suspension systems, axles and attaching parts, wheels and rims, and steering systems.” Section 396.5 states: “Every motor carrier shall ensure that each motor vehicle subject to its control is: (a) properly lubricated; and (b) free of oil and grease leaks.” Section 396.7 states: (a) General–A motor vehicle shall not be operated in such a condition as to likely cause an accident or a breakdown of the vehicle. (b) Exemption–Any motor vehicle discovered to be in an unsafe condition while being operated on the highway may be continued in operation only to the nearest place where repairs can be safely affected. Such operation shall be conducted only if it is less hazardous to the public than to permit the vehicle to remain on the highway. Title 49 CFR 393.205 addresses parts and accessories for the safe operation of wheels, stating: “(a) Wheels and rims shall not be cracked or broken. (b) Stud or bolt holes on the wheels shall not be elongated (out of round). (c) Nuts or bolts shall not be missing or loose.” Motorcoach Tire Fire Testing To better understand the events surrounding the outbreak of a tire fire and the characteristics that account for the severity of this type of fire, the Safety Board conducted three tire fire tests95 by • Running a tire at various levels of inflation below the operating pressure specified by the manufacturer, 93  The vehicle portion of the FHWA’s North American Uniform Driver Vehicle Inspection Procedure requirements, the CVSA’s North American Commercial Vehicle Critical Safety Inspection Items and Out-of- Service Criteria, and the FMCSRs’ appendix G of subchapter B, Minimum Periodic Inspection Standards, are similar documents and follow the same inspection procedures. Appendix G requires that all items to be inspected be in proper adjustment, not be defective, and function properly prior to the vehicle being placed in service. 94  FMCSA interpretation guidance assigns responsibility for inspecting and maintaining leased vehicles and for maintaining records to the motor carrier that has the vehicle subject to its control for 30 consecutive days or more, and the motor carrier is solely responsible for ensuring that the vehicles under its control are in safe operating condition and that defects have been corrected. See , November 22, 2006. 95  Participants and witnesses to the tests included staff from the Safety Board, the FMCSA, Greyhound Bus Lines, MCI, Lancer Insurance, and Bridgestone.

Factual Information 40 Highway Accident Report • Inducing failure of a wheel bearing from lack of lubrication, and • Inducing failure of a wheel bearing by removing the bearing rollers. A 2003 MCI G4500 model motorcoach, fitted with a nonsteering tag axle and Firestone FS400 tires, was used in the tests, which were run on a 7.7-mile circumference oval track at the Firestone proving grounds, Fort Stockton, Texas, on August 26–27, 2006. Test results indicated that • The underinflated tire test temperatures did not increase enough to ignite the tire. • The dry wheel bearing caused a tire fire after about 1.5 laps around the track. • The failed outer bearing led to a fire, which was not permitted to continue and ignite the tire. A portable 20-pound dry chemical ABC fire extinguisher was used in an initial attempt to extinguish the two fires. In the second test, the fire restarted and was temporarily extinguished with a hose line and water; the fire restarted two more times and was finally extinguished with the repeated use of a firefighting hose line and water application. The third test resulted in a fire between the brake shoe and brake drum components; a chemical extinguisher was used to knock down the fire, which reignited. The fire was put out again with the chemical extinguisher and did not reignite. Federal Railroad Administration Research At the Safety Board public hearing, a Federal Railroad Administration (FRA) specialist for passenger train system safety and emergency preparedness testified that, in 1999, the FRA concluded a series of rulemakings on requirements to prevent fire ignition, minimize fire spread and smoke emissions, and maximize the time available for passenger and crew egress, as codified in 49 CFR Part 238 and appendix B. Most combustible materials used in passenger railcars and locomotive cabs, organized by categories and functions, are required to be tested and meet certain flammability and smoke emission criteria. In addition, a structural floor fire endurance test is required. The FRA also submitted the following written testimony: Currently, under the FRA sponsorship, the Volpe (National Transportation Systems) Center is conducting emergency evacuation and fire safety research to assist in determining whether the amount of time available to evacuate a passenger railcar is sufficient, given the amount of time occupants actually need to evacuate safely using the available emergency egress features in a car. The Volpe Center’s research approach is two-pronged. Fire safety-related research findings can assist in determining the amount of available time for evacuation before conditions onboard become untenable due to smoke and fire, and emergency evacuation simulations can be used to predict the amount of time it takes to evacuate cars under various circumstances and in different operating environments. Findings from this research may be used to supplement existing emergency egress standards.

Factual Information 41 Highway Accident Report Appendix E provides additional excerpts from the FRA public hearing submission on passenger railcar fire and safety regulation history. Motorcoach Fires and Research Studies in Germany and Finland On behalf of the German Ministry of Transport, the consulting group DEKRA96 studied 55 motorcoach fires from 1999–2004.97 The study included review of existing regulations for fire testing of materials used in motorcoaches and testing of motorcoach components. DEKRA reported that information on fire testing could be adopted from the railroad sector for use in testing motorcoach construction materials. The study emphasized the importance of early detection and recommended a system of thermodetectors, automatic fire suppression systems, and optical smoke detectors within the passenger compartment. On February 13, 1999, the Accident Investigation Board of Finland began its investigation of a fire in a coach near Tampere, Finland. In autumn 2000, the Accident Investigation Board initiated a bus fire project to obtain bus fire statistics and determine the reasons for recurring fires.98 The study found that a fire that begins outside the passenger compartment may spread into the passenger compartment very quickly and, in the worst case, prevent passenger egress. “Normally the fire moves into the passenger compartment from outside after the flames have broken either the rear window or the side window next to the engine.” The report found no difficulties experienced during the evacuations investigated but acknowledged that “the situation could change significantly if, for example, there are disabled passengers in the vehicle.” Another conclusion, based on the fire incidents reviewed, was that “if the driver has not extinguished the fire, or has not prevented it from spreading, and the firefighters’ arrival time is more than 10 minutes, then the fire will already have moved to the passenger compartment.” The study found that fixed fire-extinguishing/suppression systems are rare in Finland; according to bus company owners and bus body manufacturers, the system’s price is considered to be the main obstacle to its widespread use. The study determined that the extra cost of the system installed in a new bus added about 1.0 percent to the purchase price. One report recommendation was that all new buses be equipped with an automatic or semiautomatic fixed fire-extinguisher system, and another called for bus company owners to provide every driver with first-hand fire-extinguishing training and at regular intervals arrange practice in the use of fire extinguishers and in passenger evacuations.99 96  See , November 14, 2006. 97  Markus Egelhaaf and F. Alexander Berg, Motor Coach Fires: Analysis and Suggestions for Safety Enhancement, Paper Number 05-0094 (Berlin, Germany: Ministry of Transport, 2005). 98  Accident Investigation Board, Bus Fires in Finland During 2000, translation from shortened Finnish version (Helsinki, Finland: 2001). 99  Recommendation numbers D1/00Y/S1 and D1/00Y/S4, respectively.

Factual Information 42 Highway Accident Report DOT Evacuation Research Studies Intercity Buses. On December 1, 1976, the FHWA contracted with the University of Oklahoma to study the evacuation of intercity buses.100 The study was the third in a series to “document the problems with evacuation or escape from automobiles and buses after a crash.”101 Part of the study included a literature review of accident reports, published materials, and research reports. One report recommendation was that emergency exit time standards be developed under different collision configurations and possibly be patterned after existing Federal Aviation Administration (FAA) aircraft exit standards. The evacuation study analyzed three evacuation simulations with a full complement of passengers102 and noted “that there is a great disparity in the total time [in] which each window exit was used for escape and the number of persons escaping.” In comparing escape times to vehicle positioning and lighting conditions, the study explained that “the overall escape times are not comparable because the use of the front door as an exit caused a significant reduction in escape time, particularly for removal of the [injured] passengers.” The study concluded that the maximum time to permit for a bus evacuation cannot be fully determined with the data currently available. However, the standard used by the FAA for aircraft evacuation should be carefully considered, i.e., 90 seconds time [Federal Aviation Administration Regulations 25 CFR Part 803] with one-half the available exits being used. Also included in the report was information about comments submitted to the DOT when Federal Motor Vehicle Safety Standard (FMVSS) 217 was proceeding through the rulemaking phases prior to becoming effective in 1973. One problem noted was the potential for injury to motorcoach passengers when the escape exit used was 7–8 feet above ground level. The Oklahoma University Research Institute suggested the following changes to the proposed FMVSS 217: The maximum allowable force of 60 pounds for opening an emergency exit should be reviewed and push-out windows serving as emergency exits should be required to include a method for keeping them open after they have been initially opened. The reason for the suggestion was that windows falling back on passengers egressing impede egress and can also produce injuries. 100  U.S. Department of Transportation, Federal Highway Administration, Evacuation of Intercity Buses, Oklahoma University Research Institute (Washington, DC: FHWA, 1977). 101  The first two studies focused on all vehicles, including passenger cars and buses. (a) U.S. Department of Transportation, Federal Highway Administration, Escape Worthiness of Vehicles and Occupant Survival, First Part: Research Program, Oklahoma University Research Institute, FH-11-7303 (Washington, DC: FHWA, 1970). (b) Escape Worthiness of Vehicles for Occupancy Survivals and Crashes, Oklahoma University Research Institute, FH-11-7512 (Washington, DC: FHWA, 1972). 102  The three conditions were: the motorcoach in an upright condition in darkness with and without the front door accessible, the motorcoach overturned onto its right side in darkness with the front loading door blocked, and the motorcoach turned on its right side with on-board emergency illumination.

Factual Information 43 Highway Accident Report Paratransit Buses and Vans. In 1984, the DOT published a report on the evacuation and rescue of elderly and disabled passengers from paratransit vans and buses.103 According to the report: To ensure the safety of passengers on paratransit vans and buses, efficient and safe methods of rescuing them are needed. Standard methods are not always useful for these patrons as a result of their physical and mental condition and their insufficient ability to manage self-evacuation. The scope of the research program included the preparedness of emergency rescue personnel and transit operators. The report recognized that “if the vehicle catches fire, the passengers and the driver may have to rely on the immediate help of nearby motorists before professional rescue personnel arrive.” In discussing emergency exits, the report states that push-out windows severely limit use by the elderly and disabled because the “release forces can be high,” and the windows “are not easily releasable from the outside.” Report data from 1984 indicate that 70 percent of all fires in intercity motorcoaches developed in the rear of the bus, particularly in the wheel well and engine compartment (accounting for 40 percent of fires); and that these fires, because of their locations, often grew before they were detected. The report also recognized that motorcoaches contain large amounts of materials capable of supporting combustion and producing smoke and flames.104 FMCSA Stakeholder Forums. In February–March 2003, the FMCSA held a series of five forums to gather stakeholder input regarding the agency’s research agenda and to educate stakeholders about the Office of Research and Technology and ongoing projects. More than 150 recommendations were made by stakeholders to the FMCSA, one of which pertained to vehicle-related research to “study the adequacy of motor coach evacuation plans for disabled and/or wheelchair dependent riders.”105 To date, no research or further information on this proposal has been published. Emergency Evacuation of Civil Aircraft. In July 1977, the FAA published a report on emergency escape of handicapped air travelers,106 which included discussion of a Civil Aeromedical Institute investigation of potential problems related to the emergency evacuation of civil aircraft carrying persons with special needs. The study included an analysis of the movement of individual subjects in an aircraft cabin and the results of 103  U.S. Department of Transportation, Evacuation and Rescue of Elderly and Disabled Passengers From Paratransit Vans and Buses, Report UMTA-MA-06-0152-84-3 (Washington, DC: 1984). 104  Such materials include wooden floors with rubberized coverings, foam insulation and upholstery, fiberglass-reinforced polyester resin body panels and components, and plastic-coated trim panels and wiring harnesses. 105  See, July 20, 2006. 106  U.S. Department of Transportation, Federal Aviation Administration, Emergency Escape of Handicapped Air Travelers, Report FAA-AM-77-11 (Washington, DC: FAA, 1977).

Factual Information 44 Highway Accident Report evacuation tests in which a portion of the test subjects either were disabled or had simulated disabilities. The report concluded: Assisting handicapped passengers in an aircraft cabin is difficult because of space limitations generated by the seat configurations. Fixed armrests, restrictive seat pitch (distance between similar points on seats), and restrictive aisle widths made assistance difficult and interfered with movement. The evacuation tests showed that 96 percent of ambulatory disabled persons reached the exit in 30 seconds or less, though only 37 percent of nonambulatory persons reached the exit in that time. These latter subjects would probably require assistance from other passengers or crew during a critical evacuation; this conclusion, according to the FAA, is in agreement with the results of previous evacuation demonstrations and analyses of accident data, which indicate that passenger movement at a rate of at least 1 foot per second is the minimum required for a successful evacuation. Federal Motor Vehicle Safety Standards The purpose of the DOT’s FMVSSs is to reduce the risk of a vehicle crash by specifying minimum performance levels for brakes, lights, and other components; and to reduce the risk of injury, should a crash occur, by specifying minimum requirements for vehicle performance as related to occupant protection, occupant restraints, roof and body joint strength, fuel system integrity, and child safety systems. FMVSS 301, Fuel System Integrity, was issued to reduce the risk of fatalities and injuries due to fires from motor vehicle crashes. The standard applies to passenger cars, light trucks, and school buses with applicable fuel (boiling point above 32º F). It prescribes impact test requirements to strengthen and protect the vehicle’s fuel system and to reduce the likelihood of fuel-fed fires caused by fuel system breaches into the vehicle. FMVSS 301 does not apply to buses with a gross vehicle weight rating over 10,000 pounds or to motorcoaches. FMVSS 302, Flammability of Interior Materials, was issued to reduce the deaths and injuries to motor vehicle occupants caused by vehicle fires, especially those originating in the interior of the vehicle from sources such as matches and cigarettes. This standard specifies burn resistance requirements for materials used in the occupant compartments of motor vehicles. It applies to passenger cars, multipurpose passenger vehicles, trucks, and buses. Emergency Evacuation of Persons With Special Needs Federal, State, and local governments, as well as individual health care facilities, have plans for responding to emergencies such as hurricanes. At the Federal level, the National Response Plan (NRP)107 provides the framework for how the Federal government 107  As established by Homeland Security Presidential Directive 5, the NRP is intended to provide a single comprehensive approach to domestic incident management to prevent, prepare for, respond to, and recover from terrorist attacks, major disasters, and other emergencies.

Factual Information 45 Highway Accident Report will assist States and localities in managing domestic incidents. The National Disaster Medical System (NDMS),108 an NRP program, includes assistance to State and local governments specifically with evacuation of hospital residents. Neither the NRP nor the NDMS addresses the evacuation of residents in nursing homes or assisted living centers, rehabilitation facilities, or hospice care. Nursing home residents fall within the broad category of populations that face particular challenges during emergencies. Nursing homes that participate in Medicare and Medicaid must comply with standards established by the HHS Centers for Medicare and Medicaid Services (CMS), which include requirements that they have plans to meet potential emergencies and disasters; the interpretive guidelines do not specifically refer to evacuation of residents. According to a July 2006 Government Accountability Office (GAO) report to Congress on evacuation of health facilities during disasters, CMS officials have established a working group to review hospital and nursing home requirements for emergency preparedness, including issues related to evacuation.109 At the Safety Board public hearing, participants discussed a range of issues concerning emergency preparedness for persons with special needs. The director of the emergency preparedness initiative for the National Organization on Disability, a witness at the hearing, defined persons with special needs as “people with disabilities, mobility impairments, sensory impairments, [or] cognitive or mental health impairments.” The senior director of the Florida Health Care Association Quality Credentialing Foundation explained at the public hearing that sheltering in place is often preferable to evacuating nursing home residents because of the risk of transporting the medically frail. Other hearing participants also stressed the difficulty of obtaining appropriate evacuation transportation in an emergency. Once the decision to evacuate is made, numerous factors have to be considered, such as the medical, mobility, and mental conditions of each individual. These factors affect the optimum mode of transportation, which in some cases will be ambulance. During a large-scale evacuation, such as those typical of a hurricane response, hospitals and other facilities for acutely ill individuals are prioritized for the limited number of ambulance and similar transportation assets in the community. Included in the public hearing was discussion of how the lack of coordination among State emergency response agencies and the lack of interstate emergency mutual aid agreements could hamper the effectiveness of evacuating persons with special needs. Texas Evacuation of Persons With Special Needs. When Hurricane Rita approached the Texas Gulf Coast, government and private entities began considering the evacuation of coastal areas. According to the Texas Building and Procurement 108  The NDMS—a partnership of the U.S. Department of Homeland Security (DHS), U.S. Department of Defense, U.S. Department of Health and Human Services (HHS), and U.S. Department of Veterans Affairs—can be activated to assist in medical response and patient evacuations. Within the NDMS, the DOT is responsible for patient evacuation from mobilization centers (airfields) to Federal coordination centers and medical facilities. 109  Government Accountability Office, Disaster Preparedness Limitations in Federal Evacuation Assistance for Health Facilities Should be Addressed, GAO-06-826 (Washington, DC: GAO, 2006) 17. See , September 26, 2006.

Factual Information 46 Highway Accident Report Commission (TBPC), it was tasked during a September 19, 2005, State Operations Center meeting with procuring 1,100 buses and motorcoaches for the evacuation of persons in levels 1 through 3 of special needs assistance.110 The TBPC contacted the American Bus Association, the United Motorcoach Association, and the Texas Bus Association for assistance in fulfilling this procurement. The TBPC eventually contracted with 48 charter bus and motorcoach companies, which provided 307 charters; it had attempted to obtain handicap-accessible buses and motorcoaches, with the objective of having one-third of the vehicles be compliant with the Americans With Disabilities Act (ADA).111 When a government or private entity requested evacuation transportation assistance via the State of Texas Emergency Operations Center, the TBPC was contacted to dispatch motorcoaches from one of the three staging areas under TxDPS control. Some specialty buses and motorcoaches were available to accommodate passengers with special needs. The TBPC stated that it was able to meet all transportation requests made through the operations center during the emergency. Sunrise management stated that they were not aware of the State’s TBPC transportation assistance when they chartered through BusBank. Since Hurricane Rita, the TBPC has entered into contingency contracts with carriers for 1,020 buses and motorcoaches.112 It has also awarded a contingency contract for bus transportation management services113 to Coach USA, LLC (CUSA).114 In the event of an emergency, CUSA is to provide logistical support, dispatch services, and an additional 80 motorcoaches. CUSA representatives will work from the State Emergency Operations Center 24 hours a day and provide support at staging areas. CUSA will have direct technical supervision over carriers during the evacuation process and is responsible for ensuring that buses and motorcoaches are appropriately equipped for the assigned mission, including having necessary ADA accommodations, sufficient fuel, functioning air conditioning, and on-board toilets and safety equipment. Texas Task Force on Evacuation, Transportation, and Logistics. In October 2005, the Governor of Texas appointed a 14-member task force to document lessons learned from the hurricane evacuation and to make recommendations for improving 110  Texas categorizes special needs individuals under five levels of increasing assistance. Level 1: dependent on others for routine care, such as eating, walking, and toileting; level 2: disabilities such as hearing or vision impairment; level 3: assistance with medical care administration or dependent on equipment; level 4: living outside an institutional facility care setting but requiring extensive medical oversight, such as needing a ventilator or life support assistance; and level 5: needing the highest level of care and living in an institutional setting. 111  The TBPC said that it considered using school buses and municipal mass transit but determined that this was not feasible because of the long distances likely to be traveled during a major evacuation, as well as fueling considerations. 112  The State of Texas has identified the need for 1,100 motorcoach-type buses to evacuate its special needs populations. One-third of the contracted vehicles must be ADA compliant. 113  The motorcoach contracts require that contractors provide copies of their insurance and have a satisfactory FMCSA safety rating. The contractors may not have existing contingency contracts that would take precedence over the State of Texas contract. 114  CUSA, operating under the Coach USA brand name, is one of the Nation’s leading providers of motorcoach services.

Factual Information 47 Highway Accident Report evacuation plans and execution. On February 14, 2006, the task force issued its final report,115 including information from public hearings held with stakeholders such as evacuees, local and State officials, charitable organizations, relief and hospital workers, medical personnel, and individuals with special needs and their caregivers. The task force found that Texas does not clearly assign responsibility for identifying, transporting, and sheltering individuals with special needs. To address this problem, it recommended that the Governor “direct the development and implementation of a statewide special needs evacuation and shelter plan.” The task force noted that care should be taken to ensure that the plan includes citizens with special needs who do not live in an institutional environment and that officials should maintain a database of citizens with specials needs to ensure proper planning and execution of their evacuation. Officials should also document those facilities or residences where medical or handicap-accessible vehicles will be required during an evacuation. The report indicated that some Texas facilities in which individuals with special needs reside do not have evacuation plans, and some that do have plans may not have ensured that they are adequate and up to date. The task force recommended that the Governor “direct all licensed and unlicensed special needs facilities to maintain evacuation plans that have been approved by the local jurisdiction and the Regional Unified Command” and update them annually. Governor Executive Order RP-57, issued on March 21, 2006,116 directed the implementation of the task force recommendations. Federal Evaluation of Catastrophic Hurricane Evacuation Plan After Hurricanes Katrina and Rita struck the Gulf Coast in 2005, Congress asked the DOT, in cooperation with the DHS, to “review and assess Federal and State evacuation plans . . . for catastrophic hurricanes and other catastrophic events impacting the Gulf Coast region.” The DOT issued its report to Congress on June 1, 2006.117 The report covered the evacuation of persons with special needs and the broader topic of the roles of Federal, State, and local governments in evacuations. Based on its evaluation of State and local evacuation plans in each of the five Gulf Coast States (Alabama, Florida, Louisiana, Mississippi, and Texas), the DOT determined that “a significant majority of the evacuation plans were judged to be either marginally or partially effective regarding provisions for evacuating persons with various special needs.”118 In particular, the report noted that the plans do not have detailed information on precisely how to evacuate special needs populations or what additional resources are necessary to do so. Furthermore, the evacuation plans of residential facilities are often not coordinated with emergency management authorities and may not function adequately within the larger evacuation framework. 115  See , September 26, 2006. 116  See , September 26, 2006. 117  See , September 26, 2006. 118 U.S. Department of Transportation and U.S. Department of Homeland Security, Catastrophic Hurricane Evacuation Plan Evaluation: A Report to Congress (Washington, DC: DOT, 2006) 4-3.

Factual Information 48 Highway Accident Report The DOT is developing a primer on evacuating populations of persons with special needs, which is intended to include essential information and technical assistance for State and local authorities, as well as for nongovernment entities charged with evacuating and sheltering people with special needs. A DOT inventory of more than 100,000 buses and motorcoaches nationwide is available for evacuation use. The DOT is working with the American Bus Association to index the capabilities of this inventory, including wheelchair compatibility, as well as the number and location of evacuation-ready vehicles and drivers. The DOT report to Congress made several recommendations to improve mass evacuation planning and implementation, including joint development of regional mass evacuation plans by State and local authorities, with Federal agency input; involvement of nursing homes and other representatives of persons with special needs, as well as transportation agencies and operators, in the development of regional plans; and cooperation of State and local authorities in working with communities to develop systems to provide specialized transport or shelter during such events.119 (See appendix F for Federal special needs evacuation recommendations.) GAO Report on Disaster Preparedness On July 20, 2006, the GAO issued a report on the evacuation of hospitals and nursing homes during disasters,120 indicating that the 2005 Hurricane Katrina response propelled the study. The report focused on the deficiencies of the NRP and the NDMS with respect to evacuating nonhospital health facilities, such as nursing homes and long- term care facilities. One of the main problems the GAO identified was the difficulty of arranging evacuation transportation. Even when facilities had contracts with transportation providers, “competition for the same pool of vehicles created supply shortages.”121 Neither the NRP nor the NDMS was designed to help State and local governments evacuate healthcare facilities other than hospitals. The report also noted two limitations of the NDMS that negatively affect its capability of assisting State and local governments with patient evacuation: • NDMS evacuation efforts begin at a mobilization center, such as an airport, and do not provide for ambulances or other means of short-distance transportation necessary to move residents from healthcare facilities. • The NDMS was not set up to handle the emergency transportation of persons with special needs who are not hospitalized, including nursing home residents.122 The GAO report called for executive action to clearly delineate how the Federal Government would assist State and local authorities in transporting hospital and nursing home occupants to mobilization centers (such as airports), where NDMS transportation 119  Catastrophic Hurricane Evacuation Plan Evaluation: A Report To Congress, ES-11 and ES-12. 120  Disaster Preparedness: Limitations in Federal Evacuation Assistance for Health Facilities. 121  Disaster Preparedness: Limitations in Federal Evacuation Assistance for Health Facilities, 4–5. 122  Disaster Preparedness: Limitations in Federal Evacuation Assistance for Health Facilities, 15–17.

Factual Information 49 Highway Accident Report responsibilities begin. It further recommended that the NDMS Federal partner agencies work together to determine how best to address the needs of nursing home residents during emergency evacuations. (See appendix F for Federal special needs evacuation recommendations.) Lessons Learned From Federal Response to Hurricane Katrina Following Hurricane Katrina, the Federal Government formally reviewed its response to this natural disaster. The Assistant to the President for Homeland Security and Counterterrorism submitted to the President The Federal Response to Hurricane Katrina: Lessons Learned report in late February 2006.123 The report included a section on the evacuation of populations of persons with special needs. Among FEMA’s critical challenges, as listed in the report, was providing buses and motorcoaches in coordination with the DOT, as provided in the NRP’s Emergency Support Function (ESF) #1, Transportation.124 The White House report made 125 recommendations for improving future Federal responses to disasters, 3 of which concern evacuation, as summarized below: • Because of shortcomings in the Federal Government’s coordination of transportation during the Hurricane Katrina evacuations, the DOT should be designated as the primary Federal agency for conducting evacuations when State and local government resources are overwhelmed, and the DOT should conduct drills for undertaking this responsibility. • The DHS should require State and local governments to “develop, implement, and exercise” plans for emergency evacuations. • The DHS should also evaluate the evacuation plans of all States, as well as of the 75 largest urban areas in the United States. See appendix F for Federal special needs evacuation recommendations. 123  The White House, The Federal Response to Hurricane Katrina: Lessons Learned (Washington, DC: 2006). See , September 26, 2006. 124  The Federal Response to Hurricane Katrina: Lessons Learned, 56.

50 Highway Accident Report Analysis The Safety Board considered the circumstances of the accident and several factors that may have been causal to the motorcoach fire, in addition to identifying safety issues related to vehicle fire reporting and inconsistent data within Federal accident databases, the FMCSA compliance review program, emergency egress from motorcoaches, fire resistance of motorcoach materials and designs, manufacturer maintenance information on wheel bearing components, transportation of partially pressurized aluminum cylinders, and emergency transportation of persons with special needs. Following a brief discussion of factors that were determined not to be causal to the accident, this analysis discusses causal factors and other safety issues. Exclusions The weather was clear and dry at the time of the accident. No defects in the highway or road design were found that would have caused or contributed to the accident. Although the hurricane evacuation was the reason for the trip, the Safety Board concludes that neither the weather conditions at the time nor the design and condition of the roadway caused or contributed to the accident. Following the accident, the motorcoach driver was not tested for alcohol because the Dallas County Sheriff’s officers detected no evidence of alcohol use or impairment. Although 49 CFR Part 382 required Global to conduct postaccident testing for alcohol and illicit drugs, the company failed to do so; therefore, the Safety Board could not determine whether the driver was under the influence of alcohol or illicit drugs at the time of the accident. Because the motorcoach driver had been on duty for over 24 hours and had been driving consistently in heavy traffic for about 12 hours, it is highly unlikely that he had the time or the means by which to consume alcohol or illicit drugs. According to the FMCSA, Global is no longer in operation; nevertheless, the Safety Board is disappointed that the company failed to fulfill its responsibility for testing the driver for alcohol or illicit drugs following the accident. Although the motorcoach driver stated that he had been diagnosed with type 2 diabetes and was under a physician’s care in Mexico, neither he nor his employer provided the Safety Board with objective documentation regarding his condition. Therefore, the Safety Board concludes that a determination could not be made regarding the potential impact of the motorcoach driver’s medical condition on his response to the emergency. When the fire occurred about 6:07 a.m. on September 23, 2005, the motorcoach driver had been on duty for just over 25 hours, and 21 hours of this time was spent driving. In addition, the fire occurred at a time of day when even well-rested individuals with daytime work hours (such as the accident driver) experience the lowest levels of alertness

Analysis 51 Highway Accident Report and performance. Scientific research has shown that fatigue is related to much more than just the time spent on a task,125 such as driving. Researchers have studied factors that affect fatigue, such as duration and quality of sleep,126 shift work, work schedules,127 circadian rhythms,128 and time of day.129 Cumulative sleep loss and circadian disruption, which the accident driver may have experienced during the Hurricane Rita evacuation emergency, can lead to a physiological state characterized by impaired performance and diminished alertness.130 Nonetheless, investigators determined that the wheel bearing fire occurred independent of the driver’s condition or actions. The Safety Board therefore concludes that the motorcoach driver was fatigued at the time of the tire fire, but his fatigue was not a causal factor in the accident. When the driver arrived in Bellaire at 11:00 a.m. on September 22, from Pharr, Texas, he had been driving for 6 hours. He began driving again between 3:00 and 3:30 p.m., when he left Bellaire, heading to Dallas. By 7:00 p.m., the motorcoach driver had reached the FMCSA-permitted hours-of-service threshold of 10 hours of driving. Thus, during the remainder of the time that he was driving, from 7:00 p.m. on September 22 until 6:00 a.m. on September 23, when the accident occurred, the driver exceeded the hours of service by 11 hours. Title 49 CFR 395.5 prohibits a passenger-carrying driver from driving more than 10 hours until being off duty for at least 8 consecutive hours; however, the regulations also state that a driver, in case of any emergency, may complete his or her run without being in violation of the provisions of the regulations, if such run reasonably could have been completed absent the emergency. The expected trip from Bellaire to Dallas was 4 hours, which would have concluded (absent the emergency situation of the hurricane evacuation) within the driver’s hours of service. Further, the Governor of Texas issued a proclamation on September 23, 2005, exempting all carriers and drivers involved in, and caught in, the hurricane evacuation from the hours-of-service regulations violations. Suspending the trip until the driver could obtain sufficient rest was 125  M. H. Kryger, T. Roth, and W. C. Dement, eds., Principles and Practice of Sleep Medicine (Philadelphia, PA: W. B. Saunders Company, 1994). 126  (a) L. C. Johnson and P. Naitoh, The Operational Consequences of Sleep Deprivation and Sleep Deficit, AGARD-AG-193 (London, U.K.: North Atlantic Treaty Organization, 1974). (b) M. R. Rosekind, P. H. Gander, L. J. Connel, and E. L. Co, Crew Factors in Flight Operations, X: Alertness Management in Flight Operations, NASA/FAA Technical Memorandum DOT/FAA/RD-93/18 (Washington, DC: National Aeronautics and Space Administration, 1994). (c) National Transportation Safety Board, Factors That Affect Fatigue in Heavy Truck Accidents, Safety Study NTSB/SS-95/01 and /02 (Washington, DC: NTSB, 1995). 127  (a) S. Folkard, T. H. Monk, and M. C. Lobban, “Towards a Predictive Test of Adjustment to Shiftwork,” Ergonomics, Vol. 21 (1979): 785–799. (b) G. R. Thomas, T. G. Raslear, and G. I. Kuehn, The Effects of Work Schedules on Train Handling Performance and Sleep of Locomotive Engineers: A Simulator Study, DOT/FRA/ORD-97-09 (Washington, DC: Federal Railroad Administration, 1997). 128  M. H. Kryger, T. Roth, and M. Carskadon, “Circadian Rhythms in Humans: An Overview,” Principles and Practice of Sleep Medicine (Philadelphia, PA: W. B. Saunders Company, 1994) 301–308. 129  C. D. Wylie, T. Schultz, J. C. Miller, and others, Commercial Motor Vehicle Driver Fatigue and Alertness Study: Project Report, FHWA-MC-97-002 (Washington, DC: Federal Highway Administration, 1996). 130  M. R. Rosekind, R. C. Graeber, D. F. Dinges, and others, Crew Factors in Flight Operations, IX: Effects of Planned Cockpit Rest on Crew Performance and Alertness in Long-Haul Operations, NASA Technical Memorandum 108839, DOT/FAA/92/94 (Washington, DC: National Aeronautics and Space Administration, 1993).

Analysis 52 Highway Accident Report not a viable option due to the impending hurricane and immense traffic delays and the lack of facilities for parking a motorcoach occupied by persons with special needs, including two who were reliant on a limited supply of medical oxygen. The initial 911 calls provided an inaccurate location for the motorcoach accident, the Wilmer dispatch office had only one dispatcher on duty to handle all emergency calls, and the route to the accident was heavily congested with evacuation traffic. Nonetheless, several officers and deputies from the Wilmer Police Department and the Dallas County Sheriff’s Office were on scene within minutes. The first emergency call was received at 6:07 a.m., and by 6:15 a.m., within 8 minutes, the fire had spread so extensively that the motorcoach was inaccessible for evacuation of the remaining passengers. Despite the initial setback to the arrival of the Wilmer Fire Department, the emergency dispatch of personnel and equipment and the arrival of law enforcement officers on scene were not unduly delayed. Once the firefighters arrived about 6:24 a.m., they promptly began to extinguish the fire, thereby preventing its spread to surrounding areas and vehicles. Postaccident, the city of Wilmer installed an updated automated dispatch system to more effectively handle heavy call volumes and dispatching in emergencies. Although only a few minutes were available for the rescue of passengers from the motorcoach, the on-scene medical care and preparation for transport to hospitals were prompt and efficient. Therefore, the Safety Board concludes that appropriate resources were dispatched to the accident scene, that responders and medical personnel arrived as quickly as possible, considering the heavily congested roadways and the initially erroneous information about the accident location, and that the injured received medical care and were transported to local hospitals in a timely manner. Accident Discussion The Safety Board identified several factors indicating that the motorcoach caught on fire because of a lack of lubrication of the right-side tag axle wheel bearing, wheel bearing failure, and subsequent ignition of the tire. Among these factors were physical evidence from the scene and vehicle, along with interviews of Global’s owner and the accident motorcoach driver. The Safety Board examined why the accident motorcoach driver, and the mechanic who provided roadside assistance on the day of the accident, did not recognize the first flat tire as an indication of an underlying mechanical issue with the vehicle. The motorcoach driver was initially alerted to the flat tire when he heard the tire blow out, and he took prudent action in pulling the motorcoach onto the interstate shoulder for the tire change. Because the flat tire occurred during the nighttime and in the middle of hurricane evacuation traffic congestion, the driver and the mechanic would not necessarily have been aware of the tire marks left by a locked wheel. When the driver assisted the mechanic by taking the flat tire and placing it into the spare tire compartment, the flat spot on the tire and wheel should have been noticeable under proper lighting conditions.

Analysis 53 Highway Accident Report However, in the circumstances that existed at the time of the tire change, even a careful driver may not have made the connection that the flat wheel rim was caused by a locked wheel dragging—and not by pulling off onto the shoulder with an already flattened tire that was exposed to contact between the rim and the road surface. The Safety Board does not believe that a motorcoach driver, when involved in the same evacuation situation with similar environmental conditions as were present at the time of the tire change, would necessarily suspect a potentially hazardous mechanical malfunction beyond a flat tire. Moreover, given the 5 minutes during nighttime hours in which the mechanic changed the tire, as well as the urgency to move the motorcoach, which was partially blocking hurricane evacuation lanes, the mechanic did not have the opportunity to assess what conditions may have led to the flat tire. The Safety Board also considered whether construction of the motorcoach contributed to the rapid propagation of the fire and whether motorcoach emergency egress systems afforded safe evacuation to occupants. Heat Source and Fire Ignition The Navarro County Sheriff’s Department received a call for the motorcoach flat tire at 3:22 a.m. on September 23, 2005, near Rice, Texas. Postaccident examination of the motorcoach and roadway revealed that the right-side tag axle (3R) tire locked just south of FM 1126, leaving 6,800 feet of tire marks on the I-45 road surface. When the 3R tire locked, the portion of the tire contacting the pavement was being pulled—not rolling— which caused the blown tire. Once the tire flattened, the weight of the vehicle caused contact between the pavement and wheel rim, wearing a flat spot on the rim. The driver heard the right-rear tire blow out, and he pulled off the roadway. The mechanic who responded to the call for roadside assistance finished the tire change by about 4:30 a.m.; however, he did not notice the locked wheel and replaced the blown tire with the motorcoach spare tire. Once the tire was changed, the Rice police officer advised the driver and the mechanic to drive their vehicles to the next exit to complete payment. Afterward, the motorcoach driver reentered I-45 and continued driving north.131 Less than 1 hour later, a motorist observed that the right-rear wheel was glowing orange-red and stopped the motorcoach driver to inform him of the problem. The driver moved the motorcoach across the lanes of travel, pulled off onto the shoulder, exited the vehicle, and immediately observed flames in the right wheel well. The Safety Board determined that the accident sequence of events began with a lack of lubrication in the right-side tag axle wheel bearings, which ultimately led to the tire fire. A wheel bearing unit can fail when it lacks lubrication, which prevents the bearing rollers from rotating freely and leads to friction, which in turn begins to generate heat. The 131  When wheel bearings seize and lock a wheel, it is possible that after a short period of cooling (such as might have taken place while waiting for the mechanic) the bearing rollers will reposition, allowing the hub and wheel to rotate again. The 3R wheel may also have rolled again due to the rollers being jarred when the motorcoach was placed on jacks, thereby allowing the applied spring brake to reposition both the 3R wheel and the rollers enough to allow the vehicle to move forward. Once the motorcoach reentered I-45 north, the temperature in the 3R wheel components, including the hub assembly, began to rise again.

Analysis 54 Highway Accident Report heat increases metal temperatures, causing deformation of the bearing rollers. The wheel bearings on the accident motorcoach were subjected to increased temperatures as they continued to support the weight (load) of the vehicle. As the roller metal began to degrade, the rollers started to flatten, disintegrate, and break down metallurgically. To deform and flatten, the rollers had to be subjected to temperatures of at least 1,000º F. The flattening of the rollers allowed them to be expelled from the bearing cages; the rollers then began to slide around within the bearing cup, and the bearing components lost concentricity around the axle spindle. Because the flattened rollers no longer supported the weight of the motorcoach and no longer maintained evenly spaced wheel assembly parts, they continued to degrade and caused the wheel, hub, and rotor assembly to shift out of position. The outer edge of the brake rotor made contact with the underside of the disc brake carrier and caliper bridge. Heat and deformation caused some of the rollers to fuse, preventing the rotation of the wheel and hub and changing the orientation of the brake rotor and hub assembly, which caused contact with the foundation brakes. One witness at the Safety Board public hearing, the senior director of the North American brake business unit for ArvinMeritor, explained that as the wheel bearings continued to deform and increase friction within the wheel, the out-of-position brake rotor and hub assembly caused contact between the brake parts. With the rotor, carrier, and caliper bridge now in contact, the rotor began to grind against the stationary disc brake carrier and caliper bridge. This contact then increased the friction, which caused an increase in metal component temperatures and a rise in air temperatures within the wheel well surrounding the rubber tire. Friction from the grinding transferred heat to the wheel hub, which became visible as the bright red glow seen by the witness who stopped the motorcoach and warned the driver. This friction, coupled with the frictional forces generated by the turning rotor contacting the brake shoes, was enough to lock and prevent turning (rolling) of the 3R wheel (also referred to as “seizing”) at highway speeds.132 At some time in this sequence, the aluminum hubcap melted off the hub end; this event would have occurred when the hubcap reached an approximate temperature of 1,150º F, at which point some of the hot and deformed rollers from the outer bearing cup were expelled from the hub and landed on the pavement.133 As noted by the ArvinMeritor representative, when the motorcoach came to rest, the now deflated tire came in contact with an area that “clearly had metal temperature in excess of the temperature required to ignite the rubber tire” (greater than 800º F). Safety Board tire fire testing conducted in August 2006 produced similar results when a motorcoach was run on a test track with wheel bearings lacking lubrication. The bearings failed, and the brake components overheated and subsequently came in contact with a blown tire, causing it to ignite. Thus, the Safety Board postaccident investigation showed that the right-side tag axle (3R) wheel hub assembly was the cause of the motorcoach fire. The Safety Board concludes that the accident motorcoach was mechanically unsafe because the right-side 132  In effect, this action binds the wheel to the axle. 133  These rollers were found by Safety Board investigators on the pavement in the area of the grass fire, approximately 3.2 miles south of the accident location.

Analysis 55 Highway Accident Report tag axle wheel bearing assembly lacked sufficient lubrication, which resulted in high frictional forces and high temperatures, causing the wheel bearings to fail and igniting the tire. Motorcoach and Bus Fire Data After this accident, the Safety Board was given access to insurance data from two companies and to the analyses performed by two large self-insured passenger-carrying motor carriers. Although these sources provided considerable data on motorcoach and bus fires, the databases do not cover the entire spectrum of bus fires. Local fire departments report vehicle fires to the States, and the States then report the data to the NFPA. However, the reporting requirements vary; and the definition of buses is broad, thus making it difficult even to search the NFPA data for information on motorcoach fires. Further, police agencies use the ANSI Manual on Classification of Motor Vehicle Traffic Accidents, which defines traffic accidents as involving motor vehicles in transport on a trafficway.134 Motorcoach or bus fires that are not caused by vehicle collisions or do not originate while the vehicle is on the roadway are often not included in these databases. As a result, major highway safety accident data files, such as NHTSA’s FARS and GES, which collect data from police reports, do not capture the entire motorcoach or bus fire problem. Other inconsistencies in fire reporting data are apparent as well. For example, the GES database listed only two motorcoach accidents from 1995–2003 that involved fires. The FARS data for 1994–2004 revealed 24 fatal motorcoach fires, a finding inconsistent with the GES data. Further, the FMCSA’s MCMIS data from 1995–2005 reported 265 motorcoach fires, of which 4 involved fatalities. The MCMIS accident file was developed to allow research on motor carrier safety problems and to potentially provide a census of all trucks and buses involved in traffic accidents. In 2002, the Safety Board noted the FMCSA’s acknowledgement that not all accidents were reported for inclusion in the MCMIS,135 even though the accident file is intended to be a census of fatal injury- and property damage-only accidents. Although the accident file contains State-supplied data from police reports involving drivers and vehicles of all motor carriers operating in the United States, an FMCSA evaluation of the database found that the overall reporting level of fatal and nonfatal involvements was lower than expected for both trucks and buses, at 63 percent and 44 percent, respectively. As a result, the FMCSA has contracted with the University of Michigan Transportation Research Institute to monitor and evaluate improvements in accident reporting by the States and resulting effects on the quality of MCMIS data. At the Safety Board public hearing, the FMCSA reported that it has recognized the difficulty in obtaining meaningful motorcoach and bus fire data and has contracted with the Volpe Center to gather data and studies relating to motorcoach fires, set up a database or spreadsheet system to structure the data, and analyze the motorcoach and bus fire 134  Manual on Classification of Motor Vehicle Traffic Accidents, section 2.4.18. 135  National Transportation Safety Board, Analysis of Intrastate Trucking Operations, Safety Report NTSB/SR-02/01 (Washington, DC: NTSB, 2002).

Analysis 56 Highway Accident Report problem, including causes, frequency, and severity.136 Although the Safety Board supports this initiative and looks forward to the anticipated completion of the Volpe study in March 2007, the Board is concerned that the gathering and analysis of bus and motorcoach fire data by the FMCSA Volpe contract will not provide for ongoing statistical compilation and study. The Safety Board concludes that continuing analysis of motorcoach and bus fire data is vital to understanding not only the trends in these vehicle fires, but also the success or shortcomings of measures taken by the Government and private industry to address this problem. Therefore, the Safety Board believes that the FMCSA should establish a process to continuously gather and evaluate information on the causes, frequency, and severity of bus and motorcoach fires and conduct ongoing analysis of fire data to measure the effectiveness of the fire prevention and mitigation techniques identified and instituted as a result of the Volpe National Transportation Systems Center fire safety analysis study. Fire Propagation Into Fuel Sources When fire burns in a confined space, the heat feedback from surroundings causes the material to burn more intensely. In this accident, the heat radiated by the glowing hub components and the confinement of the rubber tire within the wheel well significantly increased the rate at which the fire burned. From the burning 3R tire, the fire spread to adjacent tires, to other combustible wheel well area components,137 and to the composite exterior of the motorcoach. In addition, significant amounts of diesel fuel from the fuel delivery system became involved and accelerated the spread of the fire during the incipient stage. In the accident motorcoach, the fuel lines were routed through a centerline tunnel in the undercarriage. Two small access panels made of a combustible material separated the fuel lines from the wheel well. One access panel was completely consumed by fire, and the other was partially melted and deformed. The thermoplastic fuel lines were completely consumed by fire from the engine compartment to a point within 1 foot of the fuel tank. In motorcoaches, fuel lines located near engine compartments and service tunnels can burn through and provide volatile fuel to an existing fire, causing a significant increase in the fire hazard. In this accident, burnthrough occurred once the tire fire breached the two combustible access panels to the service tunnel and the fuel lines in the engine compartment. Therefore, the Safety Board concludes that, because of the proximity of the combustible access panels to the tire wheel well, where the fire originated, the fuel delivery system contributed to acceleration of the fire. Replacement of the combustible access panel with a fire-resistant barrier might preclude the early involvement of fuel in a fire in the wheel well area and thereby limit the rate of fire spread. NHTSA has developed a fuel system crashworthiness standard (FMVSS 301) to limit the amount of fuel spill as a result of an accident and thus reduce the chance of a catastrophic postcrash fire. However, this FMVSS does not apply to motorcoaches. Therefore, the Safety Board believes that NHTSA should develop an 136  Motor Coach Fire Safety Analysis Work Plan. 137  These components include bushings, mud flaps, and suspension system air bags.

Analysis 57 Highway Accident Report FMVSS to provide enhanced fire protection of the fuel system in areas of motorcoaches and buses where the system may be exposed to the effects of a fire. During the Safety Board’s public hearing, the office director for the rulemaking section of NHTSA’s Crashworthiness Standards Division stated that FMVSS 302138 is a performance (not design) requirement that “allows the latitude of the manufacturers so that the motorcoach, or any other type of a motor vehicle manufacturer, has the latitude to develop any innovative technologies.” Accordingly, until NHTSA has developed a performance standard for enhanced fire protection of fuel systems in newly manufactured motorcoaches and included it in the FMVSSs, as requested in Safety Recommendation H-07-4, the Safety Board believes that manufacturers of motorcoaches for use in the United States should use materials and designs for fuel system components that are known to provide fire protection for the system. Fire Propagation Into Passenger Compartment The most likely point of initial entry of a fire into a motorcoach is burnthrough of the combustible exterior composite materials just above the passenger-side rear wheel well area, followed by movement into the passenger compartment via both the HVAC system and the windows. In the case of a tire fire, the geometry of the wheel well and the buoyant nature of fire cause the flames to impinge on the sidewall; this exposure to severe heat is what leads to burnthrough of the combustible sidewall materials. In the accident motorcoach, the panels inside the wheel well area (those facing the roadway) were lined with stainless steel, which acted as a barrier to the fire. However, as the fire intensified above the wheel well, it burned through the exterior composite material and underlying sidewall foam insulation. The HVAC ventilation ductwork that ran along the sides of the motorcoach at the floor level opened a path for the fire and smoke, as evidenced by the destroyed recirculation duct in the right-rear wheel area and the aluminum return ducts and adjoining parts that showed signs of severe heat exposure. The missing sections had been located above the wheel well areas on both sides of the motorcoach. During the public hearing, the senior technical advisor for the motorcoach manufacturer MCI noted that body panels on coaches have been made of aluminum, steel, or fiberglass for many years and that both aluminum and fiberglass are combustible materials. The MCI representative further stated, “We provide an interior inner fender barrier between the tire area and the passenger compartment. It is always made out of stainless steel.” He explained that the exterior of the vehicle is the most prominent path of fire into the interior as flames travel up the outside and past the windows, superheating the windows and causing them to break, allowing entry into the passenger compartment. The burnthrough of the exterior wall allowed the fire’s intense heat and smoke— byproducts of the burning tires, foam, and fiberglass—to enter the passenger compartment, where interior components also began to catch on fire. The propagation of the fire into the passenger compartment and the burning of interior components caused an exponential increase in the production of smoke and heat and accelerated the fire. The 138  This standard specifies burn resistance requirements for materials used in the occupant compartment of motor vehicles.

Analysis 58 Highway Accident Report Safety Board concludes that the tire fire, caused by an overheated right-side tag axle wheel bearing assembly, which ignited the tire, spread up the side of the motorcoach and burnt through the fiberglass sidewall above the wheel well and through the motorcoach windows, creating an entry path for the smoke and fire into the passenger compartment. The Federal standard for flammability of interior materials, FMVSS 302, does not apply to the exterior of motor vehicles.139 The standard evaluates a material’s capability of resisting ignition and flame spread when exposed to a small ignition source, such as a match or a lit cigarette. It does not represent fire conditions where significant preheating of the material occurs and the ignition source is large. Additionally, the standard only tests materials in the horizontal orientation, which is a far less challenging test than the vertical orientation. MCI’s senior technical advisor stated during the public hearing that MCI uses materials throughout the coach, including exterior sidewall components, that comply with FMVSS 302. However, as is clear from this accident, the compliance of the exterior sidewall materials to this standard was inconsequential to resisting the rapid propagation of the fire, which impeded the passengers’ ability to safely evacuate. Therefore, the Safety Board concludes that the exterior of the motorcoach had not been fire-hardened in fire- prone areas, such as around the wheel wells, and was not required to be by regulation, thereby limiting the time available for safe egress in the event of a fire. The Safety Board believes that NHTSA should develop an FMVSS to provide fire-hardening of exterior fire-prone materials, such as those in areas around wheel wells, to limit the potential for flame spread into a motorcoach or bus passenger compartment. Tire Fires and Fire Suppression Systems As several witnesses at the Safety Board public hearing explained, and as documented during the motorcoach tire fire testing in August 2006, it is extremely difficult, and beyond the capacity of any practical, currently available hand-held chemical extinguisher or automatic fire suppression system, to completely extinguish a burning tire. Although the accident motorcoach driver was not able to unlatch the 5-pound dry chemical fire extinguisher, this type of fire extinguisher, as noted during the public hearing and the tire fire testing, cannot extinguish a tire fire and therefore would not have made a difference in this accident. Various manufacturers currently sell automatic fire detection and suppression systems for transit and intercity motorcoaches140 that target engine compartment and electrical system fires. According to the testimony of an MCI senior technical advisor at the public hearing, the number of MCI motorcoaches being sold with fire suppression systems has increased.141 These systems generally employ spot heat detectors and a fire suppression agent distribution network with individual nozzles near the heat sensors. 139  Title 49 CFR 571.302 applies to passenger cars, multipurpose passenger vehicles, trucks, and buses. 140  New Jersey Transit has been using vehicles with fire detection and suppression systems since 1994. 141  In addition, MCI has introduced the SmarTire pressure temperature monitoring system as an option in its motorcoaches.

Analysis 59 Highway Accident Report However, none of these systems have been specifically designed to protect against and extinguish a tire fire. As the vehicle fire suppression systems product manager with Amerex Corporation stated at the public hearing, one way to prevent a fire may be to use a heat monitoring system to provide the driver with a prefire warning alert to elevated heat in a wheel well. In addition, future wheel well fire suppression systems might be designed to preempt the outbreak of a fire by monitoring the tires to detect dangerously high temperature conditions, at which point a fire suppression agent could be used to cool the tire. In July 2006, the FMCSA announced a demonstration project initiative that will use state-of-the-art thermal imaging technology, integrated with signature recognition software, to identify faults and failures in tires, brakes, and bearings mounted on commercial motor vehicles. The contract for this 2-year project was awarded in September 2006. Additionally, the FMCSA is working with the Volpe Center to identify ways to prevent, reduce, or mitigate the severity and frequency of motorcoach fires, including the assessment of available fire suppression systems. The Safety Board concludes that because tire fires are difficult to extinguish, early detection of potentially hazardous conditions in a wheel well area is critical, as demonstrated by the sequence of events in this accident, to eliminating the fire hazard. The Safety Board believes that NHTSA should develop detection systems to monitor the temperature of wheel well compartments in motorcoaches and buses to provide early warning of malfunctions that could lead to fires. Additionally, the Safety Board believes that NHTSA should evaluate the need for an FMVSS that would require installation of fire detection and suppression systems on motorcoaches. Vehicle Global did not retain vehicle maintenance and repair records as required by the FMCSRs. Although Global had been subleasing the motorcoach for a few months prior to the accident and had conducted some repairs and one preventative maintenance servicing, it did not have in place any maintenance program to properly service the vehicle. Without pretrip inspections or the required DVIRs, Global could not ensure that the vehicle was safe to operate on a daily basis. The absence of maintenance and repair records prevents verification that vehicles are properly inspected and maintained. For several years before the accident, Global had failed to properly maintain repair records and provide routine maintenance servicing for its motorcoaches. On April 10, 2002, the TxDPS conducted an intrastate educational review of Global and found the company to be in violation for failing to maintain vehicle inspection and maintenance records. When the FMCSA conducted a 2004 compliance review, Global was cited for violating 49 CFR 396.3(b)(2) because the carrier did not have a means of indicating the nature and date of inspection and maintenance operations that were performed on its vehicles. When the FMCSA conducted a postfire compliance review on October 7, 2005, Global was cited for failing to inspect and maintain vehicles to

Analysis 60 Highway Accident Report ensure safe and proper operating conditions. Based on this compliance review, the FMCSA served Global with an operations OOS order, stating: “Global Limo has a grossly ineffective or nonexistent inspection, repair, and maintenance program.” The accident motorcoach had received preventative maintenance service once while being operated by Global. When interviewed, the accident driver stated that he did not conduct pretrip inspections and did not check the oil level in the hub cavity. Global’s owner stated that he did not pay drivers to conduct pretrip or posttrip vehicle inspections. Because they did not conduct posttrip inspections and complete the DVIRs, as required by the FCMSA, neither the driver nor the carrier was alerted to potential vehicle defects requiring maintenance or repair. The accident vehicle maintenance manual specifies that hub oil levels need to be checked daily. Some motorcoach models have a “sight glass” that allows observation of the oil level in the hub cavity; though the glass often becomes obscured and prevents an accurate view of oil levels, it can be cleaned or replaced. A wheel seal leak on a tag axle, however, can be observed only by inspecting the inside of the wheel for oil from a position underneath the motorcoach. The current design of the tag axle wheel hub makes it difficult for a roadside safety inspector to check for a wheel seal leak without an undercarriage vehicle inspection. The Safety Board concludes that because neither Global nor its employees routinely inspected the hub oil level or undercarriage of the wheel well, they did not discover the lack of lubrication of the tag axle wheel bearings; and this disregard for vehicle maintenance, pretrip inspections, and posttrip DVIRs led to a wheel bearing failure that resulted in a catastrophic fire and loss of life. Although manufacturers recommend checking the wheel bearing lubricating oil levels daily, drivers are not specifically required to do so during a pretrip or posttrip inspection. However, proper routine maintenance would reveal inadequate hub oil levels or verify the absence of a wheel seal leak. Moreover, though neither roadside nor annual periodic inspections require checking the sight glass or the wheels for a leak, 49 CFR 396.3 specifies, “Every motor carrier shall systematically inspect, repair, and maintain, or cause to be systematically inspected, repaired, and maintained, all motor vehicles subject to its control.” The regulations go on to state, under 396.5, “Every motor carrier shall ensure that each motor vehicle subject to its control is: (a) properly lubricated; and (b) free of oil and grease leaks.” Title 49 CFR 393.205 addresses the parts and accessories for safe operation of wheels and sets forth additional requirements for wheel seal and other hub leaks. The industry acknowledges that a motorcoach tire fire is the most difficult to extinguish; though detection systems may alert a driver to a potential fire situation, adequate suppression systems are not yet available. Therefore, fire prevention is the key objective. The FMCSA has established specific OOS criteria for commercial vehicles in response to safety hazards, and it is the appropriate agency to require that commercial vehicles maintain proper wheel bearing lubrication to prevent failure and possible catastrophic tire fires.

Analysis 61 Highway Accident Report A comprehensive program of proper maintenance by motor carriers, pretrip inspections, posttrip vehicle inspections by drivers, State and Federal requirements, and inspections to verify motor carrier compliance with safety regulations is necessary to prevent motorcoach fires. However, no regulations are in place that set inspection requirements for wheel bearings and wheel seal leaks. According to the FMCSA, the Volpe Center will assess the adequacy of current motorcoach operational inspection practices, both daily and periodic, as they relate to detecting and remedying situations that may lead to a fire.142 The Safety Board concludes that Federal regulations and inspection criteria do not require inspection of wheel bearings and adequate lubrication to prevent wheel bearing failure and a resulting wheel well fire. The Safety Board believes that the FMCSA should revise the FMCSRs at 49 CFR 393.205 to prohibit a commercial vehicle from operating with wheel seal or other hub lubrication leaks. The maintenance manuals published by motorcoach manufacturers afford another means of fostering owner awareness of the risks associated with improper wheel bearing maintenance. MCI, the manufacturer of the accident motorcoach, placed caution and warning text boxes throughout its maintenance manual to provide additional information on the potential hazards of failing to properly maintain specific vehicle components and on methods for handling heavy vehicle parts. The manual cautioned that wheel seal integrity could be affected by excessive wheel bearing end play and lead to bearing or seal failure; no warning was given on the potential consequences of failing to maintain adequate wheel bearing lubrication, though daily checks of hub oil levels were recommended. Maintenance guidance on vehicle components is based on manufacturers’ recommendations because they are in the best position to understand how their products work, including the consequences of not performing proper maintenance. Although the maintenance manual for the accident motorcoach included various warnings, none focused on the lubrication of wheel bearings. The Safety Board concludes that, in the absence of a specific warning in the maintenance manual, owners of vehicles with oil bath bearings may not be aware of the inherent danger of inadequate wheel bearing lubrication and the potentially serious consequences of a wheel bearing failure. The Safety Board believes that MCI should revise its product maintenance manuals to emphasize the importance of wheel bearing lubrication, specifically warning that daily inspection of hub oil levels and wheel seals is vital to prevent wheel bearing failure and that bypassing this requirement is a dangerous practice that can lead to a wheel well fire or other serious consequences. For those vehicles already sold and in service, the Safety Board believes that MCI should disseminate a customer advisory bulletin on the importance of proper wheel bearing maintenance, specifying the type of equipment or oil bath bearings that require an undercarriage inspection to detect wheel seal leaks and alerting customers to the serious consequences of lack of lubrication and subsequent wheel bearing failure. 142  Motorcoach Fire Safety Analysis Work Plan.

Analysis 62 Highway Accident Report As principal purveyors of vehicle safety information, the United Motorcoach Association and the American Bus Association need to inform their members of the dangers inherent in improper maintenance of wheel bearings and the consequences of catastrophic wheel well fires. The Safety Board believes that the United Motorcoach Association and the American Bus Association should disseminate to their motorcoach and bus operator members an advisory bulletin emphasizing the importance of proper wheel bearing maintenance, particularly the importance of checking the oil level in oil- lubricated bearings (also known as oil bath bearings) and inspecting the undercarriage of the tag axle wheels to detect wheel seal leaks, and the serious consequences of lack of lubrication and subsequent wheel bearing failure. The Safety Board also believes that the United Motorcoach Association and the American Bus Association should advise their motorcoach manufacturer members to review product maintenance manuals and, if the manuals do not emphasize the importance of wheel bearing lubrication, to revise them to specifically warn that daily inspection of hub oil levels and wheel seals is vital to prevent wheel bearing failure and that bypassing this requirement is a dangerous practice that can lead to a wheel fire or other serious consequences. Further, the Safety Board believes that the United Motorcoach Association and the American Bus Association should advise their motorcoach manufacturer members to disseminate, for those vehicles already sold and in service, a customer advisory bulletin on the importance of proper wheel bearing maintenance, specifying the type of equipment or oil bath bearings that require an undercarriage inspection to detect wheel seal leaks and alerting customers to the serious consequences of lack of lubrication and subsequent wheel bearing failure. Bus Brokers BusBank, the company that entered into a contract with Sunrise to obtain motorcoach transportation from Bellaire to another Sunrise facility on September 22, 2005, is a bus broker. According to the FMCSA, it does not have the authority to regulate brokers of motor carriers that transport passengers; bus brokers are exempt from the Secretary of Transportation’s jurisdiction. Although the FMCSA does have the authority to require brokers to maintain a bond or insurance, as needed, to protect passenger carriers, neither the FMCSA nor the DOT has imposed an insurance requirement.143 At the Safety Board public hearing, BusBank testified that it performs a due diligence check on the motor carriers it contracts with for service. However, this check consisted only of verification of the required FMCSA insurance coverage and review of FMCSA-issued safety ratings available on the Internet. At the time of the accident, Global was listed as a motor carrier of passengers with a satisfactory FMCSA safety rating. The verification performed by BusBank uncovered no safety issues that would have alerted it to potential safety risks to the traveling public. 143  The FMCSA has stated that without the authority to require registration of brokers, it has no way of identifying them and monitoring their compliance with the insurance requirement.

Analysis 63 Highway Accident Report Any member of the public can perform his or her own due diligence check on a motor carrier of passengers by contacting the FMCSA or searching the FMCSA website.144 The website also provides a link to detailed information on passenger carrier safety and on evaluating the safety practices of interstate motorcoach companies, such as those related to driver qualifications, limitations on driving, vehicle standards, subcontracting agreements, insurance requirements, carrier operating authority, and carrier insurance and safety information. Although the BusBank website describes the company as “event specialists with local knowledge of bus availability, [and] bus quality,”145 its information is gathered from much of the same FMCSA data available to the traveling public. The selection of a motor carrier of passengers and the quality of information gathered by both bus brokers and the general public is ultimately dependent on the information and safety ratings issued by the FMCSA. Federal Motor Carrier Safety Administration On April 10, 2002, a TxDPS intrastate educational review of Global uncovered numerous driver and vehicle safety violations. In February 2004, an FMCSA compliance review of Global found similar violations of the FMCSRs pertaining to commercial drivers and vehicles, though the final safety rating for the carrier was satisfactory. After the Wilmer accident in September 2005, when the FMCSA conducted a second compliance review of Global, it issued the company a safety rating of unsatisfactory, declared that Global’s operations created an “imminent hazard” to public safety, and issued an operations OOS order. The order was based on Global’s numerous driver qualification violations and FMCSA documentation of Global’s lack of vehicle maintenance, inspection, and repairs, which resulted in vehicles that were mechanically unsafe. The FMCSA OOS order stated that Global’s pattern of FMCSR violations was consistent in nature and long in history. Although the February 2004 compliance review had documented many of the same safety violations as the postaccident compliance review 19 months later, the FMCSA issued a different final rating of Global, an unsatisfactory rating. At the time of the accident, Global was not providing proper safety oversight of its operations. The accident driver had been working for Global without being properly licensed to drive a motorcoach in the United States, and after the accident, Global failed to conduct the postaccident alcohol and illicit drug testing required by the FMCSRs. Further, Global had been operating a passenger-carrying commercial vehicle, under an expired temporary trip permit tag, that was not registered in the United States, was displaying the license plate from another vehicle, and had not been systematically maintained. In light of these findings, as well as the violations found by the FMCSA during the postaccident 144  See “Safe Transportation of Passengers by Motorcoach—and What It Means to You,” , December 5, 2006. 145  See , December 1, 2006.

Analysis 64 Highway Accident Report compliance review, the Safety Board concludes that Global exhibited a lack of concern for safety management controls by violating several Federal safety regulations pertaining to its drivers and vehicles, including employing a driver who was not properly licensed to drive a motorcoach in the United States, failing to conduct the required postacccident alcohol and illicit drug testing, and operating a passenger-carrying commercial vehicle, which had an expired temporary trip tag, that was not registered in the United States, was displaying the license plate from another vehicle, and had not been systematically maintained. This accident is one of many in which the Safety Board has focused on FMCSA safety oversight of motor carriers and has found inconsistencies based on a safety rating process that fails to ensure the removal of unsafe motor carriers from the Nation’s highways.146 In reviewing the FMCSA’s safety rating system within the compliance review process, the Safety Board has found the rating methodology inadequate in two areas: • It considers only those violations defined by the FMCSA as “critical” or “acute” in determining a carrier’s overall safety rating, and • It does not factor in a carrier’s driver’s rate of OOS orders and does not fully review vehicle inspection data. The FMCSA compliance review uses a computer tabulation program to identify adherence to the FMCSRs for each rating factor, placing weighted numerical value only on violations of acute or critical regulations. Unrated violations—those that are noncritical or nonacute—are not given weight and therefore are not factored147 into the tabulation; the FMCSA does not consider a motor carrier’s violations of many FMCSRs to be an indication of safety management practices. In other words, if a carrier displayed a pattern of 100 percent noncompliance for every nonrated safety regulation violation, its overall safety rating would not be affected. This rating methodology is inconsistent with the FMCSA’s stated purpose of the compliance review, which is to make sure that a motor carrier has adequate safety management controls in place to ensure compliance with all applicable Federal safety requirements. The Volpe Center reported that for the year 2005, the FMCSA performed 8,097 Federal compliance reviews, during which a total of 61,924 violations of Federal safety regulations were found.148 However, only 1,758 violations were classified “acute,” and 146  (a) National Transportation Safety Board, Motorcoach Run-off-the-Road and Overturn, Victor, New York, June 23, 2002, Highway Accident Report NTSB/HAR-04/03 (Washington, DC: NTSB, 2004). (b) National Transportation Safety Board, Collision Between Truck-Tractor Semitrailer and School Bus Near Mountainburg, Arkansas, May 31, 2001, Highway Accident Report NTSB/HAR-02/03 (Washington, DC: NTSB, 2002). (c) National Transportation Safety Board, Selective Motorcoach Issues, Special Investigation Report NTSB/SIR-99/01 (Washington, DC: NTSB, 1999). 147  When asked during the Safety Board public hearing about how the FMCSA determines whether an FMCSR violation by a motor carrier is acute, critical, or unrated, an FMCSA field administrator stated that the agency determines certain regulations to be critical or acute depending on the relative risks of an accident (whether violation of those particular regulations would place a carrier at risk for an accident). 148  See MCMIS March 31, 2006, snapshot, , October 20, 2006.

Analysis 65 Highway Accident Report 7,102 were classified “critical”—which is to say that 85.7 percent of Federal safety regulations violations discovered in 2005 did not carry any weight against the carriers’ safety ratings. Further, 65 percent of the 8,097 Federal compliance reviews conducted resulted in satisfactory ratings for the carriers, though 53,069 “other” (nonacute and noncritical) violations (85.7 percent) of Federal safety regulations were documented. The FMCSA documented violations in 7,831 (96.7 percent) of the compliance reviews. At the Safety Board public hearing, the FMCSA field administrator stated that the agency is working with the Volpe Center to develop a risk model for all FMCSRs to make a determination as to whether a violation should be “critical” or “acute” for a compliance review safety determination. Although this study is a step in the right direction, the Safety Board has long taken the position, as expressed in its reports cited earlier, that violations of safety regulations are an indication of a motor carrier’s lack of safety management controls. The Safety Board concludes that the FMCSA’s compliance review program does not assign numerical value to safety regulation violations that are classified as neither “acute” nor “critical” during the safety fitness rating process, thereby allowing potentially unsafe carriers, which violate safety regulations without consequence, to continue operating. The two most important factors in safe motor carrier operations are the operational status of the vehicles (trucks or buses) and the performance of the individuals who drive them. However, the FMCSA compliance review process does not accurately determine a motor carrier’s safety fitness because it does not factor in the rate of a carrier’s driver OOS orders from roadside inspections, and it includes only a limited amount of vehicle inspection data. Increasing the weight of performance data for driver and vehicle factors in compliance reviews is important because deficiencies in these factors are directly related to accidents. In previous accident investigations, the Safety Board has found that several unsafe carriers were permitted to continue operating as a result of a final satisfactory safety rating, regardless of driver- or vehicle-related safety violations. In 1995, for example, the Safety Board investigated an accident in Indianapolis, Indiana,149 in which a motorcoach overturned when it entered an exit ramp; 2 passengers were killed, and 13 were seriously injured. The FHWA’s Office of Motor Carriers (now the FMCSA) conducted a postaccident compliance review of the operator, Hammond Yellow Coach Lines, Inc. (Hammond), which resulted in an unsatisfactory rating (10 out of 10 vehicles reviewed were placed out of service). Hammond had had significant safety problems before the accident and yet was still permitted to operate. From 1987–1995, the Office of Motor Carriers had inspected Hammond nine times, and the carrier continued to receive final safety fitness ratings of satisfactory, even though several compliance reviews documented hours-of-service violations and high numbers of vehicles (63 percent) meeting OOS criteria. Following the Indianapolis accident, the Safety Board recommended that the DOT 149  NTSB/SIR-99/01.

Analysis 66 Highway Accident Report H-99-6 Change the safety fitness rating methodology so that adverse vehicle or driver performance-based data alone are sufficient to result in an overall unsatisfactory rating for the carrier. On December 14, 1999, the FHWA responded that it expected to issue an NPRM that would establish a more performance-based means of determining carrier fitness to conduct commercial motor vehicle operations. The agency stated that it would take into account the Safety Board’s recommendation, including any comments received, in developing a new system. On March 17, 2000, based on the expected NPRM, the Safety Board classified Safety Recommendation H-99-6 “Open—Acceptable Response.” The recommendation is on the Safety Board’s List of Most Wanted Transportation Safety Improvements.150 On September 4, 2002, the Safety Board reiterated Safety Recommendation H-99-6 to the DOT as a result of its investigation into an accident in Mountainburg, Arkansas,151 in May 2001, when a commercial truck, operated by Stuart Trucking (Stuart), collided with a school bus and killed three children. The postaccident FMCSA compliance review of the motor carrier resulted in an overall conditional rating; however, the FMCSA staff did not inspect any vehicles during this review, in spite of the fact that the accident was vehicle related. The FMCSA relied instead on the motor carrier profile report, which listed 29 roadside inspections in the previous 12 months,152 resulting in 4 OOS vehicles (14 percent). The Safety Board asked the Missouri Division of Motor Vehicles and Railroad Safety to conduct an additional review of the carrier and inspect all of its vehicles. Of 12 vehicles examined, 5 had OOS violations (42 percent). The 2001 conditional rating for Stuart underscores the failure of compliance reviews to identify unsafe carriers. At the time of the accident, Stuart had not been rated in more than 11 years. Despite having unsafe vehicles on the road and numerous driver violations, Stuart received a conditional rating (not “unsatisfactory”) even after the accident. In June 2002, the Safety Board investigated an accident in Victor, New York,153 in which a motorcoach ran off the road and overturned because the driver fell asleep at the wheel. Five passengers were killed, and the driver and 41 passengers were injured. The FMCSA conducted a postaccident compliance review of the operator, Arrow Line, Inc. (Arrow), which resulted in a conditional rating (not “unsatisfactory”). Yet the compliance review revealed that Arrow had a 40 percent OOS rate for its vehicles, and the FMCSA noted that Arrow’s compliance review revealed noncompliance with the FMCSRs “in almost all applicable parts to Arrow Line, Inc.’s passenger transportation operation.” 150  The Safety Board’s “Most Wanted” list is a program to increase the public’s awareness of and support for action to adopt safety steps that can help prevent accidents and save lives. 151  NTSB/HAR-02/03. 152  At the time of issuance of the Safety Board report, in 2002, the FMCSA would not conduct a terminal inspection if  3 or more of a company’s vehicles had received roadside inspections in the previous 12 months. The Safety Board recommended that the FMCSA require that a motor carrier’s fleet be inspected during compliance reviews (Safety Recommendation H-02-16). 153  NTSB/HAR-04/03.

Analysis 67 Highway Accident Report Had Global’s driver and vehicle factor violations in the February 2004 compliance review resulted in an unsatisfactory rating, the carrier would have had only 45 days to correct the problems or cease operations. Instead, Global received a satisfactory rating and continued to operate and to violate safety regulations for drivers and vehicles; the FMCSA did not again review Global’s safety management practices until the accident occurred in September 2005. In the 2 years prior to the Wilmer accident, Global had accrued a driver OOS rate of 50 percent (8 roadside inspections resulted in 4 drivers being placed out of service), compared to the national rate of 6.6 percent. The accident driver himself had undergone three roadside inspections prior to the accident and had been placed out of service in two of the three. Although the motorcoach fire was the result of poor vehicle maintenance, had Global been rated “unsatisfactory” in February 2004 based on driver OOS rates and vehicle safety violations, as the Safety Board recommended in Safety Recommendation H-99-6, the company quite likely would not have been operating. If the FMCSA compliance review rating methodology were revised to give appropriate weight to driver and vehicle safety areas, the FMCSA would have accurate information regarding a carrier’s level of passenger safety; under such conditions, Global (like Arrow, Stuart, and Hammond before it) may have received an unsatisfactory rating. Following the Safety Board’s September 2002 reiteration of Safety Recommendation H-99-6, the FMCSA advised that it intended to issue an NPRM on the safety fitness rating methodology in late 2003. In June 2004, the FMCSA notified the Safety Board that it anticipated making a final determination concerning changes to the safety fitness rating methodology in 2004. The FMCSA indicated that it was considering whether to seek additional comments through a supplemental advance NPRM or to proceed directly to an NPRM. The FMCSA expected to complete the rulemaking process in 2005. In a report issued in April 2006, the Safety Board expressed disappointment that the FMCSA had not acted on Safety Recommendation H-99-6 and stated its concern that the long time between the issuance of the recommendation and final action by the FMCSA jeopardizes the safety of the traveling public through unnecessary exposure to possibly unsafe commercial motor vehicles.154 On June 15, 2006, the FMCSA briefed the Safety Board on the CSA 2010 Initiative, which the agency indicated will include a complete evaluation of the compliance review process, leading to development of a new performance-based operational model for determining motor carrier safety, with emphasis on preventative measures and early detection of unsafe driver and carrier conditions. At the August 2006 Safety Board public hearing, the FMCSA stated that it is reviewing the compliance review process and safety rating methodology. The FMCSA explained that when it originally promulgated the safety fitness determination process, the driver OOS rate information was found to be insufficient to accurately determine a driver’s safety performance; however, the FMCSA’s current goal is to develop a data- driven safety fitness determination process, which includes items such as vehicle and driver OOS rates, as part of its comprehensive examination of compliance review and enforcement oversight. Additionally, in September 2006, the FMCSA reported that it is 154  National Transportation Safety Board, Multivehicle Collision on Interstate 90, Hampshire–Marengo Toll Plaza Near Hampshire, Illinois, October 1, 2003, Highway Accident Report NTSB/HAR-06/03 (Washington, DC: NTSB, 2006).

Analysis 68 Highway Accident Report developing a new safety fitness rating methodology based on an objective measure of driver or carrier safety performance data and will issue ratings on all drivers and carriers for which there are sufficient data. According to the CSA 2010 Initiative website, the deployment date of the new operational model is year 2010. The FMCSA plans to develop and draft legislation required for the program; rulemaking within the FMCSA takes at least 2 years. Pilot testing is projected to begin in 2008; pilot tests and training for deployment and implementation are expected to take at least 2 years and thus may extend well beyond 2010. Concerned that motor carriers with significant regulatory violations for drivers and vehicles are still receiving satisfactory ratings, the Safety Board once more focuses on Federal standards for determining the safety fitness of carriers. As it has done in several accident investigations in the past 8 years, the Safety Board again concludes that the current FMCSA compliance review process does not effectively identify unsafe motor carriers and prevent them from operating. Full evaluation and implementation of the CSA 2010 Initiative will not be completed until 2010 or later, 10 years after the Safety Board first issued Safety Recommendation H-99-6. Accidents such as the Wilmer motorcoach fire, with high loss of life, underscore the need and the urgency for the FMCSA to move forward more expeditiously on this recommendation to remove unsafe motor carriers from the Nation’s highways. Therefore, the Safety Board reiterates Safety Recommendation H-99-6. Although the FMCSA has stated that the conceptual model for CSA 2010 is significantly different from the current operational model in that safety fitness determinations will be independent of the compliance review, the expected time frame for implementation of the new program is at least several more years. In the interim, deficiencies in the current compliance review system should be remedied to help prevent unsafe carriers from continuing to operate. The FMCSA is responsible for ensuring that motor carriers operate safely, and temporary measures to improve the compliance review process may be necessary until new rules are enacted. The FMCSA has already set precedent for the issuance of interim rules to improve safety programs; in 1997, the agency issued an interim final rule to immediately improve the safety rating methodology without prior notice and comment, stating that to have done otherwise would have been contrary to the public interest. Therefore, to protect the traveling public until completion of the CSA 2010 Initiative, the Safety Board believes that the FMCSA should immediately issue an Interim Rule to include all FMCSRs in the current compliance review process so that all violations of regulations are reflected in the calculation of a carrier’s final rating. The Safety Board examined whether the inability of the motorcoach driver to communicate in English was a factor in this accident. Although the driver did not speak English, one of the nursing staff was able to sufficiently communicate with him in Spanish. Further, though the accident driver did not respond verbally to the motorist who informed him that the wheel well was glowing orange-red, he immediately took action to pull over onto the shoulder of the interstate. When the driver exited the motorcoach to inspect the tire, he was accompanied by several of the nursing staff, who also observed the flames. The

Analysis 69 Highway Accident Report driver and the nursing staff reacted to the emergency and immediately began evacuating passengers. Therefore, the Safety Board concludes that although the accident motorcoach driver had previously been cited in a roadside inspection as being a non-English-speaking driver, his inability to speak the English language was not a factor in this accident. The Safety Board was pleased when, in December 2006, the FMCSA provided information on research the agency has initiated into the issue of the English language proficiency requirement for commercial motor vehicle drivers. The FMCSA contracted with the Volpe Center to assess “the extent to which commercial motor vehicle drivers must be capable of communicating in English to ensure the safe operations of their vehicles on the Nation’s highways.” The FMCSA and the Volpe Center will interview and survey Federal and State enforcement personnel, motor carrier industry groups, individual motor carriers and drivers, State driver licensing agencies and highway departments, and highway safety advocacy groups. The FMCSA anticipates completion of the final research report by October 2007. Survival Motorcoach Emergency Egress During the investigation of this motorcoach accident, the Safety Board identified problems with emergency egress from the vehicle. Although the motorcoach was equipped with emergency egress windows, they were not used in the evacuation because • The nursing staff had not been instructed on the availability of the window exits and how to use them, and they were unaware of their potential as a means of exit during the evacuation. • Most of the passengers who required assistance during the evacuation had special needs, and negotiating the movements necessary to escape through the emergency windows and the front door was all but impossible during the limited time available. The rapid propagation of the fire and the heavy, thick black smoke afforded those patient-passengers seated beyond the third row little or no opportunity to be evacuated or rescued once the fire ignited combustible elements within the passenger compartment. The intense heat from the fire, coupled with the oppressive smoke, cut off all practical egress in a matter of minutes. The Safety Board concludes that the quick-spreading fire and thick smoke prevented nursing staff, bystanders, and rescuers from extricating all passengers with special needs from the accident motorcoach. Two options are available to prevent fatalities in highway accidents: prevent the accidents or protect vehicle occupants when accidents do occur (survivability). By examining occupant survivability in motorcoach accidents, the DOT can identify means of increasing survivability. Surviving an accident depends on many factors. The structural integrity of the vehicle and passenger compartment, seat design, and restraint systems can all increase a person’s likelihood of surviving a crash. Fire-retardant materials, exit design, and prompt evacuation can assist persons in escaping a vehicle. For example, in aviation,

Analysis 70 Highway Accident Report Safety Board recommendations have provided the impetus for many improvements in occupant protection, including fire detection and suppression systems in aviation lavatories and cargo compartments, modifications in cargo compartments to delay fire spread, and fire blocking of cabin and seat materials.155 Evacuation Studies For more than 30 years, the Safety Board has addressed the issue of motorcoach emergency evacuations.156 Although the DOT conducted emergency evacuation trials of intercity buses in 1976, no industry- or Government-sponsored research on emergency evacuation of motorcoaches has taken place since then. Motorcoach designs still incorporate the same window exit heights and combustible construction material that prevailed decades ago. The Safety Board has long held that the capability of rapidly evacuating motorcoaches in emergencies is essential. Although motorcoach and bus fire data are inconsistent in current accident databases, the FMCSA, commercial insurance companies, and the industry generally acknowledge that the number of fires is increasing. Yet today, decades after release of the 1976 and 1984 DOT reports on evacuation of intercity buses157 and evacuation of elderly and disabled passengers from paratransit vans and buses,158 motorcoaches are still essentially constructed of the same combustible materials and present the same evacuation issues. Motorcoaches transport large numbers of people in a confined space. Panic can quickly ensue when occupants are threatened by fire or smoke in an unfamiliar or enclosed environment. Smoke, panicked reactions, unfamiliarity with motorcoach components, and inadequate exit design can hamper the efficient and safe use of emergency exits. The Wilmer accident demonstrates that, just as in airplane and passenger train fires, the danger to passengers is not limited to the flames themselves but also can result from the side effects of a fire, such as inhaling smoke. In the Wilmer accident, passengers died because of injuries caused by smoke inhalation, in addition to thermal injuries caused by the fire. Unlike in the aviation industry, motorcoaches, which can accommodate 55 or more passengers, are not required to perform full-scale evacuation drills. Just as passengers seated in an airplane or in a railcar are called upon to operate the emergency exits in an evacuation, passengers in a motorcoach are expected to operate exits in the event of an emergency. However, research shows that under the stress of an evacuation, passengers do 155  National Transportation Safety Board, Survivability of Accidents Involving Part 121 U.S. Air Carrier Operations, 1983 Through 2000, Safety Report NTSB/SR-01/01 (Washington, DC: NTSB, 2001). 156  (a) National Transportation Safety Board, Interstate Bus–Automobile Collision, Interstate Route 15, Baker, California, March 7, 1968, Highway Accident Report NTSB/SS-H-3 (Washington, DC: NTSB, 1968). (b) National Transportation Safety Board, Greyhound Bus Collision With Concrete Overpass Support Column on Interstate 80, San Juan Pass, Sacramento, California, November 3, 1973, Highway Accident Report NTSB/HAR-74/05 (Washington, DC: NTSB, 1974). (c) National Transportation Safety Board, Docket No. SRH-96-FH-015. 157  Evacuation of Intercity Buses. 158  Evacuation and Rescue of Elderly and Disabled Passengers From Paratransit Vans and Buses.

Analysis 71 Highway Accident Report not necessarily use the most appropriate exit. Passengers in such situations are less able to cope with new equipment and information; their natural inclination is to leave by the exits they recognize, such as the front loading door. Under stress, passengers may have difficulty figuring out the method of window operation if it is not intuitive or does not match their immediate expectations.159 The use of emergency window exits in a motorcoach is not intuitive; the hinged windows do not remain open, and the drop to ground is 7–8 feet. Safe and effective evacuation with minimal panic requires that passengers be provided with a basic understanding of the function of exits. Although the staffing level on the accident motorcoach was sufficient to provide routine care of the patient-passengers (for example, dispensing medications and monitoring the well-being of residents), once the emergency situation arose, the health care staff was insufficient to safely and rapidly evacuate the motorcoach. The ADA ensures equal opportunity and accessibility for persons with disabilities to public conveyances, whether for routine transportation needs or educational and social group outings. Moreover, typically many sightseeing excursions sponsored by senior citizens’ or children’s groups include passengers with limited mobility or physical handicaps. Motorcoach charters often include passenger populations that have a significant number of persons with special needs. The Federal Government needs to address the ability of persons with special needs to rapidly egress from a motorcoach or bus in an emergency situation. The DOT has not studied this issue or published related research since the 1984 report, Evacuation and Rescue of Elderly and Disabled Passengers From Paratransit Vans and Buses. The Safety Board has used the airEXODUS model to simulate evacuation from a wide-body aircraft with only 8 exits and 440 passengers; limiting the number of exits used can have a dramatic effect on evacuation times. The airEXODUS model is a highly specialized software tool originally developed to model the complex interactions of aircraft configuration and passenger behavior in emergency evacuations.160 Not all exits are typically available during an escape situation in airplanes, railcars, or motorcoaches. The limited available statistics on motorcoach fires indicate that the rear of the motorcoach (engine compartment and rear wheel wells) experiences the majority of fires and that the windows normally provide the fire pathway into the passenger compartment. As was the case with the accident motorcoach, not all exit windows are likely to be available for escape,161 depending on the circumstances of the emergency, such as fire, submersion in water, collision damage, rollover, or operational failure. 159  Sharon Cook and Dean Southall, PSV Emergency Exits: Passenger Behaviour and Exit Design, United Kingdom Department of Transport (London, UK: ICE Ergonomics Ltd., 1997) 5. 160  Richard W. Bukowski, Richard D. Peacock, and Walter W. Jones, Sensitivity Examination of the airEXODUS™ Aircraft Evacuation Simulation Model (Gaithersburg, MD: National Institute of Standards and Technology, 1998) 7. 161  According to the Safety Board’s interviews of the nursing staff, they had covered the windows with newspaper and could not see the latches; the newspaper caught on fire as the flames entered the passenger compartment.

Analysis 72 Highway Accident Report In December 2001, the FRA published an interim report on the fire safety of passenger trains.162 In the analysis of passenger railcar fire performance, the minimal principal acceptance criterion was considered to be the minimum necessary egress time for a fully loaded passenger car, assuming an orderly, unimpaired evacuation. If the minimum necessary egress time is less than the time available for safe egress for all design fires, the design is considered acceptable. As stated in the report, “like the 90-second certification testing for aircraft, this minimum necessary egress time is simply a consistent point of comparison for different passenger railcar configurations and fire scenarios.” In addition, the FRA, through the Volpe Center, is conducting a project related to passenger trains and fires, calling upon the Building and Fire Research Laboratory at the National Institute of Standards and Technology (NIST) for expertise in the development of models for the simulation of fires and associated hazards and risks for the broader application of fire hazard analysis to passenger train transportation.163 The FAA has also studied the use of computer simulation models to evaluate commercial aircraft evacuations. Fire hazard analysis using simulations can determine the fire performance of the entire aircraft fire protection and evacuation system by modeling both the fire environment and passenger egress.164 Using existing technology and building on the DOT research for aviation and railcar passengers, evacuation trials and computer simulation analyses can expand the application of fire safety analysis to the passenger population throughout the transportation system. Research and evacuation studies are needed to document and analyze actual evacuation scenarios, such as darkness, fire- and smoke-impaired vision, and water submersion, involving all types of passenger populations that require difficult and time-sensitive evacuations. Emergency Exit Design The Safety Board has investigated accidents involving motorcoaches with emergency windows, such as on the accident motorcoach, that are approximately 7–8 feet from the ground, hinged at the top, and operated by lifting a release bar and pushing outward.165 In several of these investigations, emergency responders and bystanders had difficulty rescuing passengers because of window height and top-hinge design, just as bystanders reported in the Wilmer accident. For example, on June 20, 1998, a 1997 MCI motorcoach operated by Greyhound Lines, Inc., was traveling westbound on the Pennsylvania Turnpike near Burnt Cabins, Pennsylvania,166 when it ran off the right side of the roadway and struck the back of a 162  U.S. Department of Transportation, Federal Railroad Administration, Fire Safety of Passenger Trains, Phase II: Application of Fire Hazard Analysis Techniques, DOT/FRA/ORD-01/16 (Washington, DC: FRA, 2001). 163  Sensitivity Examination of the airEXODUS™ Aircraft Evacuation Simulation Model. 164  Sensitivity Examination of the airEXODUS™ Aircraft Evacuation Simulation Model. 165  (a) NTSB/SS-H-3. (b) NTSB/HAR-74/05. (c) NTSB Docket No. SRH-96-FH-015. 166  National Transportation Safety Board, Greyhound Run-Off-the-Road Accident, Burnt Cabins, Pennsylvania, June 20, 1998, Highway Accident Report NTSB/HAR-00/01 (Washington, DC: NTSB, 2000).

Analysis 73 Highway Accident Report tractor semitrailer. The entire front of the motorcoach was crushed, and the front loading door was destroyed; the motorcoach driver and 6 passengers were killed, and 16 passengers were injured. The emergency responders reported difficulty in rescuing the trapped passengers and had to set up a ladder to reach the emergency windows. The Safety Board determined that when passersby and emergency responders arrive on scene to rescue trapped passengers and provide medical assistance, any impediment to rapid entry into the accident vehicle can be detrimental to timely treatment of injuries and passenger survival. In the Wilmer accident, witnesses interviewed by the Safety Board reported trying to open the motorcoach windows from the exterior. When two passersby could not reach high enough to pry open two windows, they broke the windows but were unable to rescue any passengers. Past Safety Board investigations have involved passengers of diverse ages and physical abilities who reported difficulty in evacuating because the windows were heavy and they could not hold them open while attempting to climb out and descend unassisted 8 feet to the ground. The majority of passengers in the Wilmer accident were persons with special needs, were unable to evacuate on their own, and could not be rescued before the fire destroyed the motorcoach; in other emergency situations, however, window height and design could impede the timely egress of passengers responding to a rapidly propagating fire. On July 29, 1997, for example, a 1985 TMC motorcoach operated by Rite-Way Transportation, Inc., drifted off the side of Interstate 95 near Stony Creek, Virginia,167 and down an embankment into the Nottoway River, where it came to rest on its left side, partially submerged in water. The front of the motorcoach was severely damaged, and the vehicle immediately began to fill up with water. Many passengers had to swim to the surface to escape. Some of the passengers, as young as 11, were too small to push the heavy emergency windows open far enough to evacuate. The Safety Board concluded that the strength and height needed to open an emergency window when a motorcoach is not upright pose a problem for some passengers, especially children, senior citizens, and injury victims. The Safety Board recommended that NHTSA H-99-9 Revise the Federal Motor Vehicle Safety Standard 217, “Bus Window Retention and Release,” to require that other than floor-level emergency exits can be easily opened and that they remain open during an emergency evacuation when a motorcoach is upright or at unusual attitudes. The Safety Board added this recommendation to the List of Most Wanted Transportation Safety Improvements in 2000,168 and it is currently classified 167  NTSB/SIR-99/01. 168  NHTSA originally responded to the Safety Board by letter on April 15, 1999, stating that the agency would research a “hold open” device for all emergency exit windows that are hinged at the top and determine whether the device would satisfy the conditions set forth in the Safety Board’s recommendation. If not, NHTSA stated that it intends “to perform research to establish the feasibility of a device that will limit the forces required to open emergency windows and keep emergency exit windows open when the bus its on its side. When the above is complete, NHTSA will then propose changing Standard 217 to require this device on emergency exit windows on buses and school buses.”

Analysis 74 Highway Accident Report “Open—Acceptable Response.” On October 12, 2006, NHTSA wrote to the Safety Board and stated that, as part of the regular 7-year regulatory review process, it is studying FMVSS 217 and anticipates completion of the review by early 2007. The rapid propagation of fire and quickly spreading smoke call for prompt, orderly egress of all motorcoach passengers. The circumstances of the Wilmer accident—a rapidly spreading fire, inadequate motorcoach egress systems, and destruction of the vehicle— along with the increasing number of tire fires noted by the industry, highlight the critical need to evaluate the adequacy of current motorcoach emergency egress design. In any such evaluation, passenger negotiation of the 7–8 foot window drop as a means of escape cannot be ignored. Many motorcoach window exits are 8 feet above ground, a distance higher than the wings of some airplanes, such as the 727, 737, and Canadair regional jet. Federal regulations require an approved means to assist airplane passengers in descending from an exit that is higher than 6 feet above ground; however, no such Federal regulations are in place for motorcoach exit heights. The Safety Board concludes that, in the absence of demonstrated emergency evacuation capabilities for motorcoaches, such as the accident vehicle, the effectiveness of design features in facilitating the safe escape of passengers cannot be determined. The Safety Board believes that NHTSA should evaluate current emergency evacuation designs of motorcoaches and buses by conducting simulation studies and evacuation drills that take into account, at a minimum, acceptable egress times for various postaccident environments, including fire and smoke; unavailable exit situations; and the current above-ground height and design of window exits to be used in emergencies by all potential vehicle occupants. Oxygen Cylinders To avoid dangerous rupture or explosion, a pressure relief device in oxygen cylinders, such as a burst disk, is designed to actuate when the internal pressure in the cylinder reaches 3,025–3,360 psig. As designed, when a fully pressurized cylinder is heated to 260º–315º F, its internal pressure exceeds the actuation pressure (3,025–3,360 psig) of the burst disk, and a controlled release of oxygen occurs to prevent cylinder rupture. Representatives of aluminum cylinder manufacturers stated to Safety Board investigators that, though aluminum melts at 1,020º–1,206º F, the exposure of the cylinders to temperatures well below the melting range will weaken the aluminum. A fully pressurized aluminum cylinder without a burst disk will maintain its integrity for only minutes at temperatures above 600º F because of the increased pressure levels acting on the now heated and structurally weakened aluminum cylinder. Federal HM regulations on pressure relief devices are designed for the transportation of full cylinders. The regulations require that a pressure relief device prevent the failure of a fully pressurized cylinder in a fire; however, they do not consider cylinders that are partially pressurized. Prior to 1981, this omission was not a problem because all specification cylinders permitted for the transportation of compressed gas were manufactured of steel, which is not as sensitive as aluminum to material strength loss when exposed to heat. In 1981, the HM regulations were amended to permit aluminum

Analysis 75 Highway Accident Report cylinders for use in transporting compressed gases. Because of the potential loss of material strength, the Safety Board is concerned that an aluminum cylinder might rupture at an internal pressure well below the actuation pressure of the burst disk. The Safety Board’s analysis indicated that, though the burst disk on a heated, fully pressurized cylinder actuates as designed before failure of the cylinder (that is, before the aluminum weakens and loses integrity), a partially pressurized heated cylinder can fail before the burst disk actuates. Specifically, when a cylinder containing less than 78 percent of its full charge (1,570 psig at room temperature) is heated to a temperature exceeding 400º F, it will structurally fail before its internal pressure actuates the burst disk. Thus, partially pressurized aluminum cylinders exposed to heat are more likely to rupture before the internal pressure is high enough to actuate the burst disk. When the aluminum weakens and the cylinder loses integrity (the cylinder wall fails), though the internal pressure is not high enough to actuate the burst disk, it causes the cylinder to fail, releasing the oxygen and causing the fragmented pieces of the cylinder to become hazardous projectiles. During this accident investigation, three aluminum cylinders retrieved from the motorcoach were found with intact valves, even though two cylinders displayed evidence of melting, and one had fractured and burst. Upon examination of the burst disks for these three cylinders, the Safety Board determined that two cylinders failed before the burst disks actuated. Such failures would have rapidly released large quantities of oxygen into the fire and may have propelled portions of the cylinders some distance from the point of origin. In fact, the intense burst of fire shown in figure 6, a still photograph from video footage of the motorcoach fire, was likely caused by the failure of one of these two cylinders. Emergency responders and passersby described these bursts of fire as “explosions.” The Safety Board considered what effect, if any, the venting and failure of these cylinders had on the attempted rescue of passengers remaining in the motorcoach. According to the Safety Board’s study, the first cylinder failure, which likely caused a burst of fire, would not have occurred until the temperature of the cylinder was at least 400º F. First responders and passersby who were attempting to rescue passengers reported ceasing their efforts just before, or just as, these bursts began to occur. By the time the temperature levels were high enough to cause two aluminum cylinders to fail, the heat from the fire in the rear of the motorcoach prevented rescuers from safely reaching the passengers seated there. Further, heavy, black smoke from the fire inside the motorcoach was reported to have been overwhelming within only a few minutes of the passenger evacuation and prevented rescue attempts beyond the first few rows of seats. The Safety Board concludes that the smoke and heat from the fire prevented rescuers from safely proceeding further into the motorcoach within minutes of their arrival on scene and that the aluminum cylinders failed, releasing oxygen to the fire, after successful rescue attempts were no longer possible. The rupture of aluminum cylinders caused by internal pressure exceeding the strength of the cylinder wall poses a significant hazard to emergency responders and

Analysis 76 Highway Accident Report others. Aluminum cylinders can be transported as cargo in any mode of transportation, and the presence of aluminum cylinders containing any compressed gas may pose a significant hazard in transportation fires. PHMSA recommends limiting the number of cylinders to the extent practicable and limiting the total weight of cylinders to 99 pounds per vehicle;169 however, these limitations may not be practicable in an emergency evacuation, such as in advance of a hurricane. Should aluminum cylinders be an issue for emergency responders in any mode of transportation, the safety of the vehicle occupants and the responders is of the utmost priority. The Safety Board concludes that the possibility of structural failure in partially pressurized aluminum cylinders when exposed to heat and fire, as occurred on the accident motorcoach, poses a danger to the general public and emergency responders. The Safety Board believes that PHMSA should develop standards for the safe transportation of partially pressurized aluminum cylinders by, for example, requiring the addition of temperature-actuated pressure relief devices or the reduction of residual pressure to safe limits, to ensure that such cylinders do not experience overpressure failure when exposed to a fire. Furthermore, the Safety Board believes that PHMSA should issue guidance to, at a minimum, the Fraternal Order of Police (FOP), International Association of Chiefs of Police (IACP), International Association of Fire Chiefs (IAFC), International Association of Fire Fighters (IAFF), National Association of State EMS Officials (NASEMSO), National Sheriffs’ Association (NSA), and National Volunteer Fire Council (NVFC), describing the risk of overpressure failure of partially pressurized aluminum cylinders and the steps that should be taken to protect responders and the general public from a vehicle fire when aluminum cylinders are present. In addition, the Safety Board believes that the FOP, the IACP, the IAFC, the IAFF, NASEMSO, the NSA, and the NVFC should disseminate to their members the guidance developed by PHMSA describing the risk of overpressure failure of partially pressurized aluminum cylinders and the steps that should be taken to protect responders and the general public from a vehicle fire when aluminum cylinders are present. Emergency Evacuation of Persons With Special Needs When Hurricane Rita became a threat to the Texas Gulf Coast in late September 2005, it posed unique challenges to organizations and entities responsible for ensuring the safety of persons with special needs. In many emergencies, sheltering in place is recommended because of the hazards and difficulties involved in evacuating special needs populations consisting of medically frail individuals. However, the strength of Hurricane Rita, along with the risk it posed to persons and property, made evacuation the appropriate option. 169  U.S. Department of Transportation, Pipeline and Hazardous Materials Safety Administration, Guidance for the Safe Transportation of Medical Oxygen for Personal Use on Buses and Trains (Washington, DC: PHMSA, 2005).

Analysis 77 Highway Accident Report When Sunrise officials tried to locate a nearby shelter to which the Brighton Gardens residents could evacuate in advance of Hurricane Rita, they learned that Hurricane Katrina evacuees occupied their preferred location, which was a facility closer than the 4-hour drive to Dallas, Texas. Lacking a nearby alternative to handle all of its residents, and being urged by the Bellaire fire marshal to evacuate, Sunrise determined that the best option was to travel to a more distant location capable of accommodating the residents. Sunrise monitored the evacuation situation on the news and learned that restrooms were unavailable in many locations, gasoline was in short supply, and many evacuees were stranded on the roadside. Paratransit buses designed for persons with special needs were considered unsuitable for this particular evacuation because of the limited number of seats and the lack of on-board restrooms. According to Sunrise, motorcoach transport became the best available option under the circumstances. Hurricane Rita placed extraordinary pressures on evacuation transportation operations in coastal Texas, in part because of recent demands on limited emergency resources throughout the Gulf Coast region caused by Hurricane Katrina. Given the prospect of another devastating natural disaster, the evacuation of persons with special needs from nursing homes and other care facilities in the hurricane’s path was considered necessary, despite the lack of optimal transportation. Because of the high demand for evacuation transport, both State and private organizations had difficulty locating sufficient transportation. For example, the State of Texas, through the TBPC, attempted to obtain 1,100 buses and motorcoaches for evacuation purposes but was able to locate only 307 vehicles. Unaware that the TBPC had arranged transportation for Texas residents, including persons with special needs, Sunrise officials contracted with BusBank, which it had previously used when searching for transportation in advance of Hurricane Katrina. Had Sunrise officials been aware of State efforts to obtain and coordinate emergency transportation, they might have been able to meet their needs through the TBPC, though a bus or motorcoach provided by the TBPC might not have been demonstrably safer than the accident motorcoach. After all, the accident motorcoach had received a satisfactory rating from the FMCSA, suggesting that it met minimum safety requirements. Therefore, the Safety Board concludes that, given the unusual circumstances and limited options, Sunrise took reasonable action at the time in deciding to contract with BusBank for motorcoach transportation. Sunrise has since stated that it intends to develop a national bus and motorcoach contract for emergency evacuation of its facilities. Efforts to improve planning for evacuation of persons with special needs are also under way at the State level. Shortly after Hurricane Rita, the Texas Governor established a Task Force on Evacuation, Transportation, and Logistics to review the hurricane evacuation and recommend improvements for evacuation plans and execution; in March 2006, the Governor directed that all task force recommendations be implemented. Texas has now entered into contingency contracts with out-of-State motorcoach carriers and CUSA to provide 1,100 motorcoach-type buses for emergency evacuations. Government agencies and organizations representing communities of persons with special needs are attempting to provide better information, both to long-term care industry

Analysis 78 Highway Accident Report members and to individuals with special needs (or their caregivers), on responding to emergencies that may require evacuation. In addition, in response to the 2005 hurricane disasters, private businesses, such as those operating nursing homes and long-term care facilities, have begun to improve their emergency transportation arrangements. For instance, the American Health Care Association has encouraged member facilities to make contingency arrangements for emergency evacuation transportation. The association’s draft “bus safety transport checklist,” to be included in its Disaster Preparedness Plan, even suggests that long-term health care facilities should provide backup arrangements for evacuation transportation in case the contingency contractor fails to provide transportation during an emergency, when market pressure may stress transport supplies. The Office of the President, the DHS, the DOT, the GAO, the HHS, and other Federal agencies have studied the responses to both Hurricanes Katrina and Rita. These studies include recommendations for improving emergency evacuation of persons with special needs. To deal with transport supply shortfalls when the NRP and NDMS prioritize the limited number of ambulances for hospital evacuation, the DOT has developed a nationwide inventory of more than 100,000 buses and motorcoaches that its national contractor will use for emergency evacuations. In addition, the DOT is working with the American Bus Association to index the capabilities of the buses and motorcoaches, including the numbers of available evacuation-ready vehicles and drivers and their locations, as well as the vehicles’ configurations and equipment. During its investigation into this accident and the subsequent public hearing, the Safety Board found that, since the 2005 hurricane season, many organizations have developed and disseminated information about emergency evacuation of persons with special needs. Government and private entities have also reviewed and evaluated disaster preparedness as it applies to persons with special needs. The results of these efforts appear on websites available to long-term care providers and anyone interested in ensuring the safety of persons with special needs in a disaster. Within the Federal Government, such websites include those of FEMA,170 the DHS,171 the DOT’s Office of Civil Rights,172 and the HHS.173 In addition, the website of the American Health Care Association174 offers for sale its Disaster Planning Guide: A Resource Manual for Developing a Comprehensive Preparedness Plan, developed by the Florida Disaster Preparedness Committee and the Florida Health Care Association. The website of the Joint Commission on Accreditation of Healthcare Organizations provides information in conjunction with its publication, 170  See , September 26, 2006. 171  For preparedness information for persons with special needs, see , September 26, 2006. For developments from the HHS Interagency Coordinating Council on Emergency Preparedness and Individuals With Disabilities, see , September 26, 2006. 172  See , September 26, 2006. 173  Among other HHS publications issued following the 2005 hurricanes was Nursing Home Emergency Preparedness and Response During Recent Hurricanes. See September 26, 2006. 174  See , September 26, 2006.

Analysis 79 Highway Accident Report Standing Together: An Emergency Planning Guide for America’s Communities,175 which addresses the needs of “vulnerable” populations. Many other organizations, such as the American Red Cross176 and Easter Seals,177 offer information on their websites concerning emergency planning for persons with special needs. The Safety Board is gratified that, following the disasters caused by Hurricanes Katrina and Rita, many government and private organizations have begun to improve evacuation systems by working to provide better means of emergency transportation, improving coordination among parties involved in the evacuation of persons with special needs, and disseminating emergency preparedness information to community members. 175  See , September 26, 2006. 176  See , September 26, 2006. 177  See , September 26, 2006.)

80 Highway Accident Report Conclusions Findings 1. Although the hurricane evacuation was the reason for the trip, neither the weather conditions at the time nor the design and condition of the roadway caused or contributed to the accident. 2. A determination could not be made regarding the potential impact of the motorcoach driver’s medical condition on his response to the emergency. 3. The motorcoach driver was fatigued at the time of the tire fire, but his fatigue was not a causal factor in the accident. 4. Appropriate resources were dispatched to the accident scene, responders and medical personnel arrived as quickly as possible, considering the heavily congested roadways and the initially erroneous information about the accident location, and the injured received medical care and were transported to local hospitals in a timely manner. 5. The accident motorcoach was mechanically unsafe because the right-side tag axle wheel bearing assembly lacked sufficient lubrication, which resulted in high frictional forces and high temperatures, causing the wheel bearings to fail and igniting the tire. 6. Continuing analysis of motorcoach and bus fire data is vital to understanding not only the trends in vehicle fires, but also the success or shortcomings of measures taken by the Government and private industry to address this problem. 7. Because of the proximity of the combustible access panels to the tire wheel well, where the fire originated, the fuel delivery system contributed to acceleration of the fire. 8. The tire fire, caused by an overheated right-side tag axle wheel bearing assembly, which ignited the tire, spread up the side of the motorcoach and burnt through the fiberglass sidewall above the wheel well and through the motorcoach windows, creating an entry path for the smoke and fire into the passenger compartment. 9. The exterior of the motorcoach had not been fire-hardened in fire-prone areas, such as around the wheel wells, and was not required to be by regulation, thereby limiting the time available for safe egress in the event of a fire.

1. Because tire fires are difficult to extinguish, early detection of potentially hazardous

conditions in a wheel well area is critical, as demonstrated by the sequence of events in this accident, to eliminating the fire hazard.

Conclusions 81 Highway Accident Report

1. Because neither Global Limo Inc. nor its employees routinely inspected the hub oil

level or undercarriage of the wheel well, they did not discover the lack of lubrication of the tag axle wheel bearings; and this disregard for vehicle maintenance, pretrip inspections, and posttrip driver vehicle inspection reports led to a wheel bearing failure that resulted in a catastrophic fire and loss of life.

1. Federal regulations and inspection criteria do not require inspection of wheel bearings

and adequate lubrication to prevent wheel bearing failure and a resulting wheel well fire.

1. In the absence of a specific warning in the maintenance manual, owners of vehicles

with oil bath bearings may not be aware of the inherent danger of inadequate wheel bearing lubrication and the potentially serious consequences of a wheel bearing failure.

1. Global Limo Inc. exhibited a lack of concern for safety management controls by

violating several Federal safety regulations pertaining to its drivers and vehicles, including employing a driver who was not properly licensed to drive a motorcoach in the United States, failing to conduct the required postaccident alcohol and illicit drug testing, and operating a passenger-carrying commercial vehicle, which had an expired temporary trip tag, that was not registered in the United States, was displaying the license plate from another vehicle, and had not been systematically maintained.

1. The Federal Motor Carrier Safety Administration’s compliance review program does

not assign numerical value to safety regulation violations that are classified as neither “acute” nor “critical” during the safety fitness rating process, thereby allowing potentially unsafe carriers, which violate safety regulations without consequence, to continue operating.

1. The current Federal Motor Carrier Safety Administration compliance review process

does not effectively identify unsafe motor carriers and prevent them from operating.

1. Although the accident motorcoach driver had previously been cited in a roadside

inspection as being a non-English-speaking driver, his inability to speak the English language was not a factor in this accident.

1. The quick-spreading fire and thick smoke prevented nursing staff, bystanders, and

rescuers from extricating all passengers with special needs from the accident motorcoach.

1. In the absence of demonstrated emergency evacuation capabilities for motorcoaches,

such as the accident vehicle, the effectiveness of design features in facilitating the safe escape of passengers cannot be determined.

Conclusions 82 Highway Accident Report

1. The smoke and heat from the fire prevented rescuers from safely proceeding further

into the motorcoach within minutes of their arrival on scene, and the aluminum cylinders failed, releasing oxygen to the fire, after successful rescue attempts were no longer possible.

1. The possibility of structural failure in partially pressurized aluminum cylinders when

exposed to heat and fire, as occurred on the accident motorcoach, poses a danger to the general public and emergency responders.

1. Given the unusual circumstances and limited options, Sunrise Senior Living Services, Inc.,

took reasonable action at the time in deciding to contract with BusBank for motorcoach transportation. Probable Cause The National Transportation Safety Board determines that the probable cause of the accident was insufficient lubrication in the right-side tag axle wheel bearing assembly of the motorcoach, resulting in increased temperatures and subsequent failed wheel bearings, which led to ignition of the tire and the catastrophic fire. Global Limo Inc. had failed to conduct proper vehicle maintenance, to do pretrip inspections, and to complete posttrip driver vehicle inspection reports, thereby allowing the insufficient wheel bearing lubrication to go undetected. Contributing to the accident was the Federal Motor Carrier Safety Administration’s ineffective compliance review system, which resulted in inadequate safety oversight of passenger motor carriers. Contributing to the rapid propagation and severity of the fire and subsequent loss of life was the lack of motorcoach fire-retardant construction materials adjacent to the wheel well. Also contributing to the severity of the accident was the limited ability of passengers with special needs to evacuate the motorcoach.

83 Highway Accident Report Recommendations New Recommendations As a result of its investigation, the National Transportation Safety Board makes the following safety recommendations: To the Federal Motor Carrier Safety Administration: Establish a process to continuously gather and evaluate information on the causes, frequency, and severity of bus and motorcoach fires and conduct ongoing analysis of fire data to measure the effectiveness of the fire prevention and mitigation techniques identified and instituted as a result of the Volpe National Transportation Systems Center fire safety analysis study. (H-07-1) Revise the Federal Motor Carrier Safety Regulations at 49 CFR 393.205 to prohibit a commercial vehicle from operating with wheel seal or other hub lubrication leaks. (H-07-2) To protect the traveling public until completion of the Comprehensive Safety Analysis 2010 Initiative, immediately issue an Interim Rule to include all Federal Motor Carrier Safety Regulations in the current compliance review process so that all violations of regulations are reflected in the calculation of a carrier’s final rating. (H-07-3) To the National Highway Traffic Safety Administration: Develop a Federal Motor Vehicle Safety Standard to provide enhanced fire protection of the fuel system in areas of motorcoaches and buses where the system may be exposed to the effects of a fire. (H-07-4) Develop a Federal Motor Vehicle Safety Standard to provide fire-hardening of exterior fire-prone materials, such as those in areas around wheel wells, to limit the potential for flame spread into a motorcoach or bus passenger compartment. (H-07-5) Develop detection systems to monitor the temperature of wheel well compartments in motorcoaches and buses to provide early warning of malfunctions that could lead to fires. (H-07-6) Evaluate the need for a Federal Motor Vehicle Safety Standard that would require installation of fire detection and suppression systems on motorcoaches. (H-07-7)

Recommendations 84 Highway Accident Report Evaluate current emergency evacuation designs of motorcoaches and buses by conducting simulation studies and evacuation drills that take into account, at a minimum, acceptable egress times for various postaccident environments, including fire and smoke; unavailable exit situations; and the current above-ground height and design of window exits to be used in emergencies by all potential vehicle occupants. (H-07-8) To the Pipeline and Hazardous Materials Safety Administration: Develop standards for the safe transportation of partially pressurized aluminum cylinders by, for example, requiring the addition of temperature-actuated pressure relief devices or the reduction of residual pressure to safe limits, to ensure that such cylinders do not experience overpressure failure when exposed to a fire. (I-07-1) Issue guidance to, at a minimum, the Fraternal Order of Police, International Association of Chiefs of Police, International Association of Fire Chiefs, International Association of Fire Fighters, National Association of State EMS Officials, National Sheriffs’ Association, and National Volunteer Fire Council, describing the risk of overpressure failure of partially pressurized aluminum cylinders and the steps that should be taken to protect responders and the general public from a vehicle fire when aluminum cylinders are present. (I-07-2) To the Fraternal Order of Police, International Association of Chiefs of Police, International Association of Fire Chiefs, International Association of Fire Fighters, National Association of State EMS Officials, National Sheriffs’ Association, and National Volunteer Fire Council: Disseminate to your members the guidance developed by the Pipeline and Hazardous Materials Safety Administration describing the risk of overpressure failure of partially pressurized aluminum cylinders and the steps that should be taken to protect responders and the general public from a vehicle fire when aluminum cylinders are present. (I-07-3) To Motor Coach Industries, Inc.: Revise your product maintenance manuals to emphasize the importance of wheel bearing lubrication, specifically warning that daily inspection of hub oil levels and wheel seals is vital to prevent wheel bearing failure and that bypassing this requirement is a dangerous practice that can lead to a wheel well fire or other serious consequences. (H-07-9)

Recommendations 85 Highway Accident Report For those vehicles already sold and in service, disseminate a customer advisory bulletin on the importance of proper wheel bearing maintenance, specifying the type of equipment or oil bath bearings that require an undercarriage inspection to detect wheel seal leaks and alerting customers to the serious consequences of lack of lubrication and subsequent wheel bearing failure. (H-07-10) To Motor Coach Industries, Inc., Prevost Car Inc., Setra, Van Hool, Blue Bird Corporation, Trident Industries, Inc., and IC Corporation: Until the National Highway Traffic Safety Administration has developed a performance standard for enhanced fire protection of fuel systems in newly manufactured motorcoaches and included it in the Federal Motor Vehicle Safety Standards, as requested in Safety Recommendation H-07-4, use materials and designs for fuel system components that are known to provide fire protection for the system. (H-07-11) To the United Motorcoach Association and the American Bus Association: Disseminate to your motorcoach and bus operator members an advisory bulletin emphasizing the importance of proper wheel bearing maintenance, particularly the importance of checking the oil level in oil-lubricated bearings (also known as oil bath bearings) and inspecting the undercarriage of the tag axle wheels to detect wheel seal leaks, and the serious consequences of lack of lubrication and subsequent wheel bearing failure. (H-07-12) Advise your motorcoach manufacturer members to review product maintenance manuals and, if the manuals do not emphasize the importance of wheel bearing lubrication, to revise them to specifically warn that daily inspection of hub oil levels and wheel seals is vital to prevent wheel bearing failure and that bypassing this requirement is a dangerous practice that can lead to a wheel fire or other serious consequences. (H-07-13) Advise your motorcoach manufacturer members to disseminate, for those vehicles already sold and in service, a customer advisory bulletin on the importance of proper wheel bearing maintenance, specifying the type of equipment or oil bath bearings that require an undercarriage inspection to detect wheel seal leaks and alerting customers to the serious consequences of lack of lubrication and subsequent wheel bearing failure. (H-07-14)

Recommendations 86 Highway Accident Report Reiterated Recommendations The National Transportation Safety Board also reiterates the following two safety recommendations: To the U.S. Department of Transportation: Change the safety fitness rating methodology so that adverse vehicle or driver performance-based data alone are sufficient to result in an overall unsatisfactory rating for a carrier. (H-99-6) Require motorcoach operators to provide passengers with pretrip safety information. (H-99-8) BY THE NATIONAL TRANSPORTATION SAFETY BOARD MARK V. ROSENKER DEBORAH A. P. HERSMAN Chairman Member ROBERT L. SUMWALT KATHRYN O’LEARY HIGGINS Vice Chairman Member STEVEN R. CHEALANDER Member Adopted: February 21, 2007 Member Hersman filed the following concurring statement on February 28, 2007, joined by Member Higgins. Member Higgins filed the following concurring and dissenting in part statement on April 20, 2007, and was joined concurring in part by Member Hersman.

Recommendations 87 Highway Accident Report Notation 7774A Member Deborah A. P. Hersman, Concurring: There was almost nothing about this accident that was usual. The circumstances— from the hurricane evacuation to the general health of the passengers to the traffic conditions—were extraordinary. Yet, the accident uncovered an astounding number of issues of motorcoach safety that we cannot afford to look past just because the accident happened under unusual circumstances. I will focus on just a few of the issues that were raised during our Board meeting on February 21, 2007 but are not thoroughly discussed in the final accident report. Bus Driver’s English Language Deficiency The bus driver was unable to communicate in English. Although the bus driver’s English language deficiency was not causal to the accident, it is nevertheless useful to look at how this deficiency had a tangential effect on the accident in several instances: • A training video available at Global for training drivers was in English and would not have been useful to the bus driver. • The MCI maintenance manual for the motorcoach was in English, making it of no use to the driver as far as items to look at during a pre-trip inspection, required maintenance, and proper vehicle operation. • The driver was unable to read and interpret variable message boards on the highway giving information about routing and the evacuation. • The residential care director of Sunrise, who was riding in the bus and who knew a little Spanish, had difficulty communicating to the driver their need to stop the bus in order to replace depleted oxygen tanks for two of the passengers. • The residential care director again had trouble communicating with the driver when trying to ascertain the milepost number of the place they stopped when the bus had a flat tire, so that she could notify the Navarro County Emergency Services dispatcher of their location. • When the mechanic arrived on scene to repair the flat tire, the driver was unable to converse with him about the repair. • The bus driver at first had difficulty understanding the severity of the problem when another driver signaled to him that the bus’s rear tire was on fire. • The bus driver was unable to effectively communicate to the passengers the need for them to evacuate the bus quickly. According to a Safety Board investigator’s analysis report, it was only after the nursing staff communicated among themselves about the danger threatening the passengers that the bus evacuation began, mostly through the efforts of the nursing staff and bystanders.1 1  Human Performance Group Chairman’s Memorandum of Analysis, NTSB Accident no. HWY-05-MH-035.

Recommendations 88 Highway Accident Report Federal Motor Carrier Safety Regulations (FMCSRs) require that an individual driving a commercial motor vehicle in the United States must be proficient in English.2 On February 12, 2005, the bus driver was stopped for a roadside inspection in which the inspector noted on the inspection report that the bus driver did not speak English. In accordance with 49 CFR 396.9(d), Global Limo had 15 days to correct this noncompliance, yet according to company records, the bus driver drove, not only on the day of the accident, but also on many trips between the February inspection and the day of the accident. Language has been a factor in several tragic accidents in the past several years. In 2005, the Safety Board investigated a motorcoach fire near Meriden, Connecticut. The driver of the motorcoach saw the need for passengers to quickly evacuate the bus, but he spoke only Chinese and was unable to communicate an evacuation order. Eventually, the passengers were able to interpret his body motions and communicated to one another the need to evacuate. Last year, this same motorcoach operator was involved in an accident in Boston in which 48 people were injured. As in the earlier accident, a Chinese-speaking driver could not communicate in English. This time, FMCSA cited the company for violating the English language requirement, in addition to a speeding violation, and fined the company $31,000 for both violations.3 Effective communication is the foundation for a successful response to an emergency. In 2005, the Safety Board investigated a gasoline tanker rollover accident in Davie, Florida, in which the driver’s inability to speak English impeded first responders’ efforts to ascertain what type of hazardous material he was transporting in the tanker. In 2003, the non-English speaking driver of a tractor semi-trailer involved in an accident near Slippery Rock, Pennsylvania, was unable to communicate to first responders the nature of his load when first responders noticed that the trailer, engulfed in flames, was placarded for hazardous materials. He reported through an interpreter that he had been unable to read variable message signs on the roadway, but that he just followed traffic. He also reported that he had been stopped twice for roadside inspections, in which case, he called his boss on his cell phone so that his boss could act as interpreter between him and the inspector. He was not cited for a violation of the English language requirement. A motorcoach accident near Manahawkin, New Jersey, in 2003 involved a driver who spoke Chinese and was unable to answer basic questions about the accident without a State Police interpreter. In an accident near Old Bridge, New Jersey, in 1998, the driver of a motorcoach was not able to provide needed basic information to investigating officers without a Russian interpreter. 2  49 CFR 391.11(b)(2) states: “Except as provided in Subpart G of this part, a person is qualified to drive a motor vehicle if he/she can read and speak the English language sufficiently to converse with the general public, to understand highway traffic signs and signals in the English language, to respond to official inquiries, and to make entries on reports and records.” 3  News release, U. S. Department of Transportation, Office of Public Affairs, October 30, 2006.

Recommendations 89 Highway Accident Report We cannot categorically state that if the language barrier in any of these accidents had been removed, the accidents would not have happened. However, it must be acknowledged that in these accidents, as in the accident in Wilmer, the situations would have been more effectively and safely handled had there not been a language issue. It is worthwhile to note that in 2003, the Commercial Vehicle Safety Alliance (CVSA) petitioned the Department of Transportation (DOT) to amend the FMCSRs to better address the language proficiency of commercial drivers.4 The petition cites the inability of some commercial drivers to communicate in English as compromising the inspection process as well as highway safety. CVSA suggested that the Federal Motor Carrier Safety Administration (FMCSA) work with CVSA to develop a standard test procedure for law enforcement officers to use to determine if a commercial driver meets the minimum standard for communication. CVSA also suggested that FMCSA revise the regulation at 49 CFR 391.11(b)(2) to reflect requirements for communication under the North American Free Trade Agreement under which it is the responsibility of a driver and a motor carrier to be able to communicate in the country in which they are operating so that safety is not compromised. Bus Driver’s Immigrant Status and Mexican Commercial Driver’s License The bus driver, a citizen of Mexico, was an illegal alien in the U.S. at the time of the accident. When asked by Safety Board investigators if he had a green card or a work visa, he responded that he did not. He stated that he held a commercial driver’s license in Mexico since 1988 and was an experienced bus driver in Mexico, having driven for his father’s (and later his brother’s) company for many years, but he came to the U.S. because of the “differences in pay.” At the time of the accident, he was driving under the authority of a Mexican CDL issued in 1998. As a driver with a Mexican CDL, he was permitted to drive from Mexico to the United States, or through the United States to Canada, and return. He was not legally permitted to drive from an origination point in the U.S. to a destination in U.S. as he was doing for Global Limo. On the back of his CDL, boxes indicated “No” as the response to the following medical conditions: diabetes, vision correction required, and hypertension. Although the bus driver admitted being diagnosed with diabetes in 1998 and being treated by a Mexican physician for Type II diabetes, his CDL did not reflect that he has the illness. Investigators did not find any records associated with his CDL that reflected his condition had been disclosed or was under control. When a U.S. doctor declined to give him a medical certification until he could prove that his diabetes was controlled, he continued to drive under his Mexican CDL. 4  Commercial Vehicle Safety Alliance to U.S. Department of Transportation, Federal Motor Carrier Safety Administrator, “Petition to Amend 49 CFR Part 391 to Facilitate Adequate Language Proficiency for Commercial Drivers,” September 10, 2003.

Recommendations 90 Highway Accident Report The bus driver was cited twice for speeding, once in April 2005 near Brownsville, Texas and once in August, 2005 near Laredo, Texas (he said he was trying to make up lost time after the bus broke down on the trip).5 Neither citation appeared on his license at the time of the accident or any time during the investigation. If he had pleaded guilty and paid for either or both citations, they should have appeared as convictions on his Mexican CDL. If he had failed to pay the fines or appear in court, his license should have been suspended. Data improvement efforts over the last decade have resulted in significant investments in the Commercial Driver’s Licensing system. The goal of these federal investments is to guarantee that license and conviction information is transferred between the 50 states, the District of Columbia, Mexico, and Canada. For this purpose, a database has been established in the U.S. that connects to the Federal licensing system in Mexico and so that it functions as the “52nd State.” Investigators could not find documentation to determine whether the citations were resolved through the courts or the licensing system. In this case, the system that connects traffic citations to the drivers who commit them, from one country to the other, failed. While the bus driver’s immigration status was not causal to the accident, I believe that it did have a role in keeping a sloppy motorcoach operator in business. The bus driver knew that Global buses had chronic maintenance problems. The owner of the company had avoided recommended repairs, in one instance, departing a repair shop in Aransas Pass, Texas, with a parking brake that did not work. The owner had a reputation for failing to pay for repairs, and in fact, NTSB investigators found two Global buses being held as collateral at Valley Volvo in Pharr, Texas, because Global had neglected to pay for repairs. The accident bus driver reported that he had driven the accident bus to Dallas earlier in the week and that the air conditioner was not working and the front tires were so bald they were causing the front end of the bus to vibrate. He told investigators that he “demanded” that repairs be made before the next trip. The tires were replaced, however the new tires were undersized, which may have caused the front axle to be overloaded by as much as 33.6%.6 The violations of FMCSRs accumulated by Global Limo are well documented. In the two years prior to the accident, Global’s drivers were subjected to eight roadside inspections that resulted in four drivers being placed out of service for hours-of-service violations. The driver of the accident bus underwent three roadside inspections prior to the accident and was placed out of service after two of the three inspections. Safety Board investigators learned that Global did not require drivers to keep a record of their hours of service, except when driving on behalf of FEMA. The driver said that he continued to work for Global because the company owed him several thousand dollars in back pay. He said he was promised his money once the company had more cash earned from contracts it had with FEMA to transport evacuees from New Orleans following Hurricane Katrina. 5  Driver interview, Motor Carrier Groups Chairman’s Factual Report, Texas Department of Public Safety Citation, NTSB Accident No. HWY-05-M-H035. 6  Vehicle Group Chairman’s Factual Report, NTSB Accident No. HWY-05-M-H035.

Recommendations 91 Highway Accident Report Both parties in this employer/employee relationship had deficiencies to hide and compensate for. The bus driver was an undocumented alien working illegally in this country with an apparently problematic foreign CDL with an invalid medical certification. He worked for Global because the company was willing to overlook his immigration status and other licensing problems. Global was a cash-strapped bus company operating in violation of numerous motor carrier safety violations. Global hired the bus driver because he was willing to overlook the company’s many safety issues so that he could work in this country. These two parties forged a symbiotic relationship that enabled this motorcoach company to operate on the thinnest of safety margins, until the day of this accident when the margin disappeared. The Federal Motor Carrier Safety Administration FMCSA was created by the Motor Carrier Safety Improvement Act of 1999 (MCSIA). Prior to its establishment as an independent modal administration, the functions of FMCSA were housed in the Office of Motor Carriers (OMC) within the Federal Highway Administration (FHWA). Originally, authority for the trucking and motorcoach industries was administered by the Interstate Commerce Commission, but following deregulation and the passage of the Motor Carrier Act of 1980, economic and safety authority were divorced. The Motor Carrier Safety Act of 1984 directed the Secretary of Transportation to establish a procedure to determine the safety fitness of owners and operators of commercial vehicles operating in interstate commerce. It stated that the intent of Congress was to reduce commercial vehicle crashes and fatalities through strong enforcement of motor vehicle safety laws and regulations. Thus, the OMC became responsible for safety oversight of the truck and bus industry. In the late 1990s, the OMC came under harsh criticism from safety groups, the Congress, and the DOT Inspector General for its failure to reduce large truck crashes and fatalities and for being too close to the trucking industry. The general conclusion was that the priorities of the truck and bus safety office were too buried within a huge agency, FHWA, whose primary mission was to build roads. According to the Inspector General, “The fatality rate for large truck crashes has remained flat since 1995, while the number of fatalities involved in those crashes continues to increase… The OMC has shifted emphasis from enforcement to a more collaborative, educational, partnership-with-industry approach to safety. This is a good approach for motor carriers that have safety as a top priority, but it has gone too far...”7 FHWA acknowledged in a response letter to the Inspector General that the “pendulum has swung too far towards education/outreach and now must move towards stronger enforcement, particularly for repeat offenders.” 8 In May of 1999, DOT Secretary Rodney Slater and Federal Highway Administrator Kenneth Wykle announced a safety action plan with a goal of reducing motor carrier traffic fatalities by 50% over 10 years through a comprehensive effort with

7  Department of Transportation Inspector General Report No. TR-1999-091, April 26, 1999, Motor Carrier Safety Program, Federal Highway Administration. 8   Ibid.

Recommendations 92 Highway Accident Report safety groups, industry and state and local governments.9 By September of 1999, they reported progress, citing a 59% increase in compliance reviews, followed by an increase in Federal investigators at the border from 13 to 40, and a reduction in the enforcement case backlog by two-thirds.10 Despite these actions by DOT, Congress quickly passed the MCSIA on a bipartisan basis,11 which President Clinton signed into law on December 9, 1999. The Act created FMCSA and directed it to “reduce the number and severity of large-truck involved crashes through more commercial motor vehicle and driver inspections and carrier compliance reviews, stronger enforcement, expedited completion of rules, sound research, and effective commercial driver’s license testing, recordkeeping, and sanctions.”12 The Act also authorized a large scale truck crash causation study, harsher penalties for violators, reviews of new motor carriers within 18 months of starting operations, improved data collection and reporting requirements, and substantial increases in funding for federal and state oversight efforts. FMCSA’s Budget Along with the creation of an independent agency came significant increases in funding for motor carrier safety. As part of FHWA, OMC had existed as an office within a larger agency, but the stand-alone modal administration required additional funds for the overhead costs generated by such independence. In addition, FMCSA has received significant increases each year to hire additional inspectors, complete regulatory activity and improve motor carrier safety. Since the agency opened its doors on January 1, 2000, its annual appropriation has increased by over 250%. 9  http://www.dot.gov/affairs/1999/52599sp.htm, Remarks by Secretary Slater, Commercial Vehicle Safety Action Plan, May 25, 1999. 10  FHWA 61-99 Press Release, September 28, 1999, “U.S. Transportation Secretary Slater Reports Progress in Motor Carrier Safety.” 11  In August 1999 Senator McCain introduced S. 1501, The Motor Carrier Safety Improvement Act of 1999 and Representatives Shuster, Oberstar, Petri and Rahall introduced H.R. 2679, The Motor Carrier Safety Act of 1999. 12  P.L. 106-159.

FMCSA Funding 2000-2007 181 272 361 305 364 443 490 490 0 100 200 300 400 500 600 2000 2001 2002 2003 2004 2005 2006 2007 Fiscal Year Dollars in Millions Recommendations 93 Highway Accident Report Source: 2000 (http://testimony.ost.dot.gov/test/passttest/00test/Cirillo1.htm) 2001 – 2002 (http://www.dot.gov/bib2003/fmcsa.html) 2003 – 2004 (http://www.dot.gov/bib2005/admins.html) 2005 – 2006 (http://www.dot.gov/bib2007/admins.html) 2007 (http://www.dot.gov/bib2008/bibpart06fmcsa.htm) Performance Measures FMCSA has established several performance measures and subjective data sets that provide useful information. One such data set reflects the number of fatalities in large truck crashes. One of the first goals set by FMCSA upon its creation was to reduce the number of fatalities involving large trucks by 50% in ten years. In the past eight years, however, the number of such fatalities has remained fairly constant.

Large Truck Crash Fatalities 1999-2005 5,380 5,282 5,111 4,939 5,036 5,235 5,212 0 1,000 2,000 3,000 4,000 5,000 6,000 1999 2000 2001 2002 2003 2004 2005 Fatalities 50% Reduction Target Actual Fatalities Recommendations 94 Highway Accident Report Source: 1999-2004 -http:ai.volpe.dot.gov/test/CarrierResearchResults/HTML/2004Crashfacts/tb11.htm 2005 - http:ai.volpe.dot.gov/CrashProfile/n_overview.asp As it became increasingly clear that the goal to achieve a 50% reduction in large truck fatalities was not going to be reached in the time allotted, the agency changed its goal. In DOT’s proposed Safe, Accountable, Flexible, and Efficient Transportation Equity Act in 2003, FMCSA’s “re-stated goal” was to participate in the DOT-wide goal of reducing the fatality rate in all motor vehicle crashes by 41% between 1998 and 2008. FMCSA’s part of that goal was to reduce commercial vehicle crash fatalities to 1.65 fatalities per 100 million truck miles traveled (MTMT). In April 2005, Administrator Annette Sandberg testified before Congress about the new FMCSA goal to reduce commercial vehicle crash fatalities, stating, “I am pleased to report that the FY 2003 CMV fatality rate is the lowest recorded since the Department initiated tracking in 1975.”13 While the agency came closest to meeting its goal in 2003, the gap between the annual goal rate and the actual rate increased that year and each year after that.  For example, in the FY 2007 budget submission, FMCSA stated that the goal for 2003 was a rate of 2.19, but the actual rate was 2.31.  Similarly, in 2004, the goal rate was 2.07, but the actual rate was 2.29, and in 2005, the goal was 1.96, and the estimated rate was projected to be 2.33. FMCSA has not achieved its “restated goal.” 13  Adminstrator Annette Sandberg, Testimony before the Senate Commerce, Science and Transportation Committee, April 5, 2005.

Large Truck Fatality Rate per MTMT 2.19 2.32 2.45 1.96 2.07 2.28 2.29 2.31 2.30 2.45 0 0.5 1 1.5 2 2.5 3 2001 2002 2003 2004 2005 Year Fatalities per 100 Million Truck Miles Traveled Target Actual Recommendations 95 Highway Accident Report Source: 1999-2004 (http://ai.volpe.dot.gov/test/CarrierResearchResults/HTML/2004Crashfacts/tbl1.htm) 2005-2006 (http://www.whitehouse.gov/omb/expectmore/detail/10000410.2003.html) In its FY 2008 budget estimates, FMCSA has once again changed the measure to evaluate its own effectiveness, with a new goal to be achieved by 2011.14  However, that goal is no longer expressed as the large truck fatality rate per 100 MTMT, but rather as the combined bus/large truck fatality rate per 100 million vehicle miles traveled (MVMT).  It is important to note, that the agency has done two things to change the measure: first, it merged the fatality rate with the bus/motorcoach rate, and, second, it replaced the number of fatalities per 100 MTMT (which, of course, calculates only truck miles) in favor of a new exposure denominator comprising annually accrued mileage for all motor vehicles. The bus/motorcoach fatality rates per 100 MVMT are far lower than those for trucks, so with the first change of merging bus/motorcoach fatality rates with truck rates, the combined rates were substantially lowered, with new figures expressed as the large truck-bus/motorcoach fatality rate per 100 million commercial motor vehicle miles traveled (CMVMT). In the second change, the exposure of total CMVMT was then submerged in the larger, total mileage traveled annually by all motor vehicles. Thus, FMCSA is able to portray a fatality rate that is more than an order of magnitude lower than the previous measure of large truck fatalities per 100 MTMT. Accordingly, instead of large truck fatality rates of 2.31 (2003), 2.37 (2004), and 2.34 (2005) per 100 MTMT, the rate stated in the FY 2008 budget estimates for 2005 (the earliest year cited in the body of 14  “Budget Estimates Fiscal Year 2008,” Federal Motor Carrier Safety Administration, p. 4A-14.

Recommendations 96 Highway Accident Report the FY 2008 budget estimates) is 0.184 per 100 MTVMT (million total vehicle miles traveled).  Similarly, the target goal for 2006 is 0.179, for 2007 it is 0.175, and for 2008 it is 0.171. While some may question whether this exposure denominator is appropriate, what is clear is that in less than 10 years since it has been created, the total number of commercial vehicle fatalities has remained flat while the agency has thrice revised its goals, making it very difficult for anyone to make meaningful year-to-year comparisons and obfuscating the fact that the agency has failed to meet its target reductions in total fatalities and fatality rates. Roadside Inspections and Traffic Enforcement Roadside inspections and commercial motor vehicle traffic enforcement are generally conducted by dedicated commercial vehicle safety inspectors employed by the states. The program consists of roadside inspections performed by approximately 10,000 qualified safety inspectors following the guidelines of the North American Standard, which was developed by the CVSA in cooperation with FMCSA. There are various levels of inspections for each component, which may include a vehicle component, a driver component, or both. An inspection is identified as a traffic enforcement event when at least one traffic violation is present in the inspection. The traffic enforcement program is based on 21 state or local traffic enforcement violations noted in conjunction with a roadside inspection. 15 Approximately 25% of inspections between 2003 and 2005 were traffic enforcement related.16 Most roadside inspections by the states are conducted under the Motor Carrier Safety Assistance Program (MCSAP). MCSAP is a Federal grant program administered by FMCSA to provide funding to the states for commercial vehicle safety efforts. MCSAP was initially funded at $8 million in 1984. It increased substantially after the creation of FMSCA and grew to $188 million by FY 2006.17 The money is allocated by formula, and states are required to provide a match for the Federal funding, generally apportioned on an 80/20 basis. States determine their MCSAP priorities within allowable expenditures, and they may qualify for additional incentive grants or border funds. Some states elect to spend additional state funds beyond the MCSAP program to further oversee motor carrier safety. For example, while the total federal funding for MCSAP during FY 2005 was $169 million,18 the state of California spent $137 million on commercial motor vehicle programs in FY 2005.19 A roadside inspection occurs when an inspector conducts an examination on a commercial motor vehicle and driver to determine if they are in compliance with the FMCSRs and/or the hazardous materials regulations. Serious violations result in the 15  http://ai.volpe.dot.gov/Help/Help.asp?#ri1 Volpe – A & I Program Measures, Roadside Inspections. 16  http://ai.volpe.dot.gov/ProgramMeasures/TE/TE.asp Volpe - A & I Program Measures, Traffic Enforcement. 17  DOT IG Report No. MH-2006-046 Significant Improvements in Motor Carrier Safety Program since 1999, but Loopholes for Repeat Violators Need Closing, Federal Motor Carrier Safety Administration, April 21, 2006. 18  http://www.fmcsa.dot.gov/safety-security/safety-initiatives/mcsap/mcsap-fy05.htm, FY 2005 MCSAP Grant Allocations by State and Category. 19  California’s FY is July 1 through June 30. These figures do not include Motor Carrier Safety Assistance Program (MCSAP) grant funding.

Recommendations 97 Highway Accident Report issuance of driver or vehicle out-of-service (OOS) orders. These violations must be corrected before the affected driver or vehicle can return to service. Approximately 73% of vehicles inspected are found to have at least one violation in roadside inspections. Further, 23% of vehicles have defects so serious that they are placed OOS and must be parked and repaired.20 The most common violation is out-of- adjustment brakes and defects in brake components, found in 57% of vehicles placed OOS. 21 Vehicles also may be placed OOS due to defects related to lights, tires, wheels, and cargo securement. Approximately 7% of drivers are placed OOS. The primary causes for placing drivers OOS are hours of service violations (57%), falsification of logs (12.4%), and drivers operating on suspended or disqualified licenses or without proper endorsements (8.5%).22 Roadside Inspections (1996-2005) 0 500,000 1,000,000 1,500,000 2,000,000 2,500,000 3,000,000 3,500,000 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Source: MCMIS Although the number of inspections has increased from 1.35 million in 199623 to over 3 million inspections in 2005,24 the OOS rates have remained constant. Studies have shown that targeted inspections of higher-risk carriers and completely random inspections 20  http://www.itsa.org/itsa/files/presentations/CVFMWirelessInspectionsLoftus.pps “Wireless Inspection Highlights” Jeff Lotus, FMCSA, March 2, 2006. 21  Roadcheck 2006, CVSA. 22  Ibid. 23  http://ops.fhwa.dot.gov/freight/freight_analysis/nat_freight_stats/docs/06factsfigures/table5_6.htm F reight Facts and Figures, DOT. 24  MCMIS.

Recommendations 98 Highway Accident Report result in similar OOS rates for drivers and vehicles.25 No matter the type or the number of inspections conducted in a given year, approximately one-quarter of commercial vehicles inspected have such serious violations that they must be parked and repaired before they can move. Such a high rate of safety violations is seen in no other mode of commercial transportation (air, rail, marine), nor would it be tolerated. The fact that this rate has remained high and constant over the last 10 years is significant. It means that the current penalty scheme is not sufficiently effective in ensuring that motor carriers comply with safety regulations. The sanctions imposed are considered the cost of doing business and thus suggest a tolerance level for violations of safety requirements. Vehicle and Driver Out-of-Service Rates 0 5 10 15 20 25 30 1996 1997 1998 1999 2000 2001 2002 2003 2004 Source: MCMIS Percentage Driver Out-of-Service Rates Vehicle Out-of-Service Rates Compliance Reviews Compliance reviews are the keystone of FMCSA’s safety program. According to the agency, the two main components of its safety monitoring system are compliance reviews and roadside inspections. As defined by FMCSA, a compliance review is an on- site examination of a motor carrier’s operations by a Federal safety investigator to determine a motor carrier’s safety fitness.26 A carrier cannot obtain a safety rating unless it undergoes a compliance review. Neither roadside inspections nor state safety audits similar to a compliance review result in a safety rating. There are over 900,000 active carriers,27 and the majority of carriers are unrated. 25   http://www.ai.fmcsa.dot.gov/CarrierResearchResults/PDFs/AdditionalReports/2003FleetSafety Surveys.pdf 2003 National Truck Fleet and Bus Fleet Satety Surveys: Final Report. 26   Powerpoint, “What is a compliance review?” www.fmcsa.dot.gov/documents/training/comp_rev_mx_eng. ppt - 2006-08-01. 27  MCMIS, Number of active carriers in 2005.

Recommendations 99 Highway Accident Report FMCSA prioritizes carriers for review based on their Safestat28 score or to follow up previous enforcement action. Additionally, compliance reviews may be initiated following a fatal accident or involvement in a major hazardous materials accident, as well as by complaints about carriers or at the carrier’s request. Generally, carriers subjected to compliance reviews are some of the worst carriers operating on the roadways. As identified in this accident report, only a fraction of the existing carriers received a compliance review in 2005; of the 910,866 carriers, just under 8,000, or less than 1%, were subjected to an on-site safety inspection. Of those, 5,022 carriers (63%) received a satisfactory rating, 2,138 carriers (27%) received a conditional rating, and 594 carriers (7%) received an unsatisfactory rating. In 2004, 19 months prior to the accident, Global received a satisfactory rating, despite numerous safety deficiencies cited, a fact that underscores the failure of compliance reviews to identify unsafe carriers. Although it had no maintenance program, deficiencies in its drug and alcohol program, and numerous driver violations, Global still received a satisfactory rating. (See attachment #1). Immediately following the bus fire, however, an FMCSA compliance review concluded that the carrier was not only unsatisfactory, but also an imminent hazard, and the agency ordered the company to cease operations. Although FMCSA predicts that its Comprehensive Safety Analysis of 2010 will address revisions to the carrier fitness rating system, the tragic consequences of this accident add urgency to the Safety Board’s Safety Recommendation H-99-6 to change the safety fitness rating methodology so that adverse vehicle and driver performance-based data alone are sufficient to garner an overall unsatisfactory rating. This recommendation was issued in 1999 following publication of NTSB’s Special Investigation Report on Selective Motorcoach Issues29 in which several motorcoach accidents were analyzed. It has been reiterated in this and other investigations,30 and it resides on our Most Wanted List of Transportation Safety Improvements.31 Only .0006 carriers of all carriers received a rating of unsatisfactory although the data indicate that 75% of roadside inspections result in at least one violation, with approximately 25% of vehicles and 7% of drivers having such serious violations that they must be placed OOS. The data further show that few carriers have their operating authority revoked. In addition, the Safety Board found during a recent investigation that a passenger carrier that had its interstate operating authority revoked continued to operate in interstate commerce undetected for several years. Although the carrier was subjected to at least one roadside inspection during that time, the lack of operating authority was not detected until after the company was scrutinized following its involvement in a fatal accident. 32 28  The SafeStat analysis program uses data from Federal and State sources, including roadside inspections, accident data, and enforcement actions for all carriers, to develop a safety fitness assessment of motor carrier. 29  NTSB/SIR-99/01. 30  NTSB/HAR-02/03 Collision Between Truck-Tractor Semitrailer and School Bus Near Mountainburg, Arkansas, on May 31, 2001. 31  http://www.ntsb.gov/Recs/mostwanted/highwayissues.htm. 32  NTSB Report Number HAR-06-03, Highway Accident Report: Multivehicle Collision on Interstate 90, Hampshire-Marengo Toll Plaza, Near Hampshire, Illinois, October 1, 2003.

Recommendations 100 Highway Accident Report Improvements to a carrier’s safety program and any enforcement action are predicated on the information documented in the compliance review. For years, regulators have been discussing ways to increase the number of compliance reviews, but while FMCSA’s budget has increased substantially since it was formed, there has been no commensurate increase in the number of the reviews completed. This issue was addressed by the House Appropriations Committee last year: “The Committee continues to be concerned that only a very small percentage of registered motor carriers undergo a safety compliance review each year.”33 While the agency has long promoted compliance reviews as the critical part of their mission, they often overstate the number of compliance reviews conducted each year. Testimony given by Administrator Sandberg in 2004 indicated that 11,000 compliance reviews were conducted that year.34 However data on FMCSA’s website show that less than 8,000 compliance reviews were conducted in 2004. A recent article in Bus & Motorcoach News stated that 12,000 compliance inspections are conducted annually35 when in reality, the agency has consistently fallen short of that goal. 10,389 8,443 9,301 8,347 7,651 8,114 10,102 0 2,000 4,000 6,000 8,000 10,000 12,000 2000 2001 2002 2003 2004 2005 2006 Compliance Reviews 2000-2006 Source: 2000 – 2001 (http://ai.fmcsa.dot.gov/ProgramMeasures/CR/NR/NSR/Report.asp?FC=C&RF=T&DP=P) 2002 – 2006 (http://ai.fmcsa.dot.gov/ProgramMeasures/CR//NR/NSR/Report.asp?FC=C&RF=T) 33  House Report 109-495 – Departments of Transportation, Treasury, and Housing and Urban Development, the Judiciary, District of Columbia, and Independent Agencies Appropriations Bill, 2007. 34  Administrator Annette Sandberg, Testimony before the Senate Commerce, Science and Transportation Committee, April 5, 2005. 35  “FMCSA Administrator vows to upgrade Fed’s coach safety oversight”, Bus & Motorcoach News, February 1, 2007.

Recommendations 101 Highway Accident Report Large trucks represent about 4% of registered vehicles; however, they account for 8% of the travel volume on our Nation’s highways. Approximately 12% of all the people killed in motor vehicle crashes die in crashes involving a large truck.36 There are approximately 9 million commercial truck and buses operating in the U.S. and over 900,000 registered motor carriers. The truck vehicle miles traveled increase at a rate of approximately 2% each year. FMCSA’s primary mission is to prevent commercial motor vehicle-related fatalities and injuries. It would be unfair to overlook the fact that FMCSA has made progress in certain areas: more enforcement cases have been opened and it has expanded its use of out-of-service orders consistent with authorities established in the MCSIA. In 2004, 425 carriers received OOS orders for maintaining an unsatisfactory rating for more than 60 days, and 1,378 carriers received OOS orders for failing to pay a civil penalty after 90 days. While commercial vehicles are over-represented in fatal accidents,37 fatalities have held steady in recent years although exposure is increasing due to higher vehicle miles traveled. However, while the FMCSA budget has almost increased by over 250% since the agency was established, many of FMCSA’s critical performance measures have remained essentially flat, including the number of annual fatalities in commercial motor vehicle crashes, the fatality rate, the driver and vehicle OOS rate in roadside inspections and the number of compliance reviews. Conclusion It is important to point out that for every unsafe motor carrier on the road, there are hundreds that take appropriate measures everyday to ensure the safety of their equipment and their drivers. Because the Safety Board’s role is to investigate accidents, we more often see those transportation providers (in all modes of transportation) whose approach to safety is something less than adequate. The circumstances of this tragic accident do not lead us to the conclusion that the motorcoach industry is unsafe or that motorcoaches are dangerous, because in reality, they have an excellent safety record, especially when compared to commercial trucks and passenger cars. However, it does serve to make us all aware that all motorcoach operations are not equal with respect to safety. Unfortunately, passengers place their trust in a motorcoach operator without any easy way to discern if the operator deserves that trust. They are entirely dependent on those charged with safety oversight to prevent them from entrusting themselves, or their loved ones, to the wrong carrier. Unfortunately, this accident investigation revealed that a company that violates almost all of the safety rules can still slip through the cracks. FMCSA conducted a compliance review of Global’s operations in February, 2004 and issued the company a satisfactory rating, even though major deficiencies existed. In the following year, after the September, 2005 bus fire, the agency conducted a compliance review that documented 36  http://www.dot.gov/bib2008/bibpart06fmcsa.htm, U.S. Department of Transportation, Budget in Brief – FY 2008, FMCSA. 37  Large trucks represent about four percent of registered vehicles; however, they account for eight percent of the travel volume on our Nation's highways. Approximately 12 percent of all the people killed in motor vehicle crashes die in crashes involving a large truck.

Recommendations 102 Highway Accident Report many of the same safety violations but yielded a vastly different outcome. FMCSA declared that Global’s operations created an “imminent hazard” to public safety and issued an out-of-service order stating that Global’s pattern of FMCSR violations was consistent in nature and long in history. This accident is one of many in which the Safety Board has found inconsistencies based on a safety rating process that fails to remove the most unsafe carriers from the Nation’s highways. FMCSA has the Herculean task of overseeing an industry where there are few barriers to entry and insufficient resources to conduct 100% oversight of every carrier, driver or truck. However, prior to this accident, there were multiple opportunities for intervention. FMCSA had the benefit of eight roadside inspections in the two years prior to this accident, four of which resulted in the drivers being placed out-of-service for serious violations of the Federal safety regulations. This 50% OOS rate identified Global as a high-risk carrier and prioritized them for inspection. The review conducted by the State of Texas in 2002 and the Federal compliance review conducted in 2004 documented numerous safety violations. Following the post-accident compliance review in 2005, FMCSA found that Global’s violations of the FMCSRs were “so widespread as to demonstrate a continuing and flagrant disregard for compliance” and that Global had a management philosophy “indifferent” to motor carrier safety. This disregard and indifference did not occur overnight -- it had existed for years. FMCSA has advised the Safety Board for over a decade that the rating system is going to be revised to better identify unsafe carriers. Recently, these promises were made part of FMCSA’s Comprehensive Safety Analysis 2010. But right now, this accident proves that the agency charged with safety oversight of our motor carriers is not getting even the worst of the worst carriers off the roads. The system is broken, and the traveling public can’t afford to wait until 2010 to fix it. Deborah A. P. Hersman February 28, 2007

Exhibit from Panel Six – Wilmer Public Hearing VIOLATIONS NOTED ON REVIEWS Educational Review 4/10/2002 Pre-Fire Compliance Review 2/12/2004 Post-Fire Compliance Review 10/07/2005 Part 382, Drug & Alcohol Program • No drug/alcohol testing program ACUTE Part 382, Drug & Alcohol Program • Failing to provide drivers with drug/alcohol policies • Failure to have persons trained for reasonable suspicion Part 382, Drug & Alcohol Program • Using driver w/o pre-employment drug test CRITICAL • Failing to provide drivers with drug/alcohol policies • Failure to have drug/alcohol random testing method • Failure to conduct post accident drug/alcohol test • Failure to have persons trained for reasonable suspicion Part 391, Driver Qualification Files • No driver background investigation • No driver employment application • No driver record inquiry CRITICAL Part 391, Driver Qualification Files • Failing to maintain a copy of response from each State agency • Failing to maintain a note relating to the driver’s annual record check • Failing to maintain a driver’s medical examiner certificate Part 391, Driver Qualification Files • Non-English speaking driver • Using driver w/o valid license • Using driver w/o complete employment application • Failure to maintain a Driver Qualification File • No driver record inquiry CRITICAL • Failing to maintain a note relating to the drivers annual record check • Failure to maintain list of motor vehicle violations Part 395, Hours of Service • Failure to require driver to make a record of duty status1 (log) CRITICAL Part 395, Hours of Service • False logs Part 395, Hours of Service • Permit violation 10 hour rule • Permit violation of 15 hour rule • Failure to require driver to make a record of duty status (log) 1 49 CFR Part 395.8 identifies the driver’s Record of Duty Status (RODS). The motor carrier industry and public commonly use the word “log” in lieu of the term Record of Duty Status or RODS. The term log is used in this report because of its common usage and familiarity to the public and the motor carrier industry. Recommendations 103 Highway Accident Report

• Failure to require form and manner on driver log • False log CRITICAL Part 396, Vehicle • Failure to maintain vehicle inspection and maintenance records • Failure to maintain evidence of brake inspector’s qualifications Part 396, Vehicle Failure to have a schedule for vehicle inspection and maintenance Part 396, Vehicle • Failure to maintain vehicle inspect vehicles • Fail to inspect emergency exits • Failure to require driver inspection reports CRITICAL • Operate CMV w/o Periodic Inspection CRITICAL Factor Rating Acute Critical Factor Rating Acute Critical Factor Rating Acute Critical Factor 1: S 0 0 Factor 2: U 1 1 Factor 3: U 0 2 Factor 4: S 0 0 Factor 5: N 0 0 Factor 6: S - - Factor 1: S 0 Factor 2: S 0 0 Factor 3: S 0 0 Factor 4: S 0 0 Factor 5: N 0 0 Factor 6: S 0 0 Factor 1: S 0 0 Factor 2: U 1 2 Factor 3: U 0 2 Factor 4: U 0 2 Factor 5: N 0 0 Factor 6: S - - SAFETY RATNG SAFETY RATING SAFETY RATING Unsatisfactory Satisfactory Unsatisfactory Factor 1: General = Parts 387 & 390 Factor 2: Driver = Parts 382, 383 & 391 Factor 3: Operational = Parts 392 & 395 Factor 4: Vehicle = Parts 393 & 396 Factor 5: Haz Mat = Parts 397, 171, 177 & 180 Factor 6: Accident Factor = Recordable Rate CALCULATION FORMULA Unsatisfactory Conditional Overall Rating 0 2 or fewer Satisfactory 0 3 or more Conditional 1 2 or fewer Conditional 1 3 or more Unsatisfactory 2 0 or more Unsatisfactory Recommendations 104 Highway Accident Report

Recommendations 105 Highway Accident Report Member Kathryn O’Leary Higgins, Concurring and dissenting in part: I concur with nearly all of this important report on our investigation into the tragic fire aboard a motor coach evacuating 44 assisted living residents and staff out of the forecast path of Hurricane Rita in September 2005. Twenty-three passengers were killed in that fire. Probable Cause: Naming the Federal Motor Carrier Safety Administration in the probable cause statement was justified because of the agency’s delay in making changes that are critical to improving highway safety. Eight years ago the Safety Board first recommended significant and substantive change to improve the safety of motor carrier operations: specifically, recommendation H-99-6, was issued in February 1999, was reiterated in 2002 and was added to the Most Wanted List in 2000 and is reiterated again in this report. That recommendation would require a change in the safety fitness methodology so that adverse vehicle or driver performance-based data alone would be sufficient to result in an overall unsatisfactory rating for a carrier. The status of that recommendation currently is “open- unacceptable response.” I believe that this accident could have been prevented if FMCSA had acted to implement this recommendation when it was first proposed. Under the compliance standard recommended by the Safety Board, Global Limo would have been rated unsatisfactory in pre-accident inspections based on the issues identified with both drivers and vehicle maintenance. The State of Texas conducted an educational review of the operator in 2002 and found several serious issues. That initial review was triggered by customer complaints. Information from that review was provided to FMCSA. The findings from that review were so serious that the carrier would have been put out of service if it had been a compliance review rather than an education review. At that time Texas did not have the authority to place vehicles out of service. Texas gained that authority in 2004, prior to the fatal accident. Compliance monitoring and a follow-up review was recommended in 2002 but not conducted by the state. At the public hearing the state acknowledged its earlier recommendations but offered no explanation as to why the recommended reviews were not conducted. FMCSA did not conduct a compliance review for almost two years after the initial Texas review. This was the first compliance review of Global Limo since the company began operations in 1980. The company was given a satisfactory rating because the vehicles were not inspected and not all the drivers were interviewed, nor was that required under the FMCSA compliance review system. That same system is still in place today. In my opinion, the lack of rigorous oversight, inspection and enforcement at both the Federal and state levels contributed to this accident. Only after the Wilmer accident did FMCSA place the carrier out of service, citing violations that were virtually identical to the violations found in the earlier review. This time the vehicles were inspected. I believe that both the State of Texas and FMCSA should be cited as contributing to this accident. Both failed in their responsibility to exercise oversight and enforce the regulations.

Recommendations 106 Highway Accident Report To improve safety on our highways, the current system needs an immediate overhaul. FMCSA has promised to make changes as part of their 2010 initiative. Each year there are over 5,000 fatal accidents involving federally registered motor carriers. Can we really afford to wait another three years and perhaps longer to tighten the rules that will take unsafe vehicles and drivers off the road? I am pleased that the Board voted to issue an Urgent Recommendation that asks FMCSA to issue an interim rule “to include all Federal Motor Carrier Safety Regulations in the current compliance review process so that all violations of regulations are reflected in the calculation of a carrier’s final rating”. With only 1,000 employees nationwide, FMCSA must leverage its resources more effectively by partnering with the States to ensure that the rules are being enforced. More than 910,000 motor carriers were registered in the United States in 2005. FMCSA conducted compliance reviews on almost 8,100 of those carriers. In other words, less than 1% of carriers undergo a compliance review each year. Even the IRS has a higher audit rate. As a result of those reviews, 61,924 violations were discovered yet the vast majority of those violations – 85.7% (53,064) – were not used to develop a safety rating of a carrier. It is not clear whether it is the design or the implementation of the safety program that results in this unsettling statistic. But, it is clear that change is needed. One approach is to require the states to take more responsibility for ensuring compliance. Approximately half the states are conducting compliance reviews for intrastate carriers. A similar number of states have the authority to put intrastate carriers out of service. Most of the carriers reviewed by states operate under both intra and interstate authority. We need a uniform system across the country. All states should have the authority to both conduct compliance reviews, using, at a minimum, FMCSA criteria, and put carriers out of service. If an intrastate carrier is taken out of service as a result of a state review, that carrier should no longer be able to operate across state lines. I believe the role of the states can and should be expanded in the name of making our roads and highways safer. The federal role should be to set uniform standards, develop model enforcement and compliance programs, provide technical assistance to states and operators, maintain the database and ensure state compliance with federal requirements. The current federal enforcement scheme does not raise the safety bar. States refer interstate cases to FMCSA with its regulatory scheme that has been compared to Swiss cheese. We recently celebrated the 50th anniversary of the interstate highway system. This system has connected this country from coast to coast and has made an enormous difference in the way business is conducted. Many, if not most, of the goods purchased on the inter-net are delivered via the interstate. Those roads were built with a combination of state and federal funds but to uniform standards. Why shouldn’t the rules that enforce safety on those roads be uniform, as well? Bus Brokers I firmly believe that BusBank, the broker that linked Global Limo and Sunrise, should be cited as a contributing to this accident. BusBank promotes the safety and qualifications of its operators on its website. BusBank advertises a 5-Star Guarantee, and the first star is safety. Unfortunately, as this accident revealed, that guarantee is hollow because there is no supporting qualification program behind that promised guarantee. If BusBank

Recommendations 107 Highway Accident Report had gone behind its website promises to investigate, Global Limo Inc. would have failed several of the criteria that BusBank said it used to qualify the company for referral: there were no pre-drug and alcohol testing of the driver; no driver training program: the accident driver was not properly licensed in the State of Texas and did not have a U.S. medical certificate, as required and could not communicate with the passengers because he did not speak English; the accident bus was not properly registered; and the bus was being operated in violation of the contract signed by the Canadian owners and was not maintained. Bus Bank, contrary to their claims, did not put Global Limo through a “due diligence” process, did not know the operator, and had no ongoing qualifications process for this operator. Global Limo did not even return the qualifications questionnaire sent to them by the BusBank. Without further inquiry, BusBank added Global Limo to its list of operators. The form does not ask for any of the other safety information mentioned above, nor does it ask for information from any previous inspections or reviews that might have been done on the vehicles, drivers or operators. A consumer, such as Sunrise Assisted Living, might well be swayed by the claims of independent safety oversight by a third party claiming to be a leader in the bus industry. And the stopgap, the Federal oversight on which BusBank claimed to rely and on which the American public rely also failed. When asked about their safety assurances, BusBank said they relied on the FMCSA website and the satisfactory rating given to Global Limo. They admitted that they did not look behind the rating to better understand issues that may have been identified in the compliance review. They did not seek any information from the State of Texas on Global’s operations. BusBank’s claims misled customers because BusBank did not look behind the federal rating did not seek information from the state, did not ask for relevant safety information from Global Limo nor was there any independent review of Global Limo. BusBank is in the business of connecting the public with bus transportation, claiming to be experts in their field. They ask the public to rely on their 5- Star Guarantee where “safety is first.” Yet, in our public hearing on this accident, BusBank testified that they are not “safety experts” but they guarantee safety in their promotions. FMCSA has some limited statutory authority to protect consumers by regulating household goods brokers. FMCSA does not have similar authority over brokers who connect paying passengers and bus companies. The Department of Transportation is specifically prohibited from regulating bus brokers. The traveling public is relying on the claims of BusBank and other companies when they or their representatives contract to charter a bus. The inter-net has made it much easier for individuals and companies to become transportation brokers. How is the public supposed to verify claims made by these brokers without some independent way to assess them? We don’t even know how many bus brokers there are because they aren’t required to register, as those who broker the transport of household goods are. Why have we placed a higher value on the transport of goods than the transport of people? I believe the Department of Transportation should seek repeal of the regulatory prohibition and develop standards that to require the registration of bus brokers and compliance with standards to protect and promote public safety.

Recommendations 108 Highway Accident Report NTSB staff has agreed to look into the issue of Federal jurisdiction to protect traveling consumers against deceptive and false advertising and to return to the Board with a recommended approach to highlight this issue for Federal policymakers. The Chairman has sent a letter to the Federal Trade Commission asking them to investigate BusBank’s practices. While that is a good start, I believe we should go further. We should take action to help policy makers understand this issue in order to determine the best approach to deter misrepresentation by brokers. Reporting of Bus Fires: The public hearing on this accident documented that adequate data on bus fires in this country is lacking because there is no requirement that bus fires be reported. Therefore, bus fire incidents are not captured in a consistent way in any national database. As a result of our investigation and the public hearing, we learned that the incidence of bus fires is much higher than had been previously understood. One witness testified that as many as five bus fires per week may occur in this country. The causes of bus fires are also varied and can start in the engine, in the electrical system, in the wheel wells and in the cooling system. While I am encouraged by FMCSA’s contract with the Volpe Center to gather data and set up a system to analyze the data that currently exists, I continue to be concerned that the Volpe study is examining data from previous fires, captured from a variety of sources. While that study may be useful in establishing a baseline, it does not appear to be designed to capture information on future bus fires. For that reason we have made a recommendation to FMCSA to continue to gather and evaluate information on the causes, frequency, and severity of bus and motor coach fires. I want to emphasize the importance of this issue. I urge immediate attention to this recommendation because we must begin to document these events and understand the source of the fires as well as their frequency, and the impact on passengers and the vehicles. Unless we accurately document this significant safety challenge we will not understand the dimensions of the bus fire problem, nor will we know what steps are most effective in mitigating the problem and will have no way of documenting progress in reducing the number and severity of such incidents. Fire Detection and Suppression: During our hearing we heard that bus fires are started by more than one source. We also learned that the source of the fire does not seem to affect the intensity of the fire because of the new materials and more powerful engines found on modern motor coaches. For this reason we asked the FMCSA to move expeditiously to evaluate the best way to detect fires that begin in wheel wells as well as fires ignited by other sources and then develop standards to be used by industry for purchasing and installing such detection equipment. As part of the revisions adopted at the Board Meeting and circulated afterwards for Board Member approval, a new recommendation to the National Highway Traffic Safety Administration (NHTSA) was added. The recommendation asks NHTSA to “evaluate the need for a Federal Motor Vehicle Safety Standard that would require installation of fire detection and suppression systems on motor coaches”. While I concur with the recommendation, I believe clarification of that recommendation is in order.

Recommendations 109 Highway Accident Report During our investigation of the Wilmer accident and a 2-day public hearing that followed, we learned that bus fires are an alarming and under-reported safety issue in this country. We also learned that there are multiple sources for these fires (engines, batteries, electrical systems, heaters, and tires/wheel and braking components). Our report and findings, as currently written, do not adequately address actions that should be taken with regard to fires that begin in a location other than the tire or wheel well. Our report also does not mention the important work done by staff to investigate and document other bus fires. I am concerned that the report and recommendation to NHTSA, as currently drafted, do not provide adequate guidance to NHTSA concerning the rationale for this additional recommendation. I would like to place that recommendation in context in light of my extensive personal involvement in the hearing that supported the investigation. If I were drafting this recommendation, I would ask NHTSA to “Evaluate the need for a Federal Motor Vehicle Safety Standard that would require installation of fire detection and suppression systems on motor coaches, taking into account the multiple causes and sources of bus fires and the technology available to detect and suppress these fires.” I believe this additional language offers better guidance to NHTSA as to this Member’s intent in proposing this additional recommendation. I also believe that the report would be strengthened if it included a finding reflecting the need for this recommendation. Research results, information provided separately to the Board and public testimony from the hearing confirm that bus fires occur more frequently than previously understood and are ignited in a number of different ways. Unfortunately, there is currently no federal standard requiring detection or suppression equipment on busses or motor coaches. An energetic response to this situation by NHTSA could significantly improve this situation. Evacuation of citizens with special needs: In this accident, 23 people died, and 21 escaped the burning bus with a variety of injuries. We have learned many things as result of this accident, including how ill-prepared we were to evacuate and ensure the safety of travelers with special needs. With the experience of Hurricane Katrina fresh in our minds, there was extraordinary pressure on transportation resources in advance of Hurricane Rita. Local, state and federal agencies worked, but not always in concert, to evacuate those in the path of another dangerous natural event. In an effort to get as many large trucks and buses on the road to provide disaster assistance before and after Hurricane Rita, the governor of Texas declared a state of emergency and waived certain regulatory requirements. While it has been claimed that safety requirements were not waived, this declaration process does in fact result in the temporary waiver of some federal safety requirements for drivers and companies providing direct relief efforts in a declared emergency. The only federal requirements that may not be waived are those related to commercial driver licenses, drug and alcohol testing, and insurance responsibility. I was also told that the waivers do not exempt operators from maintaining their busses. Press accounts have suggested that the operator of Global Limo could not be charged with all of the violations he committed because of the Evacuation Order and the subsequent waivers. As a result, his sentence

Recommendations 110 Highway Accident Report was much lighter than it might have been. I am concerned that in the interest of taking people out of harms way we may inadvertently be “waiving safety” and creating the potential for more harm. I hope that is not the case but this accident has raised that issue. I understand that these were terrible circumstances and extraordinary things were done to evacuate people out of the path of Hurricane Rita. And I am pleased that governments at all levels have reviewed their performance during that time. Many reports were produced that raised and changed awareness of the challenges and solutions for large- scale emergency evacuations. A particularly troubling aspect of these reports is how ill prepared we are as a nation to evacuate those who are most vulnerable, particularly the elderly, disabled and those in hospitals and nursing homes. Only a few states currently have acceptable evacuation plans. In a post 9/11 world that is both unfortunate and unacceptable. As a result of these reviews the White House designated the Department of Transportation as the lead Federal agency to coordinate and oversee transportation planning for emergency evacuations and assist state and local jurisdictions when help is needed. I hope those charged with that responsibility will review this report, the records contained in the public docket and the transcript of the public hearing. This accident must be considered in the context of the events that were occurring at the time. While the evacuation of persons with special needs does not come under the purview of the NTSB, this accident cannot be understood without looking at these issues. As the Probable Cause makes clear, the loss of life was exacerbated because of the frailty of the passengers. Motor coaches were used for this evacuation and will be used again should a similar emergency arise. For that reason alone our recommendations must be given every consideration and implemented as quickly as possible. Our findings on oversight and compliance, on survival factors, bus design and maintenance, fire detection and suppression, to list a few will hopefully move policy makers to act. None of us want to see this accident repeated and the only way to insure that doesn’t happen is to act on the changes proposed in this report. Kathryn O’Leary Higgins April 20, 2007

111 Highway Accident Report Appendix A Investigation and Public Hearing Investigation The National Transportation Safety Board was notified of the Wilmer, Texas, accident on September 23, 2005. An investigative team was dispatched with members from the Washington, D.C.; Denver, Colorado; Gardena, California; Arlington, Texas; and Parsippany, New Jersey, offices. Ellen Engleman Conners was the Member on scene. Groups were established to investigate human performance; motor carrier operations; hazardous materials; fire; and highway, vehicle, and survival factors. Participating in the investigation were representatives of the Federal Motor Carrier Safety Administration (FMCSA), the Pipeline and Hazardous Materials Safety Administration (PHMSA), the State of Texas Department of Transportation, the State of Texas Department of Public Safety (TxDPS), the Dallas County Sheriff’s Department, Motor Coach Industries, Inc. (MCI), ArvinMeritor, Inc., and Bridgestone Americas Holding, Inc. No depositions were taken. Public Hearing The Safety Board held a public hearing on this accident on August 8–9, 2006, in Washington, D.C. Board Member Kathryn O’Leary Higgins presided over the hearing, and Member Deborah A. P. Hersman participated. The issues presented at the hearing were the scope of bus fires in the United States, Government oversight of motorcoach operators and bus brokers, commercial vehicle inspections, evacuation of motorcoaches, and planning for the transportation of passengers with special needs during emergency evacuations. Safety Board investigators were members of the technical panel. Parties to the public hearing included the FMCSA, the National Highway Traffic Safety Administration, the TxDPS, the Commercial Vehicle Safety Alliance, MCI, ArvinMeritor, Inc., Bridgestone Americas Holding, Inc., Sunrise Senior Living Services, Inc., the American Bus Association, and the United Motorcoach Association.

112 Highway Accident Report Appendix B Global Limo Inc. Federal Motor Carrier Safety Administration Compliance Reviews February 2004 Compliance Review Violations 382.601(a) Violation • Failing to provide educational materials explaining the requirements of Part 382 and employer’s policies. 382.603 Violation • Failing to ensure persons designated to determine that drivers undergo reasonable suspicion testing receive 60 minutes training for alcohol and/or 60 minutes training for controlled substances. 391.25(c)(1) Violation • Failing to maintain a copy of the response from each State agency in the driver qualification file. 391.51(b)(5) Violation • Failing to maintain a note relating to the annual review of the driver’s driving record as required by 3941.25(c)(2). 391.63(a) Violation • Failing to maintain medical examiner’s certificate in driver’s qualification file. 395.8(e) Violation • False reports of records of duty status. 396.3(b)(2) Violation • Failing to have a means of indicating the nature and due date of the various inspection and maintenance operations to be performed.

Appendix B 113 Highway Accident Report February 2004 Compliance Review Recommendations This report contains citations of regulations that are deemed serious in nature and could result in penalties against your company and/or drivers. • Review with your drivers periodically the procedures for doing pretrip and posttrip inspections. Ensure that safety defects reported on driver vehicle inspection reports (DVIRs) are repaired before the vehicle is re-dispatched. Require drivers to prepare DVIRs on a daily basis. Keep them on file for 90 days. • Ensure that all vehicles are systemically repaired and maintained. Establish a complete file for each vehicle and record all inspection, maintenance, and repair operations performed. Consider keeping records pertaining to each individual unit in its own folder. • Periodically review the maintenance and inspection records for all leased vehicles as required by Part 396 of the FMCSRs. Keep a record to document these reviews and notify the owner of any violations detected. • Ensure that all drivers are fully and properly qualified before operating in interstate commerce. Maintain a complete file, as required, for each driver, documenting the qualification process. • Ensure that all drivers’ records of duty status (logs) are accurate. Check them against “supporting documents” to verify accuracy. Prohibit falsification of logs by any driver. Review rules on supporting documents. Take appropriate action against drivers who falsify logs. • Establish a system to control passenger-carrying drivers’ hours of service. Do not dispatch drivers who do not have adequate hours available to complete assigned trips legally. Do not allow drivers to exceed the 10-, 15-, and 60/70- hour limits. October 2005 (Post-Fire) Compliance Review Violations 382.301(a) Violation • Using a driver before the motor carrier has received a negative preemployment controlled substance test result. 382.303(a) Violation • Failing to conduct postaccident alcohol testing for each surviving driver. 382.303(b) Violation • Failing to conduct postaccident controlled substances testing for each surviving driver.

Appendix B 114 Highway Accident Report 382.305(i)(1) Violation • Failing to use a scientifically valid method to select drivers for random testing. 382.305(i)(2) Violation • Failing to ensure that each driver selected for random alcohol and controlled substance testing has an equal chance of being selected each time selections are made. 382.401(c)(6) Violation • Failing to maintain semiannual laboratory statistical summaries of urinalysis required by 40.29(g)(6). 382.601(a) Violation • Failing to provide education materials explaining requirements of Part 382 and employer’s policies. 382.603 Violation • Failing to ensure persons designated to determine that drivers undergo reasonable suspicion testing receive 60 minutes training for alcohol and/or 60 minutes training for controlled substances. 391.11(b)(2) (Primary) 391.11(a) (Secondary) Violation • Using a driver unable to read and/or speak the English language. 391.11(b)(5) (Primary) 391.11(a) (Secondary) Violation • Using a driver without a currently valid motor vehicle operator’s license or permit. 391.21(a) Violation • Using a driver who has not completed and furnished an employment application. 391.51(a) Violation • Failing to maintain driver’s qualification file on each driver employed. 391.51(b)(2) Violation • Failing to maintain inquiries into driver’s driving record in driver’s qualification file.

Appendix B 115 Highway Accident Report 391.51(b)(5) Violation • Failing to maintain a note relating to annual review of the driver’s driving record, as required by 3914.25(c)(2). 391.51(b)(6) Violation • Failing to maintain a list or certificate relating to violations of motor vehicle laws and ordinances required by 391.27. 395.3(a)(1) Violation • Requiring or permitting a driver to drive more than 10 hours. 395.3(a)(2) Violation • Requiring or permitting driver to drive after having been on duty 15 hours. 395.8(a) Violation • Failing to require driver to make a record of duty status. 395.8(e) Violation • False reports of records of duty status. 396.3(a)(1) Violation • Failing to inspect and maintain vehicle to ensure safe and proper operating condition. 396.3(a)(2) Violation • Failing to inspect pushout windows, emergency doors, and emergency marking lights in buses at least every 90 days. 391.11(a) Violation • Failing to require driver to prepare DVIRs. 396.17 Violation • Using a commercial motor vehicle not periodically inspected.

Appendix B 116 Highway Accident Report October 2005 (Postfire) Compliance Review Recommendations This report contains citations of regulations that are deemed serious in nature and could result in penalties against your company and/or drivers. • Review with your drivers periodically the procedures for doing pretrip and posttrip inspections. Ensure that safety defects reported by drivers on their DVIRs are repaired before the vehicle is redispatched. Require drivers to prepare DVIRs on a daily basis. Keep them on file for 90 days. • Ensure that the persons or entities that perform preventative maintenance inspections on your equipment are abiding by agreed time or mileage intervals. Ensure that records are kept of such periodic preventative maintenance inspections. Take corrective action if schedules are not being adhered to. • Require all drivers to prepare a written inspection report for each day a vehicle is operated. Ensure that each report is signed by the driver, certified, and reviewed if defects are reported, and then kept in the vehicle for a day. • Keep all driver DVIRs signed, certified, and reviewed, as required, on file for at least 90 days. • Ensure that all vehicles are systemically repaired and maintained. Establish a complete file for each vehicle, recording all repair, maintenance and inspection operations performed. • Establish a system to control drivers’ hours of service. Do not dispatch drivers who do not have adequate hours available to complete assigned trips legally. Do not allow drivers to exceed the 10-, 15-, and 60/70-hour limits. • Ensure that all drivers’ records of duty status (logs) are accurate. Check them against “supporting documents” to verify accuracy. Prohibit falsification of logs by any driver. Review rules on supporting documents. Take appropriate action against drivers who falsify logs. • Require all drivers to prepare complete and accurate records of duty status for each day and to submit them within 13 days. Maintain all duty status records on file, with all supporting documents, for at least 6 months. • U.S. Department of Transportation (DOT) drug testing rules require that employers test for marijuana, cocaine, opiates, amphetamines, and phencyclidine, 49 CFR Parts 40 and 382. • Ensure that all drivers subject to preemployment, random, reasonable cause, postaccident, return to duty, and/or followup controlled substance testing are tested as required by 49 CFR Parts 40 and 382. • Ensure that all drivers are fully and properly qualified before operating in interstate commerce. Maintain a complete file, as required, for each driver, documenting the qualification process. • Ensure that drivers provide a 10-year employment history on their employment applications.

117 Highway Accident Report Appendix C Federal Motor Carrier Safety Administration Safety Program Compliance Review The safety fitness rating begins with a compliance review conducted by the Federal Motor Carrier Safety Administration (FMCSA), as specified in 49 Code of Federal Regulations (CFR) Part 385, appendix A. The FMCSA applies six factors (general, driver, operational, vehicle, hazardous materials [HM], and accident rate [see table C-1]) to rate a carrier’s compliance with the Federal Motor Carrier Safety Regulations (FMCSRs). A carrier may be selected for a compliance review if it is identified as a high-risk carrier because of (1) a Safety Status Measurement System (SafeStat) score,1 (2) a complaint against the company, (3) an enforcement followup, (4) involvement in a fatal accident, or (5) involvement in a major HM accident. In addition, a carrier may be selected as a result of a U.S. Department of Transportation (DOT) Office of Inspector General request, a congressional inquiry, or a carrier’s request. For factor 4, vehicle, the carrier’s out-of-service (OOS) rate is determined by the number of vehicles placed out of service in relation to the number of vehicles inspected roadside. The number of roadside vehicle inspections depends on the number of vehicles in a carrier’s fleet. Only the most recent (the past 12 months in chronological order) roadside inspections are applied for the OOS calculation.2 If a carrier’s OOS rate exceeds 34 percent and the carrier has a pattern of critical or acute violations or both, the rating is unsatisfactory. If the carrier’s OOS rate exceeds 34 percent, but the carrier does not have a pattern of violations, the rating is conditional. If the carrier’s OOS rate is less than 34 percent, but the carrier has a pattern of critical or acute vehicle violations or both, the rating is conditional. Otherwise, the carrier receives a satisfactory rating for an OOS rate under 34 percent. Table C-1. Factors for FMCSA safety compliance. 1 The SafeStat analysis program uses data from Federal and State sources, including roadside inspections, accident data, and enforcement actions for all carriers, to develop a safety fitness assessment. 2 For example, a motor carrier with 20 vehicles would require a minimum of 5 vehicle inspections, and the 5 most recent inspections for the past 12 months or since the last compliance review would be used to calculate the carrier’s OOS rate. These inspections may have been conducted during a roadside inspection or at the carrier’s terminal. Factor Applicable FMCSRs and other criteria 1 – General Parts 387 and 390 2 – Driver Parts 382, 383, and 391 3 – Operational Parts 392 and 395 4 – Vehicle Parts 393 and 396 and OOS rate 5 – Hazardous materials Parts 107, 171, 173, 177, 180, and 397 6 – Accident rate Recordable accident rate

Appendix C 118 Highway Accident Report Factor 6, accident rate, is rated either “satisfactory” or “unsatisfactory”; a conditional rating is not given. The recordable accident rate is calculated by multiplying the number of interstate, reportable accidents for the 12 months prior to the compliance review by 1 million and dividing that number by the fleet’s total interstate miles. If a carrier’s accident rate exceeds 1.5 million miles for a company that operates over a 100- mile radius or 1.7 million miles for a company that operates in less than a 100-mile radius, an unsatisfactory rating is given. A calculated number under these rates results in the company receiving a satisfactory rating for this factor. The rating table establishes the motor carrier’s overall final safety rating, also designated “satisfactory,” “conditional,” or “unsatisfactory,” as defined below: • Satisfactory rating: The carrier is determined to have sufficient safety management controls in place to meet the safety fitness standards of the FMCSRs. • Conditional rating: The carrier does not have sufficient safety management controls in place and could be in violation of the safety fitness standards. • Unsatisfactory rating: The carrier does not have adequate safety management controls in place and has violated the safety fitness standards. When the FMCSA issues a final3 unsatisfactory safety rating to a carrier, the owner or operator is deemed unfit to operate.4 Owners or operators of commercial vehicles that are designed or used to transport passengers and that have been declared unfit may not operate in interstate commerce beginning on the 46th day following the date of such safety fitness determination and may not reestablish interstate operations until they become fit for such transportation. 3  A safety rating will be issued to a motor carrier within 30 days of the completion of a compliance review. A proposed safety rating of unsatisfactory is a notice to the motor carrier that the FMCSA has made a preliminary determination that it is “unfit” to continue operating in interstate commerce and that the prohibitions in 49 CFR 385.13 will be imposed after 45 or 60 days, if necessary safety improvements are not made. 4  According to 49 CFR 385.13(a), an owner or operator receiving notice of a proposed unsatisfactory safety rating from the FMCSA must improve that rating to conditional or satisfactory within 45 days of the date of the notice. Owners or operators who fail to improve their ratings within this 45-day period are prohibited from operating in interstate commerce beginning on the 46th day following the date of the rating notice. Owners or operators are “fit” to operate when the FMCSA issues a final conditional or satisfactory safety rating.

119 Highway Accident Report Appendix D Excerpts From Federal Motor Carrier Safety Regulations 49 Code of Federal Regulations (CFR) Parts 390–396 393.205 Wheels (a) Wheels and rims shall not be cracked or broken. (b) Stud or bolt holes on the wheels shall not be elongated (out of round). (c) Nuts or bolts shall not be missing or loose. 396.5 Lubrication Every motor carrier shall ensure that each motor vehicle subject to its control is (a) properly lubricated; and (b) free of oil and grease leaks. 396.7 Unsafe Operations Forbidden (a) General: A motor vehicle shall not be operated in such a condition as to likely cause an accident or a breakdown of the vehicle. (b) Exemption: Any motor vehicle discovered to be in an unsafe condition while being operated on the highway may be continued in operation only to the nearest place where repairs can safely be effected. Such operation shall be conducted only if it is less hazardous to the public than to permit the vehicle to remain on the highway. See , December 15, 2006. Appendix B, 49 CFR Part 385, Explanation of Safety Rating Process Part II. Converting Compliance Review Information Into a Safety Rating (a) The FMCSA gathers information through an in-depth examination of the motor carrier’s compliance with identified “acute” or “critical” regulations of the Federal Motor Carrier Safety Regulations (FMCSRs) and Hazardous Materials Regulations (HMRs).

Appendix D 120 Highway Accident Report (b) Acute regulations are those identified as such where noncompliance is so severe as to require immediate corrective actions by a motor carrier regardless of the overall safety posture of the motor carrier. An example of an acute regulation is §383.37(b), allowing, requiring, permitting, or authorizing an employee with more than one commercial driver’s license (CDL) to operate a commercial motor vehicle. Noncompliance with §383.37(b) is usually discovered when the motor carrier’s driver qualification file reflects that the motor carrier had knowledge of a driver with more than one CDL, and still permitted the driver to operate a commercial motor vehicle. If the motor carrier did not have such knowledge or could not reasonably be expected to have such knowledge, then a violation would not be cited. (c) Critical regulations are those identified as such where noncompliance relates to management and/or operational controls. These are indicative of breakdowns in a carrier’s management controls. An example of a critical regulation is §395.3(a)(1), requiring or permitting a property-carrying commercial motor vehicle driver to drive more than 11 hours. (d) The list of the acute and critical regulations which are used in determining safety ratings is included at the end of this document. (e) Noncompliance with acute regulations and patterns of noncompliance with critical regulations are quantitatively linked to inadequate safety management controls and usually higher-than-average accident rates. The FMCSA has used noncompliance with acute regulations and patterns of noncompliance with critical regulations since 1989 to determine motor carriers’ adherence to the safety fitness standard in §385.5. (f) The regulatory factors, evaluated on the basis of the adequacy of the carrier’s safety management controls, are (1) Parts 387 and 390; (2) Parts 382, 383, and 391; (3) Parts 392 and 395; (4) Parts 393 and 396, when there are less than 3 vehicle inspections in the last 12 months to evaluate; and (5) Parts 397, 171, 177, and 180. (g) For each instance of noncompliance with an acute regulation or each pattern of noncompliance with a critical regulation during the compliance review, one point will be assessed. A pattern is more than one violation. When a number of documents are reviewed, the number of violations required to meet a pattern is equal to at least 10 percent of those examined. (h) However, each pattern of noncompliance with a critical regulation relative to Part 395, Hours of Service of Drivers, will be assessed two points.

Appendix D 121 Highway Accident Report Part VII. List of Acute and Critical Regulations • §382.115(a): Failing to implement an alcohol and/or controlled substances testing program (domestic motor carrier) (acute). • §382.201: Using a driver known to have an alcohol concentration of 0.04 or greater (acute). • §382.211: Using a driver who has refused to submit to an alcohol or controlled substances test required under Part 382 (acute). • §382.213(b): Using a driver known to have used a controlled substance (acute). • §382.215: Using a driver known to have tested positive for a controlled substance (acute). • §382.301(a): Using a driver before the motor carrier has received a negative preemployment controlled substance test result (critical). • §382.303(a): Failing to conduct post accident testing on driver for alcohol and/or controlled substances (critical). • §382.305: Failing to implement a random controlled substances and/or an alcohol testing program (acute). • §382.305(b)(1): Failing to conduct random alcohol testing at an annual rate of not less than the applicable annual rate of the average number of driver positions (critical). • §382.305(b)(2): Failing to conduct random controlled substances testing at an annual rate of not less than the applicable annual rate of the average number of driver positions (critical). • §382.309(a): Using a driver who has not undergone a return-to-duty alcohol test with a result indicating an alcohol concentration of less than 0.02 (acute). • §382.309(b): Using a driver who has not undergone a return-to-duty controlled substances test with a result indicating a verified negative result for controlled substances (acute). • §382.503: Allowing a driver to perform safety sensitive functions, after engaging in conduct prohibited by subpart B, without being evaluated by a substance abuse professional, as required by §382.605 (critical). • §382.505(a): Using a driver within 24 hours after being found to have an alcohol concentration of 0.02 or greater but less than 0.04 (acute). • §382.605(c)(1): Using a driver who has not undergone a return-to-duty alcohol test with a result indicating an alcohol concentration of less than 0.02 or with a verified negative test result, after engaging in conduct prohibited by Part 382 Subpart B (acute).

Appendix D 122 Highway Accident Report • §382.605(c)(2)(ii): Failing to subject a driver who has been identified as needing assistance to at least six unannounced followup alcohol and/or controlled substance tests in the first 12 months following the driver’s return to duty (critical). • §383.23(a): Operating a commercial motor vehicle without a valid CDL (critical). • §383.37(a): Knowingly allowing, requiring, permitting, or authorizing an employee with a CDL which is suspended, revoked, or canceled by a State or who is disqualified to operate a commercial motor vehicle (acute). • §383.37(b): Knowingly allowing, requiring, permitting, or authorizing an employee with more than one CDL to operate a commercial motor vehicle (acute). • §383.51(a): Knowingly allowing, requiring, permitting, or authorizing a driver to drive who is disqualified to drive a commercial motor vehicle (acute). • §387.7(a): Operating a motor vehicle without having in effect the required minimum levels of financial responsibility coverage (acute). • §387.7(d): Failing to maintain at principal place of business required proof of financial responsibility (critical). • §387.31(a): Operating a passenger-carrying vehicle without having in effect the required minimum levels of financial responsibility (acute). • §387.31(d): Failing to maintain at principal place of business required proof of financial responsibility for passenger-carrying vehicles (critical). • §390.15(b)(2): Failing to maintain copies of all accident reports required by State or other governmental entities or insurers (critical). • §390.35: Making, or causing to make, fraudulent or intentionally false statements or records and/or reproducing fraudulent records (acute). • §391.11(b)(4): Using a physically unqualified driver (acute). • §391.15(a): Using a disqualified driver (acute). • §391.45(a): Using a driver not medically examined and certified (critical). • §391.45(b)(1): Using a driver not medically examined and certified during the preceding 24 months (critical). • §391.51(a): Failing to maintain driver qualification file on each driver employed (critical). • §391.51(b)(2): Failing to maintain inquiries into driver’s driving record in driver’s qualification file (critical). • §391.51(b)(7): Failing to maintain medical examiner’s certificate in driver’s qualification file (critical).

Appendix D 123 Highway Accident Report • §392.2: Operating a motor vehicle not in accordance with the laws, ordinances, and regulations of the jurisdiction in which it is being operated (critical). • §392.4(b): Requiring or permitting a driver to drive while under the influence of, or in possession of, a narcotic drug, amphetamine, or any other substance capable of rendering the driver incapable of safely operating a motor vehicle (acute). • §392.5(b)(1): Requiring or permitting a driver to drive a motor vehicle while under the influence of, or in possession of, an intoxicating beverage (acute). • §392.5(b)(2): Requiring or permitting a driver who shows evidence of having consumed an intoxicating beverage within 4 hours to operate a motor vehicle (acute). • §392.6: Scheduling a run which would necessitate the vehicle being operated at speeds in excess of those prescribed (critical). • §392.9(a)(1): Requiring or permitting a driver to drive without the vehicle’s cargo being properly distributed and adequately secured (critical). • §395.1(h)(1)(i): Requiring or permitting a property-carrying commercial motor vehicle driver to drive more than 15 hours (driving in Alaska) (critical). • §395.1(h)(1)(ii): Requiring or permitting a property-carrying commercial motor vehicle driver to drive after having been on duty 20 hours (driving in Alaska) (critical). • §395.1(h)(1)(iii): Requiring or permitting a property-carrying commercial motor vehicle driver to drive after having been on duty more than 70 hours in 7 consecutive days (driving in Alaska) (critical). • §395.1(h)(1)(iv): Requiring or permitting a property-carrying commercial motor vehicle driver to drive after having been on duty more than 80 hours in 8 consecutive days (driving in Alaska) (critical). • §395.1(h)(2)(i): Requiring or permitting a passenger-carrying commercial motor vehicle driver to drive more than 15 hours (driving in Alaska) (critical). • §395.1(h)(2)(ii): Requiring or permitting a passenger-carrying commercial motor vehicle driver to drive after having been on duty 20 hours (driving in Alaska) (critical). • §395.1(h)(2)(iii): Requiring or permitting a passenger-carrying commercial motor vehicle driver to drive after having been on duty more than 70 hours in 7 consecutive days (driving in Alaska) (critical). • §395.1(h)(2)(iv): Requiring or permitting a passenger-carrying commercial motor vehicle driver to drive after having been on duty more than 80 hours in 8 consecutive days (driving in Alaska) (critical). • §395.1(o): Requiring or permitting a property-carrying commercial motor vehicle driver to drive after having been on duty 16 consecutive hours (critical).

Appendix D 124 Highway Accident Report • §395.3(a)(1): Requiring or permitting a property-carrying commercial motor vehicle driver to drive more than 11 hours (critical). • §395.3(a)(2): Requiring or permitting a property-carrying commercial motor vehicle driver to drive after the end of the 14th hour after coming on duty (critical). • §395.3(b)(1): Requiring or permitting a property-carrying commercial motor vehicle driver to drive after having been on duty more than 60 hours in 7 consecutive days (critical). • §395.3(b)(2): Requiring or permitting a property-carrying commercial motor vehicle driver to drive after having been on duty more than 70 hours in 8 consecutive days (critical). • §395.3(c)(1): Requiring or permitting a property-carrying commercial motor vehicle driver to restart a period of 7 consecutive days without taking an off- duty period of 34 or more consecutive hours (critical). • §395.3(c)(2): Requiring or permitting a property-carrying commercial motor vehicle driver to restart a period of 8 consecutive days without taking an off- duty period of 34 or more consecutive hours (critical). • §395.5(a)(1): Requiring or permitting a passenger-carrying commercial motor vehicle driver to drive more than 10 hours (critical). • §395.5(a)(2): Requiring or permitting a passenger-carrying commercial motor vehicle driver to drive after having been on duty 15 hours (critical). • §395.5(b)(1): Requiring or permitting a passenger-carrying commercial motor vehicle driver to drive after having been on duty more than 60 hours in 7 consecutive days (critical). • §395.5(b)(2): Requiring or permitting a passenger-carrying commercial motor vehicle driver to drive after having been on duty more than 70 hours in 8 consecutive days (critical). • §395.8(a): Failing to require driver to make a record of duty status (critical). • §395.8(e): False reports of records of duty status (critical). • §395.8(i): Failing to require driver to forward within 13 days of completion, the original of the record of duty status (critical). • §395.8(k)(1): Failing to preserve driver’s record of duty status for 6 months (critical). • §395.8(k)(1): Failing to preserve driver’s records of duty status supporting documents for 6 months (critical). • §396.3(b): Failing to keep minimum records of inspection and vehicle maintenance (critical). • §396.9(c)(2): Requiring or permitting the operation of a motor vehicle declared “out-of-service” before repairs were made (acute).

Appendix D 125 Highway Accident Report • §396.11(a): Failing to require driver to prepare driver vehicle inspection report (VIR) (critical). • §396.11(c): Failing to correct out-of-service defects listed in a driver VIR before the vehicle is operated again (acute). • §396.17(a): Using a commercial motor vehicle not periodically inspected (critical). • §396.17(g): Failing to promptly repair parts and accessories not meeting minimum periodic inspection standards (acute). • §397.5(a): Failing to ensure a motor vehicle containing Division 1.1, 1.2, or 1.3 (explosive) material is attended at all times by its driver or a qualified representative (acute). • §397.7(a)(1): Parking a motor vehicle containing Division 1.1, 1.2, or 1.3 materials within 5 feet of traveled portion of highway or street (critical). • §397.7(b): Parking a motor vehicle containing hazardous material(s) other than Division 1.1, 1.2, or 1.3 materials within 5 feet of traveled portion of highway or street (critical). • §397.13(a): Permitting a person to smoke or carry a lighted cigarette, cigar, or pipe within 25 feet of a motor vehicle containing Class 1 materials, Class 5 materials, or flammable materials classified as Division 2.1, Class 3, Divisions 4.1 and 4.2 (critical). • §397.19(a): Failing to furnish driver of motor vehicle transporting Division 1.1, 1.2, or 1.3 (explosive) materials with a copy of the rules of Part 397 and/or emergency response instructions (critical). • §397.67(d): Requiring or permitting the operation of a motor vehicle containing explosives in Class 1, Divisions 1.1, 1.2, or 1.3, that is not accompanied by a written route plan (critical). • §397.101(d): Requiring or permitting the operation of a motor vehicle containing highway route-controlled quantity, as defined in §173.403, of radioactive materials that is not accompanied by a written route plan. • §171.15: Carrier failing to give immediate telephone notice of an incident involving hazardous materials (HM) (critical). • §171.16: Carrier failing to make a written report of an incident involving HM (critical). • §172.313(a): Accepting for transportation or transporting a package containing a poisonous-by-inhalation material that is not marked with the words “Inhalation Hazard” (acute). • §172.704(a)(4): Failing to provide security awareness training (critical). • §172.704(a)(5): Failing to provide in-depth security awareness training (critical).

Appendix D 126 Highway Accident Report • §172.800(b): Transporting HM without a security plan (acute). • §172.800(b): Transporting HM without a security plan that conforms to Subpart I requirements (acute). • §172.800(b): Failure to adhere to a required security plan (acute). • §172.802(b): Failure to make copies of security plan available to hazmat employees (critical). • §173.24(b)(1): Accepting for transportation or transporting a package that has an identifiable release of HM to the environment (acute). • §173.421(a): Accepting for transportation or transporting a Class 7 (radioactive) material described, marked, and packaged as a limited quantity when the radiation level on the surface of the package exceeds 0.005 mSv/hour (0.5 mrem/hour) (acute). • §173.431(a): Accepting for transportation or transporting in Type A packaging a greater quantity of Class 7 (radioactive) material than authorized (acute). • §173.431(b): Accepting for transportation or transporting in a Type B packaging a greater quantity of Class 7 (radioactive) material than authorized (acute). • §173.441(a): Accepting for transportation or transporting a package containing Class 7 (radioactive) material with external radiation exceeding allowable limits (acute). • §173.442(b): Accepting for transportation or transporting a package containing Class 7 (radioactive) material when the temperature of the accessible external surface of the loaded package exceeds 50° Celsius (C) (122° Fahrenheit [F]) in other than an exclusive use shipment, or 85° C (185° F) in an exclusive use shipment (acute). • §173.443(a): Accepting for transportation or transporting a package containing Class 7 (radioactive) material with removable contamination on the external surfaces of the package in excess of permissible limits (acute). • §177.800(c): Failing to instruct a category of employees in HM regulations (critical). • §177.801: Accepting for transportation or transporting a forbidden material (acute). • §177.817(a): Transporting a shipment of HM not accompanied by a properly prepared shipping paper (critical). • §177.817(e): Failing to maintain proper accessibility of shipping papers (critical). • §177.823(a): Moving a transport vehicle containing HM that is not properly marked or placarded (critical).

Appendix D 127 Highway Accident Report • §177.835(a): Loading or unloading a Class 1 (explosive) material with the engine running (acute). • §177.835(c): Accepting for transportation or transporting Division 1.1, 1.2, or 1.3 (explosive) materials in a motor vehicle or combination of vehicles that is not permitted (acute). • §177.835(j): Transferring Division 1.1, 1.2, or 1.3 (explosive) materials between containers or motor vehicles when not permitted (acute). • §177.841(e): Transporting a package bearing a poison label in the same transport vehicle with material marked or known to be foodstuff, feed, or any edible material intended for consumption by humans or animals unless an exception in §177.841(e)(i) or (ii) is met (acute). • §180.407(a): Transporting a shipment of HM in cargo tank that has not been inspected or retested in accordance with §180.407 (critical). • §180.407(c): Failing to periodically test and inspect a cargo tank (critical). • §180.415: Failing to mark a cargo tank which passed an inspection or test required by §180.407 (critical). • §180.417(a)(1): Failing to retain cargo tank manufacturer’s data report certificate and related papers, as required (critical). • §180.417(a)(2): Failing to retain copies of cargo tank manufacturer’s certificate and related papers (or alternative report) as required (critical). For more detailed information, see , December 15, 2006.

128 Highway Accident Report Appendix E Excerpts From Federal Railroad Administration Testimony The Federal Railroad Administration (FRA) passenger railcar regulations are principally found in 49 Code of Federal Regulations (CFR) Part 238, Passenger Equipment Safety Standards. Section 238.103 and appendix B contain specific fire safety requirements, which were issued in 1999 and amended in 2002. The purpose of the requirements generally is to prevent fire ignition, to minimize fire spread and smoke emissions, and to maximize the time available for passenger and crew egress. The majority of combustible materials used in passenger railcars and locomotive cabs, organized by categories and functions, are required to be tested and meet certain flammability and smoke emission criteria. In addition, a structural floor fire endurance test is required. January 17, 1996 The FRA published an advance Notice of Proposed Rulemaking (NPRM) concerning the establishment of comprehensive safety standards for railroad passenger equipment. February 1996 Following two serious passenger train accidents, the FRA issued Emergency Order No. 20, “Emergency Order Requiring Enhanced Operating Rules and Plans for Ensuring the Safety of Passengers Occupying the Leading Car of a Train.” Among other provisions, the order requires prompt action (within 60 days) by each commuter and intercity passenger railroad to immediately enhance emergency egress of trains by ensuring that: (1) each emergency exit location on every passenger car is clearly marked on the inside of the car and that operational instructions are posted; (2) each rescue access window is marked on the exterior of the car; (3) a representative sample of emergency window exits has been tested and is operable; and (4) each railroad discuss in an Interim Systems Safety Plan its programs and plans for liaison with and training of emergency responders with respect to emergency access to passengers, as well as the methods used to inform passengers of the location and method of operation of emergency exits, such as flyers, announcements, or messages on tickets. June 17, 1997 As a result of the investigation of the Amtrak/MARC train collision and fire that occurred in Silver Spring, Maryland, on February 6, 1996, the Safety Board issued the following fire safety recommendation to the FRA:

Appendix E 129 Highway Accident Report R-97-20 Require that a comprehensive inspection of all commuter passenger cars be performed to independently verify that the interior materials in these cars meet the expected performance requirements for flammability and smoke emissions characteristics. September 23, 1997 The FRA published an NPRM proposing that the 1989 FRA Guidelines be made mandatory standards for materials used in new and refurbished passenger cars and locomotive cabs. In particular, the NPRM addressed Safety Recommendation R-97-20. In addition, the FRA included fire safety analysis requirements for evaluation of the design and materials of new passenger cars to ensure sufficient time for passenger evacuation from the train. 1998 The FRA issued the Passenger Train Emergency Preparedness final rule, which incorporated and superseded several requirements of Emergency Order No. 20 into 49 CFR Parts 223 and 239. Specifically, 49 CFR 239.101 requires that each railroad’s emergency preparedness plan also provide for passenger awareness of emergency procedures to enable passengers to properly respond during an emergency; and each railroad must post emergency instructions inside all passenger cars and use one or more additional methods to provide safety awareness information. May 12, 1999 The FRA published the Passenger Equipment Safety Standards final rule, containing detailed fire safety analysis requirements for new equipment to reduce the risk of personal injury and equipment damage caused by a fire to an acceptable level. The rule also included a formal safety methodology and a documented analysis checklist, which considers car design, materials, and ventilation. In addition, railroads were required to determine the extent to which overheat detection and fire suppression systems must be installed to ensure sufficient time for the safe evacuation of passengers and crew. The final rule also addressed Safety Recommendation R-97-20 by requiring that passenger railroads perform a fire safety analysis of their existing equipment to determine whether materials currently installed in railcars posed an unacceptable hazard in terms of material quantity, location, and proximity to ignition sources. Railroads were required to consider the extent to which existing materials met the test criteria in appendix B of the rule and their potential hazard relating to the unacceptable risk of personal injuries. Categories of existing equipment and current rail service were to be included in the fire safety evaluation.

Appendix E 130 Highway Accident Report Other Excerpts The FRA also requires that the structural floor pass the American Society for Testing and Materials (ASTM) E 1191 fire endurance test. The nominal test period should be twice the maximum expected time under normal circumstances for a vehicle to stop completely and safely from its maximum operating speed, plus the time necessary to evacuate all vehicle occupants to a safe area. The fire resistance period required should be consistent with the safe evacuation of a full load of passengers from the vehicle under a worst case scenario. The nominal test period is a minimum of 15 minutes. Under FRA sponsorship, the Volpe National Transportation Systems Center is currently conducting emergency evacuation and fire safety research to assist in determining whether the amount of time available to evacuate a passenger railcar is sufficient, given the amount of time occupants actually need to evacuate safely using the available emergency egress features in a railcar. The Volpe Center is using fire safety- related research findings to assist in determining the amount of available time for evacuation before conditions on board become untenable due to smoke and fire and is also using emergency evacuation simulations to predict the amount of time to evacuate cars under various circumstances and in different operating environments. Findings from this research may be used to supplement existing emergency egress standards. 1  American Society for Testing and Materials, Standard Test Methods for Fire Tests of Building Construction and Materials, ASTM E-119-05a (West Conshohocken, PA: ASTM, 2006).

131 Highway Accident Report Appendix F Emergency Evacuation of Special Needs Populations: Major Federal Studies Since Hurricanes Katrina and Rita Catastrophic Hurricane Evacuation Plan Evaluation: A Report to Congress Report1 recommendations 1, 4, and 6 address transport and special needs evacuations: • Recommendation 1: Develop regional plans for mass evacuations in connection with catastrophic incidents on the scale of Hurricane Katrina. These plans should be developed jointly by State and local officials within the region in cooperation with officials from appropriate Federal agencies; providers of all safe and practical modes of transportation and providers of shelters, food, fuel, and other necessities; managers of hospitals, nursing homes, emergency medical services (air, ground, etc.), jails, and other institutions with their own evacuation plans; and representatives of various special needs populations. [Italics added.] • Recommendation 4: Transportation agencies and operators should be more directly involved in key aspects of evacuation planning and implementation. • Recommendation 6: State and local agencies should work with the special needs communities to develop systems whereby those requiring specialized transportation or sheltering services during evacuations can make those needs known to emergency managers and operators of transportation and sheltering services before evacuations. Disaster Preparedness: Limitations in Federal Evacuation Assistance for Health Facilities This report2 makes two recommendations for executive action, as follows: • Clearly delineate how the Federal Government will assist State and local governments with the movement of patients and residents out of hospitals and nursing homes to a mobilization center, where National Disaster Medical System (NDMS) transportation begins. 1  U.S. Department of Transportation and U.S. Department of Homeland Security, Catastrophic Hurricane Evacuation Plan Evaluation: A Report to Congress (Washington, DC: DOT, 2006). 2  U.S. Government Accountability Office, Disaster Preparedness: Limitations in Federal Evacuation Assistance for Health Facilities Should be Addressed (Washington, DC: GAO, 2006) 19. See , September 26, 2006.

Appendix F 132 Highway Accident Report • In consultation with the other NDMS Federal partners—the Secretaries of Defense, Health and Human Services, and Veterans Affairs—clearly delineate how to address the needs of nursing home residents during evacuations, including the arrangements necessary to relocate these residents. Federal Response to Hurricane Katrina: Lessons Learned As a lesson learned, this report3 stated: The Department of Transportation, in coordination with other appropriate departments of the Executive Branch, must also be prepared to conduct mass evacuation operations when disasters overwhelm or incapacitate State and local governments. The report made 125 recommendations for improving future Federal responses to disasters. Three of these recommendations concern evacuation (numbers 41, 42, and 43):4

1. Designate the DOT as the primary Federal agency responsible for developing

the Federal Government’s capability to conduct mass evacuations when disasters overwhelm State and local governments. The DOT should, in coordination with the U.S. Department of Health and Human Services, the U.S. Department of Defense, the U.S. Department of Veterans Affairs, the U.S. Department of Homeland Security (DHS), and the American Red Cross, plan, train, and conduct exercises for the timely evacuation of patients and transportation of medical supplies and personnel.

1. The DHS should require State and local governments, as a condition for

receiving Homeland Security grants, to develop, implement, and exercise emergency evacuation plans and to cooperate fully with all Federal evacuation activities.

1. The DHS should, in coordination with the DOT, evaluate all State evacuation

plans as well as the evacuation plans of the 75 largest urban areas. 3  The White House, The Federal Response to Hurricane Katrina: Lessons Learned (Washington, DC: 2006) 57. See , September 26, 2006. 4  The Federal Response to Hurricane Katrina: Lessons Learned, 99–100.

FD07310 ｜ 2005_美国_NTSB_MAR0603_Capsizing_of_New_York_StateCertificated_Vessel_Ethan_Allen.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2005 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

Capsizing of New York State-Certificated Vessel Ethan Allen, Lake George, New York October 2, 2005 Marine Accident Report NTSB/MAR-06/03 PB2006-916403 Notation 7755B National Transportation Safety Board Washington, D.C.

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Marine Accident Report Capsizing of New York State-Certificated Vessel Ethan Allen, Lake George, New York October 2, 2005 NTSB/MAR-06/03 PB2006-916403 National Transportation Safety Board Notation 7755B 490 L’Enfant Plaza, S.W. Adopted July 25, 2006 Washington, D.C. 20594

National Transportation Safety Board. 2006. Capsizing of New York State-Certificated Vessel Ethan Allen, Lake George, New York, October 2, 2005. Marine Accident Report NTSB/MAR-06/03. Washington, DC. Abstract: On the afternoon of October 2, 2005, the New York State-certificated public vessel Ethan Allen, with a state-licensed operator and 47 passengers on board, was on a narrated cruise of Lake George, New York. As the tour boat operator was beginning to make a turn to the right, a wave or waves generated by one or more vessels impacted the starboard side of the Ethan Allen. The public vessel rolled to port and overturned within seconds. The overturned vessel remained on the surface of the water several minutes before righting itself and sinking. Operators of recreational vessels nearby observed the accident, proceeded immediately to the site, and began rescuing survivors. Twenty passengers died, three received serious injuries, and six received minor injuries in the accident. The operator and 18 passengers survived without injury. Major safety issues discussed in this report include stability standards and procedures for passenger vessels; New York State’s use of manufacturer’s capacity plates to determine public vessel passenger loading; and regulation of New York State’s public vessels. As a result of its investigation of this accident, the Safety Board made safety recommendations to the U. S. Coast Guard and the State of New York. The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Web at http://www.ntsb.gov. Other information about available publications also may be obtained from the Web site or by contacting: National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (800) 877-6799 or (202) 314-6551 Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2006-916403 from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605-6000

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

iii Marine Accident Report Contents Abbreviations and Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Accident Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Damages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 New York State Vessel Operator Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Ethan Allen Operator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Vessel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Construction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Lifesaving Apparatus and Safety Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Vessel Certification and Inspection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Wreckage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Waterway Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Medical Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Toxicology Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Survivability-Related Rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Raw Water Pump . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 On-site Stability Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Postaccident Stability Study—Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Postaccident Stability Study—Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Other Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Stability Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Capacity Plates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Accidents Involving Out-of-Date Passenger Weight Standard . . . . . . . . . . . . . . . . . . . 30 New York State Actions Since Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Cause of the Capsizing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Modifications Affecting Vessel Stability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Overloading Due to Out-of-Date Passenger Weight Criterion . . . . . . . . . . . . . . . . . . . 40

Contents iv Marine Accident Report Influence of Vessel Motions on Stability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Capacity Plates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Postaccident Actions by Regulatory Authorities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 New York Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Coast Guard Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Postaccident Toxicological Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Survival Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Appendixes A: Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 B: Passenger Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 C: New York Press Release . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

v Marine Accident Report Abbreviations and Acronyms CAMI Civil Aerospace Medical Institute CDC Centers for Disease Control and Prevention CFR Code of Federal Regulations CO2 carbon dioxide COI certificate of inspection FAA Federal Aviation Administration ICAO International Civil Aviation Organization LGFD Lake George Fire Department OCMI (Coast Guard) Officer in Charge, Marine Inspection SST simplified stability test TCG transverse center of gravity VCG vertical center of gravity

vi Marine Accident Report Executive Summary On the afternoon of October 2, 2005, the New York State-certificated public vessel Ethan Allen, with a New York State-licensed operator and 47 passengers on board, departed the marina at Lake George, New York, for a cruise of the lake. The vessel proceeded northbound along the western side of the lake at an estimated speed of 8 mph. As it neared Cramer Point, the operator began a turn to the right. At the same time, the Ethan Allen encountered a wave or waves generated by one or more vessels on its starboard side. Within a few seconds, the Ethan Allen rolled to port and overturned. It began to sink about 15 minutes later. Operators of recreational vessels nearby observed the accident, proceeded immediately to the site, and began rescuing survivors. Twenty passengers died, three received serious injuries, and six received minor injuries in the accident. The operator and 18 passengers survived without injury. The resulting damage to the vessel and its components was estimated at $21,000. The Safety Board’s investigation of this accident identified the following major safety issues: • Stability standards and procedures for passenger vessels; • New York State’s use of manufacturer’s capacity plates to determine public vessel passenger loading; and • Regulation of New York State’s public vessels. The National Transportation Safety Board determines that the probable cause of the capsizing of the Ethan Allen was the vessel’s insufficient stability to resist the combined forces of a passing wave or waves, a sharp turn, and the resulting involuntary shift of passengers to the port side of the vessel. The vessel’s stability was insufficient because it carried 48 persons where postaccident stability calculations demonstrated that it should have been permitted to carry only 14 persons. Contributing to the cause of the accident was the failure to reassess the vessel’s stability after it had been modified because there was no clear requirement to do so. As a result of this investigation, the Safety Board makes recommendations to the U.S. Coast Guard and to the State of New York.

1 Marine Accident Report Factual Information Accident Narrative About 14151 on October 2, 2005, members of a seniors tour group from Michigan began arriving at the loading dock for Shoreline Cruises, Inc., in Lake George Village, New York, for a 1-hour round-trip narrated boat cruise of historical and other sites along the lakeside. The tour group had chartered two public vessels: the Ethan Allen (figure 1) and its sister vessel, the de Champlain. Figure 1. The Ethan Allen, shown above after the accident, was a New York State- certificated public vessel, a category of powered vessels that is permitted to transport passengers or freight for commercial purposes solely on state waters. The Ethan Allen was scheduled to take the first group out at 1500. The tour boat had made two trips earlier in the day, and the vessel operators on those cruises later told investigators that the trips had been uneventful. The vessel operator said that, in preparation for his trips that day, he had checked the bilge area and did not observe any water.2 1  All times are eastern daylight time, based on a 24-hour clock. 2  Because of the antipollution restrictions for Lake George and the fines that boat operators were subject to, Shoreline Cruises required its boat crews to check the bilges before their cruises and manually remove bilge waste into shoreside containers to ensure that the onboard bilge pumps did not discharge into the lake during a trip.

Factual Information 2 Marine Accident Report Members of the seniors group began to embark on the Ethan Allen through the portside door opening near the stern. In anticipation of viewing historical and other sites along the western shore, passengers began filling the eight three-person benches along the port side of the Ethan Allen. (See figure 2.) According to the passengers, only about seven to 10 people had boarded when the boat began to list noticeably to port. One of their members shouted out that someone had to sit on the other side of the boat. The vessel operator also advised passengers to sit on the starboard side. As people filled the starboard benches, the vessel began to level out. One of the passengers said that those boarding filled in where sitting space was available and that “we had some large people in our group.” She added that the group “didn’t seem to be balanced” across the boat when everyone was seated.3 The vessel operator extended an invitation to board to two more women; however, they later told investigators that they told the group they preferred to go shopping but they declined to board because they thought the boat looked “crowded.” Another woman said that while standing in line to board, she noticed the vessel listing to port. She stated, “I decided it wasn’t safe to be on, so I didn’t get on. I told the others that I wasn’t going.” The vessel operator stated that before leaving the dock, he delivered a safety briefing to the passengers. All passengers who were interviewed said that they received no safety briefing. Most indicated, however, that at the time, they were talking with one another and that “it was very noisy.” When the Ethan Allen ultimately sailed at 1430, the vessel had a total of 48 occupants: the vessel operator and 47 passengers. The vessel operator told Safety Board investigators that the boat’s trim was proper before it departed the dock. After leaving the marina area, the operator increased the vessel speed from the 5 mph maintained in the no-wake area of the lower lake to 8 mph, its standard speed on the lake. The operator told investigators that with as large a passenger load as he experienced on the accident cruise, the Ethan Allen was “maybe a bit slower to respond, [with] just minimal” differences in maneuverability between its fully and partially loaded conditions. He described vessel maneuverability as very good, even when fully loaded, and said that he had about “normal” freeboard.4 The operator told Safety Board investigators that he had taken the Ethan Allen out several times each season with a full load of passengers. For the voyage, the vessel’s windows, which opened inward, were in the up position and hooked to the underside of the wooden canopy (figure 2). The passengers described the conditions for the lake tour as “beautiful” and “perfect.” The lake waters were “calm.” The operator indicated that vessel traffic was normal for a Sunday afternoon. Several members of the tour group had either recreational or commercial boating experience, and most of them indicated that the master operated the boat “properly.” They said that whenever a passing vessel caused a wake,5 the operator of the Ethan Allen would turn their boat so that the bow headed into the waves. 3  Based on hospital records and interviews, the total weight of the passengers seated in the portside seats was 5,088 pounds and the total weight on those in the starboard-side seats was 3,434 pounds. 4  Distance from the vessel’s deck to the surface of the water. 5  A track of waves caused by a vessel or object moving through the water.

Figure 2. Three views of Ethan Allen interior. The vessel had 19 slatted-wood, park- style benches whose metal legs were bolted to the deck. Eight benches designed to accommodate three people faced forward along the port side of the vessel and eight benches that accommodated two people faced forward along the starboard side. Three three-person benches were in the forward portion of the vessel. One bench was positioned so that its back was against the port bulkhead and one bench was against the starboard bulkhead. The nineteenth bench, positioned center forward, had a box beneath it that stored 10 child-size lifejackets. Vessel interior, looking aft. Plexiglas side windows are in up position and hinged to canopy roof, as during accident voyage. Close-up of operator’s station. Cabinet for adult lifejackets, shown without the door, is next to operator’s station. Operator’s station Hatch Hatch Exit Exit Factual Information 3 Marine Accident Report According to witnesses, the Ethan Allen operated without incident until it reached a cove near Cramer Point (figure 3). As the vessel neared Cramer Point, some passengers observed a vessel traversing the lake to the right of the Ethan Allen, creating a wave or waves that moved toward it. Witnesses varied in their identification of the particular vessel

Factual Information 4 Marine Accident Report and in their descriptions of the size of the wave or waves. One passenger described the wave as several inches high. A recreational boater, who observed the Ethan Allen from a 50- to 75-yard distance, reported seeing no wave strike the vessel. The Ethan Allen operator said the wave was 2 1/2 to 3 feet high. The wave reportedly first contacted the starboard stern area and then moved forward along the side of the vessel, raising it upward. The operator told investigators that as he was turning to the right and proceeding out of the bay, he noticed “this wave coming at me, good-sized wave. And I started to cut into it …[but] it caught me on the right side, starboard side back by the stern corner, and flipped it [the vessel] over to the left side, the port side.” Figure 3. The 1-hour tour of the Ethan Allen on Lake George began at Lake George Village and went north to Green Harbour, a distance of about 3 miles. The tour was to continue north along the west shore and enter Green Harbour before crossing the lake and heading back along the east shore. The accident occurred off Cramer Point, a point of land directly below Green Harbour. 9 9 9 TOWN PARK Town Dock Fort William Henry Lake George Village P.O. Orcutt Bay DUNHAMS BAY Cannon Pt. Cooper Pt. Cramer Pt. Harman Pt. Plum Pt. Woods Pt. Tea Island Diamond Island HEARTHSTONE PARK PUBLIC CAMP SITE Vessel Route Vessel Route Green Harbour Approximate Intended Route N Accident Site Lake George Albany NEW YORK

Factual Information 5 Marine Accident Report A passenger seated in the last row on the port side said that she had extended her arm out the window during periods of the cruise, and when the vessel operator went into the sharp turn, the boat began to “tip” [heel] to port. She said that she looked out the window and [her hand] appeared to be “inches from the water.” She also felt the people sitting next to her begin “sliding into me.” Other survivors said that the passengers all shifted to the left in their seats and that two “large ladies” tumbled off their seats and slid to the port side of the vessel when the vessel made the turn. Another passenger stated that the vessel “never stopped rotating to the left along the axis of the boat.” As the vessel’s list to port increased, more people sitting on the starboard side tumbled to the port side, in many instances, falling onto the passengers seated on the port benches. The vessel continued to roll over, and several passengers were swept out the open windows. Both the operator and the survivors estimated that the vessel capsized in a matter of seconds. The accident occurred about 1454. The Ethan Allen remained afloat upside down for several minutes. Several survivors described the conditions inside the Ethan Allen after it overturned as “chaos underwater” or “total confusion.” In the darkness, people were “stepping on” or “crawling on” one another. One woman said that when she attempted to swim toward the light, “People were pulling on my legs to crawl up me, so they pulled me down.” Survivors said that they never had time to retrieve lifejackets; however, they also said that if people had donned lifejackets, more fatalities would have occurred because the only way for those trapped in the vessel to escape was to “swim down” and go through the open windows, which were now below water. One passenger told investigators that she initially was blocked by a Plexiglas window but was able to swim under it to escape the vessel. Once the boat occupants escaped, they clung to the overturned vessel on the surface. Several recreational boats were in the vicinity. Many of the boaters observed the capsizing and immediately proceeded to the site to render aid by throwing life preservers and flotation cushions to the survivors and rescuing them. The witnesses also called 911 on their cell phones to report the accident. After several minutes, the overturned vessel righted itself and then sank to the bottom of the lake, coming to rest upright on its keel in 59 feet of water. Injuries The injuries sustained in the Ethan Allen accident, shown in table 1, are categorized according to the injury criteria of the International Civil Aviation Organization (ICAO). The Safety Board uses the ICAO injury criteria in most of its accident reports, regardless of transportation mode. Passengers listed as seriously injured remained hospitalized for more than 48 hours.

Factual Information 6 Marine Accident Report Table 1. Injuries to passengers and crew Type of Injury Crew Passengers Total Fatal 0 20 20 Serious 0 3 3 Minor 0 6 6 None 1 18 19 Total 1 47 48 Title 49 Code of Federal Regulations (CFR) 830.2 defines a fatal injury as any injury that results in death within 30 days of an accident. Serious injury means any injury which (1) requires hospitalization for more than 48 hours, commencing within 7 days from the date the injury was received; (2) results in a fracture of any bone (except simple fractures of fingers, toes, or nose); (3) causes severe hemorrhages, nerve, muscle, or tendon damage; (4) involves any internal organ; or (5) involves second- or third-degree burns, or any burns affecting more than 5 percent of the body surface. Damages According to reports, the Ethan Allen sustained cosmetic damage to the hull and engine damage consistent with its being submerged. Repairs totaled about $21,000. See “Wreckage” section of this report for additional information. Personnel Information According to the Ethan Allen’s state certificate of inspection (COI) authorizing it to operate on New York waters, the tour boat was required to have a crew of two: a master and a deckhand when the vessel carried more than 20 passengers. On the day of the accident, a deckhand did not accompany the tour group. New York State Vessel Operator Regulations New York guidance specifies three types of licenses for operators of public vessels. A “master” license is required for the operation of a public vessel that exceeds any of the following criteria: 65-foot length, 50-ton displacement, or 65 passengers. A “joint pilot & engineer” license is required for anyone who operates smaller vessels that do not meet the vessel and carriage criteria for a master’s license. A deckhand or operator licensed as a pilot/engineer seeking a master’s license must first obtain an “apprentice master” license. To be issued a license, vessel operators are required to demonstrate both knowledge of vessel regulations and operating principles and proficiency in handling the vessel on the waters in which the vessel is operated. Ethan Allen Operator General. The Ethan Allen operator, age 74, had graduated from high school in upstate New York, enlisted in the Army, and later joined the New York State Police, where he had served as a trooper for 25 1/2 years. During his tenure with the state police, he had served in the marine unit on Lake George, operating a state police boat.

Factual Information 7 Marine Accident Report In 1982, after retiring from the state police, he joined Shoreline Cruises, which provided him with qualifying training to operate all of the company’s vessels, small and large. In 1984, he obtained a New York State Master’s License to operate public vessels. His last license renewal was valid through June 20, 2006. The owner of Shoreline Cruises characterized the operator as a good worker who was “a very conscientious person.” He further stated that the Ethan Allen operator “was always looking out for the safety of the public.” Medical. The vessel operator said that he took prescription medications for high blood pressure and cholesterol, as well as several over-the-counter vitamins. Work/Rest History. The vessel operator told Safety Board investigators that he had maintained the same schedule for several weeks before the accident, including the day of the accident. He arose by 0530, and typically left home for work around 0920 to arrive at the Shoreline Cruises office at least 30 minutes before his first scheduled cruise at 1030. He went to bed by 2100 or 2130. On October 2, he operated the Ethan Allen with a passenger load of two or three on his 1030 cruise. Vessel Information History The vessel now known as the Ethan Allen was built in 1964 by Anchorage Shipyard of Warren, Rhode Island, for Whaling City Dredge & Dock Corporation (Whaling) of Groton, Connecticut. Whaling contracted for a fiberglass excursion vessel using the Dyer 40 hull design.6 The hull, the seventh in a series based on a design for 40- foot fiberglass cruisers, was designated the Dyer 40-7. Because of the vessel’s intended operation as a small passenger vessel, it was subject to Federal oversight. U.S. Coast Guard regulations pertaining to commercial vessels the size of the Ethan Allen are contained in 46 CFR Subchapter T, “Small Passenger Vessels (Under 100 Gross Tons).”7 The Coast Guard official with the oversight responsibility for ensuring compliance with marine safety standards, including the requirements in Subchapter T, is the Officer- in-Charge, Marine Inspection (OCMI) at each Marine Safety Office, which is a local Coast Guard office having jurisdictional authority for a specific area. Any restriction or 6  The first production Dyer 40 hull design was built in the early 1960s. The hull form has been used in a variety of other vessels as well, such as sport fishing vessels, lobster boats, yacht club tenders, cruisers, pilot boats, and U.S. Army Corps of Engineers utility boats. 7   Subchapter T was promulgated in 1957 as a result of Public Law No. 106-519, which was enacted by the U.S. Congress following the capsizing of the M/V Pelican off Long Island, New York. The small commercial fishing vessel, which was designed to safely accommodate 30 persons, was carrying 64 people when it capsized in heavy seas. Because of the vessel’s overloaded condition, the sea state, and the failure of the boat’s occupants to don lifejackets, 45 people died. Subchapter T stipulates that to operate a small passenger vessel, the owner/operator must have various programs and policies, maintain various documents, and install and maintain various navigation and radio equipment, lifesaving equipment, and firefighting equipment on that vessel.

Factual Information 8 Marine Accident Report contingency that the OCMI deems necessary for the safe operation of a vessel is listed on its COI. In the case of the Dyer 40-7 excursion boat contracted by Whaling, the Coast Guard OCMI, Providence (Rhode Island), approved the initial construction plans for the vessel, which was to be named the Double Dolphin. Anchorage Shipyard did not do the finish work on the Double Dolphin. Rather, the excursion boat was delivered to Whaling for completion. Because the vessel was not fully completed at the time the vessel left the Anchorage Shipyard, the OCMI Providence did not issue a Coast Guard COI authorizing the Double Dolphin for operation. According to documentation provided by Anchorage Shipyard, the Double Dolphin was in service for Whaling in 1965.8 In January 1966, Whaling contracted with Anchorage Shipyard for two additional vessels, requesting that the vessels be similar in construction, appearance, finish, and quality to the Double Dolphin. After the two sister9 vessels were delivered to Whaling, the company operated the three Dyer 40-model boats until spring 1979, when Shoreline Cruises, based in Lake George Village, purchased them. Because Shoreline Cruises intended to operate the three Dyer 40-model boats solely on New York State waters, the vessels no longer fell under Coast Guard jurisdiction10 but became subject to state oversight. Chapter 37, “Navigation Law,” New York State Consolidated Laws, governs vessels that operate solely on New York State waters. Excerpts from the regulations pertaining to commercial passenger vessel operations are published in separate study guides issued by the New York State Office of Parks, Recreation, and Historic Preservation (Office of Parks), which has oversight responsibility for public vessels. When Shoreline Cruises acquired the vessels, the Double Dolphin’s sister vessels were configured the same as when they were delivered by the boat builder to Whaling in

1. The Double Dolphin, however, had been modified by the installation of a canvas-

covered metal-truss-frame canopy. Additional information about the structural modifications to the three vessels appears in the section entitled “Vessel Certification and Inspection.” Shoreline Cruises renamed all three vessels. The Double Dolphin became the Ethan Allen and the sister vessels became the de Champlain and the Algonquin. Table 2 8  Draft press release circa May 1966. 9  The Coast Guard Marine Safety Manual provides the following guidance on the assignment of vessel sister status: “the proposed sister vessel should have been built within approximately 2 years from one another; the vessels must be built by the same shipyard; and the same basic drawings should have been used in the construction of both vessels.” 10  Vessels operating exclusively on inland waters that have not been determined to be “navigable waters of the United States” are not subject to Coast Guard inspection and regulation. The Coast Guard does not make such determinations about every body of water within the United States. Therefore, waters that have not been determined to be “navigable waters of the United States” fall under the jurisdiction of the state in which they are located. The Coast Guard has never determined Lake George to be “navigable” for Coast Guard regulatory or inspection purposes.

Factual Information 9 Marine Accident Report summarizes events pertaining to the construction and modification of the Ethan Allen and its sister vessels. Table 2. Events in the history of the Ethan Allen and its sister vessels Date Event 1964 Anchorage Shipyard builds and delivers Double Dolphin to Whaling. Vessel comes under Coast Guard certification. 1966 Anchorage Shipyard builds and delivers sister vessels to Whaling. May 1966 Stability test may have been performed on Double Dolphin. 1966-1979 Double Dolphin fitted with metal canvas canopy. May 28, 1976 Last COI issued to Double Dolphin by Coast Guard. May 1979 Double Dolphin and sister vessels sold to Shoreline Cruises. 1979-1989 De Champlain and Algonquin fitted with metal canvas canopies by Shoreline. Ethan Allen (ex. Double Dolphin) and de Champlain fitted with Plexiglas windows. 1989 Ethan Allen’s metal canvas canopy replaced with a wooden canopy. 1990 De Champlain’s metal canvas canopy replaced with a wooden canopy. 1991 Algonquin’s metal canvas canopy replaced with a wooden canopy. April 2005 Last COI issued to Ethan Allen by New York State. October 2, 2005 Ethan Allen capsizes. Construction The main characteristics of the Ethan Allen at the time of the accident are listed below: Registration: NY1267FP Hull form: Dyer 40 fiberglass monohull Canopy: Wood Windows: Plexiglas Length: 38 feet Beam: 12 feet Propulsion: Cummins diesel engine, model 6BT5.9M, 210 horsepower Propulsion type: Conventional single-shaft, three-blade propeller, single rudder The belowdeck area was divided into four spaces: a forward space, which held a 100-gallon fuel tank; the engineroom compartment; the lazarette, which contained the steering gear; and an aft port storage space. Hatch covers on the main deck allowed access

Factual Information 10 Marine Accident Report to the belowdeck areas. In addition, a side cover on the aft storage space permitted access to the lazarette. The engine compartment was equipped with a bilge pump mounted on the port side of the forward bulkhead. The pump removed bilge water from either the engine compartment itself or the forward space, according to the setting on a selector valve. The Ethan Allen was not equipped with a bilge alarm to alert crewmembers of a high water level in the bilge area. New York state laws did not have a requirement for public vessels to be equipped with a bilge alarm.11 The Ethan Allen employed a “wet exhaust” system. Water was pumped from the lake through the engine’s cooling system and into the exhaust gas piping by the main engine raw water pump. The mixture of exhaust gases and cooling water exited the vessel stern through a common pipe. Lifesaving Apparatus and Safety Equipment New York State required the Ethan Allen to carry sufficient lifesaving equipment on board for 50 people. The vessel typically carried the following safety equipment: Adult lifejackets 50 type I Child lifejackets 5 type I Fire extinguishers One portable 5-pound carbon dioxide (CO2) and one portable 44-pound CO2 Ring buoys One type IV throwable device The adult lifejackets were stowed inside a cabinet near the operator’s console at the stern and secured by an unlocked latch. The children’s lifejackets were inside a wooden box, the top of which formed the seat of a 36-inch-wide bench near the vessel’s bow. Both adult and children’s lifejacket storage locations were marked.12 The 5-pound fire extinguisher was near the operator’s console, and the 44-pound one was inside the engine compartment.13 11  New York has proposed a state requirement similar to the Coast Guard’s current requirement that small passenger vessels have high level bilge alarms in engine spaces below the deepest load water. The legislation is pending. See “Additional Information” for a discussion of the actions New York has taken following the accident. 12  Coast Guard regulations (46 CFR 180.78) require that lifejackets be stored “in convenient places distributed throughout accommodation spaces.” New York State Navigation Law 2 (67) requires life preservers to be located in “convenient, accessible places.” 13  Coast Guard regulations (46 CFR 181) require that a portable fire extinguisher used for an engine space be in a fixed location immediately adjacent to the entry door or hatch to the space. The New York “Public Vessel Operator’s Study Guide” in effect at the time of the accident specifies the number of portable extinguishers a vessel must carry based on its length. The guide indicates that at least one extinguisher must be located near the operator’s station, but is silent on where the other extinguishers should be located.

Factual Information 11 Marine Accident Report Vessel Certification and Inspection Stability Assessments. Coast Guard regulations specify the amount of stability a vessel must have, depending on its type and its service, as well as the methods of assessment for verifying its stability. An in-depth discussion of the stability concepts involved in the Coast Guard’s passenger vessel standards appears in “Other Information.” When the Ethan Allen (formerly Double Dolphin) was built, the September 6, 1963, version of Subchapter T was in effect. These Coast Guard rules did not require stability tests for passenger vessels that were shorter than 65 feet in length and that carried fewer than 50 passengers.14 Rather, an OCMI certifying a vessel for operation could require that a stability test be performed if he or she considered it necessary that the vessel’s stability be demonstrated. If the OCMI had required a stability test for the monohull vessel, the initial assessment typically would have been a simplified stability test (SST). The OCMI also could accept alternatives, equivalents, or departures from standards if the owner or operator could show they were warranted. In the course of its investigation, the Safety Board researched Coast Guard, state, and company records on the Ethan Allen (formerly the Double Dolphin). Investigators found that few documents were on file for the period when the Double Dolphin had been subject to Federal oversight (1964 through 1979). Anchorage Shipyard provided a February 22, 1966, letter that it sent to the OCMI Providence stating that the shipyard had been contracted by Whaling to build two 40-foot excursion launches based on the previous Coast Guard approval of the Double Dolphin. Anchorage Shipyard also provided the March 1, 1966, response letter that it received from the OCMI Providence approving the submitted plans and recognizing the Double Dolphin as the original sister vessel. The OCMI Providence response letter indicates that the Double Dolphin would be given an SST in the near future. Two Whaling employees who were interviewed said that they observed a stability test on one of the Dyer 40 excursion vessels, although they could not recall when the stability assessment occurred. No Coast Guard or Whaling company files contain any record of a stability assessment for the Double Dolphin. Shoreline Cruises’ files contained a copy of the Double Dolphin’s May 28, 1976, COI issued by the OCMI New London. The Double Dolphin’s 1976 COI references a stability letter dated May 28, 1966.15 Shoreline Cruises’ files also contained COIs for the two sister vessels acquired from Whaling. In the form block labeled “Stability letter (date and time),” the COIs for the two sister vessels contain no information. New York Office of Parks officials indicated that when Shoreline Cruises applied for state certification of the Ethan Allen (formerly Double Dolphin), state officials based 14  On March 10, 1996, the Coast Guard revised 46 CFR Subchapter T, requiring all small passenger vessels carrying more than six persons to pass an SST or to demonstrate compliance with the vessel stability requirements of Subchapter S. 15  The Safety Board was unable to find a copy of the stability letter, which would have indicated the date and type of stability test performed, as well as the results of the test.

Factual Information 12 Marine Accident Report their certification of the vessel, in part, on the Coast Guard’s May 28, 1976, COI, and did not require the boat to undergo a stability assessment. The Coast Guard’s COI permitted up to 48 passengers and required a master and second crewmember regardless of passenger carriage. New York Office of Parks officials indicated that the state COI permitted a maximum of 48 passengers on the Ethan Allen and required a master and also a crewmember when the tour boat carried more than 20 passengers. Vessel Modifications. Federal regulations at 46 CFR 176.700 stipulate, in part, that modifications to a vessel that might affect its safety must not be made without the approval of the OCMI. New York State did not have regulations requiring vessel owners to notify the state in the event of a major vessel modification; however, a New York State study guide, “Public Vessel Operator’s Manual,” in effect at the time of the modification states, in part, When major alteration to the structure of a public vessel is to be accomplished…it is the duty of the owner to promptly report the same to the [State] inspector, so that he may make a thorough inspection, if the condition or age of the vessel, in the judgment of the inspector renders such examination necessary. The manual is silent on whether the owner or operator should notify the state inspector verbally or in writing. As noted earlier, when Shoreline Cruises acquired the three Dyer 40 excursion vessels from Whaling, the two sister vessels built in 1966 had the same configuration as when they had been delivered by the boat builder, that is, with no canopy structure. The Double Dolphin, however, had been modified by the installation of a metal16 truss frame that supported a canvas canopy. Shoreline Cruises then modified the de Champlain by installing a full canvas canopy with metal framework and the Algonquin with a partial canopy (figure 4). In addition, Shoreline equipped the Ethan Allen and the de Champlain with Plexiglas windows. In 1989, Shoreline Cruises contracted with Scarano Boatbuilders, Inc., of Albany, New York, to modify the Ethan Allen by installing an all-wood canopy with Plexiglas windows that could be latched open. The finished canopy had six 36-inch-high windows along each side. Moving from stern to bow, three windows measured 58 inches wide, two measured 59 inches wide, and the forwardmost side window measured 50 inches wide. The bow area had three windows. A movable window measuring 26 inches wide by 38 inches high was in the middle of the bow windows. On each side of the center window was a fixed window measuring 29 1/2 inches wide by 37 1/2 inches high. The wooden canopy that Scarano Boatbuilders installed was about 15 inches lower than the metal and canvas canopy it replaced, providing a smaller lateral surface area17 than the previous canopy. 16  There is no record of and no one interviewed recalled what type of metal was used in the frame. Materials traditionally used in such construction were steel pipe or aluminum tubing. 17  Lateral surface geometry is a factor in Coast Guard stability criteria.

Figure 4. This circa 1980 photograph shows the canopies and metal framework on the de Champlain (foreground left), the Ethan Allen (foreground center), and the Algonquin (foreground right). Factual Information 13 Marine Accident Report According to Office of Parks representatives, state inspectors examine public vessels annually and require discrepancies to be corrected before the vessel is allowed to carry passengers. New York’s policy on records retention was to maintain a document for 5 years and then discard it. The state’s file on the Ethan Allen contains no record of inspections and/or stability assessments performed between 1979 and 1991, when modifications to the vessel’s canopy reportedly were accomplished.18 Office of Parks files indicate that the last state inspection of the Ethan Allen was conducted on May 20, 2005, and covered navigation, lifesaving, machinery, electrical, fire protection, firefighting, and documentation. Inspectors noted one deficiency, a chafed rubber inlet line on the raw water pump, which Shoreline Cruises replaced. Wreckage Investigators examined the vessel after it was recovered from Lake George and observed no damage on the outside of the fiberglass hull, the rudder, the keel, the propeller, or the drive shaft components. One window at the port bow and one window on the starboard side were missing Plexiglas panes. The passenger benches were undamaged and still bolted to the main deck. The engine hatch cover was missing but was later recovered from the lake. The engine exterior was free of damage; however, further tests showed that the engine sustained internal damage after the vessel overturned and the inverted engine either ingested water or lost lubrication while it briefly continued to operate. Investigators next had the vessel returned to the water and allowed it to float for about 20 minutes to determine whether the hull had any leaks. None were found. The engine exhaust pipe had several pinhole leaks and several weld beads suggestive of previous repairs to pinhole leaks. The main engine raw water pump was bolted externally to the port forward end of the engine. This pump was located above the vessel’s waterline when fully loaded with 18  New York provided the Safety Board with records for the Ethan Allen from 1997 to 2005.

Factual Information 14 Marine Accident Report passengers. Investigators found a gap measuring 0.076 inches at the widest point between the pump base and its impeller housing. When investigators removed the raw water pump from the engine, they noted that one of the two bolts on its mounting flange was backed out 0.063 inches and was loose to the touch. The on-scene investigative team subsequently sent the raw water pump to the Safety Board’s materials laboratory in Washington, D.C. for examination and arranged for an exemplar pump to be tested at the manufacturer’s testing facility. The raw water pump previously installed on the Ethan Allen’s engine was also acquired and sent to the materials laboratory for examination. See “Tests and Research” later in this report. Investigators observed no indications of engine damage, other than that to the raw water pump. Engine compartment hoses and piping showed no signs of wear, holes, or abrasions. The engine space and the engine exterior were coated with what appeared to be lubricating oil. The vessel’s two 12-volt batteries were found cabled together and dislodged, resting over the exhaust pipe, about 3 feet aft of the engine. The bilge pump selector was positioned to the forward space. Twenty-one lead blocks used for ballast, each weighing about 55 pounds, were found unsecured in the belowdeck forward space, near the 100-gallon fuel tank. Fourteen lead blocks were under the fuel tank’s plywood support; the remaining seven were found in different locations on the port side of the space. The interior of the forward space had minor cosmetic damage from the blocks’ moving during the capsizing event. Waterway Information Lake George, located at the southernmost end of New York’s Adirondack Park region, is 32 miles long and nearly 3 miles across at it widest point. The maximum lake depth is 195 feet. Over 10,000 boats of varying sizes operate on the lake each year. Public vessel operations on the lake are conducted under regulations established by the New York State Office of Parks. The Lake George Commission, which also issues marina and special activities permits, provides law enforcement services on the lake, as do the New York State Police–Marine Unit on Lake George and the Warren County sheriff’s office. Operations General Shoreline Cruises began in 1974 when the owner of the company began renting small recreational boats for the purpose of conducting sightseeing tours on Lake George. In 1979, the Shoreline Cruises owner purchased his own fleet of small passenger vessels (the Ethan Allen, the de Champlain, and the Algonquin) for the tours. He later acquired two additional vessels: the Horicon, an 85-foot vessel with a capacity of 200 passengers, in 1988; and the Adirondack, a 115-foot vessel with a capacity of 400 passengers, in 2004.

Factual Information 15 Marine Accident Report The owner said that the year before the accident, an estimated 60,000 passengers had taken Shoreline Cruises sightseeing tours in its vessels. He said that at the height of the tourist season in 2005, the company transported about 300 passengers a day on sightseeing tours on its three small vessels, although he indicated that he would conduct a sightseeing cruise with as few as two passengers. The company recorded the number of passengers on its small vessels but did not retain those records, and therefore Safety Board investigators were unable to determine how many times the various vessels had sailed with a full load of passengers. Maintenance Shoreline Cruises had its own personnel maintain its vessels, except when extensive engine repairs were needed. The company required operators to check their vessel’s engine fluids and bilge levels at the beginning of each day. Occasionally, company maintenance personnel would perform similar checks to verify vessel and engine status that the operators reported. In July 2005, Shoreline Cruises replaced the Ethan Allen’s main engine raw water pump at the recommendation of the company’s maintenance technician after he noticed a leak at the pump’s internal water seal during a routine check. Meteorological Information The Lake George water temperature was 68° F at the time of the accident. Witnesses described the lake water as calm, except for waves created by vessels. The National Weather Service office in Albany, New York, issued no hazardous weather advisories for the area on the day of the accident. Weather observations at Floyd Bennett Memorial Airport in Glens Falls, New York, about 6 miles east-southeast of the accident site, were taken both before and after the accident. Weather observations recorded at 1353, 1453, and 1553, indicated that the wind was calm, visibility was unrestricted at 10 statute miles, the sky was clear, and the air temperature was 71° F. Medical and Pathological Information Medical Information Autopsies were performed on each of the 20 fatalities in the accident, in accordance with New York State requirements. All victims were determined to have died as a result of asphyxia due to drowning. The Safety Board examined the results of the autopsies. Thirteen of the drowned passengers suffered significant traumatic injuries, including rib fractures and head and neck injuries. Of the seven drowned passengers who did not have significant injuries, five had evidence of significant heart disease, but only

Factual Information 16 Marine Accident Report two of these had age-associated atherosclerotic heart disease. The survivors either had minimal traumatic injuries or were uninjured.19 Toxicology Testing At the time of the accident, New York State did not require postaccident toxicological testing of mariners as a matter of course; however, in the case of an accident in which a passenger was seriously or fatally injured, a law enforcement official or the local district attorney could request a state superior court judge to compel toxicology testing through a court order, if he or she believed this was warranted. In this case, local and state officials did not ask the Ethan Allen operator to provide blood and urine samples, although he offered to submit to testing within an hour of the capsizing. The Warren County sheriff said that he observed the operator at close range shortly after the accident and noted no evidence of impairment. The operator then remained with the sheriff for several hours while he provided a statement pertaining to the accident events. The sheriff indicated that based on his observations, he did not ask that court-ordered toxicology samples be obtained. On October 4, 2006, the Safety Board asked that a toxicological test of the operator be accomplished, and the operator voluntarily submitted blood and urine samples for analysis. He told Safety Board investigators that he had consumed a glass of wine with his dinner the evening of the accident but no alcohol after that time. Investigators sent the samples to the Federal Aviation Administration (FFA) Civil Aerospace Medical Institute (CAMI) in Okalahoma City, Oklahoma, for testing. The CAMI report indicated no positive results for legal and illegal drugs. The urine analysis indicated the presence of an alcohol metabolite.20 Survival Aspects Emergency Response Several people on boats and on shore saw the capsizing and called 911 on their cell phones. Warren County sheriff’s office logs indicate that these calls took place at 1454. Lake George Fire Department (LGFD) records indicate that the first units were dispatched at 1456 and arrived at 1504. The LGFD fire chief established an onshore incident command post near Cramer Point and served as the incident commander for the response to the accident. A total of 49 emergency response vehicles and vessels were dispatched to the scene. In addition, recreational boaters who observed the accident immediately went to the scene to assist in the rescue. A group of divers at a Lake George dive school saw the 19  Three survivors were hospitalized for more than 48 hours (all for less than 72 hours). One was admitted for a heart attack, one for water inhalation, and one to rule out the possibility of a heart attack. 20  The metabolite ethyl glucuronide can be detected in urine for up to 80 hours after the elimination of alcohol from the body.

Factual Information 17 Marine Accident Report capsizing and called 911 to report the accident. They advised the dispatch center that they could assist in the rescue but needed boats to take them to the site. About 15 minutes later, a recreational vessel took five dive instructors to the site, where they assisted in recovering victims from the water and the sunken vessel. Ambulances transported survivors to a hospital in Glens Falls, New York. The operator was uninjured and elected not to be taken to a hospital. Eighteen survivors were treated for minor injuries or exposure to cold and released the same day. One was admitted overnight, treated for stress and exhaustion, and released the next day; five were admitted and discharged after 2 nights; and three were discharged after 3 nights. Their injuries included water aspiration, hypothermia, possible myocardial ischemia, chest pain, and shoulder trauma. Survivability-Related Rules At the time of the accident, the Consolidated Laws of the State of New York and the study guide provided to public vessel operators were silent about crews providing passengers with a predeparture safety briefing or a safety card or pamphlet with safety- related information.21 In addition, New York laws did not specify minimum dimensions for means of escape. Following the Ethan Allen capsizing, the Office of Parks issued a pamphlet, “Technical Guidance for the Public Vessel Operators,” which states that each level on a public vessel that is occupied by passengers should have two means of egress, and that the minimum opening for doorways should be 32 inches and for windows, 24 inches. In addition, state legislation has been proposed to require that all public vessels certified to carry 20 or more passengers be equipped with at least two means of exit on each deck.22 Tests and Research Raw Water Pump Exemplar Pump Tests at Cummins Facility. To test the effect of the gap that investigators found in the raw water pump housing and to avoid possible damage to the Ethan Allen’s actual pump before it was subjected to Safety Board laboratory examination and analysis, investigators had operational tests performed on a same model and similarly configured raw water cooling pump at the engine manufacturer’s facility on 21  The Ethan Allen was not inspected by the Coast Guard and therefore was not subject to Federal regulations at 46 CFR 185.506, which require a vessel operator to ensure that, before getting underway, passengers receive an announcement or a pamphlet informing them about the location of emergency exits and ring life buoys, the locations of lifejackets, the proper method for donning or adjusting lifejackets, and the location of instruction placards for lifejackets and other lifesaving devices. The State of New York has since proposed regulatory changes, which are discussed later in this report. 22  See appendix C.

Factual Information 18 Marine Accident Report December 20, 2005. The engine test cell was configured to replicate the operating conditions on the Ethan Allen in the following conditions: • The raw water temperature was matched to that of the lake at the time of the accident. • The raw water inlet plumbing was configured to replicate the theoretical raw water inlet restriction calculated from the Ethan Allen’s actual plumbing. • The raw water inlet plumbing was configured to allow the adjustment of waterline height in relation to the pump centerline to simulate the unloaded and loaded vessel conditions. • The engine was coupled to a dynamometer to replicate the theoretical load on the engine at the time of the accident. • The engine with the installed exemplar pump was operated under several test conditions to assess its operational characteristics. Investigators then introduced a 0.076-inch gap in the pump housing that matched the gap found on the Ethan Allen’s pump. The following results were obtained:

1. Initially, the engine was running with no gap in the pump. Immediately

after the gap was introduced, the pump completely lost flow.

1. The pump was unable to establish prime when starting the engine with

the gap in place.

1. While operating with no water flow, internal friction within the pump

caused the impeller and housing to overheat and emit white smoke.

1. With the pump not supplying water flow through the engine’s cooling

system and the engine running within routine operational parameters, the engine operated 4 minutes before it overheated and had to be shut down because of high cooling water temperature. The maximum leak rate during any testing phase was 0.2 to 0.3 gallons per minute. Pump Examination at Safety Board Laboratory. Because of the observed gap in the raw water pump on the accident vessel, investigators removed it for disassembly and examination in the Safety Board’s materials laboratory. Technicians also examined the pump removed from the Ethan Allen by the Shoreline Cruises maintenance technician in July 2005 and the exemplar pump tested at the Cummins facility in December 2005 for comparison with the pump from the accident vessel. Examination of the pump removed from the Ethan Allen following the accident revealed that all three pump housing bolts were loose and the lock washer was free to rotate on the bolt. Lock washer contact was observed around two of the three pump housing bolt holes located on the bearing housing. The lock washer contact face on the bolts displayed limited plating removal and circumferential scratches consistent with the bolt being in contact with the lock washer, but no indications that it had been loosened. As

Factual Information 19 Marine Accident Report a test, exemplar bolts and lock washers were torque-loaded in accordance with the manufacturer’s specification and loosened. Examination under the head of the exemplar bolts revealed a radially oriented curl of material on the surface, consistent with the loosening action. Despite the gap between the pump and bearing housings, one side of the wear plate between them displayed a uniform imprint from the O-ring in the pump housing and the other side displayed a uniform imprint from the gasket between it and the bearing housing. The impeller contact face on the wear plate was severely discolored and significant wear was observed on the impeller tips. The examination of the three raw water pumps, conducted on January 10, 2006, revealed that the previously installed pump (removed in July 2005) had significant wear around the pump housing bolt holes, consistent with repeated tightening and loosening of the housing bolts. The impeller shaft was extremely loose in the bearing housing and the shaft’s key slot, key, and impeller keyway showed significant wear. The impeller tips had negligible wear. The exemplar pump used in the December 2005 tests at Cummins had loosening contact marks, from the lock washers, on all three pump housing bolts and wear on the impeller tips. On-site Stability Assessment Following the accident, Safety Board investigators had the Ethan Allen recovered from the water and transported to a hangar where it could be retained as evidence and examined to determine whether hull sections or equipment needed to be removed for further testing and analysis. To obtain a preliminary determination of whether stability, overloading, or both might have been factors in the capsizing, Safety Board investigators conducted a series of stability-related tests on the de Champlain, which investigators considered for test purposes to match the critical dimensions of the Ethan Allen.23 The first test was an SST, conducted in accordance with 46 CFR 178.330, “Simplified stability proof test.”24 The Coast Guard SST verifies a vessel’s stability for carrying passengers. The number of passengers to be carried is initially determined before the test is conducted, based on a review of the vessel’s drawings or physical measurements, using one of several criteria.25 The stability of the vessel is then assessed using the minimum number of passengers allowed based on the initial determination. An SST is conducted, based on Coast Guard criteria of 140 pounds per person for vessels to be operated on protected 23  Safety Board investigators compared the two vessels and found the general arrangement and construction of the hulls to be the same with some minor differences in ballast, canopy structure, type of main engine, and outfitting noted and accounted for in the tests. 24  Coast Guard criteria were used because New York State applied Coast Guard stability requirements to public vessels. 25  Length of rail—one passenger for each 30 inches of rail at the sides and stern. Deck area—one passenger per 10 square feet of deck area, excluding spaces listed in 46 CFR 176.113, which include, among other areas, concession stands, toilets, lifesaving gear storage spaces, required aisle area, and fixed seating areas. Fixed seating—one passenger for each 18 inches of fixed seating width.

Factual Information 20 Marine Accident Report waters. The areas where the vessel operated as the Double Dolphin and Lake George are considered to be protected waters. The SST protocol includes calculating wind and passenger heeling moments26 to determine whether a vessel, as built and proposed to be operated, has the required stability and reserve buoyancy. The greater of the calculated wind moment or the passenger moment is applied to the vessel, and the vessel’s reduction in freeboard is then determined. The calculation of the passenger heeling moment is based on the beam of the vessel and the number of passengers carried, while that of the wind heeling moment is based on the projected lateral surface of the vessel exposed to wind pressure. Passenger heel and wind heel moments test conditions, as well as immersion of the freeboard, were calculated and are provided in table 3. Table 3. On-site SST test conditions Passenger Heel Wind Heel Allowable Immersion Test Weight (calculated) Moment Lateral Wind Area Moment 14º Limit Angle of Heel 6,720 pounds 11,659 foot- pounds 330 square feet 13,060 foot- pounds 17.16 inches Investigators initially filled 12 55-gallon barrels with water and positioned them on wooden blocks along the vessel’s centerline. This test weight replicated loading 48 passengers with an average per person weight of 140 pounds.27 The vessel’s freeboard and the lateral area exposed to wind were then measured. To reach the maximum heeling moment of 13,060 foot-pounds, eight of the 12 barrels were emptied and repositioned against the vessel’s port side, in a two-by-four combination, with the intent of refilling all eight barrels to produce the required heeling moment. However, after only three outboard barrels had been filled, which produced a heeling moment of about 7,164 foot-pounds, the vessel heeled to within 3 inches of the reference immersion mark. Investigators noted that the vessel felt tender28 and terminated the test rather than risk endangering the vessel and test personnel by filling the remaining empty barrels (figure 5). The SST simulates a full vessel passenger load using the number of passengers allowed by the vessel design and the number of required crewmembers, multiplied by the weight standard. If the vessel’s loss of freeboard from heel with this load is greater than that stipulated in the standard, it is not permitted to carry the number of passengers determined initially. The owner must then reduce the heeling moment to enable the vessel to pass the proof test, by reducing the maximum permitted number of passengers, 26  In engineering terms, a “moment” is a force applied at some distance from a reference point. The distance may be referred to as a “moment arm” or “lever arm.” A moment may also be referred to as torque. If an object is not constrained, a moment will cause it to rotate. 27  The calculated wind heel was based on the SST conducted on the de Champlain. 28  A vessel is described as “tender” when its center of gravity is too high, making it top-heavy and “conducive to capsizing” (International Maritime Dictionary).

Factual Information 21 Marine Accident Report ballasting the vessel, or reducing the vessel’s wind profile area, if possible. As an alternative to the SST, the owner can also show, by an inclining test and design calculations, that a vessel’s loading and operation meet the stability criteria of 46 CFR Subchapter S. Figure 5. De Champlain after on-site stability assessment was terminated. 29 Investigators then conducted an inclining test on the de Champlain to determine its weight and vertical center of gravity (VCG). The test measured changes in the equilibrium heel angle of the vessel after moving water barrels, each weighing 477 pounds, transversely to various positions on the main deck. The test also derived the vessel’s lightship condition (displacement and vertical center of gravity).30 At the time of the inclining test, the wind was slack and wave action on the lake was minimal. The inclining experiment results on the de Champlain were conducted in accordance with ASTM Standard F 1321-91.31 29  Title 46 CFR 178.320 (e) allows an owner to perform rigorous stability calculations if the SST fails. 30  The lightship condition is when the vessel is complete in all respects but is without consumables, stores, cargo, crew, or passengers and has only operating fluids in the vessel’s machinery. Both the vessel’s lightship weight and the center of gravity are necessary if the vessel’s stability is to be calculated according to 46 CFR Subchapter S standards. 31  “Standard Guide for Conducting a Stability Test to Determine the Light Ship Displacement and Centers of Gravity of a Vessel.”

Factual Information 22 Marine Accident Report Both the de Champlain and the Ethan Allen were then placed in the water and freeboard measurements were taken around each vessel. The Ethan Allen measured a consistent 0.5 inch deeper in the water than the de Champlain. Both vessels were then placed on a New York State Police-certificated truck scale and weighed. The de Champlain weighed 14,870 pounds and the Ethan Allen, 15,400 pounds. Postaccident Stability Study—Method The Safety Board contracted with JMS Naval Architects and Salvage Engineers to derive the static and dynamic stability of the Ethan Allen in both the intact condition and the flooded condition.32 The contractor was to perform seven tasks:

1. Develop an accurate computer model of the Ethan Allen hull form.
2. Calculate the lightship weight and VCG of the Ethan Allen at the time of the

accident, based on the inclining experiment conducted on the de Champlain.33

1. Calculate the Ethan Allen lightship weight and VCG for previous vessel

conditions—as delivered by the builder and with various canvas canopy configurations, or variants.

1. Determine the maximum passenger loading that would meet Coast Guard

simplified stability criteria in 46 CFR 178.330, based on the lightship weights and VCGs found in tasks 2 and 3.

1. Determine the maximum passenger/crew loading that would meet the

following Coast Guard passenger vessel stability criteria in 46 CFR Subchapter S34: • 46 CFR 170.170, “Calculations Required” minimum GM35 with wind heeling moment [weather criterion], • 46 CFR 170.173(e)(2), “Criterion for Vessels of Unusual Proportion and Form” (weather criterion), and • 46 CFR 171.050, “Intact Stability Requirements for a Mechanically Propelled or a Nonself-propelled Vessel” minimum GM with passenger heeling moment [passenger loading criteria for large vessels].

1. Evaluate the effects of transverse passenger movement and internal flooding of

the main engine and forward compartments on vessel stability.

1. Evaluate the dynamic effects of wave action on the vessel.

32  Static stability is a measure of a vessel’s stability characteristics in calm water. Dynamic stability is a measure of a vessel’s characteristics and response to external forces such as wind and waves. Intact stability assumes no damage to or flooding of the vessel. 33  See “On-site Stability Assessment” section. 34  As required by 46 CFR 178.310 if the cognizant OCMI questions the stability of a small passenger vessel or if the owner chooses not to assess the vessel’s stability by means of an SST. 35  GM or metacentric height is the measure of a vessel’s ability to return to the upright position after it has experienced a heel from an external force.

Factual Information 23 Marine Accident Report Before beginning its study, the contractor performed a laser survey of the Ethan Allen to determine the hull form. The contractor then used the results of the laser survey to generate a three-dimensional computer hull model to import into naval architecture software for use in the stability analysis.36 The vessel conditions analyzed were as follows:

1. As delivered from boat builder (without a canopy).
2. With a steel canopy installed—operated in fresh water.
3. With a steel canopy installed—operated in salt water.
4. With an aluminum canopy installed—operated in fresh water.
5. With an aluminum canopy installed—operated in salt water.
6. With a wood canopy installed—operated in fresh water.

Postaccident Stability Study—Results The Ethan Allen hull form created by the contractor as task 1 is shown in figure 6. Figure 6. Computer-generated Ethan Allen hull form. Estimates of the Ethan Allen’s lightship weight and longitudinal center of gravity at the time of the accident were based on the weight measured on the truck scale and from freeboard measurements taken while the vessel was afloat. The VCG was derived from the results of the de Champlain inclining test. The hydrostatic properties based on task 1 were used for both vessels. 36  Analysis used “HECSALV,” proprietary software developed by Herbert Engineering Corporation.

Factual Information 24 Marine Accident Report In tasks 3 through 5, the contractor calculated passenger vessel stability in accordance with Coast Guard regulations in 46 CFR Subchapters S and T, in various vessel configurations, three canopy designs,37 and salt and fresh water because the vessel had operated in both. Lightship weights and centers of gravity of the five types of vessel configurations are shown in table 4. The de Champlain is included for comparison purposes, using the results of the October 5, 2005, inclining experiment. Table 4. Lightship conditions of alternate vessel configurations Item Ethan Allen 1964 Ethan Allen Steel Canopy Ethan Allen Aluminum Canopy Ethan Allen 2005 De Champlain 2005 Weight (pounds) 12,759 14,590 13,542 14,689 14,315 VCG (feet above baseline) 4.5 5.4 4.9 5.3 5.4 The task 4 stability analysis showed that the only version of the Ethan Allen (formerly Double Dolphin) that could pass the SST with a 48-passenger load was the as- delivered variant from the boat builder, that is, the vessel without a canopy. All other variants failed the SST for any passenger loading. With the canopy installed, the wind heeling moment was found to govern over the passenger heeling moment.38 The results of task 5—maximum passenger loading for Subchapter S criteria—are shown in table 5. As noted, passenger counts were based on 140 pounds per person, the Coast Guard standard for operation in protected waters. As in the simplified criteria, no metal-framed canvas canopy was found to meet the wind heel criteria, regardless of the total passenger count. The wood canopy was found to meet the criteria with a reduced number of passengers because the height of the wood canopy was lower than the height of the canvas one, resulting in a lower vertical center of gravity and a smaller wind profile than for the canvas canopy. 37  Canvas canopy with steel frame, canvas canopy with aluminum frame, and wooden canopy. 38  That is, it became the more severe of the two stability criteria that the vessel had to meet. Thus, if the vessel met the wind heeling moment, it met the passenger heeling moment as well.

Factual Information 25 Marine Accident Report Table 5. Maximum passenger/crew loading for Subchapter S stability criteria Condition 46 CFR 170.170 Wind Heel 46 CFR 170.173 Unusual Form 46 CFR 171.050 Passenger Heel Weight (pounds) Passengers/Crew (number) Weight (pounds) Passengers/Crew (number) Weigh (pounds) Passengers/Crew (number) 1

21,000 150

8,260 59 8,120 58 2 DID NOT PASS 1,540 11 6,860 49 3 DID NOT PASS 1,400 10 6,720 48 4 DID NOT PASS 5,180 37 7,560 54 5 DID NOT PASS 5,040 36 7,560 54 6 2,940 21 1,960 14 6,860 49 NOTE: Weight = total weight of passengers at 140 pounds per passenger. In task 6, the Safety Board examined the effects of the three-by-two passenger seating configuration on the vessel’s center of gravity, given the weight of those on board the vessel. The results indicate that the total passenger/crew transverse center of gravity was 0.2 foot to port of centerline and the longitudinal center of gravity was 0.36 foot forward of amidships, which created a 2.2º heel to port and 0.71-foot trim by the bow. During interviews of survivors, investigators asked whether any passengers moved shortly before the onset of the accident, and every person said that no one stood up or moved from one side of the vessel to the other. Almost all said that passengers shifted in their seats and slid or fell toward the vessel’s port side as the operator was attempting to turn starboard and the Ethan Allen began to roll to port. The Safety Board study analyzed the potential effect of the transverse movement of passengers and crew on the tendency of the Ethan Allen to capsize. In the accident condition, the righting arm was reduced to zero39 when the total passenger/crew weight load was shifted 1.0 foot off centerline, or 0.8 foot from the initial loading condition. Task 7 was a roll sensitivity study, which was conducted to understand the dynamic behavior of the Ethan Allen under varying wave conditions. Simulations were completed using Oceanic Consulting Corporation’s numerical seakeeping time-domain panel code MOTSIM.40 The characteristic waves in the wake of a vessel are governed by many factors, including vessel speed, hull size, hull shape, and whether or not the vessel in question is maneuvering. Consequently, there is no simple answer as to the height, steepness, or wave period (frequency) of the waves that will exist in a generated wake. The wake generated 39  At zero righting arm, the boat has no righting energy to resist a vessel’s heeling action, meaning it will capsize. 40  MOTSIM is a non-linear time-domain seakeeping simulation program that can predict vessel motions in six degrees of freedom in any wave condition.

Factual Information 26 Marine Accident Report by a vessel can be assessed by means of a physical model test or by using numerical simulation. For the purposes of this report, it is sufficient to state that such generated wakes may have wavelengths as long as the Ethan Allen. Such waves generally last a few seconds. In the case of the Ethan Allen, its natural rolling period also was a few seconds. Without specific knowledge of which vessel(s) created the wave(s) that impacted the Ethan Allen, the actual wave conditions experienced by the Ethan Allen are unknown. It was therefore deemed appropriate to undertake a study using regular wave analysis to examine influences on the dynamic response of the vessel. Based on witness accounts of the Ethan Allen’s movements and their descriptions of the waves encountered by the vessel as it turned and rolled and the resultant involuntary shifting of passengers and crew, this analysis examined a number of parameters in combination, shown in table 6. The 1-foot wave height was initially chosen based on passenger and operator observations. The parameters that were examined included vessel speed, heading, wave period, wave height, and passenger/crew transverse center of gravity (TCG41) position. The issue of turning was beyond the capability of the seakeeping code. Table 6. Original motion analysis simulation parameters Loading Conditions Speeds Headings Wave Height Passenger/crew TCG = -0.2ft ACTUAL 6, 7 & 8 mph 15°, 30°, 45°, 60°, 75°, and 90° 1 foot None of the study simulations using the parameters in table 6 resulted in a capsize event, indicating that a wave height of greater than 1 foot would have been required to capsize the vessel for the load condition assessed. In simulations based on encountering a 1-foot wave, the maximum roll response was about 8° to port. Maximum vertical and lateral accelerations tended to occur in beam seas (at all speeds). Lateral accelerations were also high at the 75° headings. Investigators next examined the parameters outlined in table 7. A limited set of simulations was run at higher wave heights. Over the speed range examined, the analysis identified that vessel speed had little influence on the results, and additional simulations used a nominal vessel speed of 7 mph. The results illustrated that larger motions could be expected at wave headings that were closer to beam seas (that is, headings of 90°, 75°, or 60°). The vessel response was not as pronounced at headings that were closer to following or stern quartering seas (that is, headings of 15°, 30°, or 45°). The static stability study (task 6) had determined that the vessel’s reserve righting energy was sensitive to the location of the center of gravity of the passengers and crew. 41  The transverse location of the center of gravity of passengers/crew relative to the centerline of the vessel. The TCG = -0.2 foot represents the actual departure condition of the vessel and resulted in the vessel’s initial 2.2° list to port. A TCG of –0.8 foot would produce a list of about 10° to port.

Factual Information 27 Marine Accident Report Almost all survivors stated that as the vessel rolled to port during the turn toward starboard and encountered the wave(s) from the starboard direction, passengers slid to the low (port) side of the Ethan Allen. The simulations that considered shifts in passenger/crew TCG positions as well as increased wave heights showed that the maximum roll and pitch angles occurred at headings of 60°, 75°, and 90°, with a maximum roll response of about 16° to port. Over the range of frequencies that were examined, the peak responses (that is, largest roll angles) tended to occur at higher wave frequencies. These cases were where the wavelength equaled the boat length. Table 7. Parameters for additional motion analysis simulations Loading Conditions Speeds Headings Wave Height Passengers/crew weight TCG= -0.2ft actual 7 mph 60°, 75°, 90° 1.5 foot Passengers/crew weight TCG= -0.2ft actual 7 mph 60°, 75°, 90° 2.0 foot Passengers/crew weight TCG= -0.4ft 7 mph 60°, 75°, 90° 1.0 foot Passengers/crew weight TCG= -0.6ft 7 mph 60°, 75°, 90° 1.0 foot Passengers/crew weight TCG= -0.8ft 7 mph 60°, 75°, 90° 1.0 foot Maximum roll angles increased when wave height was increased. Maximum roll angles increased when the TCG was moved farther outboard. While no capsize event occurred, it was noted that some roll angles were substantial. The Safety Board’s stability study did not include a rigorous engineering evaluation of the vessel’s roll response to the combined effects of wave action and turning because of limitations of the numerical seakeeping time-domain panel code MOTSIM. However, certain factors associated with a vessel’s roll response actions are applicable to vessels such as the Ethan Allen. If an operator turns the vessel to starboard either in calm waters or in waves, the boat will experience a roll to port during the maneuver. Calculations performed in conjunction with other tasks showed that the Ethan Allen operated with a 2.2° port list. When a listing vessel makes a turn, the added angle of roll further reduces the amount of righting energy available to counter the effects of passing waves and transverse weight shifts. Saunders discusses the heel angles associated with vessels in a turn in Hydrodynamics in Ship Design,42 stating Usually,…the center of gravity lies above the centers of pressure on the underwater hull and on the rudder, and the hull-lift force is greater than the rudder force, so that the resultant transverse moment created by these three forces causes the ship to heel outward while making a turn, despite the righting moment due to positive transverse metacentric stability. The heel due to the offset centripetal and centrifugal forces increases until the moment caused by them equals the righting moment…. 42  Harold E. Saunders, Hydrodynamics in Ship Design, Vol. 3, ch. 4, “Ship Motion Involved in Maneuvering” (New York: Society of Naval Architects and Marine Engineers, 1965), pp. 56-57.

Factual Information 28 Marine Accident Report The heel may become dangerously large if the metacentric height and the range of positive transverse metacentric stability are both small…. A boat or a ship with a surface waterplane which has fore-and-aft asymmetry changes trim as it lists or heels. There may be some disadvantage if this occurs during a turn. An everyday example is the craft with a wide transom stern which trims by the head as it heels, because it picks up more volume aft than forward with a given inclination. The Safety Board’s stability study showed that in its accident condition, the Ethan Allen had a high center of gravity, and marginal righting energy and GM. With its transom stern and its fine bow, the vessel had a significant asymmetric water plane at its accident draft. In addition to the vessel’s 2.2° list to port, it was trimmed by the bow almost 1 foot. Other Information Stability Concepts A vessel that is floating upright in still water will heel when an off-center force or heeling moment is applied. Stability is the tendency of the vessel to return to its original upright position when the force is removed. In still water, a vessel’s stability is a function of its underwater hull form and the distribution of mass of the vessel. The properties of stability are usually expressed in terms such as the magnitude of a heeling moment necessary to heel the vessel to a certain angle, the angle a vessel may heel to before capsizing, the amount of reserve energy available to return the vessel to its upright position, and other parameters that can be calculated. Coast Guard regulations and international standards specify the amount of stability a vessel must possess, depending on the type of vessel and its service. The requirements are usually expressed in terms that are easily calculated, such as GM, range of positive stability, righting energy, or other recognized technical measures. The specific stability characteristics of an individual vessel are determined based on the design drawings of its hull form (lines plan) and an inclining experiment of the vessel while afloat to determine its actual weight (displacement) and center of mass (center of gravity). Although obtained under stationary conditions, the stability characteristics represent the vessel’s ability to return to the upright position when the vessel is in service and is subject to external forces such as wind and waves, people moving about, and from inertial effects resulting from the accelerations and motions of the vessel as it moves around on the water’s surface. Such dynamic influences on a vessel are random processes and can only be predicted statistically. Studies comparing the stability characteristics of vessels that capsized (inadequate stability) and vessels that did not capsize (adequate stability) form the basis of stability criteria that are in use today. To account for unknowns, uncertainties, and randomness of the physical environment and vessel response, large safety margins are built into the criteria. The stability criteria are generally recognized as providing an adequate level of safety for vessels that are operated prudently, which means not overloaded and not operating in dangerous conditions such as hurricanes.

Factual Information 29 Marine Accident Report The stability analyses of most vessels involve substantial calculations that generally require the services of a naval architect. The calculations are based on an inclining experiment, in which very precise measurements are taken on board the vessel in order to determine its displacement and center of gravity. The inclining experiment and associated calculations and analysis cost several thousand to tens of thousands of dollars. For large oceangoing ships, the stability assessment is minor compared to the total cost, and is necessary in order to determine the maximum amount and stowage of cargo. In small passenger vessel design, stability is not optimized and usually exceeds the Coast Guard stability criteria. Because of the relatively high cost of an inclining experiment and full stability assessment, the Coast Guard permits an SST to be performed. The SST is quick, inexpensive, and more conservative than a full stability analysis. Being more conservative, the SST results in fewer passengers permitted than would be allowed based on a full stability assessment. Because the number of passengers permitted on a small passenger vessel is based on several criteria, such as deck area and seating capacity, stability is often not the governing criteria. In those cases, the SST is sufficient. However, the owner of a small passenger vessel might have space to carry more passengers than would be allowed by the SST, and so the cost of performing a full stability assessment with an inclining experiment is justified to show that additional passengers may be carried in compliance with the detailed stability regulations. The margin of safety built into the stability criteria is what provides the safety of the vessel against capsizing. The margin of safety is intended to accommodate all the things that happen with a vessel, such as rolling in waves, heeling due to wind, or listing as passengers move from one side to the other. The margin of safety is reduced if the vessel is operated in extremely high winds, surf, or is overloaded. The stability criteria are not intended for such conditions. In such extreme operating conditions, the margin of safety may be still adequate to keep the vessel upright, or it may not be adequate, resulting in a capsizing. In any case, if the intended margin of safety is not maintained, the vessel should not be considered seaworthy (safe), whether or not it capsizes. Because of the nature of stability, and the randomness and variabilities associated with it, safety is not absolute. Not meeting stability standards does not mean a vessel will capsize; it only means the margin of safety is lower than what the regulations require. A vessel can operate for years in an overloaded condition that does not meet the stability standards; because the margin of safety is less than it should be, the probability of capsizing is higher, but it could still be remote. It would take other forces, such as high winds or large waves, to cause a vessel to capsize. The more a vessel is overloaded, the less the margin of safety for stability and the higher the probability of capsizing. There is no obvious way to tell if a vessel fails to meet the stability criteria, other than through a stability test. This is why a stability test is required for all small passenger vessels. If something changes about the vessel, such as a structural modification that might affect the vessel’s stability, another stability test and assessment should be conducted. After the stability assessment is completed, the results of the assessment and any limitations, such as number of passengers or limiting operating conditions, will be placed on the vessel’s stability letter or COI.

Factual Information 30 Marine Accident Report Capacity Plates In the course of its investigation of the Ethan Allen accident, the Safety Board determined that the number of boats registered in New York as “public vessels,” that is, vessels permitted to transport freight or passengers for commercial purposes on state waters, totaled 447. Of these, state officials had based the number of passengers that 382 public vessels were permitted to carry on manufacturers’ capacity plates.43 Investigators determined that of these 382 public vessels, 125 carried more than six passengers. The required display of capacity information on a plate in sight of the helm (steering area) is contained in 33 CFR 183, Coast Guard standards governing monohull noncommercial boats less than 20 feet long, except sailboats, canoes, kayaks, and inflatable boats. Information on the plate must include the maximum horsepower recommended for the boat, the maximum person capacity (listed both as number of people and as cumulative pounds), and the vessel’s maximum carrying weight capacity (listed as the combined poundage of persons, motor, and gear). Vessels longer than 20 feet are not required to have a capacity plate; however, some manufacturers elect to install the plates on their vessels over 20 feet long. As noted earlier, New York State did not have regulations governing stability assessments for public vessels. Office of Parks representatives indicated that the state accepted either a Coast Guard-approved stability assessment or a manufacturer’s capacity plate as evidence of acceptable vessel passenger loading for public vessels. If a state inspector questioned a vessel’s stability or if the owner made major modifications to the vessel, state officials required that a stability assessment be conducted using the testing protocol in Coast Guard regulations for small passenger vessels. The Coast Guard does not rely on capacity plate information for inspected small passenger vessels. All small passenger vessels that carry more than six passengers must comply with full certification and inspection requirements, including the stability criteria in Coast Guard regulations. Accidents Involving Out-of-Date Passenger Weight Standard Following the March 6, 2004, capsizing of the pontoon-style small passenger vessel Lady D in Baltimore Harbor,44 the Safety Board identified that the Coast Guard’s passenger weight standard of 140 pounds used to assess the stability of vessels operating on protected waters posed a substantial safety risk for vessels carrying near the maximum number of permitted passengers. As a result, in advance of its final report on the accident, the Safety Board issued the following safety recommendation to the Coast Guard on December 20, 2004: 43  This category did not include the Ethan Allen, the de Champlain, or the Algonquin. 44  Capsizing of U.S. Small Passenger Vessel Lady D, Northwest Harbor, Baltimore, Maryland, March  6, 2004. Marine Accident Report MAR/06-01 (Washington, DC: National Transportation Safety Board, 2006).

Factual Information 31 Marine Accident Report M-04-4 Revise your guidance to Officers in Charge, Marine Inspection, to determine the maximum occupant capacity of small passenger pontoon vessels either (1) by dividing the vessel’s simplified stability proof test weight45 by the per person weight allowance for an average adult stipulated in Federal Aviation Administration Advisory Circular 120-27D (174 pounds per person, assuming summer clothing and a 50-50 gender mix), or (2) by restricting (at the time of loading) the actual cumulative weight of passengers and crew to the vessel’s simplified stability proof test weight. In its April 7, 2005, response to this recommendation, the Coast Guard informed the Safety Board that it “partially concurred with this recommendation,” noting that it agreed with the premise behind “option 1” but did not agree with “option 2.” The Coast Guard stated, with regard to option 2: The actions necessary to implement a change to the standard weight per person used in the simplified stability proof test for small passenger pontoon vessels go beyond a simple revision of guidance to OCMIs. The current weight standards are set in regulation at 46 CFR 178.330 and extend to all other types of small passenger vessels as well. Therefore, any change would, and realistically should, affect all other small passenger vessel types. However, passenger weight is only one of many variables in our vessel stability calculations. The Coast Guard added that it had chartered a working group to analyze the passenger weight issue and assess the potential impact of regulatory changes on vessel stability determinations. In the Safety Board’s final report on the Lady D accident, issued March 7, 2006, the Board agreed with the stated intent of the Coast Guard to address the passenger weight standard in the stability criteria for all domestic passenger vessels and classified Safety Recommendation M-04-4 “Closed—Superseded.” The Board noted however that if statistically representative average passenger weights were used, the Coast Guard needed to address how best to update the weight standard as needed. The Board further advised that even if the number of passengers permitted on board a vessel was based on a statistically representative average passenger weight, “the problem remains that a vessel can become overloaded if many of the passengers on board are heavier than the standard,” and that operators needed “an easy way of identifying whether the passenger load they are intending to carry will compromise the stability of their vessels.” To address these passenger vessel stability concerns, the Safety Board issued the following safety recommendations to the Coast Guard: 45  Subchapter T contains a separate protocol for the pontoon vessel stability test (PSST).

Factual Information 32 Marine Accident Report M-06-5 Revise regulations to require that passenger capacity for domestic passenger vessels be calculated based on a statistically representative average passenger weight standard that is periodically updated. M-06-6 Identify a method for determining the maximum safe load condition of a small passenger vessel at the time of loading, such as a mark on the side of the hull, and require that the vessel owners implement that method. On April 26, 2006, the Coast Guard published “Domestic Vessel Passenger Weights–Voluntary Interim Measures” in the Federal Register.46 The purpose of the notice was to advise owners and operators of small passenger vessels of prudent actions to take to address potentially unsafe operating conditions and to request comments on the measures. Several of the recommended measures addressed, in part, issues identified in the Safety Board’s report on the Lady D capsizing. In the voluntary interim measures, the Coast Guard asked owners and operators of small passenger vessels less than 65 feet long to reduce the total passenger capacity by using a per passenger weight standard of 185 pounds in calculating the number of passengers permitted on board the vessel. The Coast Guard said that if necessary, passengers should be weighed before boarding to verify that the vessel is not overloaded. The Coast Guard asked owners and operators of vessels for which stability was evaluated according to Coast Guard regulations in Subchapter S to review their stability guidance to ensure that they did not carry excessive passenger weight, or that increasing the per passenger weight to 185 pounds did not reduce vessel stability below Subchapter S requirements. It also recommended that owners and operators of all small passenger vessels notify the OCMI “if any significant structural or equipment changes have been made to the vessel” since stability was “evaluated by the owner and approved by the Coast Guard.” The Coast Guard also suggested that owners and operators may consider voluntarily reevaluating a vessel’s stability using a per passenger weight of 185 pounds. Finally, the Coast Guard noted that it would amend its regulations to “address the stability issues caused by increases in passenger and vessel weight.” New York State Actions Since Accident Shortly after the accident, New York State legislation was proposed to address deficiencies noted in the state’s oversight of public vessels.47 In particular, the proposed legislation called for mandatory postaccident drug and alcohol testing of vessel operators and a reduction in passenger loads on public vessels to comply with the intent of Safety 46  Federal Register, vol. 71, no. 80 (April 26, 2006), pp. 24732-24735. 47  See appendix C for more information.

Factual Information 33 Marine Accident Report Recommendation M-04-04, which called for using a passenger weight standard of 174 pounds when assessing vessel stability. On March 2, 2006, the Governor announced a comprehensive legislative effort to address additional deficiencies in the state’s oversight of public vessels. Among the initiatives was legislation requiring: • Vessels carrying 20 or more passengers to have at least two exits on each deck. • Operators and engineers to crew vessels with the number of crewmembers specified in the vessel COI, under penalty of suspension or revocation of licenses, with owners facing misdemeanor charges for violations. • Owners to inform the state before modifying vessels in a way “that would affect the stability of the vessel…,” with owners also facing misdemeanor charges for violations. • Vessels carrying more than 49 passengers to be equipped with radar. Several weeks thereafter, the Office of Parks’ Marine Services Unit circulated to the owners and operators of public vessel two draft pamphlets that contained the proposed state regulatory changes that New York intended to enact. The first pamphlet, “Technical Guidance for the Public Vessel Operators,” addresses operations, primary and auxiliary vessel systems, emergency procedures (preparatory drills and safety briefings and response activities), and safety equipment carriage requirements. The second pamphlet, “Technical Guidance for the Public Vessel Operators–Simplified Stability Test,” discusses stability concepts, offers instructions for conducting a stability test, and provides a list of navigating precautions for avoiding a capsizing.

34 Marine Accident Report Analysis General The analysis first identifies factors that can be eliminated as causal or contributory to the cause of the accident. It then discusses safety issues identified in the accident investigation. These include: • Stability standards and procedures for passenger vessels; • New York State’s use of manufacturer’s capacity plates to determine public vessel passenger loading; and • Regulation of New York State’s public vessels. This analysis also looks at survivability and toxicological testing in the Ethan Allen accident. Exclusions At the time of the accident, visibility was good, the winds were calm, and the temperature was moderate. The waves that were present on the lake were produced primarily by the activity of other vessels. Given the clear sky, moderate temperature, and calm winds, the Safety Board concludes that weather conditions were not a factor in this accident. The Safety Board examined the actions of the operator to determine what role, if any, he may have played in the cause of the accident. Passenger and witness reports were consistent that just before accident, the operator turned the vessel to starboard. He told investigators that he had begun to turn the vessel at Cramer Point to proceed along the route of the vessel’s tour, and that he continued the turn when he saw a wave about to strike the vessel. The vessel operator’s sharp turn was an attempt to meet the wave head on, which would have enabled him to better handle the force exerted by the wave. Some witnesses reported that as the vessel turned starboard, the wave struck the vessel broadside, on its aft starboard quarter, before the vessel could be turned into the wave. Therefore, the Safety Board concludes that the attempt of the Ethan Allen operator turning the vessel into the oncoming wake before the capsizing was a normal reaction to the circumstances, but not timely enough to be effective. The Safety Board also considered personal factors that could have influenced the operator’s decision-making, including whether his physical condition was affected by a sleep deficit or the use of alcohol or drugs. The operator had maintained the same work/rest schedule for several weeks before the accident, which provided him 8 to 8 1/2

Analysis 35 Marine Accident Report hours of sleep nightly. Thus, he was not suffering from sleep deprivation. The Safety Board therefore concludes that operator fatigue was not a factor in this accident. Within an hour of the accident, the operator volunteered to provide samples for toxicological testing; however, New York law enforcement officials did not request the testing, based on their observations of him and his behavior. Upon arriving on scene, Safety Board investigators asked the operator to submit to testing. He freely agreed, and samples were obtained 2 days after the accident. The operator advised Safety Board investigators at the time of testing that he had had a glass of wine the evening before the accident. The analysis of the blood samples was negative for drugs; the urine analysis showed a metabolite of alcohol, which merely indicated that he had consumed alcohol at some point within 80 hours of giving the sample. Because of the timeliness of the testing, the findings as they relate to this accident are not conclusive. The Safety Board concludes that because drug and alcohol testing of the Ethan Allen operator was not done in a timely manner, the toxicological analysis was inconclusive. The issue of timely toxicological testing, including new Federal standards and proposed New York regulatory changes, is discussed later in this analysis. Safety Board investigators examined the vessel after the accident and determined that the hull structure and propulsion and steering components were free of preexisting defects. The Safety Board therefore concludes that the Ethan Allen’s hull structure and steering and propulsion components were not factors in this accident. The nature of the capsizing led investigators to question whether water had been in the hull, which might have degraded the stability of the vessel. The bilge was among the items that the operator was to check at the start of each day. He indicated that he checked the bilge that morning and found nothing unusual. He was the second operator to captain the Ethan Allen, and the bilge check he completed would have been the second one conducted on the vessel on the day of the accident. Consistent with the company requirement, the first operator also checked the bilge, and he said that he found nothing unusual. During postaccident examination of the vessel components, investigators found a 0.076-inch gap in the main engine raw water pump. They then measured the leak rate of the pump into the bilge to determine the amount of water that could have leaked into the bilge from the pump during the 20-minute accident voyage. Investigators observed that, at most, 6 gallons of water would have leaked in, assuming the highest leak rate possible. Given the low leak rate of the pump, the two independent checks of the bilge by the operator, and the lack of any other possible source of water ingress, it is unlikely that a noticeable amount of water was in the bilge at the time of the accident. Therefore, the Safety Board concludes that at the time of the accident, the bilge might have contained, at most, an insignificant amount of water, which would not have affected the Ethan Allen’s stability.

Analysis 36 Marine Accident Report Cause of the Capsizing The monohull-style small passenger vessel Ethan Allen (New York public vessel) was built in 1964 and had operated in commercial service for almost 40 years. According to the owner of Shoreline Cruises, in the 26 years that the Ethan Allen had operated as a passenger vessel on Lake George, it probably had made 14,000 trips and had never experienced a major incident. The Ethan Allen very likely had operated with a full load of passengers during various weather and wave conditions on Lake George. On the day of the accident, a sister vessel configured exactly like the Ethan Allen (the de Champlain) and carrying a full passenger load followed the route of the accident vessel but experienced no problems. The Safety Board sought to determine what so greatly affected the stability of the Ethan Allen on the day of the accident that it capsized, and found that a combination of factors probably contributed to the vessel’s overturning. The primary conditions that affected the stability of the Ethan Allen, listed below, are discussed in greater detail in the following sections. • Modifications affecting vessel stability • Overloading due to out-of-date passenger weight criterion • Influence of vessel motions on stability Modifications Affecting Vessel Stability Postaccident Test Findings. Following the accident, the Ethan Allen was recovered from the water and transported to a hangar where it was retained as evidence relating to the accident and its components could be examined and, if necessary, removed for testing and analysis. To obtain a preliminary determination of whether stability, overloading, or both might have been factors in the capsizing, the Safety Board investigators arranged an SST of the de Champlain. Like the Ethan Allen, the de Champlain and the Algonquin had been based on the Dyer 40 boat design and built for the same owner. They had originally been under the jurisdiction of the Coast Guard, which certificated each of them to carry 48 passengers in addition to two required crewmembers. When Shoreline Cruises purchased the vessels, they came under the jurisdiction of New York. State officials indicated that they established the same load restrictions (48 passengers, two crewmembers) for the three vessels, based on the COIs issued by the Coast Guard. After surveying the de Champlain and the Ethan Allen, investigators determined that the vessels were similar enough in design and construction that the de Champlain would yield comparable results from a stability test. The assessment was then conducted in accordance with the Coast Guard’s SST criteria found in 46 CFR 178.330, which New York officials indicated the state would require for a public vessel like the Ethan Allen if its stability were questioned.

Analysis 37 Marine Accident Report Calculations for the SST indicated that the wind heeling moment and the passenger heeling moment were respectively 13,060 foot-pounds and 11,659 foot-pounds; thus the wind heeling moment was the governing criterion to use in the SST of the de Champlain. The magnitude of the required wind heeling moment was determined by the lateral wind area that included the vessel’s large canopy structure. The maximum heeling angle allowed during the SST was 14o. Testers placed twelve full test-weight water barrels on blocks along the vessel’s centerline to replicate a load condition for 48 passengers. Using the water surface as the baseline, testers placed a freeboard mark on the outside of the hull that corresponded to 14o of list. Safety Board investigators next attempted to obtain the required maximum moment for wind heel by emptying eight of the barrels, placing them on wooden blocks along the vessel’s port side, and then refilling them. Investigators had filled about three of the eight barrels when the waterline neared the reference freeboard mark on the listing de Champlain. In other words, only about half the required heeling moment was applied to the vessel before it neared the mark, meaning it would fail the SST for the carriage of 48 passengers. Safety Board investigators terminated the test because it was clear the vessel would not pass the SST, and they did not want to endanger the vessel or themselves. Because the de Champlain failed the stability proof test for the carriage of 48 passengers on a protected route, the Safety Board had reason to question the intact stability of the Ethan Allen for the carriage of 48 passengers. Subsequent investigation revealed that during the 40-year history of the Ethan Allen, the de Champlain, and the Algonquin, all had been modified by the addition of various types of canopies, but new stability assessments had not been done to determine the effects of the modifications on the vessels’ stability. The Board contracted for a study to examine the static and dynamic stability of the Ethan Allen. The study used both the SST and Subchapter S criteria to evaluate possible variants48 of the Ethan Allen for its ability to carry passengers, including the vessel in its as- delivered condition without a canopy (1964), the vessel with a metal and canvas canopy (several versions beginning in 1979), and the vessel with a wooden canopy (1989). For the SST, the number of passengers that a vessel can carry is calculated based on a review of the vessel’s drawings or physical measurements of such features as rails, seating, or deck area and verified by a simple physical test involving the movement of test weights. Because of how the SST and stability criteria were developed, the SST is considered more conservative than the criteria in Subchapter S, usually resulting in a lower allowable passenger load. The Subchapter S protocol begins with an inclining experiment on the vessel and is followed by stability calculations. Determining the allowable passenger capacity by 48  The Safety Board was unable to find documentation on the materials used to fabricate the metal and canvas canopy installed on the Ethan Allen (formerly Double Dolphin) in Groton. The Board therefore examined the effects on the vessel of an aluminum canopy and a steel canopy because these construction materials respectively represented the lightest and the heaviest materials used at that time by the marine industry for a substantial marine canopy structure.

Analysis 38 Marine Accident Report using Subchapter S stability criteria is more costly than by using an SST because an owner usually has to hire a naval architect to conduct the inclining experiment and perform the rigorous calculations. However, the results of the evaluation may show that the vessel is capable of safely carrying more passengers than would be allowed based on an SST. The SST results showed that the only configuration of the Ethan Allen that passed the SST with a 48-passenger load was the as-delivered vessel that did not have a canopy. All other variants of the Ethan Allen (formerly the Double Dolphin) failed the SST for any passenger loading because the canopy structure so greatly increased the lateral area projected to the wind that the required wind heeling moment calculated for the SST could not be accommodated. For the Subchapter S evaluation, an inclining experiment was performed on the sister vessel de Champlain at Lake George on October 5, 2005, and witnessed by Safety Board investigators and representatives of the parties to the investigation. The findings from the experiment were then used to perform the stability analysis for the Ethan Allen. The stability analysis showed that the original vessel configuration with no canopy could pass the stability criteria contained in Subchapter S for the carriage of 58 passengers. In the cases of the variants with canopies, however, the calculations yielded dramatically different results for several reasons: • The weight of each canopy caused the vessel to ride lower in the water, which reduced its reserve buoyancy. • The higher center of gravity created by a canopy reduced the righting energy and GM of the Ethan Allen, reducing its ability to resist overturning moments from forces such as wind, waves, and passenger movement. • The wind profile created by each canopy, combined with that of the vessel itself, so greatly increased the overall projected lateral area and corresponding wind heeling moment of the Ethan Allen that it could not meet the required stability criteria. By adding a canopy, the governing criterion for stability was no longer the passenger heeling moment, but rather the wind heeling moment, which was much larger than the passenger heeling moment. None of the variants having metal frame canopies with canvas covers satisfied the Subchapter S stability criteria for the carriage of any passengers. The only variation of the Ethan Allen with a canopy that could accommodate any passengers at all was the vessel with a wooden superstructure. The Ethan Allen wooden canopy was heavier than both the canvas-covered steel frame and the aluminum frame canopy variants; however, because the wood superstructure was about 15 inches lower, it presented a smaller lateral wind profile and thus a smaller wind heeling moment. The Subchapter S calculations determined that the Ethan Allen with the wooden canopy could carry only 14 passengers, using the current regulatory standard of 140 pounds per passenger.

Analysis 39 Marine Accident Report The Safety Board therefore concludes that the addition, and subsequent modification, of a canopy changed the Ethan Allen’s stability characteristics. Failure to Reassess Stability After Modifications. Documentation provided by Anchorage Shipyard and statements by former Whaling employees indicated that an SST may have been conducted in 1966 on the Double Dolphin. The Safety Board found no evidence to indicate that a stability evaluation using the tests in either Subchapter T or S was conducted after adding a metal frame canopy to the vessel while it was still in service in Groton and under Coast Guard jurisdiction. At the time, the regulations in Subchapter T concerning alterations and modifications did not specifically require testing the vessel after modifications. In 1979, Whaling sold the Double Dolphin and its two sister vessels to Shoreline Cruises, and the three vessels became subject to New York State regulations. According to Office of Parks officials, New York based the vessels’ permitted passenger capacity on the Coast Guard COIs. At this time, canopies had not yet been added to the de Champlain and the Algonquin; consequently the passenger loads permitted on their state COIs were appropriate, based on the Coast Guard stability criteria. Shoreline Cruises subsequently added metal/canvas canopies to the de Champlain and the Algonquin. During the period of 1989 to 1991, Shoreline Cruises contracted to replace the metal/canvas canopies on the three Dyer 40s with wooden canopies. Before this accident, state laws did not address stability assessments and state guidance documents contained vague language about assessments that were necessary if a public vessel was to be modified. Chapter 37 of the Consolidated Laws of the State of New York contains no regulation requiring vessel owners to notify a state inspector or inspectors if they intend to make or have made a modification to their vessels that might affect stability. The Office of Parks manual for public vessel operators that was in effect before this accident states that it is the duty of the owner to promptly report when a major alteration to a public vessel is to be accomplished so that a state inspector can determine whether a “thorough inspection” is necessary. The Safety Board found no evidence to indicate that a stability evaluation using the tests in either Subchapter T or S was conducted after any of the canopy modifications at Lake George. If a stability assessment had been conducted after the canopy installations and modifications, it would have been necessary for Shoreline Cruises to reduce the passenger capacity and/or change the design of the canopies of the three vessels in order to pass the Coast Guard stability test criteria applied by New York State. The Safety Board concludes that although Coast Guard regulations and New York State guidance to vessel owners did not contain clear requirements pertaining to testing after modifications, the Double Dolphin/Ethan Allen should have undergone a stability reassessment after each canopy installation and modification. Moreover, because the Double Dolphin/Ethan Allen did not undergo stability assessments after the addition and modification of its canopies, it was certificated to carry too many passengers. Its COI permitted 50 persons, but stability criteria should have limited the number to 14 persons.

Analysis 40 Marine Accident Report The Ethan Allen and de Champlain were retrofitted alike; thus they were sister vessels, and the results of the Safety Board’s stability study applied to both vessels. Shoreline Cruises first installed a smaller metal canvas canopy on the Algonquin and then refitted it with a partial wooden deckhouse in 1991. Consequently, the Algonquin had a smaller lateral wind profile, its displacement was less, and its VCG was lower than that of the other two vessels. The reduction in its freeboard and stability would not have been as significant as that of the Ethan Allen and the de Champlain. The Safety Board concludes that although it was the Ethan Allen that was involved in this accident, the potential for capsizing was substantially the same for the de Champlain. Overloading Due to Out-of-Date Passenger Weight Criterion From survivor interviews and its review of emergency room records, the Safety Board found that the average weight of the Ethan Allen’s occupants on the day of the accident was almost 178 pounds, significantly more than the per person weight standard of 140 pounds used to verify the allowable number of passengers in stability proof tests. The combination of the number of passengers permitted by the COI and the higher-than- assumed average weight of the people on board the Ethan Allen resulted in the vessel being significantly overloaded when it capsized. The Safety Board stability study, which used the current regulatory weight standard of 140 pounds per passenger, determined that the maximum number of persons that should have been allowed for the Ethan Allen was 14, or a total occupant capacity of about 2,000 pounds. On the day of the accident, however, the vessel carried 48 persons (1 crewmember and 47 passengers) averaging about 177.5 pounds each, or more than 8,000 pounds total weight, about four times its safe load carrying capacity. The additional weight caused the Ethan Allen to sit deeper in the water and significantly raised its center of gravity, which, in turn, reduced its reserve buoyancy, available GM, and righting energy necessary to resist overturning moments from forces such as wind, waves, and passenger movement. There was no wind on the day of the accident. When the Safety Board analyzed the effect of transverse passenger movement in the Ethan Allen accident condition, the stability study found that the vessel’s reserve righting energy was reduced to zero with only 6,800 foot-pounds of passenger heeling moment to the port side.49 All survivors stated that no one stood up or moved before the onset of the capsize; however, the lack of righting resistance to passenger heel was indicative of the minimal stability of the Ethan Allen. The Safety Board concludes that the combination of too many passengers, as permitted by the Ethan Allen’s inappropriate COI, and the use of an out-of-date average weight standard for passengers on public vessels resulted in the Ethan Allen carrying a load that significantly reduced its stability, which made it more susceptible to capsizing on the day of the accident. 49  The Ethan Allen had an initial 2.2º port list due to the asymmetrical bench seating arrangement that placed more passengers on the port side of the vessel.

Analysis 41 Marine Accident Report Influence of Vessel Motions on Stability The static stability analysis of the Ethan Allen on the day it capsized showed that while the vessel had marginal stability, it would not capsize without some other heeling force(s) or influence(s). The transverse movement of passengers, significant amounts of water in the bilges, the effects of lateral wind loading, or the grounding of the vessel could have reduced its stability, although the latter three factors can be ruled out in this case. The stability study calculated the stability sensitivity of the Ethan Allen to transverse passenger weight shifts; if enough passengers moved to one side of the vessel, a capsize could follow. This tenderness of the vessel, or lack of stability, was apparent when the passengers boarded the Ethan Allen at the dock, and then had to redistribute themselves to try to bring the vessel back on an even keel. When the overloaded Ethan Allen departed the dock, it already had a 2.2° list to port, which would have reduced the vessel’s port freeboard and limited the maximum angle of roll to port that the vessel could sustain before the deck edge submerged. In addition, the vessel had almost 1 foot of trim by the bow when it sailed. In determining the cause of the capsizing of the Ethan Allen, the Safety Board looked at the effects of the following dynamic conditions that were reported: • The Ethan Allen encountered waves generated by passing vessels. • The operator of the Ethan Allen attempted to maneuver the vessel in a sharp starboard turn to head into these waves, but did not complete the maneuver before the wave or waves hit the vessel. • As the vessel rolled to port, passengers said that they fell to the low (port side) of the vessel. Dynamic Response in Waves. At the time of the accident, the waves in the lake were produced by vessel activity. The Safety Board was unable to specifically identify the vessel or vessels that caused the particular wave or waves in question. Varying accounts of the size of the wave or waves were reported. Several passengers reported one wave that was less than a foot high, and some passengers and a boater reported seeing no wave at all. The operator estimated that the wake was 2 1/2 to 3 feet high. Because of the differences in their descriptions and the absence of other evidence, the Safety Board could not determine the precise height, frequency, and number of the waves in question. The Board therefore had simulations performed for varying heights of waves to determine their potential impact. The dynamic response in waves of the 40-foot tour boat Ethan Allen was examined using Oceanic Consulting Corporation’s time domain seakeeping panel code MOTSIM. For the conditions analyzed, a capsize event was not observed. However, the results were still useful in that they highlighted the influence of particular variables. For the conditions assessed, vessel speed was shown to be of minimal importance with respect to wave- generated motion response. Motion response was greatest at headings that were near beam seas and was less at headings that were closer to quartering or following seas. Increasing wave height and increasing shifts in passenger/crew transverse center of gravity (TCG)

Analysis 42 Marine Accident Report positions increased the dynamic response of the vessel to waves. When the study looked at a passenger/crew weight shift of 0.6 foot to port with a 1-foot wave, the wave would have produced a vessel roll of almost 16° to port. This passenger/crew weight shift could be achieved if everyone on board moved 7 inches to port. The most significant roll angle reached from the effects of wave action alone was 14° to port. While a capsize event was not produced in the simulation, the study results led to the conclusion that the actual capsize of the Ethan Allen resulted, in part, not from a single dynamic factor, but was probably from a unique set of dynamic factors that overwhelmed the vessel’s marginal stability. Dynamic Response in Turns. The Ethan Allen’s characteristics on the day of the accident met criteria that would have predicted the vessel’s rolling outboard as the operator turned the vessel into the approaching wave(s). The vessel’s high center of gravity created a significant heeling moment that tended to roll the vessel outboard in a turn. In this condition, the vessel had low GM and reserve righting energy to resist heeling moments. The vessel was designed with a fine bow and full transom, and would have had a significant asymmetric water plane at the accident condition draft. This asymmetry would have caused the Ethan Allen to trim forward as it rolled to the side. This would have increased the bow-down aspect of the vessel with its existing 1-foot static trim. While the Ethan Allen rolled to port as a result of the operator turning the vessel to starboard, the magnitude of the roll is unknown. Loss of Stability Due to Passenger Movement. The wave that impacted the Ethan Allen, together with the vessel rolling away from the turn, may have been large enough to capsize the vessel. However, according to testimony, the rolling action caught the occupants off guard. The point at which passengers lost their seating was determined by a number of factors such as their position in the vessel, their situational awareness, and the actions of passengers next to them. The survivors indicated that when the vessel turned, most passengers initially shifted to port in their seats. As the vessel continued to roll, first a few passengers and then the remaining passengers on the starboard side tumbled and slid to the low side of the vessel (port side). This shift in passenger weight shifted the overall TCG of the vessel to port, further compromising the vessel’s stability. As one survivor described, the vessel rolled to port along it axis and continued to roll over until it capsized. The Safety Board concludes that the Ethan Allen capsized as a result of insufficient stability, which made it unable to right itself from the combined forces of a passing wave or waves, a sharp turn, and the resulting involuntary shift of passengers to the port side of the vessel. Capacity Plates During its investigation, the Safety Board determined that New York State officials used the manufacturers’ capacity plates to establish the number of passengers permitted on 382 of 447 public vessels. Of the 382 public vessels with capacity plates, 125 carried more than six passengers.

Analysis 43 Marine Accident Report The display of capacity information standard, found in 33 CFR 183, requires boat manufacturers to rate the total number of persons their boats can safely carry. The standard specifically applies to noncommercial vessels under 20 feet in length and is not intended to be applied to a commercial passenger vessel carrying more than six passengers for hire. The Coast Guard requires that any commercial passenger vessel carrying more than six passengers comply with the small passenger vessel regulations found in 46 CFR Subchapter T. Consequently, the Safety Board concludes that New York State’s reliance on manufacturers’ capacity plate data to determine maximum passenger limits on public vessels that carry more than six passengers for hire is an inappropriate use of the Coast Guard noncommercial boat standard. Therefore, the Safety Board believes that New York State should discontinue the use of capacity plate data associated with the U.S. Coast Guard’s noncommercial boating standards for determining passenger loading on public vessels that carry more than six passengers and adopt the Coast Guard small passenger vessel inspection standards. Postaccident Actions by Regulatory Authorities Following the Ethan Allen accident, New York State took prompt action, proposing legislation to address safety on its public vessels. The Coast Guard issued interim measures in advance of final rulemaking aimed at addressing stability issues for small passenger vessels. New York Actions On March 2, 2006, the Governor of New York proposed legislation to strengthen the state’s regulations governing public vessels, addressing such issues as stability (as it pertained to maximum passenger carriage), drug and alcohol testing, and manning. In the area of stability, the proposed legislation included increasing the state weight requirement to 174 pounds. The weight standard proposed by New York is based on an FAA weight standard identified in a safety recommendation (M-04-4) that the Safety Board issued to the Coast Guard in advance of the Board’s report on the 2004 Lady D capsizing in Baltimore Harbor. The specific weight value was adopted in 2004 by the FAA, using the most current study findings at that time.50 In addition, the Governor directed the Office of Parks to take interim measures to ensure the safety of public vessels, which resulted in an immediate review of all existing COIs to ensure compliance with the proposed new weight standards and periodic certification of the weight capacity of all public vessels. New York’s proposed legislation to update the average passenger weight standard is a positive step toward ensuring that a vessel is properly certificated for the number of 50  In October 2004, the Centers for Disease Control and Prevention (CDC) issued the report, “Mean Body Weight, Height, and Body Mass Index, United States 1960–2002,” based on data collected annually since 1960 by the CDC’s National Health and Nutrition Examination Survey program.

Analysis 44 Marine Accident Report passengers it can safely carry. However, as current studies and sources show, weight is a variable that is subject to change. The Coast Guard now recommends that the passenger weight standard used in evaluating vessel stability be 185 pounds based on 2005 CDC studies. The Safety Board has asked the Coast Guard to periodically review national studies and update the weight standard as necessary. The Board suggests that New York monitor the regulatory changes made by the Coast Guard and update its state regulations accordingly. Even if the number of passengers permitted is based on an increased average weight standard, the problem persists that a vessel can become overloaded if many of the passengers on board are heavier than the standard weight. Operators therefore need an easy way of identifying whether the passenger load they are preparing to carry will overload their vessels. If a mark were painted on the hull that corresponded to the waterline when the vessel was under maximum approved load, any crewmember could easily determine whether the vessel was overloaded simply by observing the vessel’s draft in relation to that mark. The Safety Board concludes that New York State public vessel operators do not have a simple and ready means such as a mark on the hull to determine whether their vessels are overloaded. The legislation proposed by New York also attempts to address other issues that were not causal to the capsizing. Some of these proposed changes are discussed in the analytical sections “Postaccident Toxicological Testing” and “Survival Issues.” Coast Guard Actions The Coast Guard has been working to address the issues of an out-of-date weight standard since the capsizing of the pontoon-style small passenger vessel Lady D in Baltimore Harbor on March 6, 2004. The agency contracted for a 1-year study in 2005 to determine the potential impact on the marine industry that would result from increasing the passenger weight and size standards used when calculating the stability of domestic passenger vessels. The Coast Guard concurrently evaluated various weight studies, and on April 26, 2006, published voluntary interim measures for domestic passenger vessels in the Federal Register. The notice advised boat owners and operators that they should use 185 pounds as the weight standard when evaluating a vessel’s stability. The notice also reminded owners and operators that they are required by regulation to submit plans or specifications for any vessel changes to the cognizant OCMI. The Coast Guard asked for comments on the measures, advising the public that the changes were in advance of a final rulemaking effort. The Safety Board expressed its support of the Coast Guard’s voluntary interim measures by stating that it was pleased with the intended action of the Coast Guard and the direction of several measures. If adopted by vessel owners and operators, the measures can genuinely contribute to safeguarding the traveling public. The Board is aware that the Coast Guard intends to incorporate these measures into regulatory changes and is hopeful that this will be accomplished expeditiously.

Analysis 45 Marine Accident Report The Safety Board was also encouraged by the Coast Guard’s stated objective to establish an outreach program to vessel owners and operators to advise them of this notice and to seek the marine industry’s support of the published voluntary safety measures. This is a proactive approach that could facilitate the adoption of final rules. The Coast Guard’s efforts would benefit by enlisting the support of the state agencies that regulate commercial passenger vessels. As this accident demonstrated, New York had guidance and policies that were intended to provide the same measure of vessel safety as Coast Guard regulations; however, the language in some of the guidance was vague and did not provide clear instructions to vessel owners and operators about stability requirements. The Coast Guard can best assist the states in understanding the Coast Guard’s stability standards. The Safety Board therefore believes that the Coast Guard should provide guidance to the states on Coast Guard standards for and assessment of stability of small passenger vessels. Postaccident Toxicological Testing As noted earlier in this analysis, New York law enforcement authorities did not obtain samples for toxicological testing, although the operator of the Ethan Allen volunteered to submit to testing within a hour of the capsizing. New York State did not require compulsory postaccident testing for alcohol or drug use. There is no reason to suspect that the operator was under the influence of alcohol or illegal drugs at the time of the accident. The Safety Board is nonetheless concerned that the operator was not tested as soon as possible after the accident. Operators of passenger vessels engaged in commercial operations have an obligation to provide the highest levels of safety to their passengers and crew. For this reason, the Safety Board has worked with the Coast Guard for almost 30 years to improve the postaccident drug and alcohol testing requirements of vessel operators who have been involved in a serious marine incident. The Coast Guard recently adopted revisions to 46 CFR Part 4 that address postaccident chemical testing requirements. The new standard, which became effective on June 20, 2006, stipulates that alcohol testing must be conducted within 2 hours and drug testing must be conducted within 32 hours of the time of a serious marine incident. The legislation proposed by New York state officials after the Ethan Allen accident would require that law enforcement officials immediately obtain samples for alcohol or drug testing from operators of public vessels that have been involved in an accident causing death, disappearance, or serious physical injury. The Safety Board supports the quick enactment of this proposed legislation. Survival Issues Twenty of the 48 persons on the Ethan Allen did not survive the accident. The majority of these individuals had significant traumatic injuries, which were most likely sustained either during the capsizing itself or during attempts to escape the capsized

Analysis 46 Marine Accident Report vessel. By contrast, survivors showed little evidence of significant traumatic injuries. Several survivors described considerable confusion during their escape due to vessel inversion, submersion, darkness, and the presence of a large number of other frightened passengers. Significant traumatic injuries sustained during the capsizing could have increased disorientation and appreciably decreased the probability of successful egress from the vessel. Seven drowned passengers did not have significant injuries, and five of these had significant preexisting heart disease. Any of these five individuals possibly had some sort of abnormal heart rhythm that resulted in loss of consciousness following the capsizing, accounting for their drowning without apparent injury. However, for the majority of the drowned victims, there is no evidence that preexisting medical conditions adversely affected their survival. Therefore, the Safety Board concludes that for almost all of the passengers, survivability was not adversely affected by the presence of preexisting medical conditions. It is noteworthy that only two of the five drowning victims with preexisting heart disease had disease specifically associated with aging. The lack of an obvious association of age-related disease with survivability suggests that, for the most part, the age of the passengers per se did not affect passenger survivability. Passengers who were uninjured in the capsizing or in attempting to escape were generally able to be rescued and survive. Survivability was enhanced by the proximity of recreational vessels to the accident site and the willingness of their operators both to notify emergency personnel of the accident and to actively assist in rescuing survivors. Warren County sheriff’s office dispatch center logs indicate that emergency service personnel were informed quickly about the accident and that rescue vehicles, vessels, and personnel were dispatched to and arrived on the scene within minutes. Therefore, the Safety Board concludes that the emergency response was timely and effective. Before this accident, the Consolidated Laws of the State of New York and the study guide provided to public vessel operators were silent about safety briefings being provided to passengers; consequently, the operator of the Ethan Allen was not obligated to provide one. In this case, the vessel operator said that he gave a safety briefing before the Ethan Allen departed the dock at 1430. All survivors reported that the operator did not perform a safety briefing; however, they admitted that they were all talking to each other while the boat was docked. Such a briefing, if done properly, would have included the location of lifejackets, the method of donning them, and emergency exit guidelines. Survivors also stated that although they never had time to retrieve lifejackets, they realized that if people had donned lifejackets, probably more fatalities would have occurred. In this case, the only way for those in the overturned vessel to escape was to “swim down” and go through the open windows, which were below water. Shortly after the accident, New York proposed legislation that would require verbal safety briefings for passengers to include descriptions of the use and location of personal flotation devices and other safety devices before commencing vessel operation.

Analysis 47 Marine Accident Report A draft of the state’s “Technical Guidance for the Public Vessel Operators” described the type of information to be included in a safety briefing, information that is consistent with Coast Guard requirements. The Safety Board supports this proposed regulatory change. In this accident, surviving passengers were able to escape the capsized Ethan Allen because the windows were latched in the open position or had become separated from the vessel during the capsizing. The vessel had two means of egress at the stern. In an emergency in which the vessel did not capsize, those most likely would have been sufficient for passenger egress. The March 2006 legislation proposed by New York State includes a requirement that public vessels certified to carry 20 or more passengers be equipped with at least two means of exit on each deck. The Safety Board supports this proposed legislation. The Ethan Allen did not proceed with a second crewmember, in addition to the operator, as required by its COI. Shortly after the accident, the Governor of New York called for legislation to criminalize the operation of a public vessel with fewer than the required number of crewmembers specified in the COI or temporary permit. The Safety Board supports the regulatory proposal and looks forward to seeing it enacted into law. In sum, the Safety Board notes the timely efforts that New York State is taking to make regulatory changes related to stability, passenger carriage, postaccident toxicological testing, and manning. If adopted, the proposed changes should ensure a higher level of safety for travelers on public vessels. The Safety Board therefore concludes that the postaccident actions of New York State to improve the level of safety of public vessels were prompt and, if implemented, will address issues identified in the accident investigation. Once the regulatory changes are enacted, owners and operators need to promptly receive guidance on the new rules. The Safety Board therefore believes that New York State should address the safety deficiencies identified in the investigation of the Ethan Allen accident and issue technical guidance to vessel owners on inspection requirements for modified vessels, stability assessments and criteria, means for determining maximum safe load condition, drug and alcohol testing, manning, and safety briefings.

48 Marine Accident Report Conclusions Findings 1. Weather conditions were not a factor this accident. 2. The attempt of the Ethan Allen operator to continue turning the vessel into the oncoming wake before the capsizing was a normal reaction to the circumstances, but not timely enough to be effective. 3. Operator fatigue was not a factor in this accident. 4. Because drug and alcohol testing of the Ethan Allen operator was not done in a timely manner, the toxicological analysis was inconclusive. 5. The Ethan Allen’s hull structure and steering and propulsion components were not factors in this accident. 6. At the time of the accident, the bilge might have contained, at most, an insignificant amount of water, which would not have affected the Ethan Allen’s stability. 7. The addition, and subsequent modification, of a canopy changed the Ethan Allen’s stability characteristics. 8. Although U.S. Coast Guard regulations and New York State guidance to vessel owners did not contain clear requirements pertaining to testing after modifications, the Double Dolphin/Ethan Allen should have undergone a stability reassessment after each canopy installation and modification. 9. Because the Double Dolphin/Ethan Allen did not undergo stability assessments after the addition and modification of its canopies, it was certificated to carry too many passengers. Its certificate of inspection permitted 50 persons, but stability criteria should have limited the number to 14 persons.

1. Although it was the Ethan Allen that was involved in this accident, the potential for

capsizing was substantially the same for the de Champlain.

1. The combination of too many passengers, as permitted by the Ethan Allen’s

inappropriate certificate of inspection, and the use of an out-of-date average weight standard for passengers on public vessels resulted in the Ethan Allen carrying a load that significantly reduced its stability, which made it more susceptible to capsizing on the day of the accident.

Conclusions 49 Marine Accident Report

1. The Ethan Allen capsized as a result of insufficient stability, which made it unable to

right itself from the combined forces of a passing wave or waves, a sharp turn, and the resulting involuntary shift of passengers to the port side of the vessel.

1. New York State’s reliance on manufacturers’ capacity plate data to determine

maximum passenger limits on public vessels carrying more than six passengers for hire is an inappropriate use of the Coast Guard noncommercial boat standard.

1. New York State public vessel operators do not have a simple and ready means such as

a mark on the hull to determine whether their vessels are overloaded.

1. For almost all of the passengers, survivability was not adversely affected by the

presence of preexisting medical conditions.

1. The emergency response was timely and effective.
2. The postaccident actions of New York State to improve the level of safety of public

vessels were prompt and, if implemented, will address issues identified in the accident investigation. Probable Cause The National Transportation Safety Board determines that the probable cause of the capsizing of the Ethan Allen was the vessel’s insufficient stability to resist the combined forces of a passing wave or waves, a sharp turn, and the resulting involuntary shift of passengers to the port side of the vessel. The vessel’s stability was insufficient because it carried 48 persons where postaccident stability calculations demonstrated that it should have been permitted to carry only 14 persons. Contributing to the cause of the accident was the failure to reassess the vessel’s stability after it had been modified because there was no clear requirement to do so.

50 Marine Accident Report Recommendations As a result of its investigation of the Ethan Allen accident, the National Transportation Safety Board makes the following recommendations. To the U.S. Coast Guard: Provide guidance to the states on U.S. Coast Guard standards for and assessment of stability of small passenger vessels. (M-06-15) To New York State: Address the safety deficiencies identified in the investigation of the Ethan Allen accident and issue technical guidance to vessel owners on inspection requirements for modified vessels, stability assessments and criteria, means for determining maximum safe load condition, drug and alcohol testing, manning, and safety briefings. (M-06-16) Discontinue the use of capacity plate data associated with the U.S. Coast Guard’s noncommercial boating standards for determining passenger loading on public vessels that carry more than six passengers and adopt the Coast Guard small passenger vessel inspection standards. (M-06-17) BY THE NATIONAL TRANSPORTATION SAFETY BOARD MARK V. ROSENKER DEBORAH A. P. HERSMAN Acting Chairman Member KATHRYN O’LEARY HIGGINS Member Adopted: July 25, 2006

51 Marine Accident Report Appendix A Investigation The Safety Board learned of this accident through media reports on the afternoon of October 2, 2005. A six-person investigative team as well as the Acting Chairman of the Safety Board and representatives of the Office of Public Affairs, the Office of the General Counsel, and the Office of Transportation Disaster Assistance were launched to the scene. The following investigative groups or technical specialists were assigned to the investigation: deck operations, survival factors, engineering, materials analysis, and naval architecture/stability. The on-scene investigation was completed on October 15, 2005. The Safety Board investigated the accident according to its rules under the authority of the Independent Safety Board Act of 1974. The designated parties to the investigation were Shoreline Cruise, Inc.; New York State Office of Parks, Recreation and Historic Preservation; Warren County Sheriff’s Office, Cummins MerCruiser Diesel; Hypro Pumps; and Scarano Boat Building, Inc.

52 Marine Accident Report Appendix B Passenger Information Seat No. Sex Age Weight (pounds) Fatal Seat No. Sex Age Weight (pounds) Fatal 1 F 75 189 No 26 F 74 190 No 2 F 58 110 No 27 F 76 129 No 3 F 67 144 No 28 M 81 146 No 4 F 77 141 No 29 F 78 135 No 5 F 76 185 No 30 F 82 176 Yes 6 M 87 194 Yes 31 F 89 204 Yes 7 F 75 180 Yes 32 M 79 170 No 8 M 82 211 Yes 33 F 77 142 No 9 F 76 128 Yes 34 F 78 210 Yes 10 F 75 135 No 35 F 74 180 No 11 F 79 141 No 36 F 67 155 No 12 M 69 205 No 37 F 68 217 Yes 13 M 79 200 No 38 F 67 198 Yes 14 F 77 164 Yes 39 F 74 126 Yes 15 F 76 150 No 40 F 64 247 Yes 16 M 77 170 No 41 M 80 173 Yes 17 F 73 194 Yes 42 F 80 155 Yes 18 M 67 260 No 43 F 73 165 No 19 F 62 165 No 44 M 77 175 No 20 F 67 137 No 45 M 76 235 Yes 21 F 79 198 Yes 46 F 74 230 No 22 F 54 195 No 47 F 65 268 No 23 M 83 158 Yes 48 M 74 170 No 24 F 78 204 Yes Total 8,522 25 F 78 170 Yes Average 177.5

53 Marine Accident Report Appendix C New York Press Release FOR IMMEDIATE RELEASE: March 02, 2006 GOVERNOR PROPOSES COMPREHENSIVE BOATING REFORM LEGISLATION

Legislation Will Strengthen Laws to Improve Safety for Commercial Boat Passengers and Crews Governor George E. Pataki today unveiled comprehensive legislation that would improve safety for commercial boat passengers and crews by strengthening the laws governing public vessel operation on the State’s waterways. The proposed bill follows legislation submitted by the Governor last Fall that requires operators of commercial boats involved in incidents -- where passenger(s) are severely injured or killed -- to undergo an immediate, mandatory chemical test to determine if an operator was under the influence of alcohol or drugs. The Governor proposed the new legislation after a fatal incident with the tour boat Ethan Allen on Lake George, when 20 passengers were killed. “We have worked to make New York’s boating laws among the strongest in the nation,” Governor Pataki said. “But we must do everything we can to prevent another tragedy like the Ethan Allen from occurring. Our comprehensive legislation will take the necessary steps to further strengthen New York’s boating laws and ensure that owners and operators of public vessels take all the necessary precautions to ensure the safety of both their passengers and crew.” The Governor’s comprehensive boating reform legislation would: • Require a minimum of acceptable marine protection and indemnity insurance for all public vessels operating on State waters, as follows: Number of Passengers Minimum Amount of Insurance 1 to 10 $1,000,000 11 to 20 $2,000,000 21 to 50 $5,000,000 51 to 100 $7,000,000 More than 100 $10,000,000

Appendix C 54 Marine Accident Report • Require proof of insurance as part of the annual marine inspection by the Office of Parks, Recreation and Historic Preservation and make the operation of a public vessel without such insurance a misdemeanor; • Require all public vessels certified to carry 20 or more passengers be equipped with at least two means of exit on each deck and make it a violation for individuals who obstruct an exit; • Make it unlawful to operate a public vessel with less than the required crewmembers specified in the certificate of inspection or temporary permit, authorize the suspension or revocation of the license of any operator, pilot, or engineer who operates the vessel in this unlawful manner, and charge the vessel owner with a misdemeanor if found guilty of permitting operation; • Require that vessel owners report to Marine Inspectors prior to making any modifications that would affect the stability of the vessel including adjustments to the vessel structure or engineering plant, authorizes Marine Inspectors to inspect any vessel if deemed necessary, makes failure to notify a Marine Inspector a violation, and charges the vessel owner with a misdemeanor if found guilty of permitting operation of an un-inspected vessel; • Require that all public vessels certified to carry passengers be equipped with either a VHF radio or an operating cellular phone and require public vessels certified to carry more than 49 passengers to have radar; • Authorize the Office of Parks, Recreation and Historic Preservation Commissioner to adopt, amend and rescind rules and regulations concerning the regulation of public vessels. In the aftermath of the Ethan Allen tragedy last year, the Governor proposed legislation that would make it mandatory for law enforcement officials to immediately administer a chemical test to all operators of public, or commercial, vessels that have been involved in a accident causing death, disappearance or serious physical injury. This would allow for the identification and/or elimination of alcohol or drugs as a factor in a boating accident in the earliest stages of an investigation. In the event that an operator of a commercial boat fails to submit to a chemical test, the Governor’s proposal calls for the immediate suspension of the operator’s boating privileges and the immediate revocation of any public boating licenses issued by the State. Together with a fine of not less than $2,500, this provision would be stronger than current federal regulations. In addition, the proposal allows for the refusal of an operator of commercial vessel to submit to a chemical test to be used as evidence at any subsequent criminal or administrative hearing. In addition, the Governor directed the Office of Parks, Recreation and Historic Preservation to increase the State weight requirement to 174 pounds, exceeding the federal standard of 141 pounds, and called on the United States Coast Guard to expedite their adoption of a higher threshold for weight when determining capacity. The prior standard

Appendix C 55 Marine Accident Report used for capacity on lakes, rivers, and streams was based on the United States Coast Guard’s rating of 141 pounds. The Coast Guard is currently reviewing the weight requirement and the National Transportation Safety Board has also joined in the Governor’s call for an increase in the Coast Guard’s weight standards to 174 pounds. State Parks Commissioner Bernadette Castro said, “The operation of public vessels on state waters has historically been a very safe and important industry within New York. This package of proposed reforms follows Governor Pataki’s steps to strengthen existing statues and safety requirements. In the aftermath of the Ethan Allen accident and the tragic loss of life, it is imperative that we take an even closer look at these commercial boating ventures and the laws and regulations governing them.” In addition, these proposed safety measures build upon a number of interim steps undertaken by the State Office of Parks, Recreation and Historic Preservation at the Governor’s direction, which include, the immediate review all existing certificates of inspection to assure compliance with new weight standards; periodic recertification of the weight capacity of all public vessels; strengthened staff requirements for public vessels including experience and training requirements for crewmembers; mandatory verbal safety briefings for passengers on the use and location of personal flotation devices and other safety devices before commencement of vessel operation; increased penalties for owners and operators who fail to comply with statute, regulations and conditions of certificate of operation.

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FD07311 ｜ 2005_美国_NTSB_PAB0701_Natural_Gas_Service_Line_Break_and_Subsequent_Explosion_and.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2005 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

NTSB/PAB-07/01 1 E

P L U R IB US UN U M

N A T I O N A L

T R A S P O R T A T I O N

B O A R D S A FE T Y N National Transportation Safety Board Washington, D.C. 20594

Pipeline Accident Brief

Accident No.:

DCA-06-MP-001 Type of System:

Natural gas distribution Accident Type:

Pipeline break, explosion, and fire Location:

Bergenfield, New Jersey Date:

December 13, 2005 Time:

9:26 a.m. eastern standard time1 Owner/Operator: Public Service Electric and Gas Company Fatalities:

3 Injuries:

5 Property Damage and Losses: $863,300 Material Released:

Natural gas Pipeline Pressure:

11 1/2 pounds per square inch, gauge Component Affected:

1 1/4-inch steel service line The Accident On December 13, 2005, at 9:26 a.m., an apartment building exploded in Bergenfield, New Jersey, after natural gas migrated into the building from a damaged pipeline. Investigators found a break in an underground 1 1/4-inch steel natural gas distribution service line that was operating at 11 1/2 pounds per square inch, gauge. The break occurred at an underground threaded tee connection downstream from where excavators were removing an oil tank that was buried under the asphalt parking lot adjacent to the building. The break occurred, under the parking lot, about 7 feet 4 inches from the building’s wall. Three residents of the apartment building were killed. Four residents and a tank removal worker were injured and transported to hospitals. The property damage consisted of the apartment building, which was a complete loss. (See figure 1.) According to Bergen County tax records, the assessed value of the apartment building was $863,300. JP Management, a real estate company that owned the apartment building, hired the American Tank Service Company (American Tank) to remove and replace the buried oil tank. On December 5, 2005, American Tank requested markouts2 of the utilities at 30 Elm Street through the New Jersey One Call System.3 On December 7, 2005, a Public Service Electric and

1 All times are eastern standard time. 2 A markout is a ground marking that is typically color coded and that indicates the location of underground utilities. 3 New Jersey One Call is a one-call operation for anyone planning to dig (excavation, demolition, blasting), regardless of the size of the project. This operation is for both commercial construction and homeowners.

NTSB/PAB-07/01 2 Gas Company (PSE&G)4 street inspector went to the site and marked the location of the buried gas service line to the building. The marked location showed that the service line ran under the parking lot and about parallel to the building’s wall. At a point downstream of the excavation area, the pipeline turned 90o toward the building. (See figure 2.)

Figure 1. Damage caused by explosion. About 8:30 a.m. on Monday, December 12, the American Tank crew arrived at the site, saw the gas and water utility markouts, and began excavating in the asphalt parking lot that was adjacent to the building. The work contract indicated that the tank capacity was 2,000 gallons. According to the American Tank foreman, when the excavation was about 30 inches deep, the top of the tank was exposed. At this time, the crew realized that the tank was a 5,000-gallon tank rather than a 2,000-gallon tank.5 Because the larger tank was wider, longer, and heavier than expected, and thus closer to the natural gas service line, the excavation crew had concerns about its safe removal. In an interview, one of the crewmembers stated, “[At the time] I said our concern is once we move the tank or roll it over, to roll it and take it out, it may undermine the gas line.” An American Tank vice president went to the site to verify that it was a larger tank and to reassess its removal. He arranged for his office staff to call New Jersey One Call for a second markout of the utilities. The PSE&G inspector arrived at the apartment building about 11:14 a.m. and re-marked the gas service line. He made a slight change to the original marking where the gas line entered the building.

4 PSE&G is one of the largest combined electric and gas companies in the United States and is New Jersey’s oldest and largest publicly owned utility. 5 Based on the length and depth of the tank, an American Tank vacuum truck operator referred to the tank capacity reference books that he carried in his truck and correctly determined the capacity of the tank to be 5,000 gallons.

NTSB/PAB-07/01 3

Figure 2. Diagram of accident site.

NTSB/PAB-07/01 4 The American Tank foreman told investigators that on December 12 he asked the PSE&G inspector whether the gas line could be shut off while they excavated. This request was a precaution to prevent the release of gas if the line was damaged during the tank removal. The PSE&G inspector told investigators he stated to the American Tank foreman that because it was wintertime the gas could not be shut off. However, the PSE&G inspector said that he would ask his supervisor. When the supervisor told the inspector that turning off the natural gas to the building would not be possible, the inspector informed the American Tank foreman. According to the PSE&G, shutting off the gas to the building without making prior arrangements with the PSE&G and the building’s owner would have created a health risk to the residents by leaving them without gas for heat, hot water, and cooking. The American Tank foreman and assistant manager said during postaccident interviews that, based on their examination of the worksite after the initial excavation, they thought the excavation was stable and secure, and the excavation wall was far enough from the pipe to be safe. However, the American Tank crew did not evaluate the soil at the walls of the ditch for stability.6 The excavation crew exposed a portion of the gas pipeline by excavating with hand shovels to confirm the service line’s location. The excavation was done by digging into the eastern trench wall, near the gas pipeline and the building, while standing in the trench. The PSE&G street inspector who had marked the pipeline told Safety Board investigators that he was on site when the service line was first uncovered. The service line was partially exposed in two locations that were each about 1 foot long. The service line was buried about 30 to 36 inches and was about 2 feet from the extended eastern edge of the trench. To excavate the 5,000-gallon tank, the crew had to open a trench that was about 24 feet long, which was considerably larger than originally planned. The PSE&G inspector determined that the pipeline was a PSE&G gas pipeline and that it was accurately marked. According to the inspector, he reminded the American Tank crewmembers of their obligation to protect the gas pipe from damage by supporting the pipe against an immovable object, such as the building, or shoring the trench. The PSE&G inspector did not remain on the job to ensure that the pipeline was adequately protected. In addition, he did not attempt to test the curb valve to ensure it could be rapidly closed if the pipeline was broken. The inspector gave the American Tank foreman his business card and asked him to call if he needed assistance or had any questions. The inspector departed the site at 11:47 a.m. According to the American Tank foreman, the trench was not shored and was about 4 to 5 feet deep at the end of the first day. The American Tank crew (assistant manager, foreman, and two crewmembers) arrived about 8:30 a.m. on Tuesday, December 13, 2005, to continue work on the excavation. The American Tank crewmembers told Safety Board investigators that they did not start any of the excavation equipment or expand the excavation on December 13, the day of the accident. When they first arrived, they saw that the ground surrounding the pipeline had collapsed and fallen from underneath portions of the asphalt parking lot along the eastern wall of the trench. The

6 Trench wall soils can be tested for stability by using a penetrometer, which is a mechanical device that measures the force needed for a probe to enter the soil. Another method is the “thumb test,” in which the thumb is pushed into the soil along the wall.

NTSB/PAB-07/01 5 crewmembers said that they tied one end of a rope to the gas pipeline and the other end to the oil tank vent pipe at the building wall in an effort to help support the pipeline. The American Tank crew also placed a pump into the trench and was removing some of the water that had accumulated when some crewmembers reported hearing a “popping” sound and two crewmembers smelled natural gas. Shortly afterward, the other two crewmembers smelled natural gas. From across the street, a local business owner saw the American Tank crew working at 30 Elm Street. He said that he saw water flowing down the road and when he went across the street to where the American Tank crew was working, he smelled natural gas. The business owner said that he would call the police for them. He called the Bergenfield Police Department7 at 8:49 a.m. and reported a gas leak. His call was the only one that the Bergenfield Police Department received about the incident before the explosion. An apartment resident later told Safety Board investigators that she also had smelled natural gas, but had not called the police department, the fire department, or the PSE&G. The American Tank foreman called the PSE&G at 8:54 a.m. and reported that the ground had collapsed and the service line was broken. According to the Bergenfield Police Department dispatch logs, at 8:52 a.m., the Bergenfield Fire Department’s chief,8 a fire official,9 and an engine company responded to an initial notification of a gas leak. Two Bergenfield Police Department police officers were also dispatched. A Bergenfield police officer directed traffic away from the area. After arriving on scene about 8:54 a.m., the fire chief asked the police dispatchers to notify the PSE&G. At 8:58 a.m., police dispatchers notified the PSE&G of the incident. The fire chief told Safety Board investigators that he had not observed any signs of a leak at the trench (that is, smelling gas, hearing a “hissing” sound, or seeing bubbling of water in the trench). The fire official said that he did not smell gas at the scene. No one from the Bergenfield Fire Department checked the apartment building for the presence of natural gas. The fire department did not attempt to evacuate the building before the explosion. The Bergenfield fire chief said that the American Tank crew warned him, before the explosion, about the soil giving way in the trench and to be careful while walking near the trench. The fire chief also said that he looked into the trench and could see that the soil beneath the asphalt on the east side of the trench had fallen into the trench. About 9:22 a.m., a PSE&G service technician arrived on scene. The technician attempted to close the curb valve to shut off the gas, but he was unable to apply enough force to close it. In a postaccident interview, the service technician said that as he approached the building to investigate the gas leak, an American Tank crewmember told him to not get too close to the trench because it had already collapsed. The service technician said that he had seen a piece of asphalt that had fallen into the trench. The service technician, using a portable gas detector,

7 The Bergenfield Police Department dispatches the police department and the fire department. 8 The Bergenfield Fire Department was composed mostly of volunteers. The fire chief, a volunteer, served for a 1-year term. 9 Bergenfield had five career fire officials who conducted site inspections and fire investigations. The fire officials also responded to fire incidents.

NTSB/PAB-07/01 6 detected a positive gas reading just inside the boiler room doorway of the apartment building. He started moving away from the building as it exploded at 9:26 a.m. The police and fire departments, American Tank, and the PSE&G started rescue actions. The fire departments started firefighting. About 10:00 a.m., a PSE&G street crew was able to shut off the gas to the service line by closing the curb valve. Inspection and Recovery of Pipeline When the pipeline was later uncovered during the postaccident excavation, a frayed rope was found attached to the gas pipeline. Additionally, a broken piece of “two-by-four” lumber was found near the gas pipeline. During pressure tests on the steel service line, the only leak was found at the iron threaded tee connection that was about 7 feet 4 1/2 inches from the building wall. The tee had separated from the service line and had a gap of about 3 inches. (See figure 3.) The tee and the separated end of the service line were removed and sent to the Safety Board’s Materials Laboratory for analysis.

Figure 3. Separation of steel service line. The threaded end of the service line fractured at the connection. The exposed threads on either side of the mating surfaces showed no evidence of corrosion degradation or fatigue cracking. Microscopic examination of the fracture revealed features consistent with an overstress separation. The evidence is consistent with the pipeline separating in overstress after the ground collapsed into the trench and caused the pipeline to move.

NTSB/PAB-07/01 7 American Tank’s Procedures and Training American Tank’s written procedures covered certifications and licensing, obtaining contracts, the steps from signed contract to job execution, and the steps for job completion. American Tank’s written procedures for excavation work were limited to using the New Jersey One Call System for marking buried utilities, including gas pipelines. The company did not have written operating procedures for the protection of utilities while excavating. According to American Tank, its unwritten procedures for the protection of utilities included the following: • Visit the job site to survey for hazards and logistical issues. • Obtain all needed permits. • Survey the job site to ensure markings are in place. • Uncover the top of the tank to determine its direction and hand excavation of nearby utilities. • Evaluate the nature of the soil to determine the possibility of collapse. • Contact the utility company and request shutoff. • Protect and support the utility; contact the utility company if damaged. • If damage to the utility is observed, call the emergency telephone numbers for the utility and call 911 or fire and police department emergency telephone numbers. American Tank had no formal training program on the protection and support of utilities. PSE&G’s Excavation Damage Prevention Program and Emergency Plan The PSE&G participated in the New Jersey One Call system. It also participated in various damage prevention and awareness activities in 2005. These activities included distributing damage prevention materials to home improvement stores, contractors, equipment rental companies, retail stores, and municipalities. The PSE&G does not use direct mailing to contractors unless damage has been reported. Then, the PSE&G sends information letters about New Jersey’s damage prevention laws to contractors who have damaged their company’s underground facilities. The PSE&G has an emergency plan that was developed in accordance with State and Federal regulations. However, the PSE&G emergency plan does not have a provision requiring the testing of curb valves to determine whether the valves can be quickly operated to shut down a service line when excavation activities place the line at risk.

NTSB/PAB-07/01 8 Regulations, Standards, and Oversight There are a number of applicable regulations and standards regarding excavation safety. These include regulations and standards from the State of New Jersey, the U.S. Occupational Safety and Health Administration (OSHA), the U.S. Department of Transportation, and industry standards and best practices. New Jersey Board of Public Utilities The New Jersey Board of Public Utilities publishes a handbook that explains the requirements of the New Jersey One Call law for excavators. Excavators are required to notify New Jersey One Call from 3 to 10 days before excavating and to immediately report any damage to the operator of the facility. Furthermore, the New Jersey Underground Facility Protection Act, section N.J.S.A. 48:2-82 d(2 and 3) requires excavators to “plan the excavation or demolition to avoid damage to and to minimize interference with underground facilities” and “to use reasonable care during excavation or demolition to avoid damage to or interference with underground facilities.” The Board of Public Utilities is charged with overseeing and enforcing compliance with the New Jersey Underground Facility Protection Act and the New Jersey One Call law. The Board of Public Utilities also has delegated authority to enforce Federal natural gas pipeline safety standards in 49 Code of Federal Regulations (CFR) Part 192. On November 28, 2006, the New Jersey Board of Public Utilities sent Notices of Probable Violation to American Tank and the PSE&G. American Tank was cited for a probable violation of the New Jersey Underground Facility Protection Act for not planning the excavation to avoid damage and minimize interference with an underground facility and not using reasonable care in an excavation. The Board of Public Utilities cited the PSE&G for three probable violations of 49 CFR Part 192. The first probable violation was that the PSE&G employee, after being notified of a potential hazard, left the site with the potential hazard remaining. The second probable violation was that the PSE&G’s response did not facilitate the most effective course of action under the circumstances following the notice of a reported gas leak and ruptured service on December 13,

1. The third probable violation was that the PSE&G did not have sufficient communication

and exchange of information with the Bergenfield fire officials regarding its gas emergency programs. The outcome of the citations to American Tank and the PSE&G is pending as of May 1, 2007. U.S. Occupational Safety and Health Administration OSHA investigated this accident. Title 29 CFR 1926.651 establishes excavation requirements designed to safeguard employees and prevent damage to underground utilities, including a requirement to establish the location of underground installations before excavating.

NTSB/PAB-07/01 9 OSHA and American Tank reached a stipulated agreement for two violations in which American Tank was fined for its conduct during this accident. American Tank was cited for the failure to use safe and acceptable means to exactly locate the underground vent pipe for the oil storage tank and for the failure to safeguard employees while the excavation was open. Federal Pipeline Safety Requirements The Pipeline and Hazardous Materials Safety Administration’s (PHMSA’s) pipeline safety regulations require that each operator of a buried natural gas pipeline must carry out a written program to prevent damage to the pipeline from excavation activities. Specifically, in 49 CFR 192.614(c), the damage prevention program must provide for the inspection of those pipelines that an operator “has reason to believe” could be damaged by excavation activities. These inspections must be done as “frequently as necessary” during and after the excavation activities to verify the integrity of the pipeline. Title 49 CFR 192.615(a) requires that each natural gas pipeline operator have a written emergency plan that establishes procedures for minimizing the hazards resulting from a natural gas pipeline emergency. The emergency plan must address several emergency responses, including emergency shutdown and pressure reduction in any section of the pipeline system necessary to minimize hazards to life or property and elimination of any actual or potential hazard to life or property. Industry Guidance The Gas Piping Technology Committee10 (GPTC) publishes the Guide for Gas Transmission and Distribution Piping Systems to help natural gas operators ensure regulatory compliance. The section of the GPTC guide referring to Section 192.614c(6) states the following: Where required, the inspection may include periodic or full-time surveillance and may include leakage surveys during and after construction. The operator should consider maintaining field contact with the excavator during the excavation activities to avoid potential problems. The section of the GPTC guide referring to Section 192.615(a) states, “The objective of the (emergency) plan should be to ensure that personnel who could be involved in an emergency are prepared to recognize and deal with the situation in an expeditious and safe manner.” The Common Ground Alliance Best Practices11 manual, version 3.0, states that the excavator must use reasonable care to avoid damaging underground facilities. The excavator

10 The GPTC is an American National Standards Institute technical committee composed of technical specialists from industry, government, and the public. 11 The Common Ground Alliance, composed of technical specialists from industry, government, and the public, provides a guide on underground utility damage prevention best practices and promotes their use throughout the United States.

NTSB/PAB-07/01 10 should plan the excavation to avoid damage or minimize interference with the underground facilities in or near the work area. The manual also states that the protection of exposed underground facilities is as important as preventing damage to the facility when digging around the utility. Section 5-22 of the manual indicates that excavators are to support or brace exposed underground facilities and protect them from moving or shifting, which could result in damage to the facility. Methods to support, brace, and protect these facilities include shoring the facility from below or providing a timber support with hangers across the top of the excavation to ensure that the facility does not move or bend. Excess Flow Valves Excess flow valves are designed to respond to an excessive flow of gas by automatically closing and restricting the gas flow, thereby reducing the likelihood of an explosion and fire. The valves are typically installed at the connection of a service line to a main pipeline. The valves can greatly reduce the consequences of service line breaks. The investigation examined whether an excess flow valve that was compatible with the operating conditions for the apartment building would have been effective. Had the break in the service line been exposed to the open atmosphere, an excess flow valve would have activated immediately to restrict the flow of gas; however, in this accident, the broken section of pipe was underground and under asphalt pavement. A leakage test conducted 2 days after the accident resulted in a flow rate of natural gas through the broken service line of about 1,600 standard cubic feet per hour. The leakage test could not be conducted until the excavation site was stabilized.12 Soil conditions at the time of the leakage test were significantly different than at the time the service line was broken; this difference likely affected the flow rate measured during the test. Further, the flow rate of natural gas to the apartment building at the time the service line was fractured cannot be determined.13 At the time of the accident, it was quite cold; the temperature was about 18° F. It would be reasonable to assume that the heating system and the replenishment of hot water for the tenants would have been operating near maximum capacity. However, given the uncertainty in the leakage test results and the unknown flow rate to the building, the Safety Board was not able to determine whether an excess flow valve, had one been installed, would have activated after the service line was broken in this accident. Bergenfield Fire Department Procedures and Training According to the fire chief, the Bergenfield Fire Department did not have written procedures for natural gas incidents. Safety Board investigators were told in Fire Department

12 During the firefighting operations, significant amounts of water had been used in the area. The trench adjacent to the broken section of pipe had been filled as a precautionary measure due to concerns that the building wall might collapse. Later, the trench was partially excavated then refilled because of unstable soil. Trench boxes were necessary to stabilize the excavation before the investigators could access the site. 13 The flow rate to the building could not exceed 2,500 standard cubic feet per hour because of the capacity of the metering equipment.

NTSB/PAB-07/01 11 interviews that the Bergenfield Fire Department relied heavily on the assistance of the PSE&G in deciding whether to evacuate a structure. Effective July 5, 2005, the State of New Jersey improved its written course material regarding natural gas hazards for Firefighter I training. The new material is in the Firefighter’s Handbook: Essentials of Firefighting and Emergency Response—New Jersey Edition, and Addendum. In this handbook, Section D, Chapter II, “Recognizing and Avoiding the Hazards of Natural Gas and Carbon Monoxide,” describes the properties of natural gas, the natural gas delivery system, natural gas detection, and the response to natural gas emergencies. In the section, “Secure the Site,” the manual has the following recommendation: When the presence of gas is strong, the best rule is to evacuate people from the dwelling and move them across the street or a distance far away that would prevent injuries if the structure were to explode. The video Natural Gas: Recognizing and Avoiding the Hazards, which was produced with the cooperation of several companies and government agencies in New Jersey, including the PSE&G, is also included as part of the Firefighter I course. As a result of a July 1999 accident in Fairlawn, New Jersey, and a March 2006 agreement with the Board of Public Utilities, the PSE&G agreed to expand its emergency response training, which is coordinated with the Bergen County Fire Academy. As a result of the Bergenfield accident and a March 2006 agreement between the Board of Public Utilities and the PSE&G, the Board of Public Utilities obtained permission to distribute a PSE&G-produced video for firefighters and first responders in the State of New Jersey. This video includes information on how to handle gas leak emergencies, and when to check the building, and when to evacuate. In October 2006, the PSE&G mailed a computer disk containing electric and gas hazard awareness information to police departments, fire departments, and emergency management officials within the PSE&G’s service area to help them to develop standard operating procedures for electrical and gas emergencies. Probable Cause The National Transportation Safety Board determines that the probable cause of the December 13, 2005, natural gas explosion and fire in Bergenfield, New Jersey, was the failure of the American Tank Service Company to adequately protect the natural gas service line from shifting soil during excavation, which resulted in damage to the service line and the release and migration of natural gas into the apartment building. Contributing to the accident was the failure of the Public Service Electric and Gas Company to conduct effective oversight of the excavation activities adjacent to the gas service line and to be prepared to promptly shut off the flow of natural gas after the service line was damaged. Contributing to the casualties in the accident was the failure of the Bergenfield Fire Department to evacuate the apartment building despite the strong evidence of a natural gas leak and the potential for gas to migrate into the building.

NTSB/PAB-07/01 12 Recommendations As a result of its investigation of the Bergenfield, New Jersey, pipeline accident, the National Transportation Safety Board made the safety recommendations listed below. For more information about these recommendations, see the safety recommendation letters14 to the recipients. To the Pipeline and Hazardous Materials Safety Administration: Provide a summary of the lessons learned from the Bergenfield, New Jersey, accident to recipients of emergency planning and response grants. (P-07-1) To the New Jersey Department of Community Affairs: Establish a requirement that all career and volunteer firefighters receive recurrent training on natural gas safety and incident response. (P-07-2) To the Borough of Bergenfield: Establish and implement written operating procedures for responding to natural gas incidents and emergencies. (P-07-3) To the American Tank Service Company: Establish and implement written procedures for safe excavation near pipelines, and provide initial and recurrent training on these procedures to employees. (P- 07-4) To the Public Service Electric and Gas Company: Modify your excavation damage prevention program and emergency plan to require site-specific risk assessments of excavators’ plans, and implement procedures to effectively manage the risk, such as increased surveillance of excavator actions to protect the pipeline and ensuring that gas shut-off valves are tested so that they can be closed promptly if the pipeline is damaged. (P-07-5) To the International Association of Fire Chiefs: Notify your members of the circumstances surrounding the December 13, 2005, accident in Bergenfield, New Jersey, and urge them to establish and implement procedures for emergency responders to rapidly assess situations involving natural gas leaks and to determine whether prompt evacuations are warranted. (P-07-6)

14 These letters are available on the National Transportation Safety Board’s web site.

NTSB/PAB-07/01 13 BY THE NATIONAL TRANSPORTATION SAFETY BOARD MARK V. ROSENKER Chairman DEBORAH A. P. HERSMAN Member STEVEN R. CHEALANDER Member ROBERT L. SUMWALT Vice Chairman KATHRYN O’LEARY HIGGINS Member

Adopted: May 1, 2007

Kathryn O’Leary Higgins, Member, filed the following concurring statement on May 8, 2007.

I concur in the accident brief and safety recommendation letters issued on the natural gas service line break and subsequent explosion and fire in Bergenfield, New Jersey, that occurred on December 13, 2005. I believe the recommendations that resulted from this investigation will help prevent other similar accidents in New Jersey. As I noted in the board meeting, however, I believe we should go further to prevent similar accidents in other states and communities. I believe we should have issued a recommendation to the Pipeline and Hazardous Materials Safety Administration (PHMSA) to share the lessons learned in this investigation with the rest of the country. Our investigation found serious deficiencies in practices and procedures followed by the excavation contractor, the utility company, and the community of Bergenfield. We make recommendations to the State of New Jersey concerning recurrent training for firefighters in dealing with gas leaks. We ask the contractor to implement written procedures. We make similar and appropriate recommendations to the Borough of Bergenfield, the Public Service Electric and Gas Company, and the International Association of Fire Chiefs. I am concerned that we could see a similar accident in another community. I believe the best way to prevent a similar tragedy is to ask PHMSA, the Federal agency with regulatory and enforcement responsibility for pipeline safety, to take a leadership role in helping all states and communities understand the mistakes that led to this accident so they can be addressed. I am pleased that the Board voted to adopt a recommendation to PHMSA to spread the word about this accident to emergency planning and response grant recipients so that training funded by these grants will incorporate the lessons learned from the Bergenfield tragedy. Member Hersman joined Member Higgins in this statement.

FD07312 ｜ 2005_美国_RAR0502.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2005 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

Derailment of Amtrak Train No. 58, City of New Orleans, Near Flora, Mississippi April 6, 2004 Railroad Accident Report NTSB/RAR-05/02 PB2005-916302 Notation 7642A National Transportation Safety Board Washington, D.C.

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Railroad Accident Report Derailment of Amtrak Train No. 58, City of New Orleans, Near Flora, Mississippi April 6, 2004 NTSB/RAR-05/02 PB2005-916302 National Transportation Safety Board Notation 7642A 490 L’Enfant Plaza, S.W. Adopted July 26, 2005 Washington, D.C. 20594

National Transportation Safety Board. 2005. Derailment of Amtrak Train No. 58, City of New Orleans, Near Flora, Mississippi, April 6, 2004. Railroad Accident Report NTSB/RAR-05/02. Washington, DC. Abstract: About 6:33 p.m. central daylight time on April 6, 2004, northbound National Railroad Passenger Corporation (Amtrak) train No. 58 (City of New Orleans), derailed on Canadian National Railway Company railroad track near Flora, Mississippi. The entire train, consisting of one locomotive, one baggage car, and eight passenger cars, derailed near milepost 196.5 while traveling about 78 mph. The train was carrying 61 passengers and 12 Amtrak employees. The derailment resulted in 1 fatality, 3 serious injuries, and 43 minor injuries. The equipment costs associated with the accident totaled about $7 million. As a result of its investigation of the accident, the Safety Board identified the following safety issues: the Canadian National Railway Company's continuous welded rail maintenance and inspection procedures and standards, Amtrak's emergency response training of its employees, and the Federal Railroad Administration's oversight of continuous welded rail maintenance programs and Amtrak's emergency response training of its employees. As a result of its investigation of this accident, the Safety Board makes safety recommendations to the Federal Railroad Administration, the Canadian National Railway Company, and Amtrak. The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Web at http://www.ntsb.gov. Other information about available publications also may be obtained from the Web site or by contacting: National Transportation Safety Board Public Inquiries Section, RE-51 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (800) 877-6799 or (202) 314-6551 Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2005-916302 from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605-6000 The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

iii Railroad Accident Report Contents Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Accident Synopsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Accident Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Local Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 CN Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Amtrak Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Amtrak Train-Operating Crew . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 CN Track Maintenance Personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 FRA Inspection Personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Toxicological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Operations Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Signal Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Event Recorder Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Site Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Track Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Postaccident Track Condition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Continuous Welded Rail . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Track Maintenance History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 CN CWR Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Federal Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 CN Track Inspections and Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 CN Track Maintenance Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Regulatory Oversight of CWR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 FRA Track Safety Program and CWR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 FRA Track Inspections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Postaccident FRA Inspections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Preaccident Inspections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Postaccident Inspections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Emergency Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Amtrak Personnel Emergency Preparedness Training . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Amtrak Emergency Preparedness Training for Communities . . . . . . . . . . . . . . . . . . . . 29 CN Emergency Preparedness Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Madison County Emergency Preparedness Training . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Survival Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Superliner Passenger Car Emergency Windows . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Other Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Previous Derailment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Contents iv Railroad Accident Report Postaccident Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 The Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Track Condition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Track Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 CN CWR Maintenance and Inspection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 FRA Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Emergency Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Amtrak Crewmember Emergency Preparedness Training . . . . . . . . . . . . . . . . . . . . . . . 39 Emergency Responder Training Provided by Amtrak . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Passenger Train Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Emergency Window Handles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Appendixes A: Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 B: Emergency Responders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 C: Previous Safety Board Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

v Railroad Accident Report Executive Summary About 6:33 p.m. central daylight time on April 6, 2004, northbound National Railroad Passenger Corporation (Amtrak) train No. 58 (City of New Orleans) derailed on Canadian National Railway Company railroad track near Flora, Mississippi. The entire train, consisting of one locomotive, one baggage car, and eight passenger cars, derailed near milepost 196.5 while traveling about 78 mph. The train was carrying 61 passengers and 12 Amtrak employees. The derailment resulted in 1 fatality, 3 serious injuries, and 43 minor injuries. The equipment costs associated with the accident totaled about $7 million. The National Transportation Safety Board determines that the probable cause of Amtrak’s City of New Orleans accident on April 6, 2004, near Flora, Mississippi, was the failure of the Canadian National Railway Company to properly maintain and inspect its track, resulting in a rail shift and the subsequent derailment of the train, and the Federal Railroad Administration’s ineffective oversight to ensure the proper maintenance of the track by the railroad. The safety issues addressed in this report are: • The Canadian National Railway Company’s continuous welded rail maintenance and inspection procedures and standards, • Amtrak’s emergency response training of its employees, and • The Federal Railroad Administration’s oversight of continuous welded rail maintenance programs and Amtrak’s emergency response training of its employees. Other items discussed in this report include: • Establishment of incident command during emergency response and • Operation of handles to remove emergency windows to allow egress from damaged cars. As a result of its investigation of this accident, the Safety Board makes safety recommendations to the Federal Railroad Administration, the Canadian National Railway Company, and Amtrak.

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1 Railroad Accident Report Factual Information Accident Synopsis About 6:33 p.m. central daylight time1 on April 6, 2004, northbound National Railroad Passenger Corporation (Amtrak) train No. 58 (City of New Orleans) derailed on Canadian National Railway Company (CN) track near Flora, Mississippi. The entire train, consisting of one locomotive, one baggage car, and eight passenger cars, derailed near milepost (MP) 196.5 while traveling about 78 mph. Six of the passenger cars rolled onto their right sides, and three of those cars came to rest on a hill that sloped down below the tracks. The last two cars were almost upright. The train was carrying 61 passengers and 12 Amtrak employees. The derailment resulted in 1 fatality, 3 serious injuries, and 43 minor injuries (including injuries to 2 emergency responders). The equipment costs associated with the accident totaled about $7 million. Accident Narrative Northbound Amtrak train No. 58, City of New Orleans, originated at New Orleans, Louisiana, on April 6, 2004, bound for Chicago, Illinois. (See figure 1 for a map showing the train’s route and the accident location.) The train consisted of a locomotive, a baggage car, and eight Superliner passenger cars.2 According to the conductor, the train had successfully completed the required air brake test before departure. Train No. 58 departed New Orleans about 1:55 p.m. The trip from New Orleans to Jackson, Mississippi, was uneventful. At Jackson, which is a passenger stop, a crew change for engineers occurred. The inbound and outbound engineers discussed the condition of the train. The inbound engineer said that “everything was fine” and the braking and power were good. The train departed Jackson, Mississippi, at 6:02 p.m., with the new engineer. After the train left Jackson, the engineer performed a running air brake test, which he said was successful. The conductor recalled making a safety announcement before the train left Jackson. 1 All times are central daylight time. 2 The Superliner cars on the train were one sleeper car, one dining car, one lounge car, one crew dormitory car, and four coach cars.

Factual Information 2 Railroad Accident Report According to the conductor, after leaving Jackson the train passed a wayside train defect detector at MP 209.2, and no defects were detected. He also recalled that a railroad employee observing the passing Amtrak train notified him that the portable marker at the rear of the train was functioning, although he did not remember the employee or the employee’s location at the time of the observation. Near MP 197, while the train passed a block signal displaying a clear indication (green aspect), the engineer said he looked at the track ahead of the train and observed something that was “not right.” (The train was traveling about 78 mph at the time.) Ahead of the train were two bridges over the Big Black River flood plain, with a filled levee between the bridges. According to the engineer, the track between the bridges looked “pretty bad.” He immediately started a service application of the brakes. The engineer described what happened next as follows: I get up to it and I can see that the rail is kinked, and my engine goes through. I think the baggage car went through it too, and I started to feel everything moving and shaking. I knew something wasn’t right. And my engine is already through it, and I’m not looking in the mirror, I’m looking ahead and I can see the right, or east rail rolling over, [so] I shot it.3 Figure 1. Map showing train route and accident location. 3 Shot it is railroad jargon for applying the air brakes in emergency. LITTLE ROCK New Orleans JACKSON LA AR AL MS Memphis Flora

Factual Information 3 Railroad Accident Report About 30 minutes after departing Jackson (6:33 p.m.) the conductor felt the train start to derail, and then, he said, “… things got worse and worse.” He stated that the car he was in turned over on its side. Once the car came to rest, he became aware that he was still breathing, and then he heard a lot of moaning from the passengers. The entire train derailed beginning on the filled levee about halfway between the two bridges over the Big Black River. The locomotive and the baggage car reached the second bridge and came to rest upright, although the rear of the baggage car hung over the right side of the bridge. The remaining eight cars derailed to the right of the track. (See figure 2 for a photograph of the derailed train and figure 3 for a diagram of the accident aftermath.) The first passenger car, a transition sleeper car,4 separated from the baggage car and went off the fill to the right of the track before it reached the second bridge. The transition sleeper and the seven cars following it remained coupled. The transition sleeper, the dining car, the lounge, and the first coach car rolled to the right 90° and came to rest on their sides on the flood plain below the bridge. The last four cars in the train did not reach the second bridge and were on the filled area of the track between the bridges when they derailed. The first of these cars rolled on its side on the downward slope of the raised fill and came to rest at about a 110° angle from upright. The second car tipped over 90°, the third car leaned at about a 45° angle, and the last car came to rest near the tracks in an upright position. 4 Part of this car is a rest area and dormitory for the on-board crewmembers, and part of the car is a sleeper for passengers. This car is always coupled to the baggage car with the rest of the passenger cars behind. Figure 2. Wreckage of derailed train.

Factual Information 4 Railroad Accident Report The engineer told investigators that after the locomotive stopped he looked back and all he could see was dust on both sides of the train. He announced “emergency” on the radio three times. He then contacted the train dispatcher and requested help for the passengers and crew of the train. The engineer shut down the electrical system that provides high voltage electricity through the train. Then he walked back through the locomotive toward the derailed cars. The conductor could hear the engineer talking on the radio to the CN train dispatcher. He also heard a car attendant calling 911. The conductor heard the train Figure 3. Diagram of wreckage. Not to scale Concrete Span Bridge over Big Black River flood plain Locomotive Coach Coach Coach Coach Sleeper Lounge Dining Car Transition Sleeper Baggage Car N

Factual Information 5 Railroad Accident Report dispatcher on the radio say that emergency responders had been notified and were on the way. He then contacted Amtrak’s Consolidated National Operations Center.5 The evacuation process started, and the conductor remembered someone opening an emergency window exit. Then he left the train with the rest of the passengers and crew. Emergency Response Local Emergency Response The first 911 call was made from the train by an Amtrak employee at 6:37 p.m. At 6:52 p.m., the first firefighter, the Flora Volunteer Fire Department chief, arrived on scene near Ratliff Road. (The map in figure 4 shows the derailment area, including the location of the command post, the triage area, the staging area, the helicopter landing area, and Ratliff Road.) The road crossed the tracks at MP 196.85, but there were no roads between this point and the accident site, so the only access to the derailed cars was by the railroad tracks and across the Big Black River railroad bridge. 5 The Consolidated National Operations Center, in Wilmington, Delaware, is Amtrak’s 24-hour operations center. It handles many functions, including train crew assignments, nationwide locomotive and rail car deployment, and coordination of train operations with host railroads when trains are operating on freight railroads. Figure 4. Map of derailment area. 49 1 2 3 4 1 2 3 4 Command Post Triage Area Staging Area Helicopter Landing Zone Big Black River Ratliff Road Livingston-Vernon Road Point of derailment

Factual Information 6 Railroad Accident Report According to the Flora Volunteer Fire Department chief, when he arrived on scene he went to the derailment location and began to assess the passenger cars and to triage the injured passengers. Approximately 21 minutes after the accident, the Kearney Park Volunteer Fire Department requested the assistance of the Madison Fire Department. Five minutes later, the Madison County Sheriff’s Office officially requested the Madison Fire Department to respond to the scene. At 6:55 p.m., the chief requested mutual assistance from the Gluckstadt Volunteer Fire Department. The chief told investigators that although he did not officially establish a command post or assume incident command, he did direct firefighters during the initial passenger extrication and triage. He stated that he assigned several 3-person crews from the Flora, Kearny Park, and Gluckstadt Volunteer Fire Departments to search all the cars and gather the passengers at a collection point south of the derailment location. At 7:05 p.m., the Madison County sheriff arrived on scene and began to direct the emergency response. The conductor told National Transportation Safety Board investigators that he informed the sheriff that there were about 61 passengers on board the train. The passenger manifest was lost on the train when the derailment occurred, but it was later located in the dining car by city of Madison6 Fire Department firefighters. The Madison Fire Department was not notified of the accident during the initial dispatch of emergency responders, but approximately 52 minutes after the derailment, the emergency medical services (EMS) director for the Madison Fire Department arrived on scene after traveling more than 20 miles from Madison. He immediately began to look for the command post and the incident commander in order to find out what resources were needed. Approximately 15 minutes later, he approached the Madison County sheriff, assuming that the sheriff was the incident commander. During this meeting with the sheriff, the EMS director learned that there was no command post or incident commander. At 7:45 p.m., he established a command post south of the derailment. The EMS director assumed incident command under the Unified Command System with the assistance of the Madison County sheriff. A representative from CN was present at the command post. Once the command post was established, the EMS director began to assign emergency response activities, including extricating and triaging passengers and moving them to a collection point. About 7:50 p.m., a CN representative offered the use of CN’s hy-rail7 vehicles to transport injured passengers from the accident scene, across the Big Black River, and up to Ratliff Road. Emergency responders reached the accident site by driving for 1 mile on a dirt road that paralleled the railroad right-of-way followed by walking approximately 1/2 mile on the railroad tracks across the Big Black River. The EMS director then tasked the operations manager for American Medical Response (a private medical transportation company) with setting up a triage area at the north end of Ratliff Road and a helicopter landing zone south of the triage area. The EMS director wanted to direct all the people from the accident scene to the triage area to ensure an accurate accounting of persons and to organize the transport of the injured from the 6 Throughout this report the city of Madison will be referred to as “Madison,” and Madison County will be referred to as “Madison County.” 7 A hy-rail vehicle, or hy-rail, is a truck that has flanged wheels attached to the front and rear so it can travel over railroad tracks and easily get on or off the track at a road crossing.

Factual Information 7 Railroad Accident Report scene. The EMS director had ambulances waiting at the staging area located at Ratliff Road and Livingston-Vernon Road. As the injured were transported off hy-rail vehicles, the ambulances were dispatched to the triage area to transport the injured to area hospitals. By 7:57 p.m. it was estimated that 50 persons were injured but could walk, 1 or 2 were moderately8 injured, 1 needed immediate transportation by helicopter, and 1 had been fatally injured. By 8:12 p.m. all persons had been evacuated from the train. Between 8:34 p.m. and 10:24 p.m., 58 persons were transported to hospitals. Uninjured passengers were transported to a shelter. A final search of the train was conducted at 9:50 p.m., and by 10:25 p.m. all persons had been located and counted. A total of 21 agencies (fire, police, and municipal and private ambulance companies) responded to the derailment. Appendix B contains a list of those agencies. CN Emergency Response At 6:35 p.m., the CN dispatcher received an emergency broadcast from the engineer of Amtrak train No. 58. The CN dispatcher immediately notified the CN police dispatcher that Amtrak train No. 58 had derailed on the Yazoo Subdivision near MP 196.2. The engineer had requested police, ambulance, and fire department response. The CN police dispatcher immediately notified the Madison County Sheriff’s Office and the Yazoo County Sheriff’s Department. A CN assistant superintendent who overheard the emergency radio broadcast knew that the accident site was not accessible by road. He therefore requested all engineering employees in the area to respond. Two CN employees with hy-rail trucks responded immediately. The assistant superintendent radioed them and asked them to direct emergency responders to the accident scene from the south across the Big Black River. About 7:00 p.m., the assistant superintendent arrived at the accident scene. He noticed emergency responders arriving at the scene on foot and in all-terrain vehicles (sometimes referred to as quads). He told the ambulance personnel that since ambulances would not be able to reach the site, the CN hy-rail vehicles could be used to transport injured passengers from the accident site to the staging area and the ambulances. The Madison County sheriff agreed with this plan for transporting the injured passengers. Amtrak Emergency Response At 6:50 p.m., the CN train director in Homewood, Illinois, notified Amtrak’s operations center that Amtrak train No. 58 had derailed at MP 195.6,9 north of Jackson, 8 As patients are triaged, they are usually assigned a color code based on the severity of their injuries. In this case, the emergency responders used green to signify those persons that were injured, but still able to walk; yellow was used to signify those persons who were moderately injured; red was used to signify a critical injury; and black was used to signify a confirmed fatality. 9 The derailment actually occurred at MP 196.5.

Factual Information 8 Railroad Accident Report Mississippi, at 6:35 p.m. The notification further stated that some derailed cars were on their sides, injuries were reported, and local police and rescue personnel and CN representatives were en route to the accident scene. At 6:51 p.m., the operations center notified the Amtrak police about the derailment. Between 6:51 p.m. and 7:00 p.m., the operations center dispatchers continued internal notifications. Amtrak’s Customer Services Group provided assistance to passengers after the accident. On the day of the accident, group representatives went to a shelter the Red Cross had established for passengers in the Flora accident. The group arranged for hotel accommodations, needed clothing and medicine, and continuing transportation. Counselors from Amtrak’s Employee Assistance Program arrived on site the day after the accident to provide mental health services for passengers and Amtrak employees. Injuries A total of 58 persons (passengers and crew) were transported to six Jackson, Mississippi, area hospitals.10 One Amtrak employee was subsequently transferred to North Oaks Medical Center in Hammond, Louisiana. Two emergency responders transported themselves to area hospitals where they were treated and released. The derailment resulted in 1 passenger fatality, due to a traumatic impact injury, 1 passenger with serious injuries, and 34 passengers with minor injuries. Amtrak employees sustained two serious and seven minor injuries. Two emergency responders received minor injuries. (See table 1.) Table 1. Injuries. 10 Not all persons transported to hospitals were injured. Injury Typea Train Crew Emergency Responders Passengers Total Fatal 0 0 1 1 Serious 2 0 1 3 Minor 7 2 34 43 Total 9 2 36 47 a 49 Code of Federal Regulations (CFR) 830.2 defines fatal injury as “any injury which results in death within 30 days of the accident” and serious injury as “an injury which: (1) requires hospitalization for more than 48 hours, commencing within 7 days from the date the injury was received; (2) results in a fracture of any bone (except simple fractures of fingers, toes, or nose); (3) causes severe hemorrhages, nerve, or tendon damage; (4) involves any internal organ; or (5) involves second- or third-degree burns, or any burn affecting more than 5 percent of the body surface.”

Factual Information 9 Railroad Accident Report Damage As a result of the derailment, about 273 feet of the main track were destroyed, which required the installation of 7 track panels11 and about 1,100 feet of rail. A multispan concrete bridge spanning the Big Black River flood plain sustained damage to the concrete structure on the east side wall. The track damage was approximately $100,000. Two cars, the transition sleeper and the dining car, were damaged beyond repair. Amtrak estimated monetary damage to the equipment as shown in table 2. Table 2. Estimated damage to rail equipment. Personnel Information Amtrak Train-Operating Crew Engineer. The engineer was hired by Amtrak on December 22, 1998. He was promoted to engineer after he completed the Amtrak engineer class on March 10, 2000. He was assigned to on-the-job training as a student engineer from March 11, 2000, to January 30, 2001, when he was certified as a train service engineer. He was recertified as a train service engineer on January 23, 2003. He qualified on the CN operating rules and territorial characteristics in 2003. During the month before the accident he had transited the accident territory about 21 times. He received Amtrak’s PREPARE (Passenger Railroad Emergency Preparedness and Response Education) training on January 7, 2001. 11 Track panels are generally 39 feet long. They are preconstructed sections of two rails affixed to crossties. Car Number Car Type Damage Estimate 82 Locomotive $50,000 1223 Baggage $55,000 32036 Transition Sleeper $2,000,000 38009 Dining $2,000,000 33013 Lounge $700,000 31592 Coach $700,000 34069 Coach $650,000 34087 Coach $350,000 32005 Sleeper $215,000 34135 Coach $176,000 Total $6,896,000

Factual Information 10 Railroad Accident Report Conductor. The conductor was hired by Amtrak on April 13, 1993. He had previously been employed as a conductor by the Illinois Central (IC) Railroad in 1973, and worked the same territory on which the accident occurred. He was qualified on the CN operating rules on January 30, 2004, and completed air brake instruction on March 21,

1. He received Amtrak’s PREPARE training on September 11, 2002.

Assistant Conductor. The assistant conductor was hired by Amtrak in April

1. On June 18, 2002, he began his current assistant conductor position. He was

qualified on the operating rules on February 6, 2004, and on the territorial characteristics on July 7, 2003. He received air brake instruction on July 23, 2002, and Amtrak’s PREPARE training on April 25, 2002. CN Track Maintenance Personnel Track Supervisor. The track supervisor was hired in 1963 by the IC Railroad. He was promoted to general foreman in 1976. He became the supervisor for the Yazoo Subdivision in 1997. Track Inspector. The track inspector was hired by the IC Railroad in 1971 and worked for 5 years on a bridge gang. He later transferred to the track department and was promoted to track inspector in 1978. He has spent most of his career inspecting track throughout the Yazoo Subdivision. He regularly attended annual training on the operating rules and Federal Railroad Administration (FRA) regulatory guidelines covering track standards, which allowed him to maintain his qualifications as a track inspector. Track Foreman. The track foreman went to work for the IC Railroad as a laborer in 1969. He was promoted to track foreman in 1972, and 5 years later he became a track inspector. He worked various jobs before he began his current track foreman position in

1. He was responsible for the portion of the Yazoo Subdivision from MP 144 to

MP 217. 12 The track foreman attended a required 1-day on-track safety training class annually, annual operating rules training, FRA training in 2002, and a 2-day training session on standard practices circulars that included CN’s continuous welded rail (CWR) engineering policies. Track Welder. The track welder was hired by the IC Railroad in August 1996. In July 1999, he took a welder helper position, and in August 2000, a welder position. He had worked on the Yazoo Subdivision since 2002, and was currently assigned to Yazoo City, Mississippi, along with a welder helper. The welder had attended periodic annual training, which included welding instruction, CN’s practices and procedures contained in the standard practices circulars, and the operating rules. He had been trained on the FRA regulatory guidelines covering track standards, which allowed him to inspect track and supervise remedial actions. 12 The operating timetable designated the Yazoo Subdivision from MP 5.4 to MP 218.6.

Factual Information 11 Railroad Accident Report FRA Inspection Personnel Track Inspector. The track inspector went to work for the IC Railroad as a track laborer in 1972. Over the next 30 years he worked as a track foreman, a machine operator, a track inspector, a track supervisor, and a road master for the Kansas City Southern Railroad. He was hired by the FRA in January 2003. The inspector received classroom training covering 49 CFR Part 213, “Track Safety Standards,” and Part 214, “Railroad Workplace Safety,” of 1 week each. These classes also covered the use of the “Track Safety Standards Compliance Manual.” His other training included a 1-week orientation class, accident investigation, photography, report writing, and computer classes. Since starting with the FRA, he had attended two regional workshops that lasted several days and included various classes. He also had had 5 months of on-the-job training with senior inspectors, and he said, “I do have a mentor, and [on-the-job training] is the largest part of it ….” Toxicological Information The Amtrak engineer, conductor, and assistant conductor provided blood and urine specimens for toxicological testing as required by 49 CFR Part 219, Subpart C. Northwest Toxicology, Inc., Salt Lake City, Utah, conducted the tests. Specimens were screened for cannabinoids, cocaine, opiates, amphetamines, methamphetamines, phencyclidine, barbiturates, and benzodiazapines. All results were negative for the presence of alcohol and cited drugs. Meteorological Information In the Flora, Mississippi, area on April 6, 2004, the lowest overnight temperature was 45° Fahrenheit (F) about 4:00 a.m. The temperature rose to about 79° F in the afternoon. At the time of the accident, the weather was clear with a few broken clouds, there was a light breeze less than 10 mph, and the temperature was about 77° F. Before the accident there had been several weeks of little or no precipitation. The weather on dates related to this accident is described in table 3. The weather data were recorded at Jackson, Mississippi, about 40 miles southeast of Flora, Mississippi. On April 9, 2004, 3 days after the accident, the rail temperature near the point of derailment was measured at 114° F at 5:45 p.m. April 9 was sunny with a few clouds, and the maximum ambient temperature was 82.9° F.

Factual Information 12 Railroad Accident Report Table 3. Weather conditions in accident area (Jackson, MS) on selected dates.a Operations Information Train movements on the CN Central Division, Yazoo Subdivision, are governed by the CN/IC Railroad U.S. Operating Rules, Second Edition, the August 10, 2003, revision. The trains were authorized by signals using a centralized traffic control system operated by a train dispatcher in Homewood, Illinois. CN train crews used the Central Division Timetable/Special Instructions, effective August 10, 2003, for specific instructions about the territory. The timetable/special instructions indicated that the maximum speed for passenger trains in the area of the accident was 79 mph. Signal Information The derailment occurred on a single main track in centralized traffic control system territory that was signaled for movement in both directions, between the north end of control point Ragin, MP 198.0, and the south end of control point South Anding, MP 191.8. The traffic control system consisted of color-light wayside signals, power operated switch machines, and coded electronic track circuits controlled by the train dispatcher in Homewood, Illinois. Date Max. / Min. Temp. (°F) Avg. Wind Speed (mph) Visibility (miles) Sky Cover Precip- itation (inches) January 29b 56 / 24 2.1 9–10 Clear to 9 a.m. Overcast 9 a.m. to midnight. 0.00 March 6c 73 / 50 5.1 10 Clear all day. 0.00 March 9d 67 / 45 12.7 10 Clear with a few clouds 3–6 p.m. 0.00 March 10d 62 / 36 4.4 9–10 Clear all day. 0.00 April 6 80.6 / 39.2 0–6.91, avg. 2.3 10 Clear with a few broken clouds 4–9 a.m. 0.00 April 7 80.6 / 51.8 0–9.21 10 Partly cloudy all day. Trace April 8 80.6 / 51.8 0–12.7 0.25–10 Partly cloudy. 0.00 April 9 82.9 / 50 0–8.06 5–10 Clear with few clouds 1–5 p.m. 0.00 a Source: National Climatic Data Center, Asheville, North Carolina. b Date rail plug was installed. c Date track condition was inspected and reported. d Dates crossties were installed and area of repaired rail was tamped.

Factual Information 13 Railroad Accident Report Event Recorder Information According to the data from the event recorder, at 6:32:00 p.m. (event recorder time),13 the train was traveling 77 mph with the locomotive throttle in notch T3. The automatic brake pressure and the brake cylinder pressure indicated that the brakes were released and fully charged. At 6:32:13, the horn was sounded, and 1 second later the bell was activated. At 6:32:46 and 6:33:07, the alerter was acknowledged while the train speed and throttle remained unchanged. The throttle position was increased to notch T4 at 6:33:24. One second later the train speed increased to 78 mph. At 6:33:26, the horn was again sounded. At 6:33:27, the automatic brake handle was moved from the release position to the suppression position. One second later, the automatic brake pipe pressure began to decrease. The automatic brake handle was moved from suppression to emergency at 6:33:33 p.m. The event recorder indicated that the pneumatic control switch14 had opened and the brakes had an engineer-initiated emergency. With the throttle indicating “idle,” the train speed dropped and brake cylinder pressure increased until the speed decreased to 0 mph, 13 seconds later. The data further indicated that the locomotive traveled approximately 398 feet during those 13 seconds. Site Description The derailment occurred near Flora, Mississippi, at MP 196.5. The single track was oriented north and south. The train was traveling north when the derailment occurred. The milepost numbers decreased northward. Between MP 197.0 and MP 196.5, the track was straight with a very slight descending grade of 0.13 percent. The Big Black River Bridge was between MP 196.7 and MP 196.6. From MP 196.5 to MP 194.75 the track was level as it crossed the flood plain of the Big Black River. Part of the track through the flood plain was on a 6- to 8-foot fill area, or levee, between the bridges. At the end of the fill was a multispan concrete bridge over the remainder of the Big Black River flood plain. Beyond the flood plain from MP 194.75 to MP 194 there was an ascending grade of 0.34 percent. From MP 194 to near MP 192.9 there was an ascending grade of 0.14 percent reaching a flat area for approximately 1/2 mile. A train traveling in this area in either direction descends on a slight grade to the flood plain. Between 22 and 24 trains operated through the territory daily. Two of those trains were the northbound and southbound City of New Orleans passenger trains. The reported annual tonnage was about 44.4 million gross tons. 13 All times in this section are from the event recorder. The event recorder’s independent clock may indicate a time that differs from the correct time if the clock has not been calibrated recently. 14 The pneumatic control switch is activated by the emergency application of the brakes and translates this pneumatic activity into an electrical signal to drop the engine to idle and disable the power.

Factual Information 14 Railroad Accident Report CN designated the track as FRA Class 4 track, which permitted a maximum authorized speed of 60 mph for freight trains and 80 mph for passenger trains, according to 49 CFR Part 213, “Track Safety Standards.” Track Information The track in the accident area was CWR on wooden ties secured with tie plates15 and cut spikes. The rail was 136-pound rail manufactured by Tennessee-USA in October

1. CN did not maintain records of track installation dates, and railroads are not

required to keep such records. Postaccident Track Condition The first point of derailment was identified as MP 196.5, on the fill between the bridges. In January 2004, a 12-foot 11 1/2-inch portion of the east rail in this location was replaced with a replacement rail plug and bolted into place. The postaccident inspection of the gage side of the east rail revealed gouge marks 19.6 feet north of the rail plug. The west rail on the gage side opposite these marks exhibited similar gouge marks. The east rail was rolled over and spread east off the multispan bridge. The bolts of the north joint of the replacement rail plug had been sheared off, and the joint bars, bolts, and rail were separated. The south joint had strike marks on the joint bars on the gage side. The west rail was intact and resting in its original prederailment position. The intact west rail at the derailment site showed abrasion marks between the rail spikes and the inside base of the rail that indicated longitudinal movement of the rail. (See figure 5.) This rail movement was 2 inches. The east rail showed very little sign of longitudinal rail movement. Just south of the derailment site, the rail was box anchored16 at every tie on the 200-foot approach to the Big Black River Bridge. The rail on the open deck portion of the Big Black River Bridge was anchored on every tie with elastic metal clip fasteners.17 (See figure 6.) The anchor applies pressure on the top of the base of the rail. If a rail moves longitudinally, shiny areas appear where the anchor contacts the rail. No shiny areas were found on the open deck portion of the bridge. 15 Tie plates are rectangular pieces of steel placed under the rail to distribute the weight of a train over a greater area of the tie than the base of the rail alone. 16 Box anchoring places rail anchors on both rails across from each other against each side of a tie. 17 This type of fastener replaces both spikes and rail base anchors; it fastens the rail to the crosstie and also retards rail movement.

Factual Information 15 Railroad Accident Report North of the 200-foot approach to the Big Black River Bridge, in the direction of the derailment site, was evidence that rail anchors had been applied to every other tie from the gage side. (See figure 7.) Investigators found 281 crossties in the area and 295 anchors placed against the sides of the ties. If the ties were box anchored on every other tie, that is, two anchors on each rail on every other tie, there would have been 281 anchors on each rail. The west rail had 144 anchors (51.25 percent), and the east rail had 151 anchors (53.74 percent). Additional anchors were lying on the ballast near by or away from the sides of the crossties. Figure 5. Abrasion marks on west rail. Figure 6. Elastic metal clip anchors.

Factual Information 16 Railroad Accident Report Ballast. The crossties were surrounded by limestone ballast approximately 24 inches deep and 12 inches wide on the outside for shoulder support. The areas between the ties (the tie cribs) were filled with ballast. Near MP 196.6 at the north approach to the Big Black River Bridge were signs of improper drainage from fouled ballast.18 (See figure 8.) Title 49 CFR 213.103, the FRA regulation regarding ballast, states that all track shall be supported by material which will restrain the track laterally, longitudinally, and vertically under dynamic loads imposed by railroad rolling equipment and thermal stress exerted by the rails, provide adequate drainage for the track, and maintain proper track crosslevel, surface, and alignment. Tie Plates. The CWR was seated in 14- by 7 3/4-inch double-shoulder tie plates.19 The tie plates were designed with eight holes punched to accommodate two rail-holding spikes on both the field and the gage sides of the rails and two holes to secure the plate to the ties on each side of the rails. The rails were fastened to the crossties with 6-inch cut track spikes. Each tie plate had at least two spikes: a rail-holding spike on both the gage side and the field side. Additional spikes anchoring the plates to the ties were present at irregular intervals, particularly on the gage side. Figure 7. Ties with few anchors, indicated by arrows. 18 Fouled ballast refers to dirt intermixed with ballast. 19 A tie plate shoulder is a small raised portion of metal that forms a ridge next to the base of a rail to help properly position the tie plate and prevent the rail from shifting laterally.

Factual Information 17 Railroad Accident Report Crossties. The wooden crossties, or ties, were 8 feet 6 inches long with an average spacing of 19 1/2 inches between the centerlines of the crossties. Federal regulations, at 49 CFR 213.109, specify the condition of crossties required to provide support for the rail: they must not be “… broken through, split or otherwise impaired to the extent the crossties will allow the ballast to work through, or will not hold spikes or rail fasteners.” Each class of track requires a minimum number of ties that do not display the above defects for each 39-foot section of track. Class 4 track must have a minimum of 12 crossties in good condition for each 39 feet of rail on tangent (straight) rail and curves of equal to or less than 2°. Several crossties near the point of derailment were broken through and split and showed signs of not holding the spikes. (See figure 9.) Neither the number nor the pattern of defective ties exceeded those allowed by the regulations. The crossties and track surface had been rehabilitated in 1998. CN had planned to do the next rehabilitation project for this area in the first quarter of 2005, but after the Flora accident, it accelerated the schedule. (See Postaccident Actions in the Other Information section of this report.) Continuous Welded Rail CWR is subject to mechanically induced outside forces when loaded and to thermally induced internal forces from expansion or contraction. CWR must be longitudinally restrained to prevent rail movement caused by these mechanical and thermal forces. Longitudinal restraint in CWR generally takes the form of additional rail anchors, solid crossties, and compacted ballast. Figure 8. Fouled ballast.

Factual Information 18 Railroad Accident Report According to the American Railway Engineering and Maintenance-of-Way Association (AREMA),20 the magnitude of force that may be developed within CWR, independent of its length, is directly proportional to the difference in temperature between the “neutral rail temperature”21 and the current rail temperature. On a sunny, cloudless day, rail temperature can increase up to 50° F above the ambient temperature. Neutral rail temperature is the temperature at which there are no thermally induced forces in the rail. When the temperature of rail is different from the neutral temperature, internal forces develop within the rail. Rail anchors are an integral part of the track restraint system for CWR. Rail anchors prevent or restrict the longitudinal movement of the rail, localizing the compressive or expansive forces in the rail and allowing these localized forces to be uniformly distributed throughout the whole track structure. Without the restraint of sufficient, effective, and evenly distributed rail anchors, if temperatures are higher than the neutral temperature, the rail will expand. The expected amount of expansion or contraction of an unrestrained rail can be calculated using a standard formula that multiplies the rail length by the change in temperature and by the standard coefficient of expansion for steel rail.22 For example, a 1-mile section of unrestrained CWR can expand as much as 18.5 inches if it experiences a 45° F change in temperature. CN’s CWR program contains a CWR thermal expansion table that lists for given lengths of CWR how Figure 9. Ties that are broken and not holding spikes. 20 AREMA is an independent industry association that sets recommended standards of practice for railroad construction and maintenance. AREMA’s stated purpose is “The development and advancement of both technical and practical knowledge and recommended practices pertaining to the design, construction and maintenance of railway infrastructure.” 21 This is the same as the anchoring temperature, when the rail is free of any internal longitudinal forces. 22 The internal stress of restrained rail is the product of the coefficient of expansion and the modulus of elasticity of the steel multiplied by the change in temperature.

Factual Information 19 Railroad Accident Report much the length of the rail changes at various changes in temperature. (An abbreviated portion of CN’s thermal expansion table is in table 4.) In the absence of proper anchoring, compressive forces within the rail may build up and overcome the lateral restraint at the weakest point in the track, which may create a track buckle. These forces may lift the rail out of the tie plates. Because “rail tends to expand in the direction of least resistance, it often expands upward sufficiently to free it from lateral restraint,” which allows the rail to move laterally.23 To prevent such problems, rail anchors must be in good condition and properly placed. They must also retain their clamping strength and be tight against the side of the tie. Table 4. CN CWR Thermal Expansion Table. Railroads determine the temperature at which CWR will be under the least amount of stress throughout seasonal temperature changes, and this temperature is a railroad’s preferred rail laying temperature. The intent is to lay rail at a temperature at which the rail is subject to no internal forces and that closely matches the rail temperatures found for the rail for the majority of the year. For example, CN’s preferred rail laying temperature for most of Canada is 90° F, and the preferred rail laying temperature for the Central Division is 105°. In CN’s “Policy on Continuous Welded Rail,” dated April 2003, the preferred rail laying temperature is defined as the target temperature for CWR installation and anchoring. Track Maintenance History Since the beginning of 2004, several track maintenance procedures had been performed in the area near the point of derailment (MP 196.5). On January 29, welders cut out a 12-foot 11 1/2-inch portion of the east rail with a crushed rail head. When the piece of rail was cut out, the remaining rail pulled apart, and the replacement rail plug had to be 2 1/2 inches longer to fill the opening. The replacement rail plug was 13 feet 2 inches long. At that time, the rail plug was bolted rather than welded into place. The welder told investigators that the temperature was cold when the rail was repaired. The meteorological report for that day showed overcast conditions with a high of 56° F. After using a rail thermometer on the rail plug, the welder entered 60° F on the repair record, called a Non- 23 W.W. Hay, Railroad Engineering, 2nd ed., p. 588 (New York, NY: John Wiley and Sons, 1982). Temp. Change (°F) 200 (ft.) 400 (ft.) 600 (ft.) 800 (ft.) 1000 (ft.) 1200 (ft.) 1400 (ft.) 1600 (ft.) 35 5/8 in. 1 1/8 in. 1 3/4 in. 2 1/4 in. 2 7/ in.8 3 3/8 in. 4 in. 4 1/2 in. 40 5/8 in. 1 1/4 in. 1 7/8 in. 2 5/8 in. 3 1/4 in. 3 7/8 in. 4 1/2 in. 5 1/8 in. 45 3/4 in. 1 1/2 in. 2 1/8 in. 2 7/8 in. 3 5/8 in. 4 3/8 in. 5 1/8 in. 5 3/4 in. 50 3/4 in. 1 5/8 in. 2 3/8 in. 3 1/4 in. 4 in. 4 7/8 in. 5 5/8 in. 6 3/8 in. 55 7/8 in. 1 3/4 in. 2 5/8 in. 3 1/2 in. 4 3/8 in. 5 1/4 in. 6 1/4 in. 7 1/8 in. 55 1 in. 1 7/8 in. 2 7/8 in. 3 7/8 in. 4 7/8 in. 5 3/4 in. 6 7/8 in. 7 3/4 in.

Factual Information 20 Railroad Accident Report Compliance Work Report. The work report was submitted to the track supervisor to report the condition of the anchor pattern and ballast; the rail adjustment amount; the location, weight, and temperature of the rail; and the type of repair. The work report also had an entry for how the rail temperature of the rail plug related to the preferred rail laying temperature of 105° F. The welder said that he had not filled in that section of the report. Further, he explained that he did not know the formula to make those calculations and indicated that he would need guidance or training to do the calculations and complete that part of the form. The welder also explained that the dispatcher had allotted him 1 hour to make the repair because of the amount of train traffic in the area. The time allotted was not enough to weld the joints or to heat and expand the CWR, so he inserted a plug using joint bars at both ends. Because the rail pulled apart, or contracted, when the piece of rail was cut out, as noted above, and the welder had to add a longer piece of rail to fill the space, he was required to fill out a Non-Compliance Work Report. According to CN instructions, the welder was required to assess the status of the rail anchors for 200 feet from the repair site in each direction. On the Non-Compliance Work Report submitted for January 29, 2004, he had circled “Yes” to indicate that “Anchoring Pattern [was] in Accord With IC Policy.” He also added the word “Corrected” at the bottom of the page. He told investigators that he wrote this so that the supervisor would know that he had corrected the crushed head and replaced it with a good piece of rail. There were no records to indicate that the plug had been adjusted or shortened to the length of the rail replaced before the derailment. CN’s rail insert procedure required the welder to mark on the rail the difference in length between the piece of rail removed and the replacement rail. The welder could not recall whether he had marked or written on the rail. No markings were found on the rail plug after the derailment. One month before the accident, on March 6, 2004, an operating crew reported a track problem near MP 196.5. The conductor on the local train said that the track appeared to bow out on the east rail. The local track inspector found two locations near the derailment site with irregularities. He corrected a 1-inch-wide gage condition at the plug inserted in January but was unable to repair a profile24 problem at the north end of the multispan bridge over the flood plain. He opted to reduce the train speed through the area to 25 mph for freight trains and 30 mph for passenger trains. The track inspector told investigators that he remembered that some anchors were missing around the rail plug, but he did not remember seeing any rail movement to indicate that the rail was beginning to buckle. The inspection records submitted by the track inspector did not indicate that any action was necessary in connection with the rail anchor conditions. 24 Profile is the relative elevation of the two rails along the track. A profile condition is when the track structure dips or heaves. The dip normally occurs under the load of a train. The profile measurement is the deviation (up or down) at the mid-ordinate of a 62-foot chord.

Factual Information 21 Railroad Accident Report A few days later, the track foreman returned to the area to replace ties. Inserting the ties in two locations reinforced the correction of the gage problem and repaired the profile problem at the north end of the bridge. According to testimony by the track foreman, he “put the [existing] anchors back on” the area where the plug was inserted. As shown in figure 10, the new ties were not box anchored on every other tie. He maintained the speed restriction set earlier by the track inspector. The track supervisor visited the area where the inspector and the foreman had performed the track work. He told investigators that he thought it was around March 16. He noted that “they had left a couple anchors out on a tie.” Other than the missing anchors, however, he said, “… everything was to my satisfaction that day ….” CN had a table depicting the number of trains and the tonnage necessary to compact the track area that had been disturbed by the track work. Following CN railroad guidance for the number of trains and tonnage necessary to compact track after track work, train speeds were restricted to 25 mph for freight trains and 30 mph for passenger trains between MP 196.6 and MP 196.2 from March 6 to March 24. On March 24, the track supervisor determined that the necessary number of trains and tonnage had traversed the track, and he increased the train speeds to 60 mph for freight trains and 79 mph for passenger trains. The track supervisor told investigators that he entered the data from the Non- Compliance Work Report into a computerized rail defect tracking system (RDTS). He stated that the RDTS does not have a function that highlights anything that needs immediate attention when he accesses the system. He said that he believed that a system that alerted him to conditions that needed to be addressed would be an improvement. Figure 10. New ties with few anchors. Bracket indicates new ties. Arrows indi- cate anchors.

Factual Information 22 Railroad Accident Report The CN engineering superintendent stated that the RDTS was primarily used for tracking defective rails and that he does not use the system a lot. He added that the RDTS does not provide an overview of rail defects and that it could be improved. The CN division engineer said that the track supervisor handles the data from the Non-Compliance Work Report that are entered into the RDTS. He stated that the engineering superintendent audits some of the forms or checks field conditions, but not for every rail plug. According to the CN regional engineer, the RDTS has two functions: to store data about defective rail that has been replaced and to track corrective actions. He stated that he was not aware of a feature to alert the system user to locations where rail length has been changed, but that the system has the ability to sort the data by subdivision or by location where rail has been replaced. CN CWR Program CN’s CWR program in effect in 2004 was its “Policy on Continuous Welded Rail,” dated April 2003. This document superseded the IC railroad’s CWR program, which had been submitted to the FRA in February 1999. However, one employee told investigators that he had not received the latest CWR policy until after the derailment. The introduction to CN’s April 2003 CWR program regarding rail expansion states that “the distance that rail expands and contracts is directly proportional to the change in the temperature of the rail.” CN’s instructions (CN Standard Practices Circular (SPC) No. 3205, “Continuous Welded Rail,” revision 2, January 2003) to the maintenance-of-way employees identified the preferred rail laying temperature range of 105° F to 130° F. The instructions, under “General,” continue as follows: CWR will be installed and anchored within the [preferred rail laying temperature range] without further adjustment. CWR installed below the [preferred rail laying temperature] must be de-stressed25 as soon as possible after laying. De-stressing must be completed before any seasonal increase in temperature. The more specific instructions under “Maintenance” were as follows: Precautions must be taken to monitor the length of rail installed during rail changes. c) … the amount of rail added or removed will be marked on the rail and [reported] to the Track Supervisor. d) Track Supervisor will be responsible for the locations and amounts of rail added or removed. These locations, must, if required, have correct length plug installed and welded prior to the onset of warm weather. 25 De-stressing is the procedure used to readjust a rail’s temperature to the desired value. It typically consists of cutting the rail and removing rail anchoring devices, allowing for the necessary expansion and contraction, and then reassembling the track.

Factual Information 23 Railroad Accident Report From interviews with the local maintenance-of-way employees, the consensus was that adjusting for the seasonal increase in temperature was to be completed before May 1. The track supervisor stated, however, that when the accident occurred, he had 15 other locations where 2 to 3 inches of rail had been added during the winter that were on the priority list for welding before the warm weather. Federal Regulations Title 49 CFR 213.119(b) requires that railroads with CWR have in their CWR programs “rail anchoring or fastening requirements that will provide sufficient restraint to limit longitudinal rail and crosstie movement to the extent practical.” The CWR regulations further state that railroads shall have in effect: Procedures which specifically address maintaining a desired rail installation temperature range when cutting CWR including rail repairs, in-track welding, and in conjunction with adjustments made in the area of tight track, a track buckle, or a pull-apart. Rail repair practices shall take into consideration existing rail temperature so that— (1) When rail is removed, the length installed shall be determined by taking into consideration the existing rail temperature and the desired rail installation temperature range; and (2) Under no circumstances should rail be added when the rail temperature is below [the desired rail installation temperature range designated by the railroad],26 without provisions for later adjustment.27 CN Track Inspections and Testing Hy-Rail. The tracks were inspected from a hy-rail vehicle in the derailment site on April 4, 2004, 2 days before the accident, by a CN employee qualified under 49 CFR 213.7, “Designation of qualified persons to supervise certain renewals and inspect track.” The record of this inspection showed no track defects. However, the same track inspector had entered a crosslevel variance of 1 1/4 inches at MP 196.6 on the inspection reports from the previous week. Ultrasonic Rail Testing. CN tests its rail ultrasonically four to five times annually. The last seven tests were conducted on April 3, July 18, September 12, September 15, and December 8, 2003, and January 15 and April 2, 2004. Sperry Rail Service conducted the most recent ultrasonic rail test on April 2. The defect closest to the derailment that was found during this test, and repaired the same day, was a transverse detail fracture of 30 percent at MP 197.06, about 0.6 of a mile south of the derailment location. 26 CN’s range is 105° F to 130° F. 27 Title 49 CFR 213.119(c).

Factual Information 24 Railroad Accident Report Track Geometry Measurements. CN had tested the track geometry on the Yazoo Subdivision with its geometry test car.28 The most recent tests were performed on February 19, 2004, and December 5, July 10, and February 26, 2003. These four tests measured 22 separate locations that produced data indicating 20 locations of profile (crosslevel) deviations and 2 locations of wide gage between MP 196.0 and MP 197.0. The regulation allows profile variances for Class 4 track not to exceed 2 inches and wide gage not to exceed 1 inch. None of the nonstandard measurements exceeded the allowed variance specified by the regulations for Class 4 track. The number of noted variances also increased from February 2003 to February

1. In February 2003, the geometry tests had two notations of variances between

MP 196.0 and MP 197.0. For this same mile, 10 variations were found with the geometry test car in February 2004. CN Track Maintenance Procedures CN’s track maintenance procedures were assembled in its Standard Practices Circulars (SPCs). SPC 3601 addresses application and maintenance of rail anchors. The SPC that addresses general CWR maintenance is SPC 3205, “Continuous Welded Rail.” Following are relevant excerpts from that SPC discussing track buckling and the importance of rail temperature:

1. When practicable, rail will not be added to CWR track. In the event that

replacement rail of the same length cannot be installed and additional rail must be added the following guidelines will be met: when repairing a rail failure and rail ends have pulled apart, the distance separation of the two rail ends will be noted. If rail heaters or expanders are not available to assist in bringing the rail back to its original length, the length of the replacement rail, installed with a joint gap not exceeding 1/2 inch, plus the distance of separation will be marked on the rail and reported to the Track Supervisor. Locations of track buckle susceptibility are at bottoms of grades, track abutting immovable objects (switches, crossing frogs, road crossings, etc.), areas of recently disturbed track, marginal tie or anchor condition, fouled ballast, light ballast section or locations where heavy train braking or accelerating occurs. Indications of tight rail are bunched or pushing ties which are plowing ballast, rail running whether through rail anchors or with the anchors, rail lifting up under the spike heads, rail pushing against both shoulders of the tie plates, canting rail on curves, gaps at the ends of the ties indicating lateral movement of the track or track having a kinky alignment. When these signs are apparent, immediate remedial action will be taken by either placing a speed restriction or adjusting the rail. 28 This car takes dynamic measurements of the track geometry, which, among other things, includes degree of curves, gage, and rail elevation.

Factual Information 25 Railroad Accident Report

1. When it is evident that the neutral temperature of a section of rail has been

decreased to a level that a track buckle may occur, the neutral temperature should be adjusted back to the Preferred Rail Laying Temperature. The method of de- stressing involves removing rail anchors, cutting the rail and removing rail to achieve the correct rail laying temperature. Regulatory Oversight of CWR FRA Track Safety Program and CWR The FRA regulations covering CWR are at 49 CFR 213.119, “Continuous Welded Rail, General,” which states, in part: Each track owner with track constructed of CWR shall have in effect and comply with written procedures which address the installation, adjustment, maintenance and inspection of CWR, and a training program for the application of those procedures, which shall be submitted to the FRA by March 22, 1999. The FRA headquarters staff is responsible for reviewing the plans submitted by railroads in accordance with the regulation, as noted above. The plans are reviewed for CWR installation, adjustment, anchoring, rail temperatures (during installation, repair, and maintenance), monitoring, appropriate speeds, inspection, training for employees working on CWR, and record-keeping. The FRA enforces a railroad’s own CWR program, as detailed in the railroad’s written CWR plan and standards (if any). A CWR defect noted by the FRA generally reflects the failure of a railroad to comply with its own CWR standards. CN’s former owner, the IC, submitted its first CWR policy, dated February 1999, to the FRA. In 2003 CN submitted an updated version of its CWR policy. Before the accident, FRA headquarters staff had not reviewed either of the CWR programs submitted. After the accident, the FRA headquarters staff reviewed CN’s CWR program. (See Postaccident Actions in the Other Information section of this report.) FRA Track Inspections The FRA “Track Safety Standards Compliance Manual” cross-references sections of the Track Safety Standards with instructions and codes for defects found. Selected sections contain information for FRA inspectors regarding what they should look for during an inspection and how to code defects that are found. The Manual states the following regarding the identification and documentation of instances of noncompliance: A defect is a condition that is not in compliance with the Track Safety Standards. Defects are noted on inspection reports, which serve as notification to the railroad of FRA’s awareness of the defect’s existence …. An FRA inspector may choose to also take a violation for the defect, and so note the decision on the inspection form. …

Factual Information 26 Railroad Accident Report In many cases, documenting conditions of noncompliance is sufficient to achieve compliance with the Track Safety Standards. However, there are many instances where a condition warrants a violation. When recommending a violation, the inspector must prepare a well-documented narrative report describing the seriousness of the condition. … A non-complying condition under one set of circumstances may warrant a defect, while the same condition under a different set of circumstances may warrant a violation. The enforcement discretion considerations in Part 209, Appendix A require the Inspector to consider the inherent seriousness of the condition. The Manual is available on the Internet. This access to the Manual gives railroads the opportunity to learn what FRA inspectors look for during inspections based on the different sections of the Track Safety Standards from 49 CFR Part 213. The section of the Manual covering 49 CFR 213.119 contains instructions to FRA inspectors concerning the CWR programs submitted by railroads: Inspectors must be aware of the procedures in effect before inspecting each railroad. When conducting inspections, the Inspector must make observations to determine if the railroad is following its basic safety procedures. Further, the Manual explains that there are procedures for a railroad to perform maintenance work on the track without complying specifically with the guidelines of its CWR program. However, a railroad must have a method of recording this work and a process through which the work is later corrected to comply with the railroad’s CWR program. The Manual stresses the point that just recording the noncompliance situation is not enough; the followup work to correct the noncompliance is necessary to avoid a track defect violation. The FRA inspector based in Petal, Mississippi, was responsible for a territory covering north central Mississippi south to the Gulf Coast, which includes the area around Flora. The inspector had copies of CN’s two CWR programs (February 1999 and April 2003), and he stated that he used them to check CN’s compliance with its own CWR maintenance instructions. He said he used the FRA “Track Safety Standards Compliance Manual” to guide his inspections. He said that during his inspections he specifically checks an employee’s awareness “… of what’s in [the railroad’s] program and [the employee’s] noticing the conditions … in the field.” This FRA inspector, accompanied by CN’s track inspector, had conducted two recent track inspections before the derailment: for 3 days in June 2003 and 3 days in February 2004. These inspections were not identified as followup inspections, and even though several defects were noted, no violations were filed. The FRA inspector stated that two of the inspection reports from June 2003 contained comment items. He explained that information about upcoming program maintenance work schedules for a particular portion of a territory guided his decision whether to write in the comment section. His goal was to inspect the Amtrak and hazardous materials routes twice a year.

Factual Information 27 Railroad Accident Report From the June 2003 track inspection, the inspector’s comment on June 10 pertained to the area between MP 145 and MP 180. The comment was “… [at] numerous locations tie distribution is marginal, rail anchors are ineffective against longitudinal displacement.” The inspector’s comment on June 11, 2003, pertained to the area between MP 180 and MP 217. The comment was “… numerous locations [have] marginal effective ties and the rail anchors are not controlling longitudinal displacement.” The FRA track inspector stated that the CN inspector who was with him during the inspections agreed with the conditions noted in the comments, but the FRA inspector did not expect the railroad to “follow through with the repairs” on those items, and he noted that the railroad was not required to make the repairs because they were not entered as defects. In interviews, the FRA track specialist, who was the FRA inspector’s technical advisor, said he also did not expect the railroad to make repairs based on comment items. Postaccident FRA Inspections The FRA conducted a walking inspection of the track on either side of the derailment on April 8, 2004. The report from that inspection noted 4 fouled ballast locations and identified 28 loose rigid rail braces at the turnouts at a nearby siding. The four fouled ballast locations were at MPs 197.6, 196.3, 196.1, and 195.8. The fouled ballast locations also had profile deviations of 1/2 to 3/4 inch. The regulation allows for a 2-inch profile deviation in Class 4 track. The FRA performed a focused inspection on the entire Yazoo Subdivision29 April 26–28, 2004. The report from this inspection included 7 record-keeping defects and 130 track defects that required remedial action by CN. In addition, the FRA found 24 occurrences of failure to comply with CN’s written CWR procedures (insufficient anchors), 5 locations with insufficient anchorage to restrain rail movement in turnouts, and 1 location where the crosstie condition was unacceptable, at MP 188.0. Equipment Maintenance, inspection, and repair records for the locomotives and all cars in the train were reviewed. Additionally, the locomotives and all cars on the train were mechanically inspected and evaluated after the accident. The results of those inspections are detailed below. Preaccident Inspections Each car in the train was mechanically inspected prior to departure. There were no unrepaired defects at the time of departure. Additionally, all the cars were up to date in Amtrak’s ongoing preventative maintenance program. 29 The Yazoo Subdivision includes the territory inspected by the FRA before the accident, but it is larger than that territory.

Factual Information 28 Railroad Accident Report The locomotive was within all required inspection parameters, and the required information was recorded and maintained on the locomotive unit. Postaccident Inspections The foundation brake rigging, wheels, and underframe were inspected on the locomotive unit and each car after the accident. The overturned cars were inspected in both the horizontal and vertical positions. Each car and the locomotive unit had friction burns from metal-to-metal contact. Those marks were lighter under the locomotive unit and baggage car than under the rest of the train. A significant impact mark was noted on the number 7 wheel and brake disk of the transition sleeper, and a similar mark was noted on the number 5 brake disk of the dining car. The connecting rods and lateral guide links were deformed rearward, beginning at the trailing end of the transition sleeper and continuing toward the rear of the train. Those components on the leading end of the transition sleeper were not bent. Inspection of the wheels, brake disks, and brake pads of the trailing car (an unoccupied coach car) indicated normal contact and wear patterns. The wheels and brake disks were worn smooth and were shiny, but were within their respective tolerances. All the brake pads were worn, but none had reached its condemning limit, or the point at which it required repair. A postaccident air brake test equivalent to an initial terminal air brake test was performed on the locomotive unit and baggage car, and they successfully completed it. Because the passenger cars had damaged components, a postaccident air brake test could not be performed on them. However, brake pipe pressure was maintained on the rear car for 2 days after the accident. Each passenger car in the train displayed normal contact and wear patterns similar to those on the trailing car. The locomotive engineer stated that the brakes had handled as expected throughout the trip. Emergency Preparedness Amtrak Personnel Emergency Preparedness Training Amtrak has developed an emergency preparedness training program for its crewmembers as required by 49 CFR Part 239. The purpose of Amtrak’s 8-hour Passenger Railroad Emergency Preparedness and Response Education (PREPARE) is to prepare operating crewmembers and on-board employees to respond to train emergencies. Amtrak had until January 29, 2001, to ensure that all current crewmembers received the initial PREPARE training.30 The regulation requires refresher training once every 2 years after the initial training has been completed. 30 Title 49 CFR 239.101.

Factual Information 29 Railroad Accident Report In the weeks following the accident, Amtrak provided Safety Board investigators with the emergency preparedness training records for all the Amtrak employees on the accident train. According to the training records provided by Amtrak from its database after the accident, 8 of the 12 crewmembers on board the train had attended a PREPARE training course in the 2 years before the accident. For the remaining four crewmembers, Amtrak’s records indicated that one crewmember had never received PREPARE training, and three were not current because they had gone more than 2 years without the required training. More than a year after Amtrak provided its training records, Amtrak located additional records that were not in the database. These records show that three more crewmembers were current with PREPARE training, bringing to 11 the number of crewmembers who had received the required training. On March 14, 2003, Amtrak officials told Safety Board investigators that Amtrak is “currently improving … technological resources to afford [Amtrak] the opportunity to better track PREPARE training for all active on-board service personnel.” Amtrak hopes that these improvements will allow it “to better monitor the status of all active employees’ PREPARE training.” Amtrak Emergency Preparedness Training for Communities On June 9, 1999, an Amtrak emergency preparedness manager provided training to approximately 21 members of the Yazoo City Fire Department, the Bentonia Volunteer Fire Department, the Benton Volunteer Fire Department, and the Tri-Community Volunteer Fire Department in Yazoo, Mississippi. The training course was Amtrak’s Passenger Train Emergency Response course, known as SAFE 015.31 The same Amtrak emergency preparedness manager conducted another SAFE 015 course in Meridian, Mississippi, on February 23, 2004. A Ridgeland Fire Department captain attended the training in Meridian. According to records provided by Amtrak, no firefighters from 8 of the 10 fire departments that responded to the Flora accident have attended any training provided by Amtrak. (See appendix B.) CN Emergency Preparedness Training According to CN, since November 2003 it has provided nine training opportunities for emergency responders from Madison and Yazoo Counties. This training included CN 911 Tank Car/TRANSCAER/Emergency Responder and Grade Crossing Collision Investigation presentations. State, local, and volunteer firefighters, paramedics, and emergency management agencies were invited to attend these training opportunities. A 2-day training session was conducted in Canton, Mississippi, (Madison County) February 11–12, 2004. The first day was for emergency responders, and the second day was for law enforcement responders. Two 2-hour sessions were offered on February 11 for all emergency management and fire department personnel within a 1 1/2-hour drive of the Canton area. CN sent a notice for the February 11 training to representatives from 40 31 SAFE 015 includes instruction on safety on railroad property and equipment, contacts for the region’s railroads, familiarization with Amtrak’s equipment and crew, and emergency access to the passenger cars and locomotives, among other subjects.

Factual Information 30 Railroad Accident Report emergency response agencies in the Canton area. According to records provided by CN, the notice was not sent to the following agencies that responded to the derailment on April 6, 2004: Madison County Emergency Management Agency, Madison Fire Department, Flora Volunteer Fire Department, Kearney Park Volunteer Fire Department, Gluckstadt Volunteer Fire Department, Southwest Madison Volunteer Fire Department, Bentonia Volunteer Fire Department, Camden Volunteer Fire Department, and Farmhaven Volunteer Fire Department. A total of 6 firefighters from the Flowood Fire Department, 18 firefighters from the Canton Fire Department, and 1 firefighter from the Jackson Fire Department attended the training on February 11. None of these departments responded to the derailment. Madison County Emergency Preparedness Training The Madison County Emergency Management Agency director told investigators that the Madison County emergency plan was not implemented as a result of this accident. In addition, according to the director, there had not been any countywide disaster drills before the accident. Survival Factors Superliner Passenger Car Emergency Windows During an on scene inspection of the sleeper car, Safety Board investigators noted an emergency window handle that had been partially pulled free from the rubber grommet surrounding the window. One screw had pulled right through the rubber grommet. The window handle is normally attached to the grommet with two steel screws that are about 1 1/4 inch long and have a head diameter of 1/4 inch. When investigators attempted to open the window, the second screw also pulled right through the rubber grommet, leaving the grommet and window in place, preventing removal of the window for emergency egress. (See figure 11 for a photograph of the emergency window handle.) The grommet was not marked with a date of manufacture. Title 49 CFR 239.107 requires that a representative sample of emergency windows be tested at least once every 180 days and that the window inspection and maintenance records be kept for 2 calendar years. Prior to the accident, Amtrak’s Preventive Maintenance and Standard Maintenance Procedures outlined requirements to test and remove only one emergency window during each maintenance cycle (typically every 3 months). These procedures did not require documentation of which emergency window was removed and inspected. Title 49 CFR 238.113 requires that each main level of a passenger rail car have a minimum of four emergency windows and that the windows allow rapid and easy removal without the use of tools. All windows on the Superliner passenger cars are emergency windows. Each is equipped with a handle to remove a rubber grommet that surrounds the window and holds it in place. Once the rubber grommet is removed from the window assembly, the window itself can be moved.

Factual Information 31 Railroad Accident Report Since the accident, Amtrak has informed Safety Board investigators that it will increase to four the minimum number of emergency windows tested per car during each 3- month cycle for all Superliner, Surfliner, and Viewliner passenger cars. If a failure is detected during the inspection, the same number of additional windows will be tested to ensure compliance and operability. Amtrak has stated that it will also record in its maintenance database the location of each window tested on each car, and its Standards and Compliance Group will randomly audit the database. According to Amtrak, this new procedure will ensure that every emergency window on each passenger car will be tested at least once every 4 years. Additionally, at Amtrak’s request, as of July 2004, both emergency window handle manufacturers began stamping the date of manufacture on the handle area of the window gasket assembly. Other Information The last train over the accident location before the arrival of train No. 58 was a southbound freight train, CN G89291-04, at 4:30 p.m. on April 6. It consisted of 2 locomotive units, 132 loaded freight cars, and 3 empty freight cars. The empty cars were the 21st, 24th, and 30th from the head end. The train weighed 17,118 tons and was 8,200 feet long. Thirty-two cars were set out at Jackson, Mississippi. After the derailment, those 32 cars were mechanically inspected at Jackson, and the remainder of the train was inspected at Collins, Mississippi. No defective cars were found during those inspections. Figure 11. Emergency window handle that partially pulled free from rubber grommet.

Factual Information 32 Railroad Accident Report Previous Derailment On July 18, 1997, the IC Railroad (the previous owners of the railroad) had a derailment at MP 196.8. According to the FRA database, 12 cars of a 125-car train derailed. Two hazardous materials cars released their product, and 4,000 local residents were evacuated. There were no deaths or injuries. The database indicates that the cause of the derailment was “track alignment irregularity (buckled/sunkink).” 32 Postaccident Actions CN. CN has started the track structure rehabilitation program that was planned for the first quarter of 2005. The local engineering superintendent stated that since May 2004, crews have replaced 52,322 defective ties, about one-third of the existing ties, reapplied rail anchors, added ballast, and tamped the ballast around and under the ties between MP 164 and MP 217. CN also installed 34,853 new ties, which accounted for about a third of the ties, and surfaced the track between MP 92.7 and MP 124.0. FRA. After the accident, the FRA headquarters staff reviewed CN’s CWR program. The results of that review were sent to CN in a June 22, 2004, letter that recommended that CN clarify several terms and phrases used in the CWR program. One of the phrases CN was asked to clarify was “onset of warm weather.” As of July 26, 2005, the FRA had not received a response to its request for clarification. After the accident, Safety Board investigators asked the FRA whether it had audited Amtrak’s records of employee training. The FRA had no record of this type of audit for the region in which the Flora accident occurred. However, between April 26 and 29, 2004, the FRA reviewed employee training records as part of an audit of Amtrak’s passenger train emergency preparedness program (49 CFR Part 239) for the Northwest Region of the Pacific Division, which includes Amtrak’s operations in Oregon, Washington, Idaho, and Montana. For one group of employees, one-third (10 out of 30) had not received the PREPARE training within 2 calendar years. For a second group of employees, two-thirds (four out of six) did not have the PREPARE training within 2 calendar years. The FRA filed two violations based on these findings. Mississippi Emergency Management Agency Emergency Preparedness Training. Since the accident, the Mississippi Emergency Management Agency has conducted incident command system training in Madison and Yazoo Counties. The 16- hour course was conducted in Madison County on April 28 and 29, 2004, and in Yazoo County on May 17 and 18, 2004. The purpose of this course was to provide the necessary training for all agencies in every county to be familiar with the National Interagency Incident Management System that was standardized for all responses by the Mississippi governor’s Executive Order 851 in October 2001. Attendees of these courses included emergency responders from agencies that responded to the April 6, 2004, derailment: fire departments (including volunteer agencies), emergency medical services, law enforcement, emergency management, the American Red Cross, and the Mississippi Department of Health. 32 Sunkink refers to a heat induced expansion of the rail that results in misalignment of the rail.

33 Railroad Accident Report Analysis The Accident The Amtrak City of New Orleans passenger train derailed on April 6, 2004, at approximately 6:33 p.m. between two bridges near Flora, Mississippi. The engineer noted that the rail ahead of the train and between the bridges was “kinked,” and he attempted to slow the train from 78 mph. Before he could stop, the train reached the irregularity, and the train started derailing. The engineer applied the emergency brakes while the train continued to derail. The derailing train stripped the east rail out from under the locomotive; the engineer said he could see the right hand rail roll over in front of the locomotive. The derailed locomotive continued rolling onto the second bridge before it stopped. The train broke away from the baggage car (directly behind the locomotive) and tipped over to the right. Most of the passenger cars slid to a stop on their sides at the bottom of the flood plain of the Big Black River. Only the locomotive, the baggage car, and the unoccupied last car remained upright. Exclusions None of the Amtrak on-board personnel reported any significant problems or unusual events involving the equipment during the train’s preaccident journey. The engineer said that the train had handled as expected and he did not recall any signal or train control problems. Postaccident inspections of the train, subsequent tests of the braking systems, and a review of vehicle maintenance records did not indicate any problems with the train equipment. Therefore, the Safety Board concludes that Amtrak train No. 58 and its related equipment functioned as intended and did not cause the derailment. A review of the event recorder data with respect to train handling showed that before the locomotive passed over the track irregularity, the engineer handled the train in accordance with accepted practices and procedures. Postaccident drug and alcohol testing results for the train operating crewmembers were negative. The work-rest histories of the train-operating crewmembers indicated that fatigue had no role in the accident. Therefore, the Safety Board concludes that the operation of the train was not a factor in the accident. The postaccident testing of CN signal equipment and the train control system demonstrated that they worked as intended. No communications problems were reported among the train-operating crewmembers or between the train crew and the dispatcher.

Analysis 34 Railroad Accident Report Track Condition The conditions leading to the rail shift at the point of derailment had developed over time since the plug had been inserted in the rail in January 2004. When the welder installed the plug, he had three options for adjusting the CWR correctly: cut the plug to the same dimensions as the original piece of rail and heat the rail on both sides of the plug before installation; secure the existing rail with additional anchors before cutting out the defective piece to prevent the cold rail from shrinking away from the cut; or insert a plug longer than the original piece of rail and return later, before the onset of warm weather, to adjust the rail to the proper length. The welder chose the third option and marked the correction form to note that this plug needed adjusting before the “onset of warm weather.” Because an increase in temperature can increase the potential for track failure in CWR, the phrase “before the onset of warm weather” is inadequate for specifying when an adjustment needs to be made. Adjusting CWR correctly in relation to temperature changes requires monitoring of actual temperatures. According to the testimony of the track maintenance employees, informal policy set May 1 as the date for the onset of warm weather. On the day of the accident, April 6, the air temperature was approximately 80° F with broken clouds. Three days later, a similar day with a temperature of 82.9° F and a few clouds, the rail temperature was measured to be 114° F. Rail temperatures can be much greater than the ambient temperature, depending on the amount of radiant heating by the sun. The rail plug was inserted at a temperature of 60° F in January. The standard neutral rail temperature for the surrounding rail should have been the same as the preferred rail laying temperature of 105° F. When the plug was inserted at the lower temperature and fitted against the existing rail, it changed the neutral rail temperature of the existing rail to well below the original neutral rail temperature. When the weather changed, the entire rail, including the rail insert with the lower neutral temperature and the rail on both sides of the insert, heated up and expanded, creating internal compression forces in both the existing rail and the new plug, which was tight against the existing rail. Three critical components of the track structure that help secure the rail and counter the forces during an increase in temperature that causes the rail to expand are the number and pattern of effective anchors applied tightly against the sides of the crossties, the effectiveness of the ties in holding the spikes to prevent the rail from lifting from the compressive forces, and the presence of ballast tamped around the tie and applied to the shoulders to prevent the ties from moving. Approximately 50 percent of the anchors were ineffective. There were split ties and ties in marginal condition with reduced spike-holding ability. Even though several locations had fouled ballast, there appeared to be enough shoulder ballast to prevent the track from moving laterally. The ineffective anchoring and the marginal tie condition were the weakest of the three rail restraints. When the rail expanded in the heat and tried to “run” longitudinally, it moved northward away from the Big Black River Bridge. Exacerbating that movement was the

Analysis 35 Railroad Accident Report speed reduction through the derailment site between March 6 and March 24, 2004. As a train approached the speed reduction from either direction, the train brakes were applied. Because of the frictional forces between the wheels and the rail during deceleration, the rail was pushed ahead of the train. At the bridge the rail was anchored solidly with elastic clips, and the rail could not move longitudinally in that area. However, because the rail was not anchored effectively in the area away from the bridge, its ability to move longitudinally increased the compressive forces within the rail between the bridge structures. With the adequate shoulder support from the ballast preventing the track structure’s lateral movement between the bridges, the east rail could move only upward to relieve the forces within it. The east rail started to bow, and the spikes were lifted out of the ties because the ties were split and could not hold the spikes effectively. The rail is designed to rest in a metal tie plate with raised portions against the outside and inside of the rail that help prevent lateral movement when secured to ties imbedded in well-tamped ballast. Once the rail bowed high enough to clear the raised portions on the tie plates, the rail moved more easily outward. At MP 196.5, the east rail moved enough laterally to widen the gage of the rail and allow the wheels of train No. 58 to drop between the rails. The west rail remained intact, resting on the tie plates, and appeared to be moderately secure. The Safety Board concludes that the inadequately restrained east rail lifted out of the tie plates because of expansion caused by warm temperatures resulting in the rail shifting and the gage widening, causing the wheels of the train to drop between the rails. Track Maintenance CN CWR Maintenance and Inspection CN’s instructions for the maintenance of CWR addressed the installation of rail plugs and the adjustment required before the onset of warm weather if a plug is installed during cold weather. Because he did not use rail heaters or expanders to achieve the desired CWR adjustment at the time the rail plug was installed in January 2004, the welder was required to mark the rail for later adjustment and make a report to the supervisor. Many of the conditions that can cause rail to be susceptible to buckles and compression forces, as noted in CN’s CWR maintenance instructions, existed at the accident location. These include location at the bottom of a grade, abutting an immovable object (the Big Black River Bridge), location in an area of recently disturbed track (ties were inserted in March), marginal tie or anchor condition, and heavy train braking. The track welder installed the plug in January 2004. He entered both the temperature of the inserted piece of rail and the number of inches of added rail into the repair form. He was also required to mark the rail plug with the amount of rail added. However, no markings were found on the plug after the accident, so it is unlikely that the rail had been marked. The track welder also noted on the repair form that he had checked the anchor pattern for 200 feet from the insert in both directions and the proper number of anchors were there. However, postaccident observations found that only about half of the anchors were in functioning positions against the sides of the ties, and those anchors were not enough to retard or restrain the longitudinal rail movement. It is unlikely that the condition of the anchors had changed much between January and the time of the accident.

Analysis 36 Railroad Accident Report Further, on March 6, 2004, the track inspector made repairs at the location of the rail insert. He remembered seeing that some of the anchors were missing but since he did not see any rail movement (longitudinally) he considered their absence to be inconsequential. A few days later, the track foreman put some new ties under the rail plug. The foreman recalled that the rail anchors that were removed from the old ties were put on the new ties. The postaccident examination showed that anchors were not applied box style on every other tie of the new ties as required by the CWR program. Following these 2 separate days of work by the track inspector and the track foreman, the track supervisor visited the site to evaluate the work performed by them and the welder. He told investigators that the work was satisfactory but noted that a couple of anchors had been left off. Between January and March 2004, four maintenance employees (welder, track inspector, track foreman, and track supervisor) had been at or near MP 196.5 on four different occasions, and all four employees said they had examined the condition of the anchors. However, even though CN’s standard for anchors in CWR was full box anchoring on every other tie, none of the four employees adjusted or added anchors although half of the anchors were missing or not against the sides of the ties. Further, CN did not have an adequate system to alert key personnel of critical maintenance activities, such as followup rail adjustments before the onset of warm weather. The Safety Board concludes that although CN had written instructions for maintaining CWR and preventing track buckling, track employees at multiple levels did not follow or ensure adherence to these instructions. The Safety Board also concludes that had the employees who maintained the track at the accident site followed the written procedures the rail shift condition likely would not have occurred. Therefore, the Safety Board believes that CN should establish an audit program to verify that employees follow the current written track maintenance and inspection procedures, including rail anchoring requirements and specifically maintaining the preferred rail laying temperature. FRA Oversight The FRA is responsible for determining the adequacy of a railroad’s CWR program, but the FRA did not review either the old IC program or the CN program before the accident. This type of oversight deficiency was identified by the Safety Board during its investigation of a January 18, 2002, derailment near Minot, North Dakota.33 The FRA’s failure to evaluate rail carriers’ CWR programs until after serious rail accidents is particularly disturbing given the movement of trains carrying passengers and hazardous material over rail routes throughout the country and the serious consequences that can result when a derailment occurs. Since the Flora accident, the FRA has reviewed CN’s CWR program and has asked the railroad to clarify certain details within the program. One of the details the FRA has asked CN to clarify is the specific meaning of the phrase, “onset of warm weather.” This is important in connection with the Flora accident because the CWR where the oversized rail plug was inserted near the derailment site needed to be adjusted before it was affected by the increasing temperature. 33 National Transportation Safety Board, Derailment of Canadian Pacific Railway Freight Train 292- 16 and Subsequent Release of Anhydrous Ammonia Near Minot, North Dakota, January 18, 2002, Railroad Accident Report NTSB/RAR-04/01 (Washington, DC: NTSB, 2004).

Analysis 37 Railroad Accident Report Before the Flora accident, although the FRA inspector had the railroad’s CWR program and he found areas in which the ties were marginal and the rail anchors were ineffective against longitudinal displacement, he did not write up any defects, nor did he identify instances where anchors were not applied box style on every other tie. However, such instances were found and identified as defects after the accident prompted a more focused FRA inspection. The FRA inspector had several methods available to inform the railroad of corrections necessary to improve the track conditions. The most severe was to note a defect and file a violation on that defect. An alternative was for the inspector to note a defect, but not file a violation, which gives the railroad time to correct the problem. A third method, which he used, was to write comments to the railroad, although this method has no enforcement element. Later, the FRA inspector and the FRA track specialist agreed that the railroad was not required to respond to written comments and they did not expect the railroad to make repairs based on comment items. In his written inspection comments to CN in June 2003, the FRA inspector characterized the anchoring as “ineffective against longitudinal displacement,” indicating that the rail could move because of changes in temperature. However, in a February 2004 return visit to the same territory, the FRA inspector did not comment on the condition of the anchors, and no records were found to indicate that anchors had been applied between June 2003 and February 2004 to meet CN’s CWR program requirement that anchors be applied box style on every other tie. An inspection after the derailment found that approximately 50 percent of the anchors in the area of the accident were missing or not properly positioned. Although the FRA inspector had brought the anchor deficiencies to CN’s attention about 10 months before the accident, he did not link this deficiency to CN’s CWR program and communicate the problem in a formal way—as a defect—that would have likely prompted corrective action by CN. The Safety Board concludes that although an FRA preaccident inspection identified track deficiencies, the FRA’s oversight was not effective in ensuring corrective action by CN. The Safety Board believes that the FRA should emphasize to its track inspectors the importance of enforcing a railroad’s CWR program as a part of the Federal Track Safety Standards, and verify that inspectors are documenting noncompliance with the railroad’s program. Emergency Response Immediately following the derailment, an Amtrak crewmember in the dining car of the accident train called the Madison County Sheriff’s Office (911) on his cellular telephone to report the accident. He was able to provide the 911 dispatcher with detailed information about the number of passenger cars derailed, the number of passengers, and the location of the derailment. The Madison County 911 dispatcher immediately dispatched people from the Madison County Sheriff’s Office, the Kearney Park Volunteer Fire Department, and the Flora Volunteer Fire Department. Within 16 minutes of the derailment, the Madison

Analysis 38 Railroad Accident Report County Sheriff’s Office arrived on scene. Approximately 3 minutes later, the first firefighter (the chief of the Flora Volunteer Fire Department) arrived on scene. The location of the derailment was approximately 1 1/2 miles from the nearest paved road. Although the derailment occurred in a remote area, emergency responders were able to find the derailment site and respond quickly. When the chief of the Flora Volunteer Fire Department arrived on scene, he immediately began to triage the injured passengers on the train. As the first responding firefighter (and most senior responder on the scene), the chief should have established a command post, declared himself incident commander, and initiated the formal management of the emergency response. If he had established command, the resources needed for the emergency response could have been better managed at the beginning of the response. During the period in which there was no official command post or incident commander, emergency responders were responding to the scene and assisting with injured passengers. The emergency responders were gathering the passengers together to ensure that everyone was either evacuated or in the process of receiving medical treatment. The establishment of the command post and the staging and triage areas by the EMS director organized the emergency response operations already in progress. The establishment of incident command made it easier to allocate proper resources to the search for and triage of passengers and the extrication and medical transport of injured passengers. The survival of victims of a mass disaster may be directly attributable to the decisions made by medical and fire rescue personnel at the scene. These critical decisions include the allocation of resources, such as medical, fire, and rescue personnel and equipment. The purpose of the incident command system at the scene of a disaster is to methodically allocate resources and objectively make important decisions in an emotionally charged atmosphere with potentially life or death consequences. The Madison County Emergency Management Agency director told investigators that there had not been any countywide disaster drills before the accident. Such drills provide emergency response agencies the opportunity to test their response, communication, and coordination with each other. A disaster drill also provides an opportunity to test the effectiveness of the incident command system in managing an emergency. Madison County emergency responders at the Flora accident were able to work well and effectively together even though they had not practiced or drilled together before the accident. However, the lack of an established incident command during the early stages of the response could have had a serious negative effect on the overall response. Since the accident, the Mississippi Emergency Management Agency has conducted incident command system training for emergency responders in Madison and Yazoo Counties. The 16-hour course was conducted in Madison County in April 2004 and in Yazoo County in May 2004.

Analysis 39 Railroad Accident Report Emergency Preparedness Amtrak Crewmember Emergency Preparedness Training During emergency situations, particularly those involving passenger evacuations, the train crew and on-board service personnel are responsible for managing and directing the safe evacuation of passengers. Passengers rely on the training, experience, and leadership of the on-board service personnel. Required periodic emergency situation training should prepare the train crewmembers to perform their duties confidently when emergency situations occur. This periodic training is important because policies and procedures change over time, both skills and memory erode unless exercised and emergencies are rare, and the training is required by Federal regulation. Although Amtrak is required to train current and new employees in emergency procedures, of the 12 crewmembers on train No. 58, 1 had gone more than 2 years without retraining. Title 49 CFR Part 239 has been in effect since January 1, 1999; therefore, Amtrak has had ample time to train all of its crewmembers.34 The Safety Board has long been concerned with the emergency preparedness training of Amtrak crewmembers and has previously made six recommendations (Safety Recommendations R-79-36, R-83-24, R-83-72, R-89-35, R-93-23, and R-98-59) to Amtrak regarding this issue. (Appendix C has a list of previous Safety Board recommendations relating to the issues addressed in this accident.) Safety Recommendation R-79-36,35 which asked Amtrak to establish a program to train crewmembers in the proper procedures for care of passengers in derailment and emergency situations, was classified “Closed—Acceptable Action” on October 8, 1980, after Amtrak said that all employees had received training and that an ongoing training program was in place. In response to Safety Recommendations R-83-2436 and R-83-72,37 Amtrak developed an advanced 4-hour course on emergency procedures for on-board crewmembers and supervisory personnel.38 Safety Recommendation R-89-3539 asked Amtrak to develop procedures and equipment for evacuation of passenger cars involved in 34 Title 49 CFR 239.101 provided a 2-year grace period commencing on January 29, 1999, for completing the initial training for current employees and training within 90 days of hire for new employees. After the initial training, periodic training is then to occur at least once every 2 years. 35 National Transportation Safety Board, Rear End Collision of Conrail Commuter Train No. 400 and Amtrak Passenger Train No. 60, Seabrook, Maryland, June 9, 1978, Railroad Accident Report NTSB/RAR- 79/03 (Washington, DC: NTSB, 1979). 36 National Transportation Safety Board, Derailment of Amtrak Train No. 5 (the San Francisco Zephyr) on the Burlington Northern Railroad, Emerson, Iowa, June 15, 1982, Railroad Accident Report NTSB/RAR-83/02 (Washington, DC: NTSB, 1983). 37 National Transportation Safety Board, Fire Onboard Amtrak Passenger Train No. 11, Coast Starlight, Gibson, California, June 23, 1982, Railroad Accident Report NTSB/RAR-83/03 (Washington, DC: NTSB, 1983). 38 Safety Recommendation R-83-24 was classified “Closed—Acceptable Action” on October 12, 1984, and Safety Recommendation R-83-72 was classified “Closed—Acceptable Action” on June 3, 1986. 39 National Transportation Safety Board, Derailment of National Railroad Passenger Corporation Train 7, on Burlington Northern Railroad near Saco, Montana, August 5, 1988, Railroad Accident Report NTSB/RAR-89/03 (Washington, DC: NTSB, 1989).

Analysis 40 Railroad Accident Report an accident and train employees in those procedures and equipment. Amtrak updated its emergency evacuation procedures manual and provided annual refresher training to all train and engineering and on-board crews. Safety Recommendation R-89-35 was classified “Closed—Acceptable Action” on January 16, 1990. In response to Safety Recommendation R-93-23, Amtrak now provides all on-board service personnel with comprehensive training in first aid, cardiopulmonary resuscitation, and the use of the public address system.40, 41 Safety Recommendation R-98-59 asked Amtrak to implement effective controls to monitor and ensure that all train crews and on-board service personnel receive the necessary initial and recurrent emergency training to provide for passenger safety.42, 43 In response, Amtrak established a computerized database that tracks the attendance of all on-board crewmembers in initial and recurrent training in passenger emergency preparedness and response education. However, Amtrak had difficulty locating accurate training records for 4 of the 12 crewmembers after this accident because the database had not been updated. Amtrak also centralized the training records into a single database for compliance monitoring by Amtrak’s human resources office. Despite the existence of an employee training database, an Amtrak on-board employee in this accident had not had training as required by Federal regulation. Amtrak’s continued failure to provide passenger emergency training to its crews has the potential to put the traveling public at risk should an emergency occur on an Amtrak train. Although it was not a factor in this accident, the Safety Board concludes that Amtrak was not assuring that all of its crewmembers received emergency preparedness training. For almost 2 years, Amtrak officials have been telling Safety Board investigators that Amtrak is “currently improving … technological resources to afford us the opportunity to better track PREPARE training for all active on-board service personnel.” Amtrak hopes that these improvements will allow it “to better monitor the status of all active employees’ PREPARE training.” However, because of the importance of this issue and Amtrak’s continued failure to ensure all employees receive PREPARE training, the Safety Board believes that Amtrak should report to the Board within 90 days a schedule for training its employees who have not received emergency preparedness training as required by 49 CFR Part 239. According to the regulation all Amtrak employees that worked on trains had to be trained for emergency response by January 29, 2001, and retrained every 2 years thereafter. However, Amtrak has failed to meet this requirement. The FRA is 40 National Transportation Safety Board, Derailment and Subsequent Collision of Amtrak Train 82 with Rail Cars on Dupont Siding of CSX Transportation Inc. at Lugoff, South Carolina, July 31, 1991, Railroad Accident Report NTSB/RAR-93/02 (Washington, DC: NTSB, 1993). 41 Safety Recommendation R-93-23 was classified “Closed—Acceptable Action” on December 5, 2000. 42 National Transportation Safety Board, Derailment of Amtrak Train 4, Southwest Chief, on the Burlington Northern Santa Fe Railway near Kingman, Arizona, on August 9, 1997, Railroad Accident Report NTSB/RAR-98/03 (Washington, DC: NTSB, 1998). 43 Safety Recommendation R-98-59 was classified “Closed—Acceptable Action” on December 5, 2000.

Analysis 41 Railroad Accident Report responsible for ensuring that Amtrak is in compliance with this regulation, but Safety Board investigators identified only one FRA audit of Amtrak’s emergency preparedness training. Moreover, that audit occurred after the accident and in one location in a different region. Before the Part 239 regulation was in effect, this issue had surfaced in six Amtrak accident investigations over 18 years, resulting in recommendations to improve emergency training. Further, since Amtrak’s failure to ensure such training surfaced in another accident after the regulation required the training, the Safety Board concludes that the FRA was not conducting periodic audits of Amtrak’s passenger train emergency preparedness plan to ensure that all crewmembers were receiving the required emergency preparedness training. Therefore, the Safety Board believes that the FRA should establish an audit and enforcement program to verify that Amtrak complies with initial and periodic emergency preparedness training for all crewmembers systemwide, as required by 49 CFR Part 239. Emergency Responder Training Provided by Amtrak Amtrak has provided its “Passenger Train Emergency Response” course to emergency responders in Yazoo County. However, very few responders from Yazoo County responded to the accident, and most of their formal training from Amtrak occurred approximately 5 years before the accident. Amtrak is required by 49 CFR 239.101(a)(5) to provide training to emergency responders along passenger rail routes. According to records provided by Amtrak, no firefighters from Madison County (the Flora Volunteer Fire Department, the Kearney Park Volunteer Fire Department, the Gluckstadt Volunteer Fire Department, the Madison Fire Department, the Southwest Madison Volunteer Fire Department, the Camden Volunteer Fire Department, the Canton Volunteer Fire Department, and the Farmhaven Volunteer Fire Department) have attended any training provided by Amtrak. The lack of the training was demonstrated by the delayed implementation of an incident command system. However, these problems stem more from a lack of preparedness among the volunteer fire departments than from a lack of training provided by Amtrak. Passenger Train Equipment Emergency Window Handles An emergency window on the sleeper car had a handle that partially pulled free from the rubber grommet around the window, preventing removal of the window for emergency egress. Therefore, the Safety Board concludes that the handle on an emergency window on the sleeper car was found to have failed. Without knowing the date of manufacture of the gasket, investigators were unable to determine how the age of the rubber may have affected the failure of the screws to remain attached to the grommet. Prior to the accident, Amtrak’s Preventive Maintenance and Standard Maintenance Procedures outlined requirements to test and remove only one emergency window during each maintenance cycle (typically every 3 months). These procedures did not require documentation of which emergency window was removed and inspected.

Analysis 42 Railroad Accident Report Since the accident, Amtrak has informed the Safety Board that it will increase the number of emergency windows tested on all Superliner, Surfliner, and Viewliner passenger cars from one to a minimum of four during each 3-month cycle. The new requirement for number of windows tested will increase the total number of emergency windows tested and inspected to 16 annually. According to Amtrak, this new procedure will ensure that every emergency window will be tested on each passenger car at least once every 4 years. Amtrak has stated that it will also record the location of each window tested on each car in its electronic maintenance database. According to Amtrak, its Standards and Compliance Group will randomly audit this database. Additionally, Amtrak has asked both of its emergency window handle manufacturers to begin adding a date of manufacture stamp to the handle area of the window gasket assembly. Because Amtrak appears to be taking an appropriate approach to testing, maintaining, and documenting the emergency windows on the entire fleet, a safety recommendation to address the failed emergency window handles in this accident is not necessary. However, the Safety Board will continue to monitor and document this issue in future accident investigations to ensure that the emergency window handles function as designed.

43 Railroad Accident Report Conclusions Findings 1. Amtrak train No. 58 and its related equipment functioned as intended and did not cause the derailment. 2. The operation of the train was not a factor in the accident. 3. The inadequately restrained east rail lifted out of the tie plates because of expansion caused by warm temperatures resulting in the rail shifting and the gage widening, causing the wheels of the train to drop between the rails. 4. Although the Canadian National Railway Company had written instructions for maintaining continuous welded rail and preventing track buckling, track employees at multiple levels did not follow or ensure adherence to these instructions. 5. Had the employees who maintained the track at the accident site followed the written procedures the rail shift condition likely would not have occurred. 6. Although a Federal Railroad Administration preaccident inspection identified track deficiencies, the Federal Railroad Administration’s oversight was not effective in ensuring corrective action by the Canadian National Railway Company. 7. Although it was not a factor in this accident, Amtrak was not assuring that all of its crewmembers received emergency preparedness training. 8. The Federal Railroad Administration was not conducting periodic audits of Amtrak’s passenger train emergency preparedness plan to ensure that all crewmembers were receiving the required emergency preparedness training. 9. The handle on an emergency window on the sleeper car was found to have failed. Probable Cause The National Transportation Safety Board determines that the probable cause of Amtrak’s City of New Orleans accident on April 6, 2004, near Flora, Mississippi, was the failure of the Canadian National Railway Company to properly maintain and inspect its track, resulting in a rail shift and the subsequent derailment of the train, and the Federal Railroad Administration’s ineffective oversight to ensure the proper maintenance of the track by the railroad.

44 Railroad Accident Report Recommendations As a result of its investigation of the April 6, 2004, derailment of Amtrak’s train No. 58, the City of New Orleans, near Flora, Mississippi, the National Transportation Safety Board makes the following safety recommendations: To the Federal Railroad Administration: Emphasize to your track inspectors the importance of enforcing a railroad’s continuous welded rail program as a part of the Federal Track Safety Standards, and verify that inspectors are documenting noncompliance with the railroad’s program. (R-05-05) Establish an audit and enforcement program to verify that Amtrak complies with initial and periodic emergency preparedness training for all crewmembers systemwide, as required by 49 Code of Federal Regulations Part 239. (R-05-06) To the Canadian National Railway Company: Establish an audit program to verify that employees follow the current written track maintenance and inspection procedures, including rail anchoring requirements and specifically maintaining the preferred rail laying temperature. (R-05-07) To the National Railroad Passenger Corporation (Amtrak): Report to the Board within 90 days a schedule for training your employees who have not received emergency preparedness training as required by 49 Code of Federal Regulations Part 239. (R-05-08) BY THE NATIONAL TRANSPORTATION SAFETY BOARD MARK V. ROSENKER RICHARD F. HEALING Acting Chairman Member ELLEN ENGLEMAN CONNERS DEBORAH A. P. HERSMAN Member Member Adopted: July 26, 2005

Recommendations 45 Railroad Accident Report Deborah A. P. Hersman, Member, filed the following dissenting opinion on July 28, 2005. Notation 7642A Member HERSMAN, dissenting: I voted against the recommendations made in this report because I believe we have missed the mark -- the probable cause of this accident has to do with CN’s lack of compliance with their own CWR program. In order to make a positive change, we must rely on the actions of the railroad and appropriate FRA oversight to prevent similar accidents from occurring in the future. What did not contribute to the cause or the severity of this accident was the currency of Amtrak crew’s PREPARE training. RECS #2 and #4 - Emergency preparedness training I cannot reconcile the fact that 50% of the recommendations issued in the report are focused on the emergency preparedness training of the Amtrak crew whose actions were appropriate during the accident. Moreover, there is no finding in the report that such training or lack of training was causal to the accident or even a contributing factor. Nor is there any discussion in the report about any inappropriate action or inaction by the Amtrak crew during the accident sequence. Amtrak crew members notified CN dispatch, Amtrak’s CNOC, and local 911 via radio or cell phones as soon as possible after the derailment. A call made to local 911 by a member of the crew provided detailed information about the train’s location, the number of passengers aboard and the general conditions of the accident. The fact that local responders arrived on scene within 16 minutes of the derailment is a testament to the accurate information provided, even though the crew member called from his cell phone in the overturned dining car and the derailed train was approximately 1 1/2 miles from a paved road. I agree that Amtrak was not in compliance with the emergency preparedness provisions of 49 CFR Part 239. However, FRA has the responsibility to enforce this regulation. Our role is to identify the probable cause and make recommendations to prevent similar accidents from occurring. Neither the training of the crew nor their actions post accident were a factor in this accident; in fact, their actions were entirely appropriate. However, by devoting two of four recommendations to the issue of Amtrak’s emergency preparedness training, the report implies otherwise. RECS #1 and #3 - Continuous Welded Rail (CWR) The two recommendations to FRA and CN regarding CWR are consistent with the probable cause, but I would have preferred to see more specificity with respect to certain areas of CWR programs. With only 119 track inspectors at the state and federal level overseeing the safety of more than 200,000 miles of track, we must rely on the railroads to develop robust CWR programs and follow through on implementing them. While we ask FRA to enforce CWR programs and verify that inspectors are documenting noncompliance, we do not ask FRA to review all CWR programs to

Recommendations 46 Railroad Accident Report ensure that railroads have in effect (as per the CWR regulations) procedures which specifically address maintaining a desired rail installation temperature range when making rail repairs (49 CFR 213.119). It is unacceptable that CN has not responded to FRA’s request from over a year ago to clarify what it means by the “onset of warm weather” in its CWR program. As early as 1971, the FRA recognized that installation temperature and anchoring were fundamental CWR issues. Disturbing CWR beyond the installation temperature is widely understood to affect the rail. The failure of CN to effect a more permanent repair to the CWR in the vicinity of the accident is identified in our findings as a factor in this accident. Furthermore, it was not an isolated occurrence on the CN, according to the track supervisor who stated that there were 15 other locations where 2 to 3 inches of rail had been added during the winter but had not yet been welded at the time of the accident. I believe that there are other areas that we might have addressed to improve the safety of CWR. For example, we could ask FRA to: 1) review best practices (several Class I railroads have not had any reportable accidents caused by buckled rail in a year) and draft a model CWR program; or 2) compare submitted proposals to the AREMA manual’s section on CWR (1988) which provides basic guidance. These recommendations could constitute improvements to the existing program without being overly prescriptive. Additionally, I remain concerned about the many situations in which “temporary” repairs become long-term or permanent. We could recommended that, in light of this accident and others involving derailments due to temporary repairs of CWR, FRA review the nature and duration of “temporary” repairs to CWR and determine when delays in making such temporary repairs more permanent is acceptable. (One Class I railroad achieves permanent repairs on CWR in a much more expedited fashion because it makes temporary repairs operationally inconvenient). Finally, in the report, there is some discussion of a CN computerized rail defect tracking system (RDTS) which appears to be underutilized or ineffective. Yet another major Class I railroad uses a rail tracking program that readily identifies those locations in CWR that may be vulnerable to buckling because more permanent repairs have not been made to rail cuts or plugs inserted and may be subjected to excessive longitudinal forces. Why wouldn’t we recommend that CN improve their data collection and tracking systems? The draft report was timely and thorough, and I commend the staff and the parties on their work. However, I believe we missed an opportunity to address the root cause of derailment through our recommendations. We shouldn’t wait for another accident to develop a more complete record of weaknesses in CWR maintenance. We already possess enough information to make needed recommendations to improve the safety of CWR.

47 Railroad Accident Report Appendix A Investigation The National Transportation Safety Board was notified about 8:30 p.m. eastern daylight time on April 6, 2004, that an Amtrak train had derailed near Flora, Mississippi. The Safety Board launched a railroad accident investigation team to the site. The team included Vice Chairman Mark Rosenker (accompanied by a public affairs representative and a family affairs representative) and investigative groups for operations, track, signals, mechanical, human performance, and survival factors/crashworthiness factors. Parties to the investigation included the Federal Railroad Administration, the Canadian National Railway Company, Amtrak, the Madison County sheriff, United Transportation Union, and the Brotherhood of Locomotive Engineers and Trainmen.

48 Railroad Accident Report Appendix B Emergency Responders The agencies in the following list responded to the Flora accident:

1. Flora Volunteer Fire Department
2. Gluckstadt Volunteer Fire Department
3. Ridgeland Fire Department
4. Bentonia Volunteer Fire Department
5. Canton Volunteer Fire Department
6. Madison County Sheriff’s Office
7. Madison Police Department
8. Yazoo County Emergency Management Agency
9. American Medical Response
10. Acadian Ambulance Service
11. University of Mississippi Medical Center – Air Care
12. Kearney Park Volunteer Fire Department
13. Madison Fire Department
14. Southwest Madison Volunteer Fire Department
15. Camden Volunteer Fire Department
16. Farmhaven Volunteer Fire Department
17. Madison County Emergency Management Agency
18. Yazoo County Sheriff’s Office
19. Mississippi Emergency Management Agency
20. EmergyStat Ambulance Service
21. University Hospital and Clinics – Holmes

49 Railroad Accident Report Appendix C Previous Safety Board Recommendations The Safety Board has issued numerous recommendations to Amtrak to improve the emergency response and emergency training of its employees and emergency responders in communities through which Amtrak trains travel; and to the FRA to improve exit window and CWR maintenance and inspection procedures and intervals. Listed below are 10 recommendations issued from 1979 through 2004. Eight recommendations asked Amtrak to upgrade training in emergency response. One recommendation to the FRA asked for improvements in maintenance and inspection of all emergency window exits, and another recommendation to the FRA requested compliance with correct CWR inspection procedures. Emergency Preparedness and Passenger Safety Training Accident. On June 8, 1978, a Conrail commuter train, consisting of 4 self- propelled cars, struck the rear of an Amtrak passenger train consisting of 1 locomotive and 14 cars at Seabrook, Maryland. The impact caused eight cars of the Conrail train and eight cars of the Amtrak train to derail, injuring 16 crewmembers and 160 passengers. Relevant findings. Emergency personnel were unfamiliar with the train’s emergency equipment because Amtrak and Conrail had not provided training and familiarization for railroad emergencies to local rescue organizations. Passengers on both trains had little or no guidance in evacuating the trains and obtaining medical assistance. Crewmembers lacked knowledge of emergency procedures, including how to manually open doors. Relevant recommendations. R-79-35 to Amtrak Arrange for a program along passenger train routes for training and famil- iarizing emergency rescue organizations in the type of equipment being used. Issued 3/21/1979; Closed—Acceptable Alternate Action, 10/8/1980 Amtrak said it prepared an emergency procedures manual and distributed it to fire departments and rescue squads along Amtrak routes. The manual covered the entry to Amtrak equipment and evacuation of passengers and crewmembers during emergencies. Amtrak said it did not have funding to undertake a training program throughout the system and that the booklet was designed to be self-instructive.

Appendix C 50 Railroad Accident Report R-79-36 to Amtrak Establish a program to train crewmembers in the proper procedures for care of passengers in derailment and emergency situations. Issued 3/21/1979; Closed—Acceptable Action, 10/8/1980 Amtrak said newly hired and existing on-board service crewmembers had been trained in a standard Red Cross multi-media first aid training program by fully qualified instructors since early 1978. Amtrak said the training program was ongoing for newly hired and existing employees and said it trained 1,173 on-board service personnel in fiscal year 1979 and expected to train an additional 1,200 employees in fiscal year 1980. All new employees receive, as part of their regular training, detailed training in emergency procedures. Amtrak said it trained 636 employees in fiscal year 1979 and expected to train 600 in fiscal year 1980. Accident. On June 15, 1982, an Amtrak passenger train with 315 persons on board derailed near Emerson, Iowa, while traveling 74 mph when it encountered flood waters over the top of washed-out rails. The accident resulted in 1 passenger fatality and 27 injuries. Relevant findings. Emergency personnel were not aware, prior to the accident, of Amtrak’s emergency evacuation procedures booklet, and thus were not informed of the proper procedures to be used in entering and evacuating passenger cars. Amtrak’s training program in emergency procedures for its on-board employees was not effective in providing adequate assistance to passengers involved in the accident. Relevant recommendations. R-83-23 to Amtrak Provide copies of Amtrak’s emergency evacuation procedures booklet to all emergency response organizations not possessing those procedures from the original distribution, along all designated passenger train routes. Issued 2/28/1983; Closed—Acceptable Action, 10/12/1984 Through the National Safety Council, Amtrak said it distributed 2,140 emergency evacuation manuals to emergency medical service units throughout the country, and planned to distribute 1,000 more copies. Amtrak said 15,000 copies had already been distributed in the previous 2 years. It also said instructional meetings with emergency medical services and fire departments groups were held in Arkansas, Nebraska, and California, and more meetings would be held on request. R-83-24 to Amtrak Review and revise, where necessary, the training and retraining programs for on-board employees in emergency procedures, including the operation of emergency exits, to improve on-board employee competence to render effective assistance to passengers in emergency situations.

Appendix C 51 Railroad Accident Report Issued 2/28/1983; Closed—Acceptable Action, 1/11/1985 Amtrak said it developed and distributed to its field offices an updated, advanced 4-hour course on emergency procedures. The course contained instructions pertaining to several train types and was expanded to include transfer of passengers from stalled trains and evacuation from tunnels. The course uses lecture, discussion, and role play techniques to teach proper response to an emergency as well as hands-on experience in extinguishing a fire under controlled conditions. Accident. On June 23, 1982, an Amtrak 10-car passenger train with 307 persons on board stopped at Gibson, California, after fire and dense smoke were discovered in a sleeping car. Two passengers died, 2 passengers were injured, and 57 passengers and 2 train crewmembers were treated for smoke inhalation. Relevant finding. Amtrak and railroad operating personnel should be given hands-on training in procedures for emergency evacuation from passenger equipment. Relevant recommendation. R-83-72 to Amtrak Include both Amtrak supervisory personnel and on-board service personnel in refresher training programs covering the changes in Amtrak emergency procedures. Arrange with all railroads, over which Amtrak trains are oper- ated, emergency training for train crew employees qualified for assignment to passenger service. Issued 7/8/1983; Closed—Acceptable Action, 8/20/1986 Amtrak said it developed emergency procedures refresher training for supervisors and on-board service employees and a course for front-end train crews and contract railroad crews. It also said that new crews and contract crews must take a 3-day course that includes emergency procedures. Accident. On August 5, 1988, an Amtrak passenger train derailed near Saco, Montana. Five passengers and 1 Amtrak service crewmember were seriously injured, and 87 passengers and 13 Amtrak service employees received minor injuries. Relevant finding. Difficulties were experienced by crewmembers and emergency responders in extricating passengers from the overturned cars, including a passenger from a designated handicapped sleeping compartment that was not equipped with an emergency window.

Appendix C 52 Railroad Accident Report Relevant recommendation. R-89-35 to Amtrak Develop procedures and equipment for evacuation of passenger cars involved in an accident, and train employees in those procedures and equipment. Issued 5/31/1989; Closed—Acceptable Action, 1/16/1990 Amtrak said it had previously distributed 50,000 copies of its emergency evacuation procedures manual. The manual was updated in 1989, and distributed. Amtrak said initial and refresher emergency situation training was being given to all train crews annually, and its new training programs were being presented to police, fire, and medical response personnel. Amtrak said its evacuation procedures were effective and it did not plan to institute additional procedures. Accident. On July 31, 1991, an Amtrak passenger train, consisting of 2 locomotives, 3 baggage cars, and 15 passenger cars, derailed 6 cars in Lugoff, South Carolina. The derailed passenger cars collided with freight train hopper cars stored at a nearby siding. Eight passengers were killed, 12 passengers were seriously injured, and 12 on-board service personnel and 53 passengers sustained minor injuries. Relevant finding. On-board service crewmembers were not required to attend periodic training in first aid or emergency procedures and failed to follow appropriate established emergency procedures, such as using the public address system to inform passengers about the emergency, and give related instructions or to locate passengers who had medical expertise and might have been able to render assistance. Relevant recommendation. R-93-23 to Amtrak Require that all on-board service personnel periodically take training in the emergency operating rules in first aid, cardiopulmonary resuscitation, and the use of the public address system during train emergencies. Issued 11/30/1993; Closed—Acceptable Action, 12/5/2000 Amtrak said that it provides all on-board crewmembers with comprehensive training called PREPARE (Passenger Railroad Emergency Preparedness and Response Education). It contains training in the following: cardiopulmonary resuscitation, emergency first aid, prevention of disease transmission, communications procedures, situational awareness, passenger evacuation, and rail equipment familiarization. The course is required every 2 years. Accident. On August 9, 1997, an Amtrak passenger train with 294 passengers and 18 Amtrak employees on board derailed near Kingman, Arizona. Traveling at 89 mph, the

Appendix C 53 Railroad Accident Report train derailed after it encountered a hump in the tracks and crossed a bridge that had been damaged by a flash flood. Ten Amtrak employees and 173 passengers were injured. Relevant finding. Amtrak’s current system for providing emergency training for train crews and on-board service personnel has not been effective, which has resulted in personnel being provided differing levels of emergency situation training. Relevant recommendation. R-98-59 to Amtrak Implement effective controls to monitor and ensure that all train crews and on-board service personnel received the necessary initial and recurrent emergency training to provide for passenger safety. Issued 9/16/1998; Closed—Acceptable Action, 12/5/2000 Amtrak said its human resources division developed guidance for training Amtrak employees and established a central repository of training information and accurate record-keeping procedures. When an employee completes an internal or external course, Amtrak said the information is recorded in a database and checked periodically. Emergency Window Exit Maintenance and Inspection Accident. On February 16, 1996, a Maryland Rail Commuter (MARC) train collided with an Amtrak passenger train near Silver Spring, Maryland. The MARC train consisted of one locomotive and three cars. The Amtrak train had 2 locomotives and 15 cars. All three operating crewmembers and eight passengers on the MARC train were killed in the derailment and subsequent fire. Eleven passengers on MARC and 15 of the 182 crewmembers and passengers on the Amtrak train were injured. Relevant finding. Prescribed inspection and maintenance test cycles are needed to ensure reliable operation of emergency windows in all long-distance and commuter rail passenger cars. Relevant recommendation. R-97-18 to the Federal Railroad Administration: Provide promptly a prescribed inspection and maintenance test cycle to ensure the proper operation of all emergency exit windows as well as pro- vide that the 180-day inspection and maintenance test schedule is pre- scribed in the final rule. Issued 8/28/1997; Closed—Acceptable Alternate Action, 7/27/2001 The FRA issued a final rule, effective July 12, 1999, that included significant passenger safety upgrades. It included a requirement for mechanical inspection every 3 months of a representative sample of emergency window exits for proper operation. The

54 Railroad Accident Report rule requires the FRA to notify railroads of inspection results and require railroads to correct deficiencies. Before the rule became effective, the FRA issued an emergency order on April 20, 1996, requiring window exit inspections and repair of deficiencies. Welded Rail Inspections Accident. On January 18, 2002, a Canadian Pacific Railway freight train derailed 31 of its 112 cars near Minot, North Dakota. Five tank cars carrying anhydrous ammonia ruptured, resulting in a vapor plume covering the derailment site and surrounding area. One resident was killed and about 60 area residents were rescued. As a result of the accident, 11 people sustained serious injuries and 322 people, including 2 train crewmembers, sustained minor injuries. Relevant finding. FRA’s oversight of Canadian Pacific Railway’s CWR program was ineffective because the agency neither reviewed the program nor ensured that its track inspectors had copies of the program to determine if the railroad was in compliance with it. Relevant recommendation. R-04-03 to the Federal Railroad Administration Instruct Federal Railroad Administration track inspectors to obtain copies of the most recent continuous welded rail programs of the railroads that fall within the inspectors’ areas of responsibility and require that inspectors use those programs when conducting track inspections. Issued 3/15/2004; Closed—Acceptable Action, 6/22/2005 The FRA said it would issue a technical bulletin, which will be a rewrite of its track compliance manual, to emphasize the requirement that inspectors must be aware of the procedures in effect before inspecting each railroad. When conducting inspections, the inspector must make observations to determine if the railroad is following its basic safety procedures. The FRA also said that inspectors were reminded of this requirement during technical workshops in 2004.

FD07313 ｜ 2006_美国_AAR0601.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2006 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

Collision with Trees and Crash Short of the Runway, Corporate Airlines Flight 5966 BAE Systems BAE-J3201, N875JX Kirksville, Missouri October 19, 2004 Aircraft Accident Report NTSB/AAR-06/01 PB2006-910401 Notation 7694A National Transportation Safety Board Washington, D.C.

AVIATION ACCIDENT REPORT NTSB/AAR-06/01 (PB2006-910401)

COLLISION WITH TREES AND CRASH SHORT OF THE RUNWAY CORPORATE AIRLINES, FLIGHT 5966 BAE SYSTEMS BAE-J3201, N875JX KIRKSVILLE, MISSOURI OCTOBER 19, 2004

• Page 27, first paragraph has been corrected to indicate 10 seconds instead of 19 seconds as originally printed. (7 MARCH 2006) • Page 44, first complete paragraph has been corrected to indicate 10 seconds instead of 19 seconds as originally printed. (7 MARCH 2006)

THE CORRECTIONS BELOW ARE INCLUDED IN THIS VERSION OF THE PUBLISHED REPORT

Aircraft Accident Report Collision with Trees and Crash Short of the Runway, Corporate Airlines Flight 5966 BAE Systems BAE-J3201, N875JX Kirksville, Missouri October 19, 2004 NTSB/AAR-06/01 PB2006-910401 National Transportation Safety Board Notation 7694A 490 L’Enfant Plaza, S.W. Adopted January 24, 2006 Washington, D.C. 20594 E

P L U R IB US UN U M

N A T I O N A L

T R A S P O R T A T I O N

B O A R D S A FE T Y N

National Transportation Safety Board. 2006. Collision with Trees and Crash Short of the Runway, Corporate Airlines Flight 5966, BAE Systems BAE-J3201, N875JX, Kirksville, Missouri, October 19, 2004. Aircraft Accident Report NTSB/AAR-06/01. Washington, DC. Abstract: This report explains the accident involving Corporate Airlines flight 5966, a BAE Systems BAE-J3201, N875JX, that crashed short of the runway on approach to land at Kirksville Regional Airport, Kirksville, Missouri. Safety issues in this report focus on operational and human factors issues, including the pilots’ professionalism and sterile cockpit procedures, nonprecision instrument approach procedures, flight and duty time regulations, fatigue, and flight data/image recorder requirements. The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Web at http://www.ntsb.gov. Other information about available publications also may be obtained from the Web site or by contacting: National Transportation Safety Board Public Inquiries Section, RE-51 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (800) 877-6799 or (202) 314-6551 Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2006-910401 from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605-6000 The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

iii Aircraft Accident Report Contents Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii

1. Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2. 1

History of Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.2 Injuries to Persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.3 Damage to Aircraft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.4 Other Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.5 Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 1.5.1 The Captain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1.5.2 The First Officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 1.6 Airplane Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 1.7 Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 1.7.1 Official Kirksville Weather Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 1.7.2 Kirksville Weather Information Provided by Witnesses . . . . . . . . . . . . . . . . . . . . . 14 1.7.3 Predeparture Weather Information Obtained by the Pilots . . . . . . . . . . . . . . . . . . . 15 1.8 Aids to Navigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1.9 Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1.10 Airport Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1.11 Flight Recorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 1.11.1 Cockpit Voice Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 1.11.2 Flight Data Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 1.11.2.1 Flight Data Recorder Parameter Requirements/Information . . . . . . . . . . . . . . . 17 1.12 Wreckage Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 1.13 Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 1.14 Fire/Explosion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 1.15 Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 1.15.1 Emergency Response Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 1.15.1.1 Emergency Response Personnel Statements . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 1.15.1.2 Postaccident Emergency Response Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 1.16 Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 1.16.1 Airplane Performance Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 1.16.2 Ground Proximity Warning System Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 1.17 Operational and Management Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 1.17.1 Corporate Airlines Policies/Procedures/Training . . . . . . . . . . . . . . . . . . . . . . . . . . 27 1.17.1.1 Training Information—General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 1.17.1.2 Non-Precision Approach/Missed Approach Guidance . . . . . . . . . . . . . . . . . . . . 28 1.17.1.3 Crew Schedule Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 1.17.2 Federal Aviation Administration Oversight of Corporate Airlines . . . . . . . . . . . . . 31 1.18 Additional Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 1.18.1 Sterile Cockpit Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Contents iv Aircraft Accident Report 1.18.2 Additional Flight Crew-Related Accident Information . . . . . . . . . . . . . . . . . . . . . 35 1.18.3 Nonprecision Instrument Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 1.18.4 Flight and Duty Time Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 1.18.5 Fatigue-Related Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 1.18.5.1 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 1.18.5.2 Previously Issued Fatigue-Related Recommendations . . . . . . . . . . . . . . . . . . . . 41 1.18.5.3 Department of Transportation Operator Fatigue Management Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

1. Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
2. 1

General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 2.2 The Accident Sequence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 2.3 Crew Performance/Professionalism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 2.4 Nonprecision Instrument Approach Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 2.4.1 Descent Below the Minimum Descent Altitude on Nonprecision Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 2.5 Pilot Flight and Duty Time and Fatigue Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 2.5.1 Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 2.6 Flight Recorder Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

1. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
2. 1

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 3.2 Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

1. Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
2. 1

New Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 4.2 Previously Issued Recommendations Reiterated in This Report . . . . . . . . . . . . . . . . . . 59 4.3 Previously Issued Recommendation Classified in This Report . . . . . . . . . . . . . . . . . . . 60

1. Appendixes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

A: Investigation and Public Hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 B: Cockpit Voice Recorder Transcript . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

v Aircraft Accident Report Figures

1. This graph shows the estimated duty schedules for both pilots

and the estimated sleep schedule for the captain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

1. Map of the accident region, with pertinent airport locations shown.. . . . . . . . . . . . . . . . . . . 7
2. Diagram of the accident airplane’s cabin and cockpit configuration. . . . . . . . . . . . . . . . . . . 13
3. An approach chart depicting the localizer DME approach to runway 36 at IRK. . . . . . . . . 16
4. Photograph of the main wreckage area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
5. The accident airplane’s descent profile during the accident approach

with the airport/runway location shown. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

1. The accident airplane’s descent profile during the accident approach

with CVR comments overlaid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

1. Aviation accident data from 55 accidents involving U.S. air carriers

between 1978 and 1999, indicating that accidents are more prevalent as the length of the pilots’ duty period increases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

vi Aircraft Accident Report Abbreviations AC advisory circular AD airworthiness directive agl above ground level APOI assistant principal operations inspector ARFF aircraft rescue and firefighting ARTCC air route traffic control center ASOS automated surface observation system ATC air traffic control BRL Southeast Iowa Regional Airport C celsius CAM cockpit area microphone CAMI Civil Aeromedical Institute CFIT controlled flight into terrain CFR Code of Federal Regulations cg center of gravity CRM crew resource management CTAF common traffic advisory frequency CVR cockpit voice recorder DFDR digital flight data recorder DME distance measuring equipment DMORT Disaster Mortuary Operational Response Team DOT Department of Transportation EGPWS enhanced ground position warning system FAA Federal Aviation Administration FAF final approach fix FDR flight data recorder fpm feet per minute FSF Flight Safety Foundation

Abbreviations vii Aircraft Accident Report FSS flight service station GPWS ground proximity warning system Hg mercury IC incident commander IFR instrument flight rules ILS instrument landing system IMC instrument meteorological conditions IRK Kirksville Regional Airport LEPC Adair County Local Emergency Planning Committee LPFD LaPlata Fire Department MAP missed approach point MDA minimum descent altitude MSA minimum safe altitude msl mean sea level MVFR marginal visual flight rules NDR National Driver Registry NIMS National Incident Management System nm nautical mile NPRM notice of proposed rulemaking NWS National Weather Service POI principal operations inspector S/N serial number SEP Surveillance and Evaluation Program sm statute mile STL Lambert-St. Louis International Airport TAWS terrain awareness and warning system TDZE touchdown zone elevation TWA Trans World Airlines UIN Quincy Regional-Baldwin Airport VASI visual approach slope indicator VFR visual flight rules

viii Aircraft Accident Report Executive Summary On October 19, 2004, about 1937 central daylight time, Corporate Airlines (doing business as American Connection) flight 5966, a BAE Systems BAE-J3201, N875JX, struck trees on final approach and crashed short of runway 36 at the Kirksville Regional Airport (IRK), Kirksville, Missouri. The flight was operating under the provisions of 14 Code of Federal Regulations Part 121 as a scheduled passenger flight from Lambert-St. Louis International Airport, in St. Louis, Missouri, to IRK. The captain, first officer, and 11 of the 13 passengers were fatally injured, and 2 passengers received serious injuries. The airplane was destroyed by impact and a postimpact fire. Night instrument meteorological conditions (IMC) prevailed at the time of the accident, and the flight operated on an instrument flight rules flight plan. The National Transportation Safety Board determines that the probable cause of the accident was the pilots’ failure to follow established procedures and properly conduct a nonprecision instrument approach at night in IMC, including their descent below the minimum descent altitude (MDA) before required visual cues were available (which continued unmoderated until the airplane struck the trees) and their failure to adhere to the established division of duties between the flying and nonflying (monitoring) pilot. Contributing to the accident was the pilots’ failure to make standard callouts and the current Federal Aviation Regulations that allow pilots to descend below the MDA into a region in which safe obstacle clearance is not assured based upon seeing only the airport approach lights. The pilots’ unprofessional behavior during the flight and their fatigue likely contributed to their degraded performance. The safety issues in this report focus on operational and human factors issues, including the pilots’ professionalism and sterile cockpit procedures, nonprecision instrument approach procedures, flight and duty time regulations, fatigue, and flight data/image recorder requirements.

1 Aircraft Accident Report 1. Factual Information 1.1 History of Flight On October 19, 2004, about 1937 central daylight time,1 Corporate Airlines (doing business as American Connection)2 flight 5966, a BAE Systems BAE-J3201, N875JX, struck trees on final approach and crashed short of runway 36 at Kirksville Regional Airport (IRK), Kirksville, Missouri. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 as a scheduled passenger flight from Lambert-St. Louis International Airport (STL), in St. Louis, Missouri, to IRK.3 The captain, first officer, and 11 of the 13 passengers were fatally injured, and 2 passengers received serious injuries. The airplane was destroyed by impact and a postimpact fire. Night instrument meteorological conditions (IMC) prevailed for the flight, which operated on an instrument flight rules (IFR) flight plan. The flight crew was on a regularly scheduled 4-day sequence that began on Sunday, October 17, 2004. The accident occurred on the last flight of the third day, which departed from STL about 1842. Based on air traffic control (ATC) and cockpit voice recorder (CVR)4 information and Corporate Airlines dispatcher statements, the departure and en route phases of the accident flight were routine; the captain was the flying pilot and the first officer was the nonflying/monitoring pilot.5 When the flight was about 23 minutes from its destination, the pilots listened to the IRK automated surface observing system (ASOS) weather information, which indicated a wind from 040° at 6 knots, visibility 4 miles in mist, ceiling6 overcast at 300 feet above ground level (agl), temperature and dew point 9° Celsius (C), and an altimeter setting of 29.95 inches of mercury (Hg). After hearing the weather observation, the captain commented, “we’re not getting in...we don’t have an ILS [instrument landing system].”7 The first officer responded, “I know…go all this [expletive] way. Well, let’s try it.” The captain responded, “yeah, we’ll try it.” About 30 seconds later, the captain said, “I don’t 1 Unless otherwise indicated, all times are central daylight time, based on a 24-hour clock. 2 In February 2005, Corporate Airlines was renamed Regions Air, Inc. For the purposes of this report, the name Corporate Airlines will be used. 3 IRK is located in northeastern Missouri, about 162 miles northwest of STL. 4 The CVR recorded the last 30 minutes and 12 seconds of cockpit communications before the accident. See appendix B for a transcript of the CVR recording. 5 In its February 2003, advisory circular (AC) 120-71A, the FAA emphasized the importance of the nonflying pilot’s role in monitoring and crosschecking, especially during critical phases of flight like the approach and landing. 6 The cloud ceiling is the lowest layer of clouds reported as broken or overcast, or the vertical visibility into a surface-based obscuration. 7 The ILS is a precision instrument landing system that provides horizontal and vertical flightpath guidance to the pilot.

Factual Information 2 Aircraft Accident Report want to…go all the way out here for nothing tonight,” and moments later said, “I’ll be so happy when we have an ILS everywhere we go.” The first officer concurred, and the captain continued, “I thought we were gonna have it easy tonight.” According to ATC, radar, and CVR information, the flight was at 12,000 feet mean sea level (msl) and about 20 minutes from the destination airport when the Kansas City air route traffic control center (ARTCC) asked the pilots which approach they wanted into IRK. The pilots requested vectors for the localizer DME8 approach to runway 36 at IRK. The controller acknowledged the pilots’ request and cleared them to descend from 12,000 to 8,000 feet msl “at pilot’s discretion.” The pilots acknowledged the clearance and began the descent checklist. The ARTCC controller advised the pilots to fly their present heading (which was about 300°) and to expect radar vectors for the localizer DME approach to runway 36. About 1920:06, the pilots again listened to the IRK ASOS weather information, which then indicated a wind from 040° at 5 knots, visibility 3 miles in mist, ceiling overcast at 300 feet agl, temperature and dew point 9° C, and an altimeter setting of 29.95 inches Hg. The first officer sighed, then stated, “it’s three miles and mist now,” and sighed again. The captain responded, “Really?…so it’s going down the tubes.” Flight data recorder (FDR) data indicated that the airplane descended through 10,000 feet msl (bringing into effect sterile cockpit rules)9 about 1921:24. As the airplane further descended to 8,000 feet msl, the ARTCC controller cleared the pilots to descend at their discretion to and maintain 3,000 feet msl. The pilots acknowledged the clearance, and the captain briefed the approach,10 stating, “one eleven point five, three fifty seven’s the inbound. Twenty five hundred at KEMMY.[11] Thirteen twenty is our MDA [12], and we have a three hundred sixty foot approach set in the radar altimeter…nine sixty six for the airport elevation, nine sixty four is the touchdown zone elevation [TDZE]. Speeds as previously briefed, fifteen, twenty one, and thirty. If we have to go missed we’ll set max power, flaps ten, positive rate, gear up…and we’ll climb to three thousand feet then direct Kirksville VOR,[13] and hold.” 8 DME (distance measuring equipment) is expressed in nautical miles. 9 For additional information regarding sterile cockpit regulations, see section 1.18.1. 10 Figure 4, in section 1.10, is an approach chart depicting the localizer DME approach to runway 36 at IRK. 11 KEMMY was the final approach fix for the localizer DME approach to runway 36 at IRK and was located about 5.2 DME miles south of the approach end of the runway. 12 The MDA (minimum descent altitude) is a specified altitude in a nonprecision approach or circling approach below which descent must not be made unless the pilots have visual contact with the runway environment. The MDA at IRK was 1,320 feet msl. The Corporate Airlines flight manual defines visual contact with the runway environment as visual contact with any of the following: the approach light system; the visual approach slope indicator; runway end identification lights; the runway threshold, threshold markings, or threshold lights; runway lights; touchdown zone lights; touchdown zone or zone markings; or the runway or runway markings. 13 VOR refers to the very high frequency omnidirectional radio range navigation aid.

Factual Information 3 Aircraft Accident Report As the airplane began to descend into the top of the clouds, the CVR recorded the captain stating, “…we’re going into the crap. Look, ooh, it’s so eerie and creepy…get a suffocating feeling when I see that.” The first officer made a barking sound followed by a groan, and, about 1925:13, the captain continued, stating, “I’m drowning…,”14 then he remarked, “MSA[15] is thirty one hundred.” The first officer responded, “correcto mundo.” About 25 seconds later, CVR recorded a yawn on the first officer’s channel,16 then he stated, “they have a VASI [visual approach slope indicator] on the left hand side,” and the captain responded, “yeah. Wish we had an ILS on the front side.” The first officer said, “yeah, that’d be nice.” When the airplane was about 10 minutes from its destination, the ARTCC controller advised the pilots to turn 10° to the right to intercept the localizer for runway 36 at IRK. The pilots complied, turning to a heading of 310.° About 2 minutes later, the captain asked, “how’s…Kirksville looking weather wise? Getting any worse?” The pilots again listened to the IRK ASOS weather information, which indicated a wind from 030° at 6 knots, visibility 3 miles in mist, ceiling overcast at 300 feet agl, temperature and dew point 9° C, and an altimeter setting of 29.95 inches Hg. The captain stated, “temp [and] dew point’s right where you don’t want it,” and the first officer responded, “yeah…still three hundred.” The pilots performed the approach checklist as the airplane descended and leveled off at 3,100 feet msl. About 1930:35, the ARTCC controller told the pilots they were 11 miles south of the final approach fix (FAF) for the localizer DME approach to runway 36 at IRK. He advised them to turn right to a heading of 330° and maintain an altitude of 3,000 feet msl until they were established on the localizer, then cleared them for the localizer DME approach to runway 36 at IRK. The pilots complied and the first officer advised the captain that the localizer course was “alive.”17 The captain stated, “Let’s go flaps ten and we’ll configure early…give ourselves as much time as we can.” The first officer agreed and selected and verified 10° of flaps as the airplane intercepted the final approach course. Less than 1 minute later, the captain confirmed with the first officer that they could descend to 2,500 feet msl at that point in the approach, then asked the first officer to extend the landing gear, select 20° of flaps, and perform the before landing checklist. About 1932:48, the first officer stated, “gear down…flaps selected indicating twenty” and continued the before landing checklist. About 1933:40, the ARTCC controller approved a frequency change (to the IRK common traffic advisory frequency [CTAF]) and advised the pilots to report after they landed. The first officer acknowledged the instructions and, 14 For additional information on the pilots’ conversation, see section 1.18.1 and the CVR transcript in appendix B. 15 The MSA (minimum safe altitude) depicted on the approach chart ensures at least 1,000 feet of obstacle clearance within a 25-mile radius of the pertinent facility. 16 The CVR recorded additional yawning sounds by both the captain (about 1915:03) and the first officer (about 1923:43, 1925:44, and 1929:27) during the flight. 17 Pilots commonly use the term “alive” to indicate the movement of the localizer needle that occurs as the airplane nears the localizer course.

Factual Information 4 Aircraft Accident Report at the captain’s request, keyed the microphone to activate the pilot-controlled runway lights at IRK.18 According to FDR, CVR, and radar data, the airplane was at 2,500 feet msl when it crossed the FAF at 19:35:36, and the first officer advised the captain that they could descend to 1,320 feet msl, the MDA for the approach. The captain acknowledged, stating, “thirteen twenty, here we go.” Radar and calculated FDR data indicated that the airplane then began to descend about 1,200 feet per minute (fpm) while tracking the localizer. About 1936:23, as the airplane descended through about 1,600 feet msl, the first officer stated, “five hundred, four hundred to go.” About 17 seconds later (at 1936:30.6), as the airplane descended through about 1,450 feet msl (about 500 feet agl), the CVR recorded the airplane’s ground proximity warning system’s (GPWS) mechanical announcement, “five hundred.” At 1936:33.9, as the airplane descended through about 1,380 feet msl, the first officer stated “thirteen twenty.” The captain thanked him and about 3 seconds later (as the airplane reached the MDA), stated, “I can see ground there.”19 As he finished speaking, the GPWS annunciated, “minimums, minimums,” indicating that the airplane had reached 1,320 feet msl. Calculated FDR data indicated that the airplane continued to descend at a rate of about 1,200 fpm. At 1936:40.5, the captain asked, “what do you think?,” and the first officer responded, “I can’t see [expletive].” About 2 seconds later, as the airplane continued to descend, the captain stated, “yeah, oh there it is. Approach lights in sight.” Almost immediately, the GPWS annunciated “two hundred” feet agl and the first officer stated, “…in sight…continue.” The airplane was descending through about 1,160 feet msl (160 feet below the MDA) at this time. As the pilots continued the approach, still descending about 1,200 fpm, the first officer asked the captain if he wanted the flaps extended to 35.° At 1936:52.2, the captain responded, “no,” and the GPWS began to announce, “sink rate.”20 One second later, the first officer exclaimed, “trees,” and the captain stated, “no, stop.” The first sounds of impact with the trees were recorded at 1936:55.2, and numerous sounds of impact were recorded before the CVR stopped recording at 1936:57.5. 18 During nighttime hours, all runway, taxiway, and approach lighting at IRK is pilot-controlled and activated by a pilot keying the microphone with the radio tuned to the airport’s CTAF. Keying the airplane microphone activates the airport lighting as follows: three times (within 5 seconds) results in low intensity, five times results in medium intensity, and seven times results in high intensity. The captain requested high-intensity airport lighting for the accident approach; the first officer activated the airport’s lighting system accordingly and confirmed the activation with ground personnel at IRK. 19 According to Corporate Airlines procedures and training, when the airplane reaches the MDA during an instrument approach, the flying pilot is to level off and monitor the flight instruments while the nonflying pilot looks outside the airplane for visual cues to determine whether the descent can be continued. 20 The accident airplane’s GPWS was designed to provide a “sink rate” alert when, based on its altitude and rate of descent, the airplane penetrated the GPWS system’s alert envelope. According to the GPWS design, the airplane would have penetrated the alert envelope as it descended through about 100 feet agl at a 1,200 fpm rate of descent.

Factual Information 5 Aircraft Accident Report FDR and radar data and the National Transportation Safety Board’s airplane performance study21 indicated that the airplane maintained a relatively constant heading and flightpath angle during the descent from the FAF until the pilots saw the trees immediately before the initial impact occurred. At that time, the Safety Board’s performance study indicated a reduction in the airplane’s descent rate and increases in airplane nose up elevator movement and vertical acceleration. Physical evidence showed that the airplane first contacted the trees more than 1.3 nautical mile (nm) south of the approach end of runway 36, about 50 feet agl (about 996 msl), and continued descending through trees toward the runway. The airplane came to rest with the forward fuselage aligned on about a 190° heading and the aft fuselage on about a 240° heading. The main wreckage site was located about 775 feet north of the initial impact site and about 1.2 nm south of the approach end of runway 36. 1.2 Injuries to Persons Table 1. Injury chart. Note: Title 14 CFR 830.2 defines a serious injury as any injury that (1) requires hospitalization for more than 48 hours, starting within 7 days from the date that the injury was received; (2) results in a fracture of any bone, except simple fractures of fingers, toes, or the nose; (3) causes severe hemorrhages or nerve, muscle, or tendon damage; (4) involves any internal organ; or (5) involves second- or third-degree burns or any burns affecting more than 5 percent of the body surface. 1.3 Damage to Aircraft The airplane was destroyed by impact forces and a postimpact fire. 1.4 Other Damage Trees along the wreckage path were damaged by impact forces and a postimpact fire. 21 For additional information regarding the Safety Board’s airplane performance study, see section 1.16.1. Injuries Flight Crew Cabin Crew Passengers Other Total Fatal 2 0 11 0 13 Serious 0 0 2 0 2 Minor 0 0 0 0 0 None 0 0 0 0 0 Total 2 0 13 0 15

Factual Information 6 Aircraft Accident Report 1.5 Personnel Information The flight crew consisted of a captain and a first officer, who had flown together since their October schedule began on October 3. The captain and first officer commuted from their homes in New Jersey and Ohio, respectively, to report for duty at STL about 1345 on October 17 for the first flight of the trip sequence. The pilots arrived at their overnight destination, Quincy Regional-Baldwin Airport (UIN) in Quincy, Illinois, about

1. According to the flight logs, the pilots flew three flights on October 17 for 3 hours

and 3 minutes of flight time and 7 hours and 55 minutes of duty time.22 On Monday, October 18, the pilots departed UIN about 1415 after more than 15 hours off duty. They arrived at their overnight destination, Southeast Iowa Regional Airport (BRL) in Burlington, Iowa, about 1945. According to the flight logs, the pilots flew four flights on October 18 for 3 hours and 36 minutes of flight time and 6 hours and 21 minutes of duty time. On the third day of the trip sequence (October 19), the pilots’ duty period began about 0514 at BRL after about 9 hours off duty.23 They departed on the first flight of the day about 0544 and flew to STL, where they arrived about 0644. The pilots were originally scheduled to depart STL again about 0930, fly to UIN and then return to STL; however, those two flights were cancelled because of poor weather conditions.24 They then resumed their normal flight schedule, departing STL again about 1236. They flew to IRK and returned to STL, where they arrived about 1453. The pilots departed STL again about 1513, flew to BRL, and returned to STL, where they arrived about 1745. The accident flight departed STL about 1842. The pilots were flying their sixth flight of the day and had flown about 6 hours and 14 minutes in 14 hours and 31 minutes of duty time when the accident occurred. Figure 1 is a graph showing the estimated duty schedules for both pilots and the estimated sleep schedule 22 For planning/scheduling purposes, Corporate Airlines added 30 minutes of duty time before the morning departure time and 15 minutes of duty time to the arrival time to account for pre- and post-flight paperwork and duties. Because a pilot’s duty time begins when he or she begins preflight duties before the first flight of the day and ends after he or she has completed postflight duties after the last flight, the duty times documented in the flight log exceeds the time between the beginning of the first flight to the end of the last flight of the day. According to 14 CFR 121.471, flight crews flying domestic Part 121 operations may fly up to 8 hours between required rest periods, 30 hours per week, 100 hours per month, and 1,000 hours per year. If the scheduled flight time is less than 8 hours, the minimum rest period in the 24 hours preceding the scheduled completion of the flight segment is 9 hours. If the scheduled flight time is 8-9 hours, the minimum rest period in the 24 hours preceding the scheduled completion of the flight segment is 10 hours. If the scheduled flight time is equal to or greater than 9 hours, the minimum rest period in the 24 hours preceding the scheduled completion of the flight segment is 11 hours. These minimum rest periods may be reduced if the following rest periods, to begin no later than 24 hours after the commencement of the reduced rest period, are increased to 10, 11, and 12 hours, respectively. 23 Hotel records indicate that, on the day of the accident, the captain and first officer received wakeup calls at 0410 and 0430, respectively. 24 According to Corporate Airlines personnel, a captain and a dispatcher will often consult and agree to cancel a flight or flights. However, in this case, the Corporate Airlines dispatcher independently cancelled the roundtrip flight between STL and UIN because of the weather conditions. The weather at UIN was low IFR and the airport’s ILS was out of service.

Factual Information 7 Aircraft Accident Report for the captain.25 Figure 2 is a map of the region where the accident occurred, with pertinent airport locations shown. 25 Information about the pilots’ schedules was derived from company records, telephone records, hotel records, and interviews with the captain’s fiancée, the first officer’s mother, and other pilots (friends and coworkers). The captain told his fiancée that he had not slept well the night before the accident and that he had a headache that morning. Information about the first officer’s sleep schedule during the trip sequence was limited. Figure 1. The estimated duty schedules for both pilots and the estimated sleep schedule for the captain. Figure 2. Map of the accident region, with pertinent airport locations shown. Kirksville (IRK) Quincy (UIN) Burlington (BRL) St. Louis (STL) M I S S O U R I I L L I N O I S I O WA

Factual Information 8 Aircraft Accident Report 1.5.1 The Captain The captain, age 48, began flying in the late 1980s and obtained his flight instructor certificate in 1991. Because of limited job opportunities in aviation, he subsequently worked in non-aviation positions in the computer industry. In September 1999, the captain left a job in the computer industry to return to the aviation industry as a flight instructor. Corporate Airlines hired him as a BAE-J3201 first officer on March 20,

1. At the time of the accident, the captain held an airline transport pilot certificate

(issued August 26, 2003) with airplane multiengine land ratings and a type rating in the BAE-3100.26 According to Corporate Airlines training records, the captain was upgraded from first officer to captain on the BAE-J3201 on September 17, 2003. The captain’s most recent Federal Aviation Administration (FAA) first-class airman medical certificate was issued on June 22, 2004. Table 2 shows the captain’s most recent training, proficiency and line checks, and flight experience. Table 2. Captain’s recent training, proficiency and line checks, and flight experience. A review of FAA records found no accident, incident, or enforcement actions, and a search of the National Driver Registry (NDR) database indicated no record of driver’s license suspension or revocation. Postaccident interviews with four Corporate Airlines pilots who had flown with the captain revealed that they considered the captain to be a competent pilot who followed 26 This type rating included the BAE-J3201 airplane. Recurrent training June 13 and 15, 2004a a. During the June 13, 2004, recurrent training, the captain failed two items (takeoff with a loss of engine power after the airplane reached takeoff decision speed and single-engine ILS approach). He was retested on June 15, 2004, and passed. Recurrent ground training July 7, 2004b b. Corporate Airlines records indicate that the captain received controlled flight into terrain (CFIT) training during this recurrent training. Proficiency check July 16, 2004 Line check September 28, 2004 Total flight time 4,234 hours BAE-J3201 flight time 2,510 hours Flight time last 90 days 191 hours Flight time last 30 days 72 hours Flight time last 24 hours 6 hours

Factual Information 9 Aircraft Accident Report procedures. Pilots also described the captain as a relaxed, intelligent, and friendly person with a sense of humor. The captain’s fiancée characterized the captain’s health as good and indicated that no major changes had occurred in his health, eating or sleeping habits,27 off-duty activities, or financial situation in the year before the accident.28 The captain’s fiancée told investigators that flying for Corporate Airlines was the captain’s first major aviation job and he loved it. According to several pilot friends, the only complaint the captain had about Corporate Airlines was the lack of an autopilot on the BAE–J3201, which resulted in pilots having to fly the airplanes manually through any weather and workload.29 At the time of the accident, the captain anticipated a job interview with a major airline30 and was reportedly very happy. According to the captain’s fiancée, the captain went to bed between 2300 and midnight on Friday, October 15 and awoke between 0630 and 0700 on Saturday, October 16. She stated that they spent a routine day at home. He did laundry and got clothes organized for his upcoming trip sequence; they shopped and did some basic maintenance around the house. She estimated that he went to bed about midnight Saturday night and woke up about 0700 on Sunday, October 17. According to the captain’s fiancée, they ate breakfast together before he left home about 0800 to commute to STL. Hotel records indicated that after the last flight of the day on Monday, October 18, the captain checked into the hotel at Burlington, Iowa, about 2020. According to the hotel desk clerk who checked him in, the captain indicated that he was going directly to bed because the next day was a long flight day. The captain’s telephone records indicated that he called his fiancée about 2027 that night and the call duration was about 8 minutes. During postaccident interviews, a Corporate Airlines pilot told investigators that he observed the captain resting on a small couch31 when he was in the company crew room at STL for about 45 minutes in the morning (starting about 0730 or 0800) on October 19. The Corporate Airlines pilot indicated that when he returned to the crew room 27 The captain’s fiancée reported that when he did not have work demands, the captain normally went to bed about midnight and woke up about 0630 to 0700. She indicated that his sleep patterns during the days leading up to this trip sequence were consistent with this habit. 28 According to the captain’s fiancée, they had known each other for 9 years and lived together for the past 3 years. 29 According to a BAE Systems representative, the accident airplane was designed with an autopilot system as an optional feature; none of Corporate Airlines BAE-J3201 airplanes had autopilots installed. 30 A former Corporate Airlines pilot and long-time friend of the captain’s flew for a larger airline at the time of the accident and was helping the captain get an interview with that company. 31 The Corporate Airlines pilot told investigators that there were three couches in the crew rest room— a long couch, a “regular”-size couch, and a small couch. The pilot stated that the captain, who was 6’4” tall (according to his flight physical), was curled up on the small couch. Several company pilots described the crew room as a noisy meeting area that is not ideal for sleeping.

Factual Information 10 Aircraft Accident Report about 1030 or 1100, he saw the captain resting on the same couch.32 He stated that the captain and first officer left shortly after that to have lunch with other pilots.33 The captain’s fiancée stated that when they spoke that morning, the captain told her that he had not slept well in the hotel the night before and that he had awakened with a headache. He also discussed the bad weather they were experiencing34 and mentioned that some of his flights for the day had been cancelled. The captain also told his fiancée that he liked the first officer, enjoyed flying with him, and remarked that he was quite skilled. The captain stated that he and the first officer worked well together. When asked about the flight schedules at Corporate Airlines, the captain’s fiancée stated that the captain had mixed feelings about the schedules; he enjoyed being home for 3 days, but he thought some of the flight days (specifically those involving eight flight legs) were long. She said he loved to fly and never mentioned being tired. She indicated that when the captain was away on a trip he did not typically go to bed immediately after the last flight of the day. Rather, it was his habit to have a nice dinner and get things ready for the next day before going to sleep. She said that he did not have any real issues with the schedule. 1.5.2 The First Officer The first officer, age 29, obtained his private pilot certificate in 1994 and his commercial and flight instructor certificates in 1996. According to the company’s records, the first officer worked as a flight instructor at Eastern Cincinnati Aviation from July 1996 to August 2004. In addition, from July 2000 to June 2002, the first officer attended the Embry-Riddle Aeronautical University extended campus in Cincinnati, Ohio. Within this time period (from February 2001 to October 2001), the first officer also worked as a first officer at Sunworld International Aviation, based in Florence, Kentucky. In October 2001, he was furloughed from Sunworld, after having flown 86 hours for the company. Corporate Airlines hired the first officer on July 19, 2004.35 The first officer held a 32 Telephone records indicated that the captain was not resting continuously between these observations; on the day of the accident, numerous calls were made from and received on the captain’s telephone between 0900 and 1230. 33 If the roundtrip between STL and UIN had not been canceled that morning, the pilots would have been flying from UIN to STL about this time. The first officer’s mother told investigators that he often packed sandwiches in advance because this trip sequence did not provide the pilots with enough time to eat between flights. It is unknown what the pilots had for lunch; however, during the flight to IRK the captain discussed food. About 1912:51, the CVR recorded him stating, “All I’m thinking of is a Philly [expletive] cheesesteak and an iced tea.” 34 Several Corporate Airlines pilots that were interviewed after the accident indicated that the weather around STL during those three days (October 17 through 19) was bad, with consistently low ceilings and visibility; one pilot indicated that it was “among the worst” he had experienced in a long time and that weather had frequently been worse than forecast at the destination. 35 The first officer’s employment records indicate an overlap between his hire date at Corporate Airlines (July 19, 2004) and his resignation at Eastern Cincinnati Aviation (August 2004). Although the first officer would have attended Corporate Airlines training in STL during this time, it is possible that he worked with flight students at Eastern Cincinnati Aviation on weekends.

Factual Information 11 Aircraft Accident Report commercial pilot certificate with airplane multiengine land and instrument ratings (issued December 19, 1999). The first officer’s most recent FAA first-class airman medical certificate was issued on February 17, 2004. Table 3 shows the first officer’s initial training, proficiency check, and flight experience. Table 3. First officer’s initial training, proficiency check, and flight experience. A review of FAA records found no accident, incident, or enforcement actions, and a search of the NDR database indicated no record of driver’s license suspension or revocation. During a postaccident interview, the company chief pilot described the first officer as upbeat, hard-working, and ready with a joke. According to several witnesses, the first officer was happy with his job at Corporate Airlines and hoped to advance to a larger airline in a few years. Several witnesses indicated that the first officer enjoyed flying with the captain. The first officer lived in Cincinnati, Ohio, with his mother. The first officer’s mother characterized his health as good and indicated that no major changes had occurred in his health, eating, or sleeping habits,36 off-duty activities, or financial situation in the year before the accident. According to his mother, when he was working, the first officer normally left home on Sunday morning, flew his schedule, and returned home Wednesday evening. He did not normally call home when he was gone. She stated that, although the first officer took a reduction in pay when he accepted the job at Corporate Airlines, he was satisfied because he saw the Corporate Airlines job as an entry path to the major airlines and a way to “build valuable flight time.” The first officer’s mother told investigators that her son had mentioned the accident captain favorably and indicated that they had a lot in common. He told her that he and the captain planned to ask to fly together again in the upcoming month. The first officer’s mother told investigators that he seemed normal in the days leading up to the accident trip sequence. According to his mother, on Thursday, October 14, the first officer watched rented movies with a pilot friend and went to bed about 2230. She indicated that on Friday, October 15, he went out with friends and that she was asleep when he returned, so she did not know what time he went to bed. She stated that on Saturday, Initial training August 15, 2004a a. Corporate Airlines records indicated that the first officer received CFIT training during his initial training/BAE-J3201 proficiency check. Proficiency check August 15, 2004 Total flight time 2,856 hours BAE-J3201 flight time 107 hours Flight time last 90 days 107 hours Flight time last 30 days 72 hours Flight time last 24 hours 6 hours 36 The first officer’s mother reported that when he did not have work demands, the first officer’s sleep schedule was variable, depending on social and flight instruction obligations. She indicated that he occasionally had difficulty sleeping.

Factual Information 12 Aircraft Accident Report October 16, he came home early from visiting friends, they spoke briefly, and he went to his bedroom about 2230. According to the first officer’s mother, she had not yet seen him the next morning (Sunday, October 17) when she left the house about 0725.37 The first officer’s mother told investigators that her son mentioned that the flight schedule on the day of the accident typically resulted in a long day. According to several pilots who spoke with the first officer that day, he seemed alert and happy. 1.6 Airplane Information Records indicated that the accident airplane, N875JX, a BAE Systems BAE-J3201 airplane, serial number (S/N) 875, was ordered by Nashville Eagle and delivered to that company in February 1990. Nashville Eagle operated the airplane until March 1994, when it was reregistered and leased to Trans State Airlines (part of Trans World Express fleet [or TWA]). Corporate Airlines began to operate the airplane under a code share agreement with TWA on April 26, 2000, and continued operating the airplane under a code share agreement with American Airlines after American Airlines acquired TWA. At the time of the accident, the accident airplane had accumulated about 21,979 flight hours and 28,973 cycles.38 The accident airplane was equipped with two Honeywell TPE331 engines, rated at 1,100 horsepower, and two McCauley propeller assemblies. The left engine had accumulated about 12,919 hours total flight time, including about 342 hours since its most recent overhaul and its installation on the accident airplane. The right engine had accumulated about 21,583 hours total flight time, including about 2,774 hours since its most recent overhaul and its installation on the accident airplane. Both engines underwent their most recent inspections about 56 hours before the accident. On the basis of Corporate Airlines dispatch records, the Safety Board calculated that the airplane’s estimated landing weight was 15,185 pounds, including about 2,989 pounds of payload (passengers and cargo) and about 1,688 pounds of fuel. The airplane’s maximum allowable landing weight was 15,609 pounds. Calculations showed that the airplane’s center of gravity (cg) was within approved cg limits during all phases of the accident flight. The accident airplane was configured with 19 passenger seats in the cabin and 2 flight crew seats in the cockpit.39 The passenger seats comprised seven single seats along the left cabin wall and six sets of double seats along the right cabin wall. The main cabin 37 The first officer’s mother indicated that he needed to leave home about 0900 or 1000 to commute to STL for the trip sequence. 38 An airplane cycle is one complete takeoff and landing sequence. 39 Because of its maximum payload and number of passenger seats, Corporate Airlines was not required to provide flight attendants on the BAE-J3201; therefore, there was no flight attendant jumpseat on the airplane. (According to 14 CFR 121.391, operators must provide at least one flight attendant for airplanes having a maximum payload capacity of 7,500 pounds or more and having a seating capacity of more than 19 but less than 51 passengers.)

Factual Information 13 Aircraft Accident Report door was located on the left side of the cabin behind the farthest aft passenger seat. There were overwing emergency exits at row 4 on both sides of the cabin. Figure 3 is a diagram of the airplane’s cabin and cockpit configuration. 1.7 Meteorological Information 1.7.1 Official Kirksville Weather Information IRK is equipped with an ASOS, which continuously measures wind direction and speed,40 visibility, present weather (for example, precipitation and obstructions to vision), sky condition (cloud height and sky cover), temperature, dew point temperature, and altimeter setting. National Weather Service (NWS)-certificated weather observers augment this automated weather observation system as needed. Figure 3. Diagram of the accident airplane’s cabin and cockpit configuration. 40 The ASOS station samples wind direction and speed every 5 seconds and records a 2-minute average wind direction and speed every minute.

Factual Information 14 Aircraft Accident Report The ASOS observation at 1935:31 (closest to the time of the accident) reported wind from 020° at 6 knots, visibility 4 statute miles (sm) in mist, ceiling overcast at 300 feet agl, temperature and dew point temperature at 9° C, and an altimeter setting of 29.96 inches Hg. The Safety Board’s review of the 5-minute ASOS observations for IRK from 1900:31 to 1955:31 revealed visibilities that varied between 3 and 5 miles in mist41 and ceilings that varied between 300 and 500 feet agl. The NWS surface analysis chart for the time of the accident showed a cold front that extended west-southwest from western Kentucky through a low pressure area located in western Missouri, southern Oklahoma, and northern Texas. Information on this chart indicated an extensive area of clouds and precipitation along and north of the frontal boundaries across the region. The NWS weather depiction chart for 2000 (just after the accident) showed a large area of IFR weather conditions42 throughout Illinois and northeastern Missouri (including the accident site). Marginal visual flight rules (MVFR)43 weather conditions were depicted over western and southern Missouri and a portion of Iowa. The weather observations on the regional weather depiction chart showed visibilities between 2.5 and 4 sm in mist, with overcast ceilings between 300 and 800 feet throughout northeastern Missouri and western Illinois. Review of the weather data for the region revealed no evidence of precipitation echoes, convective activity, or conditions conducive to inflight ice accumulation, significant turbulence, or low level windshear along the route of flight or at the accident site. 1.7.2 Kirksville Weather Information Provided by Witnesses The Safety Board interviewed several pilots who landed and/or took off at IRK before and after the accident, all of whom described weather conditions consistent with the ASOS observations around those times. For example, a pilot who landed in a Cessna 182 airplane about 1840, a little more than an hour before the accident, stated that he flew the localizer DME approach to runway 36 at IRK in “smooth,” “solid IMC” conditions. He stated that he broke out of the clouds about 1,600 feet msl (534 feet agl) and the visibility was 4 miles in mist. The Safety Board also received a statement from the pilot of a Gulfstream jet (N720DR) who flew the same approach and landed at IRK about an hour after the accident. He stated that after the airplane crossed the FAF, he descended to the MDA. The copilot called minimums and reported that the airport was in sight, and the pilots landed without incident. The pilot estimated that the ceiling was “right at minimums” (1,320 feet msl) and the visibility was about 5 to 6 miles. 41 The Safety Board’s airplane performance study indicated that the airplane was about 1.9 nm (about 2.2 sm) from the end of the runway when it descended through the MDA and between 1.6 and 1.7 nm (about 1.85 to 1.95 sm) from the end of the runway when the pilots stated that the approach lights were in sight. 42 IFR weather conditions are defined as a ceiling of less than 1,000 feet agl and/or visibility less than 3 sm. 43 MVFR weather conditions are defined as a ceiling between 1,000 and 3,000 feet agl, inclusive, and/or visibilities from 3 to 5 miles, inclusive.

Factual Information 15 Aircraft Accident Report The Safety Board also received written and verbal statements from a charter pilot who was on the ground waiting to depart when the accident occurred. He estimated that the weather conditions at the time of the accident were overcast clouds about 300 feet agl and visibility about 3 to 4 miles. 1.7.3 Predeparture Weather Information Obtained by the Pilots Corporate Airlines dispatch personnel provided the pilots with a weather synopsis, reported and forecast weather conditions for the route of flight, destination, and two alternate airports (STL and UIN),44 notices to airmen, and an IRK field condition report. Additionally, Corporate Airlines obtains pertinent forecasts from Meteorlogix, a contract weather information provider. The Meteorlogix forecast for IRK that the pilots received predicted winds from 040° at 5 knots, visibility between 2 and 4 sm in mist, and an overcast ceiling at 800 feet agl around the time of the accident. Corporate Airlines dispatch personnel in STL had access to air-to-ground radio communication with the accident flight, if needed, to provide the flight crew with weather updates or other information. However, the dispatcher on duty in STL reported that, on the day of the accident, she had no postdeparture communications with the flight crew. 1.8 Aids to Navigation No difficulties with the navigational aids were known or reported. 1.9 Communications No communications problems were reported between the pilots and any of the air traffic controllers who handled the flight. 1.10 Airport Information IRK is located about 6 miles southeast of Kirksville, Missouri. The official airport elevation is 966 feet. The primary runway at IRK, runway 18/36, is concrete, 6,005 feet long, and 100 feet wide. At the time of the accident, runway 36 was equipped with medium-intensity runway lights, a medium-intensity approach lighting system, and VASI lights located on the left side of the runway. The localizer DME approach to runway 36 at IRK is categorized as nonprecision because it does not include electronic vertical glidepath guidance. The approach procedure requires airplanes to pass over the FAF, an outer marker that is located 5.2 DME miles 44 According to Federal regulations (14 CFR 121.619), two alternate airports are required anytime the forecast weather conditions for the destination and first alternate airport indicate ceilings less than 2,000 feet above the airport elevation and/or visibilities less than 3 miles within an hour of the estimated time of arrival.

Factual Information 16 Aircraft Accident Report south of the airport. After the airplane passes the FAF, pilots can descend to the MDA of 1,320 feet msl, which is 356 feet above the runway touchdown elevation. Pilots can not descend beneath the MDA unless they can see the runway environment, in which case, they are allowed to descend to 100 feet above the TDZE (964 feet) and continue the approach until they can see the runway itself. If the pilots do not see the runway environment or the runway by the time they reach the missed approach point (MAP, near the approach end of runway 36), they are required to perform a missed approach. (Figure 4 is an approach chart for the localizer DME approach to runway 36 at IRK.) Figure 4. An approach chart depicting the localizer DME approach to runway 36 at IRK.

Factual Information 17 Aircraft Accident Report 1.11 Flight Recorders 1.11.1 Cockpit Voice Recorder The CVR installed on the accident airplane was an L-3 Communications/Fairchild model A-100A, S/N 55843, magnetic tape CVR. The exterior of the CVR showed significant structural damage; however, the interior of the recorder and the tape showed no apparent heat or impact damage and the tape was successfully played back. The CVR recording consisted of four channels of good quality45 audio information: one channel contained audio information recorded by the cockpit area microphone (CAM), two other channels contained audio information recorded through the radio/intercom audio panels at the captain and first officer positions, and the fourth channel was not used (nor was its usage required) on this recording. The recording began about 1906:46 and ended about 1936:58, after it recorded the sounds of numerous impacts. A transcript was prepared of the entire 30-minute, 12-second recording. See appendix B for a complete transcript of the CVR recording. 1.11.2 Flight Data Recorder The FDR was an L-3 Communications/Fairchild Model F1000, S/N 00511, that recorded six parameters of airplane flight information (time, altitude, airspeed, vertical acceleration, magnetic heading, and radio transmissions/keying) in a digital format using solid-state flash memory. The outer sleeve of the FDR showed evidence of thermal damage, but the recorder was otherwise in good condition, and more than 130 hours of data were successfully downloaded. The accident flight was the last flight on the recording and its duration was about 41 minutes. The CVR and FDR times were correlated based on their one commonality—the microphone key times are recorded by the FDR and the sounds associated with keying the microphone are recorded by the CVR. 1.11.2.1 Flight Data Recorder Parameter Requirements/Information In response to numerous Safety Board recommendations, the FAA has issued a series of rule changes regarding FDR requirements since 1987, which gradually increased the number of required recorded parameters from six to the current requirement of 88 (for newly manufactured aircraft). In particular, 14 CFR 121.344a requires most turbine-engine-powered airplanes that seat from 10 to 19 passengers to be equipped with FDRs that record a minimum of 18 parameters. However, this regulations applies only to airplanes entered on the U.S. registry after October 11, 1991; airplanes entered on the U.S. registry before this date are not required to be equipped with an FDR. In addition, an exception to 14 CFR 121.344a allows some airplanes, including the BAE-J3201, to operate under Part 121 with FDRs that record fewer parameters (the accident airplane’s FDR recorded six parameters). These airplanes are listed in paragraph (f) of the 45 The Safety Board rates the quality of CVR recordings according to a five-category scale: excellent, good, fair, poor, and unusable. See appendix B for a description of these ratings.

Factual Information 18 Aircraft Accident Report regulation. According to the FAA’s FDR rule change, issued on July 17, 1997,46 exceptions to the rule were made because the cost of re-certifying and retrofitting47 airplanes that were not originally designed to record the additional parameters outweighed the benefit of additional recorded data for select airplane models. Currently, the FAA registry shows more than 500 airplanes that are exceptions to 14 CFR 121.344a; about 40 percent of these airplanes are BAE-J3201, BAE-J3101, and Beech 1900 airplanes, which are involved in Part 121 passenger-carrying operations. The Safety Board notes that new technology—specifically, onboard image recorders48—could provide supplemental parametric information on airplanes that are operating either without FDRs or with FDRs recording a limited number of parameters. The use of image recorders would not require extensive modifications to the airplane during installation, and thus could be installed at a more reasonable cost than upgraded FDRs. Image recorders would also provide additional information not readily available from the CVR and/or FDR, such as the environment within the cockpit and outside the cockpit window and the manipulation of controls and switches in the cockpit. In April 2000, the Safety Board issued Safety Recommendation A-00-30, which asked the FAA to do the following: Require that all aircraft operated under Title 14 CFR Part 121, 125, or 135 and currently required to be equipped with a CVR and digital flight data recorder (DFDR) be retrofitted…with a crash-protected cockpit image recording system. The cockpit image recorder system should have a 2-hour recording duration, as a minimum, and be capable of recording, in color, a view of the entire cockpit including each control position and each action (such as display selections or system activations) taken by people in the cockpit. The recording of these video images should be at a frame rate and resolution sufficient for capturing such actions. The cockpit image recorder should be mounted in the aft portion of the aircraft for maximum survivability and should be equipped with an independent auxiliary power supply that automatically engages and provides 10 minutes of operation whenever aircraft power to the cockpit image recorder and associated cockpit camera system ceases, either by normal shutdown or by a loss of power to the bus. The circuit breaker for the cockpit image recorder system, as well as the circuit breakers for the CVR and the DFDR, should not be accessible to the flight crew during flight. (A-00-30) Additionally, on December 22, 2003, the Safety Board issued Safety Recommendation A-03-65, asking the FAA to do the following: 46 See the Federal Register (FR), 62 FR 38362. 47 FDR modifications required for retrofit include adding sensors at and wiring to each of the control surfaces, actuators, and/or other components being added as parameters. 48 Image recorders obtain audio information (similar to that recorded by CVRs), provide an alternate means of discovering event data that is often recorded by FDRs, and record information about the environment within the cockpit and outside the cockpit window.

Factual Information 19 Aircraft Accident Report Require all turbine-powered, nonexperimental, nonrestricted-category aircraft that are manufactured prior to January 1, 2007, that are not equipped with a [FDR], and that are operating under 14 Code of Federal Regulations Parts 135 and 121 or that are being used full-time or part-time for commercial or corporate purposes under Part 91 to be retrofitted with a crash-protected image recording system by January 1, 2010. (A-03-65) In a March 29, 2004, letter to the Safety Board, the FAA stated that safety recommendations regarding CVRs, FDRs, and image recorders “are uniquely difficult for the FAA to respond to in a manner that the Safety Board finds acceptable.” The FAA also stated that recorder recommendations presented unique challenges, including difficulties in cost/benefit analysis, technical hurdles, retrofit problems, data use issues, and privacy concerns. On June 3, 2004, staff from the FAA and the Safety Board met to discuss in general the FAA’s response to CVR, FDR, and image recorder recommendations. On December 15, 2004, the Board wrote to the FAA stating that, although the meeting was constructive, the substance of previously issued safety recommendations was not discussed. Because the FAA had not advised the Board of any actions to address the previously mentioned safety recommendations, the Board classified them “Open— Unacceptable Response.” On February 22, 2005, the FAA issued a notice of proposed rulemaking (NPRM) titled, “Revisions to Cockpit Voice Recorder and Digital Flight Data Recorder Regulations,” which did not address image recorders. In an April 29, 2005, response to this NPRM, the Safety Board stated that it was disappointed about this omission. The Board also stated that image recorders would have provided in-depth information about the facts, conditions, and circumstances surrounding numerous accidents. The Board restated its opinion that image recorders could play a key role in accident investigations by providing critical human performance and cockpit environment information that would be otherwise unavailable. The Board encouraged the FAA to move quickly to implement the image recorder recommendations. In an October 11, 2005, letter to the Safety Board, the FAA stated that it conducted simulator and flight tests in June 2005 to address issues regarding what to record and whether an image recorder would be sufficient to record parametric data. The FAA indicated that the results of these tests would be available in a final report, which the FAA anticipated would be completed by December 2005. On January 26, 2006, the FAA published a proposed image recorder technical standard order (TSO-C176) for a crash-protective video recording system. Public comments are due by February 27, 2006. 1.12 Wreckage Information The first evidence of impact (damage to two trees located near the top of a slight ridge) was observed about 1.3 miles south of the approach end of runway 36. The airplane first impacted trees about 50 feet above the ground (about 996 feet msl), and a swath of

Factual Information 20 Aircraft Accident Report broken trees continued in a northerly direction to the main wreckage area, about 775 feet north of the initial impact. Many of the broken trees that were near the main wreckage area exhibited moderate charring and burning. The main wreckage (which included the remains of the fuselage and the empennage, the right wing, the inboard portion of the left wing, and the remains of the right engine and propeller and the left propeller) was located in an almost circular area about 30 feet in diameter and exhibited extensive fire damage. Most of the main wreckage and the surrounding vegetation were consumed by fire. Figure 5 is a photograph of the main wreckage area. The identifiable remnants of the forward fuselage included the forward instrument panel and associated wiring bundles and some small pieces of the lower forward fuselage structure. The flight instruments on the captain’s side of the instrument panel and most of the center instrument panel were almost completely destroyed by fire. Many of the flight instruments on the first officer’s side of the instrument panel exhibited impact, fire, and/or smoke damage. The first officer’s altimeter was retained for further examination. Subsequent examination and disassembly revealed that the altimeter was capable of normal operation at the time of impact and that the barometric setting was between 29.95 and 29.96 inches Hg. The landing gear selector was found loose and the surface features had been consumed by fire; the internal mechanism was in the gear-down position. Figure 5. Photograph of the main wreckage area. The forward section of the airplane is in the foreground, and the tail section is in the background (the aft pressure bulkhead is indicated by the red arrow).

Factual Information 21 Aircraft Accident Report The center fuselage structure was largely consumed by fire, and no evidence of the over-wing exits was found. A portion of the aft fuselage was found relatively intact and on its left side; the remainder was consumed by fire. The main cabin door, which was located on the left side of the aft fuselage, was found in the closed and latched position with some fire damage to the interior. The lower half of the vertical stabilizer, the lower third of the rudder, and the left horizontal stabilizer and elevator remained attached to the aft fuselage. The top half of the vertical stabilizer was located between two trees at the northern edge of the main wreckage site, and the top two-thirds of the rudder was located in pieces about 70 feet north of the main wreckage site. The right horizontal stabilizer and elevator were not attached to the aft fuselage; however, portions of these assemblies were located in the main wreckage site near the upper portion of the vertical stabilizer. The left wing was broken into three major pieces. The outboard portion of the left wing was located about 15 feet above the ground in a tree located about 530 feet from the initial point of impact, with other wing debris located between the initial impact point and the outboard wing section. The leading edge of the outboard portion of the left wing exhibited significant impact damage, including four distinct, semicircular impact marks. No fire damage was evident on the outboard portion of the left wing or along the wreckage path leading to the point where the outboard portion of the left wing was found. The middle portion of the left wing was found among branches and other tree debris, all of which exhibited substantial fire damage. The inboard portion of the left wing was located at the main wreckage site and exhibited extensive fire damage. The left main landing gear remained attached to this portion of the wing, and its actuator was in the extended position. The right wing was found in two sections, both of which were located at the main wreckage site. Most of the inboard portion of the right wing had been consumed by fire; however, small, unmelted portions of the right wing forward and rear spars and the right wing inboard and outboard flaps were found at the main wreckage site. The outboard portion of the right wing was located at the main wreckage site at the edge of an area of intense fire damage and exhibited light-to-moderate fire damage. The leading edge of the outboard portion of the right wing exhibited semicircular impact damage similar to that seen on the outboard portion of the left wing. The right main landing gear remained attached to the inboard portion of the wing, and its actuator was in the extended position. The left engine was located about 30 feet northwest of the main wreckage site and was largely intact with no fire damage. The right engine was located amidst the inboard right wing wreckage at the main wreckage site and exhibited extensive fire damage. Postaccident examination and teardown of the engines and their components revealed no evidence of preexisting defects or anomalies that would have prevented normal engine operation. Both engines exhibited rotational damage through the compressor and turbine sections and metal spray on static and rotating parts of the turbine sections.

Factual Information 22 Aircraft Accident Report The left and right propeller assemblies had separated from their respective engines and were located at the main wreckage site. Postaccident examination and teardown of the propeller assemblies revealed no evidence of preexisting defects or anomalies that would have prevented normal propeller operation. All eight propeller blades exhibited bends, twists, and/or curls that were consistent with rotation at the time of impact. 1.13 Medical and Pathological Information The chief medical examiner from Sedgwick County, Kansas, with assistance from other Disaster Mortuary Operational Response Team (DMORT)49 personnel, performed autopsies and toxicology tests on the fatally injured pilots and passengers. The blood specimens collected from the captain and first officer tested negative for ethanol and a wide range of drugs, including drugs of abuse.50 Subsequent toxicological tests were performed by the FAA Civil Aeromedical Institute (CAMI); a urine specimen collected from the captain tested positive for acetaminophen (101.6 ug/ml);51 blood and liver specimens obtained from the first officer revealed an unspecified quantity of quinine.52 1.14 Fire/Explosion A postimpact fire destroyed most of the airplane. 1.15 Survival Aspects Autopsy and toxicological results indicated that the cause of death for the 13 fatally injured passengers was “multiple blunt force injuries” resulting from the impact. The two survivors had serious injuries, including fractures and lacerations. The surviving passengers occupied seats 4A and 4C,53 which were located over the main wing spar and near the emergency exits. (No one was seated in seat 4B.) During postaccident interviews, the survivors reported that they exited the airplane through a break in the left side of the fuselage at the exit row and were able to move a safe distance away from the wreckage before the postimpact fire engulfed the airplane and surrounding trees. 49 DMORT services are arranged through an interagency agreement between the Safety Board and the Department of Homeland Security. Upon request, DMORT assists local medical examiners and coroners in victim identification and cause of death determinations. 50 The drugs tested in the postaccident analysis include (but are not limited to) marijuana, cocaine, opiates, phencyclidine, amphetamines, benzodiazapines, barbiturates, antidepressants, antihistamines, meprobamate, and methaqualone. 51 According to the captain’s fiancée, the captain awoke with a headache on the day of the accident. 52 Quinine is found in tonic water and is not quantified in CAMI results unless a substantial quantity is present. 53 See figure 1, which is a diagram of the accident airplane’s cabin and cockpit configuration, in section 1.6 of this report.

Factual Information 23 Aircraft Accident Report 1.15.1 Emergency Response Information IRK is an uncontrolled airport that operates in accordance with 14 CFR 139.209, “Limited Airport Operating Certificate: Airport Certification Specifications.” Postaccident interviews indicated that the airport operator (whose duties included aircraft rescue and firefighting [ARFF] response, line service [fueling, cleaning, towing, deicing of airplanes], weather observation augmentation, and general airport and customer services) was on duty at the airport when the accident occurred. He stated that he was performing routine duties in the office and listening to the local Kansas City ARTCC frequency on the radio monitor in anticipation of the arrival of the accident flight. He stated that when he heard the ARTCC controller clear the accident flight for the approach, he walked outside to watch for the airplane descending through the clouds. When the flight did not arrive, the airport operator returned to the office and changed to the IRK CTAF to listen for communication from the accident flight. He stated that when he heard nothing on that frequency, he changed back to the local ARTCC frequency; he heard nothing for a few minutes and then heard ARTCC trying to make radio contact with the accident flight.54 The airport operator stated that he subsequently received a telephone call from a local farmer who advised him that an airplane had crashed south of the airport. About 1953, after obtaining a more detailed description of the accident location, the airport operator telephoned Kirksville 911 dispatch to report the accident. According to the Kirksville 911 dispatch timeline, between 1955 and 2003, the dispatcher initiated emergency response regarding the accident, including contacting the Macon County 911 Center, LaPlata Fire Department (LPFD), AirEvac, Southwest Rural Fire Department, Kirksville Police Department, Adair County Sheriff Department, and Adair County Ambulance Dispatch. In addition, a Missouri State Highway Patrol trooper was at the Macon County 911 Center when the notification telephone call was taken, and he responded to the accident site. The Kirksville 911 dispatch timeline indicated that first responders from LPFD reached the accident site about 2020. 1.15.1.1 Emergency Response Personnel Statements According to postaccident interviews with the LPFD incident commander (IC) for the accident response, he was contacted about 2000 and advised to standby for information regarding a possible missing airplane. About 3 minutes later, Kirksville 911 dispatch personnel directed LPFD personnel to an airplane accident south of IRK. The IC stated that he and his colleagues were en route by about 2006 and were the first responders to reach the accident site about 2020. He reported that the airplane was located in a wooded area between farmed fields and was burning when they arrived. He indicated that the responders split into teams to start searching for survivors. As 54 According to ATC records, the ARTCC controller tried to contact the accident flight repeatedly (about 1943:37, 1951:48, 1959:50, and 2008:41). In between these calls (about 1954:44) the ARTCC controller determined that the pilots had not canceled their IFR clearance with the Columbia, Missouri, Flight Service Station (FSS). Records indicate that the airport operator contacted the FSS about 2000:59 to report an airplane accident south of IRK.

Factual Information 24 Aircraft Accident Report responders from other jurisdictions arrived at the accident site, the LPFD responders located the two survivors and helped them to the Adair County ambulance. According to the IC and several LPFD firefighters, maintaining control of the site became a challenge as law enforcement personnel from multiple jurisdictions arrived at the accident site.55 LPFD and other firefighting and emergency medical services personnel had difficulty communicating with some law enforcement personnel because of the use of different radio frequencies and traffic congestion near the accident site. According to an LPFD firefighter, the traffic congestion created a situation in which the Adair County ambulance could not immediately exit the area until law enforcement vehicles from multiple jurisdictions were moved. The Adair County ambulance dispatch nurse/emergency medical technician stated that she did not believe that the movement of the other vehicles delayed the ambulance’s departure because she was working to stabilize the survivors while those vehicles were moved. 1.15.1.2 Postaccident Emergency Response Actions On November 30, 2004, the Adair County Local Emergency Planning Committee (LEPC) organized a meeting with representatives of the agencies that responded to the accident to evaluate the emergency response. Meeting participants identified several areas that needed improvement, including communications and coordination at the accident scene and additional training specific to aircraft accident response and emergency response management techniques. The LEPC formed a committee to address these issues. Subsequently, the city of Kirksville acquired a mobile command vehicle for use at incident and accident sites and LaPlata and Kirksville Fire Department personnel attended a 2-day aircraft accident response course presented by the University of Missouri and a 6-hour IC training course at IRK on the use of the new mobile command vehicle during emergency responses. In addition, personnel from the LPFD, Kirksville Fire Department, Sheriff’s Department, 911 Dispatch, and some Missouri State Highway Patrol completed the National Incident Management System (NIMS) training course.56 Further, the chairman of the LEPC advised the Safety Board that the Adair and Macon County emergency response agencies are currently working to establish a common command frequency system to be used by all responding agencies at accidents or incidents within their jurisdictions. 55 According to the Adair County emergency medical technician who drove the truck and arrived at the accident site about 2025, he saw between 50 and 75 vehicles parked along the road with more arriving and a “mass cluster of…people.” 56 NIMS is a nationwide training course developed by the Department of Homeland Security in July 2004 to provide fire and rescue personnel with comprehensive and standardized information regarding incident command and emergency response management techniques.

Factual Information 25 Aircraft Accident Report 1.16 Tests and Research 1.16.1 Airplane Performance Study Safety Board investigators used available data from the accident airplane’s FDR and CVR, radar data from IRK Air Route Surveillance Radar, atmospheric data from the IRK ASOS, and physical evidence from the accident scene to calculate the airplane’s flightpath, angle of attack, and power settings during the airplane’s descent on the accident approach. The Board’s study indicated that the airplane did not appear to deviate in flightpath angle or heading until just before it impacted the first set of trees at an altitude of about 996 feet msl. Further, the study indicated that the airplane was in a steady descent with minimal engine power settings before the initial tree strike. Figure 6 shows the airplane’s altitude profile during the accident approach with the airport/runway location shown. Figure 7 shows the airplane’s altitude profile during the accident approach with CVR comments overlaid. Figure 6. The accident airplane’s descent profile during the accident approach with the airport/runway location shown. The following altitudes are also shown: MDA, 100 feet above the TDZE, and the TDZE. Additionally, a 3.4° visual glidepath to the airport is shown for reference purposes only.

Factual Information 26 Aircraft Accident Report Figure 7. The accident airplane’s descent profile during the accident approach with CVR comments overlaid. The following altitudes are shown: MDA, 100 feet above the TDZE, and the TDZE. Additionally, a 3.4º visual glidepath to the airport is shown for reference purposes only.

Factual Information 27 Aircraft Accident Report 1.16.2 Ground Proximity Warning System Evaluation The Safety Board evaluated the GPWS equipment on board the airplane and compared it with the enhanced GPWS (EGPWS)57 technology that was available at the time of the accident. The Board’s evaluation indicated that the GPWS installed on the airplane operated as designed and provided a “sink rate” warning when the airplane descended through about 1,050 feet msl (about 104 feet agl) and entered the GPWS outer warning boundary about 2 to 3 seconds before the CVR recorded the first sounds of impact. The Board’s evaluation further indicated that if the airplane had been equipped with currently available EGPWS technology, the pilots would have received a “too low terrain” warning when the airplane descended below the EGPWS runway field clearance floor for that area about 10 seconds before impact. Federal regulations (specifically, 14 CFR Part 121.354, 135.154, and 91.223) required that all turbine engine powered airplanes operating under Part 121 be equipped with terrain awareness and warning systems (TAWS) or EGPWS58 by March 29, 2005 (about 5 months after the accident). According to Corporate Airlines personnel, the company had scheduled its BAE-J3201 fleet for EGPWS installation as part of its regular maintenance program. At the time of the accident the company had installed EGPWS on 2 of the company’s 12 operating BAE-J3201 airplanes and the remainder were installed before the FAA’s March 2005 deadline. 1.17 Operational and Management Information When Corporate Airlines (now known as RegionsAir), began operations in December 1996, it was a privately held Part 121 air carrier headquartered in Smyrna, Tennessee. At the time of the accident, Corporate Airlines was doing business as American Connection under an agreement with American Airlines and based its flight operations out of STL and Nashville International Airport in Nashville, Tennessee. At that time, the company operated 12 BAE-J3201 airplanes, employed 65 pilots and 5 dispatchers, and provided service to 14 cities. 1.17.1 Corporate Airlines Policies/Procedures/Training 1.17.1.1 Training Information—General Corporate Airlines’ initial pilot training program included 3 weeks of ground school, flight training in a simulator and in an airplane. The pilots then received initial operating experience in an airplane. The ground school portion included training and testing in the following: basic company indoctrination; airplane performance; weight and 57 EGPWS provides an aural ground proximity warning based on a comparison of the airplane’s location to an on-board terrain map rather than the radio-altitude information used by a GPWS. 58 The FAA uses the term TAWS to refer to systems, including EGPWS, that meet the standards of AD 2004-08-15.

Factual Information 28 Aircraft Accident Report balance; checklist philosophy; crew resource management (CRM);59 stabilized, precision, and nonprecision approaches; CFIT;60 cockpit flows and instrument panel scans (practiced in a cockpit procedures trainer); and airplane systems (1 week of sessions). Corporate Airlines representatives indicated that they did not provide (nor were they required to provide) company pilots with formal fatigue-related training. Eighty-five percent of a new pilot’s flight training would take place in the simulator (usually during about five simulator sessions), and the remainder of the flight training would occur in an airplane (usually during two night sessions). Upon completion of flight training, a pilot-trainee’s initial operating experience would typically consist of a trip sequence (about 20 hours) with a Corporate Airlines check airman. Postaccident interviews indicated that company pilots described the training as challenging and intense;61 according to the director of training, some of the company’s initial training classes had up to a 25 percent failure rate. He stated that he encouraged new-hires to familiarize themselves with the airplane information available on the company’s Web site before they reported for training. 1.17.1.2 Non-Precision Approach/Missed Approach Guidance Corporate Airlines’ BAE-J3201 aircraft manual stated the following:62 If the missed approach point is reached without establishing visual contact, a missed approach must be initiated. In the event that visual contact is made with the runway, the nonflying pilot will call, “runway in sight” and will continue to make the appropriate altitude callouts, referenced to airport elevation. Upon hearing the “runway in sight” call by the nonflying pilot, the flying pilot will transition to visual cues outside the cockpit, and upon seeing the runway/airport will state, “going visual, leaving minimums, flaps 35 degrees.” 59 Corporate Airlines’ CRM training involved a 6-hour session that complied with existing FAA regulations and addressed CRM concepts and policies of cockpit responsibility and duties during flight. During postaccident interviews, several Corporate Airlines pilots and check airmen stated that the company’s CRM training was good and effective. 60 Corporate Airlines’ CFIT training was provided to pilots during initial and recurrent training. It consisted of an FAA-produced presentation on CFIT, supplemented by a videotape and instruction from/classroom discussion with the assistant chief pilot on CFIT/CRM issues that included references to CVR transcripts from recent accidents. Pilots were given a handout of CFIT information and were tested on the CFIT information. 61 According to the captain’s fiancée, the captain stated that Corporate Airlines training personnel taught the material well, and he learned what he needed to know. According to his mother and a pilot friend, the first officer indicated that the training was difficult and very intensive; he told her that quite a few pilots had dropped out of his training class. 62 Postaccident interviews indicated that Corporate Airlines’ nonprecision-approach-related training was consistent with this guidance.

Factual Information 29 Aircraft Accident Report Upon reaching the missed approach point, if the nonflying pilot has not stated “runway in sight” or if transition to visual cues is not possible, or if the aircraft is not in position for a normal landing, the flying pilot will initiate a missed approach by stating, “missed approach.” According to Corporate Airlines’ BAE-J3201 flight manual, nonprecision instrument approach and landing callout procedures required the nonflying pilot to announce when the localizer indicator became active on the flight instruments,63 to provide the flying pilot with directional information as needed upon sighting the runway, and to announce when the airplane descended below the MDA. In addition, Corporate Airlines’ procedures required the nonflying pilot to make a “100 feet above minimums” callout when the airplane was 100 feet above the MDA and then to callout “minimums” when the airplane reached the MDA during a nonprecision approach.64 According to the Corporate Airlines BAE-J3201 systems manual, the airplane’s GPWS makes callouts at 500 feet agl, the MDA (based on the radio altimeter setting), and 200 feet agl during nonprecision approaches to assist pilots in maintaining situational awareness.65 According to the Corporate Airlines BAE-J3201 aircraft manual, if the nonflying pilot established visual contact with the runway environment after the MDA was reached, that pilot would call, “approach lights in sight, continue.”66 At that point Federal regulations would allow the flying pilot to continue the descent beyond the MDA to 100 feet above the TDZE. According to 14 Part 121.651(c)(3), pilots are permitted to descend below the MDA to 100 feet above the TDZE67 if at least one of the following items is “distinctly visible and identifiable” to them: any portion of the approach lighting system; VASI lights; runway end identification lights; the runway threshold, threshold markings, or threshold lights; runway lights; touchdown zone lights; the touchdown zone or touchdown zone markings; and/or the runway or runway markings. If none of these items/visual aids are “distinctly visible and identifiable,” Corporate Airlines’ BAE-J3201 flight manual, section 7, Approach and Landing, pages 14 and 15, stated that pilots must perform a missed approach when they reach the MAP. Corporate Airlines’ BAE-J3201 flight manual, section 7, Approach and Landing, pages 8 and 9, also stated that an immediate missed approach is mandatory if an approach becomes unstabilized while operating in IMC. The manual stated that 900 fpm was the maximum rate of descent for a stabilized approach between 300 feet agl and 50 feet agl. Further, in Corporate Airlines’ flight manual, phase 2 of the stabilized approach procedure allows a 1,200 fpm descent rate from 1,000 feet agl down to 300 feet agl. Current FAA 63 About 1931:38, the CVR recorded the first officer stating that the localizer course was alive. 64 CVR evidence indicates that the first officer did not make the required “100 above minimums” or “minimums” callouts. However, shortly after the GPWS annunciated 500 feet agl, as the airplane descended through about 1,360 feet msl, the first officer stated “thirteen twenty.” (The MDA was 1,320 feet msl.) 65 The CVR’s CAM recorded all of the required GPWS callouts during the accident approach. 66 About 1936:48, as the airplane descended through about 1,160 feet msl (160 feet below the MDA), the CVR recorded the first officer stating, “…in sight…continue.” 67 Descent below this altitude is not permitted unless the approach lighting system’s red terminating bars or the red side row bars are visible.

Factual Information 30 Aircraft Accident Report guidance (as stated in AC 120-71A Standard Operating Procedures for Flight Deck Crewmembers) states that one of the criteria for a stabilized approach is a descent rate no greater than 1,000 fpm below 1,000 feet agl. FAA Order 826.3B states that published nonprecision instrument approach procedures ensure obstacle clearance down to the MDA but obstacle clearance is not ensured below the MDA. When the nonflying pilot announced, “runway in sight,” the flying pilot was to transition from cockpit instruments to external visual cues, and, upon seeing the runway, was to state “going visual, leaving minimums, flaps 35 degrees.”68 1.17.1.3 Crew Schedule Information During postaccident interviews, Corporate Airlines’ director of operations (former chief pilot) told investigators that it was difficult to maintain a pilot-staffing level sufficient to crew the company’s scheduled flights. He stated that the company flight schedules were legal but that it was a challenge to balance what pilots wanted and what the company needed. The director of operations stated that the pilots who commuted to their duty station typically wanted as much flight time as possible per duty day so they could complete their assigned flight hours efficiently and maximize their time off; they did not like “down time sitting around.” For example, he indicated that pilots would be pleased if he assigned them 7 or more hours of flight time per day with 3 duty days per week, rather than fewer hours per day with more duty days. Several Corporate Airlines managers and pilots who were interviewed during this investigation commented that the long days scheduled by the company could be tiring, especially when ceilings and visibilities were low throughout the region. One Corporate Airlines captain/check airman stated that he thought pilots complained about the scheduled flight and duty times when their workload increased during periods of bad weather. He also stated that the lack of an autopilot could increase crew fatigue especially when operating in adverse weather. According to several current and former Corporate Airlines employees (including the chief pilot at the time of the accident,69 several line check airmen, and line pilots), the company did not pressure pilots to fly if they felt fatigued. Interviewees indicated that there would be no adverse ramifications if a pilot declined a trip because he/she was fatigued. The chief pilot at the time of the accident stated that he never questioned pilots who removed themselves from the schedule because of fatigue; however, he stated that it rarely occurred. According to Corporate Airlines’ Director of Safety at the time of the accident, examination of the company database of pilot-reported and other safety issues revealed no reports of fatigue.70 68 The CVR did not record the captain making this or any similar callout. 69 The chief pilot at the time of the accident became director of operations in December 2004. 70 Corporate Airlines provided a forum for employees to report safety issues and maintained a database for tracking safety issues.

Factual Information 31 Aircraft Accident Report The FAA’s principal operations inspector (POI) for Corporate Airlines acknowledged that the schedule that the accident pilots flew on the day of the accident involved a lengthy duty day that started early in the morning after a limited rest period and that the schedule was demanding. However, he indicated that Corporate Airlines’ schedules met Federal flight and duty time requirements. The Corporate Airlines POI also indicated that he had frequent discussions with Corporate Airlines managers and pilots about the company’s management of crew duty time.71 He stated that he typically got one telephone call a month from a Corporate Airlines pilot expressing concern about crew duty days. He stated that Corporate Airlines was short-staffed and tried to optimize its pilot scheduling to make use of the available pilots. Both the POI and assistant POI (APOI) stated that they did not believe that the company would pressure its pilots to fly if they felt sick or fatigued or otherwise unable to complete a scheduled flight.72 1.17.2 Federal Aviation Administration Oversight of Corporate Airlines The FAA air carrier certificate for Corporate Airlines was overseen by the Nashville, Tennessee, flight standards district office. The POI at the time of the accident was the original certification project manager for review and approval of the Corporate Airlines operating certificate and had been the POI for the company since it began operations in December 1996. The APOI had been assigned to the Corporate Airlines certificate for about 1 1/2 years at the time of the accident. Corporate Airlines’ POI reported that, as a part of its operator surveillance, the FAA conducted an Office Special Inspection Program and a Regional Special Inspection Program of the company in 1998 and 1999, respectively. Both inspections identified only minor findings, mostly in the administrative and maintenance areas (for example, maintenance outsourcing; management of manuals and inspection records; completion of forms/documents/trip reports; dispatch and flight following; deicing program; and carriage of cargo). In 2001, the FAA changed its oversight/inspection program and began to conduct its surveillance of Corporate Airlines through the Surveillance and Evaluation Program (SEP) risk analysis and resolution tool.73 71 The POI also stated that one of his greatest challenges was understanding and explaining the FAA’s flight and duty times to operators. During the Safety Board’s public hearing on the August 18, 1993, accident at Guantanamo Bay, Cuba, the manager of the FAA’s Air Carrier Branch expressed concern “about the clarity and the possible ambiguity of” flight crew flight and duty time rules. For additional information, see National Transportation Safety Board, Uncontrolled Collision With Terrain, American International Airways Flight 808, Douglas DC-8-61, N814CK, U.S. Naval Air Station, Guantanamo Bay, Cuba, August 18, 1993, Aircraft Accident Report NTSB/AAR-94/04 (Washington, DC: NTSB, 1994). 72 Neither the POI nor the APOI knew of any pilot declining a trip because they were fatigued. However, the POI told investigators that several pilots declined flights for emotional reasons during the days after the accident, with no repercussions from the company. 73 According to Corporate Airlines’ POI, the FAA’s certificate management team uses the SEP to assess Corporate Airlines’ areas of risk and the severity and likelihood of those risks, and to develop a plan for addressing those risks.

Factual Information 32 Aircraft Accident Report In an October 15, 2004, letter, the POI advised Corporate Airlines that the FAA intended to focus its surveillance efforts in the upcoming months on the following, in part: the company’s deicing program (including training and equipment); maintenance task card completion; outsource maintenance vendors; and training for flight crews (because of pilot turnover and equipment changes) and maintenance and ground support personnel (because of changes to equipment and procedures). The POI told investigators that he was attentive in his surveillance of Corporate Airlines, specifically focusing on flight crew training/evaluation because the company, as an “entry-level” 14 CFR Part 121 airline, had a relatively junior pilot workforce and was often short-staffed. 1.18 Additional Information 1.18.1 Sterile Cockpit Information During portions of the 30-minute, 12-second CVR recording, the pilots engaged in conversation that was not directly related to the conduct of the flight (see appendix B). For example, about 1910:13, the captain stated “gotta have fun” and criticized first officers he had flown with previously for being too serious.74 About 1912:02, the captain transmitted a burp over the ARTCC radio frequency that would have been heard by other pilots and air traffic controllers. An unknown voice on the radio frequency responded to the captain’s burp, stating, “nice tone,” and the CVR recorded the accident pilots chuckling. About 1912:53, the captain talked about deliberately dropping a flight manual on a passenger whose foot had intruded into the cockpit. The first officer engaged in banter with the captain, and both pilots used informal, nonstandard terminology during the flight. Although productive working relationships in the cockpit often involve nonessential conversation during relatively low workload periods (which is permitted by Federal regulations), research75 indicates that crews that overemphasize social team cohesion may not perform as effectively as crews that focus on functional teamwork. Moreover, when the airplane is being operated in critical phases of flight, including the higher workload environment below 10,000 feet msl, the “sterile cockpit” rule (as stated in 14 CFR 121.542)76 applies. This rule states the following, in part: No flight crewmember may engage in, nor may any pilot in command permit, any activity during a critical phase of flight which could distract any flight crewmember from the performance of his or her duties or which could interfere in any way with the proper conduct of those duties. Activities such as eating meals, 74 Beginning about 1910:18, the CVR recorded the captain stating, “too many of these [expletive] take themselves way too serious, in this job. I hate it, I’ve flown with them and it sucks. A month of [expletive] agony…all you wanna do is strangle the [expletive] when you get on the ground.” 75 D. Druckman and J.A. Swets, Enhancing Human Performance: Issues, Theories, and Techniques, National Academy Press (1988): 159-163. 76 Sterile cockpit rules for commuter and on-demand flight operations are addressed in 14 CFR 135.100.

Factual Information 33 Aircraft Accident Report engaging in non-essential conversations within the cockpit and non-essential communications between cabin and cockpit crews, and reading publications not related to the proper conduct of the flight are not required for the safe operation of the aircraft. At times, the pilots’ conversation after the airplane descended below 10,000 feet msl (about 1921:24) was not consistent with these sterile cockpit procedures. For example, about 1922:17, the captain and first officer complained about passenger noise and the captain expressed a desire to make a public announcement telling the passengers to “shut the [expletive] up.” As the pilots neared the airport, prepared for, and initiated the approach, they generally adhered to operationally relevant communications; however, in many instances their communications were not wholly consistent with company-approved phraseology and involved nonessential communication. The Safety Board’s review of FAA and Corporate Airlines records and postaccident interviews provided no evidence that either pilot habitually communicated or behaved in an unprofessional manner. In January 1969, as the result of a December 24, 1968, accident involving an Allegheny Airlines Convair 580,77 the Safety Board issued Safety Recommendation A-69-2, which recommended the following, in part, to the FAA: 1 Pilots, operators and regulatory agencies should renew emphasis on, and improve wherever possible, cockpit procedures, crew discipline and flight management. 2 Both the air carrier industry and the FAA should review policies, procedures, practices, and training toward increasing crew efficiency and reducing distractions and nonessential crew functions during the approach and landing phase of flight. 3 Crew functions not directly related to the approach and landing should be reduced or eliminated, especially during the last 1,000 feet of descent. 4 During the final approach, …pilot should maintain continuous vigilance of light instruments inside the cockpit until positive visual reference is established. In February 1969, the FAA responded to these issues as follows: 1 The FAA reiterates their immediate concern and has initiated a program of follow-up action in the areas of procedures and cockpit discipline and vigilance. 77 For additional information, see National Transportation Safety Board, Allegheny Airlines, Inc., Convair 580, N5802, near the Bradford Regional Airport, Bradford, Pennsylvania, December 24, 1968, Aircraft Accident Report NTSB, Bureau of Aviation Safety, PB189649 (Washington, DC: NTSB, 1969).

Factual Information 34 Aircraft Accident Report 2 FAA inspectors have been directed to review, on a continuing basis, cockpit checklists and procedures to assure that minimum checking will be done during the more critical periods of flight, such as departures, approaches, and landings. 3 FAA believes the airlines require all cockpit check procedures to be completed well before the last 1,000 feet of descent. However, the FAA inspectors are to double check and take action where warranted. 4 FAA inspectors have been directed to assure that cockpit check procedures are arranged so that the pilot flying devotes full attention to flight instruments. In [a December 30, 1968] FAA wire to all U.S. airline presidents, FAA stressed crew vigilance and cockpit discipline. On the basis of these FAA’s actions, the Safety Board classified Safety Recommendation A-69-002, “Closed—Acceptable Action” on November 27, 1974. As the result of a September 27, 1973, accident involving a Texas International Airlines Convair 600,78 in which pilot professionalism was identified as an issue, the Safety Board issued Safety Recommendation A-74-86, which recommended the following, in part, to the FAA: Develop an air carrier pilot program, similar to the General Aviation Accident Prevention Program (FAA Order 8000.8A) that will emphasize the dangers of unprofessional performance in all phases of flight. In an October 17, 1974, response, the FAA indicated that it agreed with this recommendation and that it would increase its participation in industry accident prevention seminars, hold meetings to discuss the subject, and urge FAA regional offices to emphasize professional performance. On the basis of the FAA’s response and subsequent actions, on March 10, 1977, the Safety Board classified Safety Recommendation A-74-86, “Closed—Acceptable Action.” The Safety Board’s investigation of a September 11, 1974, accident involving an Eastern Airlines DC9-31,79 determined that the probable cause was, in part, “the flight crew’s lack of altitude awareness at critical points during the approach due to poor cockpit discipline.” The Board’s report noted that the flight crew engaged in conversations on topics ranging from politics to used cars during the descent from cruise altitude. The Board concluded that “these conversations were distractive and reflected a casual mood 78 For additional information, see National Transportation Safety Board, Texas International Airlines, Inc., Convair 600, N94230, Mena, Arkansas, September 27, 1973, Aircraft Accident Report NTSB/AAR-74-4 (Washington, DC: NTSB, 1974). In its recommendations related to this report, the Safety Board cited several other airline accidents that involved pilot performance issues, the Board report numbers for which are as follows: NTSB/AAR-72/04; NTSB/AAR-72/20; NTSB/AAR-72/31; NTSB/AAR-73/17; and NTSB/AAR-74/03. 79 For additional information, see National Transportation Safety Board, Eastern Airlines, Inc., Douglas DC-9-31, N8984E, Charlotte, North Carolina, September 11, 1974, Aircraft Accident Report NTSB/AAR-75-9 (Washington, DC: NTSB, 1975).

Factual Information 35 Aircraft Accident Report and lax cockpit atmosphere, which continued throughout the remainder of the approach and which contributed to the accident.” In response to accident and other industry evidence of pilot performance deficiencies, the FAA enacted the sterile cockpit rule in 1981. 1.18.2 Additional Flight Crew-Related Accident Information In 1994, the Safety Board conducted a study of flight-crew-involved major accidents of U.S. air carriers80 that found that more than 80 percent of the accidents studied occurred when the captain was the flying pilot and the first officer was the nonflying (monitoring) pilot.81 (This finding is consistent with testimony at the Board’s public hearing on the August 6, 1997, accident involving Korean Air flight 801,82 which indicated that CFIT accidents are more likely to occur when the captain is the flying pilot.)83 The Board’s study found that a frequent factor in accidents involving pilot errors was the failure of first officers to challenge errors (especially tactical decision errors) made by a flying captain. In addition, the study noted, “a first officer may have difficulty both in deciding that the captain has made a faulty decision, and in choosing the correct time to question the decision.” 1.18.3 Nonprecision Instrument Approaches FDR and radar data and the Safety Board’s airplane performance study revealed that the rate at which the airplane descended from the FAF to (and through) the MDA was rapid, relatively constant, and resulted in it reaching the MDA well before the MAP. This type of descent was consistent with the more traditional nonprecision approach technique that Corporate Airlines pilots were trained to use. The Safety Board notes that some air carriers (including United Airlines) have adopted alternative approach techniques for nonprecision instrument approaches, such as the “constant angle of descent” technique. The constant angle of descent technique involves establishing and maintaining a constant descent angle at a moderate descent rate from the FAF to the MDA, reaching the MDA very near the MAP while meeting all crossing restrictions described on the nonprecision approach plate. This constant angle of 80 For additional information, see National Transportation Safety Board, A Review of Flightcrew-Involved Major Accidents of U.S. Carriers, 1978 through 1990, Safety Study NTSB/SS-94/01 (Washington, DC: NTSB, 1994). 81 Typically in U.S. air carrier operations, the captain and first officer alternate flying pilot duties on flight legs. 82 The Safety Board’s public hearing on this accident was held from March 24 to 26, 1998, in Honolulu, Hawaii. 83 This testimony was provided by a British Airways Boeing 777 captain who was a member of the Flight Safety Foundation CFIT Awareness Task Force. For additional information, see National Transportation Safety Board, Controlled Flight Into Terrain, Korean Air Flight 801, Boeing 747-300, HL7468, Nimitz Hill, Guam, August 6, 1997, Aircraft Accident Report NTSB/AAR-00/01 (Washington, DC: NTSB, 2000).

Factual Information 36 Aircraft Accident Report descent may be established and maintained through use of vertical navigation equipment or solely by reference to published approach plate data.84 As a result of the Korean Air flight 801 accident investigation,85 the Safety Board issued Safety Recommendation A-00-14, asking the FAA to do the following: Require, within 10 years, that all nonprecision approaches approved for air carrier use incorporate a constant angle of descent with vertical guidance from on-board navigation systems. In a February 23, 2004, letter to the FAA, the Safety Board noted that at that time, the FAA had incorporated a constant angle of descent in about 90 percent of the nonprecision approaches at airports that serve air carriers and that the remaining airports were scheduled to have constant-angle-of-descent information added by September 2007. As a result of the FAA’s actions, the Board classified Safety Recommendation A-00-14, “Closed—Acceptable Action.” Additionally, in numerous publications (including FAA-H-8083-3A Airplane Flying Handbook and Air Traffic Bulletin #2001-3), the FAA has endorsed the constant-angle-of-descent approach technique, stating that “…for a nonprecision approach…[constant-angle-of-descent procedures] facilitate stabilized approaches…. other procedures that require abnormally high descent rates inhibit a pilot’s ability to descend toward the runway in a stabilized constant descent configuration.” Further, in its “Approach and Landing Accident Reduction” Briefing Note #7.2 (August—November 2000), the Flight Safety Foundation (FSF) stated that a constant-angle-of-descent approach profile “provides a more stabilized flightpath, reduces pilot workload, and reduces the risk of error.” 1.18.4 Flight and Duty Time Information According to FAA regulations, a two-person flight crew engaged in scheduled, domestic operations (such as the accident flight crew) would be limited to 8 flight hours between required rest periods (see section 1.5). However, these regulations do not take into consideration the starting time of day, the length of the duty day, the number of flight segments, weather conditions, equipment on board (for example, an autopilot), or other factors that might affect a pilot’s workload, and thus, a pilot’s fatigue. The aviation regulatory authorities of Great Britain have adopted flight and duty time regulations that reflect information from fatigue and sleep-related research. These British regulations take into consideration a pilot’s starting time and number of flight legs, as well as the total duty time.86 The relevant British flight and duty time regulations for two or more flight crewmembers are summarized in table 4. 84 According to Corporate Airlines, its airplanes are not equipped with vertical navigation equipment for constant-angle-of-descent approaches. 85 For additional information, see Aircraft Accident Report NTSB/AAR-00/01. 86 See Civil Aviation Authority of Great Britain, The Avoidance of Fatigue in Aircrews: Guide to Requirements. CAP 371, Section B (2004): 9.

Factual Information 37 Aircraft Accident Report Table 4. British duty time regulations in hours (hrs) for flight crewmembers, in number of hours permitted. The Safety Board has issued numerous recommendations regarding length of duty issues, including Safety Recommendations I-89-02 and -0387 and A-95-113.88 However, despite repeated efforts to revise and update the flight and duty time rules that began in the mid- to late-1970s, there have been no significant changes to the Federal flight and duty time regulations in the U.S. since the Federal Aviation Regulations were recodified in 1964. In May 1999, the Safety Board issued a safety report that evaluated the DOT’s efforts to address operator fatigue in transportation. The Board’s safety report stated that, “despite the acknowledgement by the DOT that fatigue is a significant factor in transportation accidents, little progress has been made to revise the hours-of-service regulations to incorporate the results of the latest research on fatigue and sleep issues.”89 As a result, the Board recommended that the FAA: Establish, within 2 years, scientifically based hours-of-service regulations that set limits on hours of service, provide predictable work and rest schedules, and consider circadian rhythms and human sleep and rest.90 Number of flight legs Local start time 1 flight leg 2 flight legs 3 flight legs 4 flight legs 5 flight legs 6 flight legs 7 flight legs 8 flight legs 0600-0759 13 hrs 12.25 hrs 11.5 hrs 10.75 hrs 10 hrs 9.5 hrs 9 hrs 9 hrs 0800-1259 14 hrs 13.25 hrs 12.5 hrs 11.75 hrs 11 hrs 10.5 hrs 10 hrs 9.5 hrs 1300-1759 13 hrs 12.25 hrs 11.5 hrs 10.75 hrs 10 hrs 9.5 hrs 9 hrs 9 hrs 1800-2159 12 hrs 11.25 hrs 10.5 hrs 9.75 hrs 9 hrs 9 hrs 9 hrs 9 hrs 2200-0559 11 hrs 10.25 hrs 9.5 hrs 9 hrs 9 hrs 9 hrs 9 hrs 9 hrs 87 These safety recommendations were issued to the Department of Transportation (DOT) and addressed upgraded regulations regarding hours of service, as well as the development and dissemination of educational materials regarding work and rest schedules and proper regimens of health, diet, and rest to personnel in all modes of transportation. The Safety Board has classified Safety Recommendation I-89-02, “Closed— Acceptable Response,” and Safety Recommendation I-89-03, “Closed—Unacceptable Action/Superseded.” 88 This safety recommendation asked the FAA, in part, to “finalize the review of current flight and duty time regulations and revise the regulations, as necessary, within 1 year to ensure that flight and duty time limitations take into consideration research findings in fatigue and sleep issues.” The Safety Board has classified Safety Recommendation A-95-113, “Open—Unacceptable Response.” 89 For additional information, see National Transportation Safety Board, Evaluation of U.S. Department of Transportation Efforts in the 1990s to Address Operator Fatigue, Safety Report NTSB/SR-99/01 (Washington, DC: NTSB, 1999). 90 This safety recommendation is on the Safety Board’s “Most Wanted” list of transportation safety improvements.

Factual Information 38 Aircraft Accident Report In June 1999, the FAA published a notice of intent in the Federal Register indicating the agency’s intent to enforce regulations concerning flight time limitations and rest requirements and issue a supplemental NPRM in spring 2001. However, at an October 1999 meeting, FAA personnel advised the Safety Board that the FAA would not be able to meet the recommendation’s deadline for a new rule. In April 2001, the Safety Board indicated that it was frustrated by the FAA’s lack of progress on this safety issue and classified Safety Recommendation A-99-45 “Open—Unacceptable Response.” In May 2001, the FAA published another Notice of Intent in the Federal Register reiterating its interpretation of regulations regarding pilot flight, duty, and rest times and restating that it intended to deal stringently with any violations. In October 2001, the Board wrote (in its final report on the American Airlines flight 1420 accident at Little Rock, Arkansas)91 that, although it was encouraged by the FAA’s increased efforts to enforce current pilot flight and duty time regulations, recent accidents highlighted the need to expedite efforts to comprehensively address the issue of fatigue in aviation. Therefore, the Board reiterated Safety Recommendation A-99-45 in that accident report. The Safety Board has received no further correspondence from the FAA regarding this safety recommendation.92 In its February 1, 2005, mandatory annual report to Congress regarding the regulatory status of the Safety Board’s “Most Wanted” recommendations, the DOT wrote: The FAA issued an NPRM proposing to amend existing regulations to establish one set of duty period limitations, flight time limitations, and rest requirements for flight crewmembers engaged in air transportation. The FAA encountered a number of technical and operational issues as a result of the NPRM and is presently looking at alternatives. Safety Recommendation A-99-45 remains classified, “Open—Unacceptable Response.” No final rule addressing this issue has been issued to date. 1.18.5 Fatigue-Related Information 1.18.5.1 General Since 1989, the Safety Board has issued more than 70 fatigue-related safety recommendations for all modes of transportation. In addition, human fatigue in transport operations has been included in the Board’s annual list of Most Wanted Transportation Safety Improvements since the list’s inception in September 1990. Research has shown that in general, long duty days can be associated with fatigue and degraded performance. 91 For additional information, see National Transportation Safety Board, Runway Overrun During Landing, American Airlines Flight 1420, McDonnell Douglas MD-82, N215AA, Little Rock, Arkansas, June 1, 1999, Aircraft Accident Report NTSB/AAR-01/02 (Washington, DC: NTSB, 2001). 92 In preparation for its annual review of the Safety Board’s “Most Wanted” list of transportation safety improvements, Board staff has requested an update from the FAA on this recommendation; these requests have not yet produced any updates on FAA action related to implementation of Safety Recommendation A-99-45.

Factual Information 39 Aircraft Accident Report For example, researchers93 observed increased sleepiness and degraded performance in workers on a 12-hour shift when compared with those on an 8-hour shift. Workers on a 12-hour shift also reported reduced amount and quality of sleep. Aviation accident data show that human-performance-related airline accidents are substantially more likely to happen when pilots work long days. For example, the Safety Board’s 1994 study of flight-crew-related major aviation accidents94 found that captains that had been awake for more than about 12 hours made significantly more errors than those that had been awake for less than 12 hours.95 Such errors included failing to recognize and discontinue a flawed approach. In fatigue-related aviation accidents, pilots often exhibit a tendency to continue the approach despite increasing evidence that it should be discontinued. Additionally, accident data96 indicate that pilots who worked schedules that involved 13 or more hours of duty time showed an accident rate that was several times higher than that of pilots working shorter schedules. The research reported that there was a “discernable pattern of increased probability of an accident the greater the hours of duty time for commercial aircraft pilots in the United States.” Figure 8 shows data from 55 human factors-related accidents involving U.S. air carriers between 1978 and 1999, as well as exposure data on pilot work patterns obtained from 10 airlines. About 1 percent of the schedules reviewed involved 13 or more hours of duty time; however, pilots flying these schedules had accident rates several times higher than pilots flying schedules with shorter duty days. Research also indicated that fatigue increased with the number of flight segments in a duty day.97 For example, an increase from one to four flight segments within a duty day increased fatigue an amount equivalent to an additional 2.77 hours on duty. In addition, research indicated that the hour at which a pilot awakens and/or is operating could result in fatigue-related degraded performance. Specifically, because the body is physiologically primed to sleep between 0300 and 0500, wakeup times in this range can result in fatigue-related degraded performance.98 93 R.R. Rosa, M.J. Colligan, and P. Lewis, “Extended Workdays: Effects of 8-Hour and 12-Hour Rotating Shift Schedules on Performance, Subjective Alertness, Sleep Patterns, and Psychosocial Variables,” Work and Stress, Vol. 3, No. 1 (1989): 21-32. 94 For additional information, see Safety Study NTSB/SS-94/01. 95 There was evidence that the captain of flight 5966 napped on a small couch in the company crew rest room. Research indicates that, although naps are a recognized countermeasure for fatigue, the effect of a nap would only last a few hours. See M.R. Rosekind, R.C. Graeber, D.F. Dinges, L.J Connell, M.S. Rountree, C.L. Spinweber, and K.A. Gillin, “Crew Factors in Flight Operations: IX. Effects of Planned Cockpit Rest on Crew Performance and Alertness in Long-Haul Operations,” Technical Memorandum 103884, (1994): National Aeronautics and Space Administration. 96 J.H. Goode, “Are Pilots at Risk of Accidents Due to Fatigue?,” Journal of Safety Research, Vol. 34 (2003): 309-313. 97 See Civil Aviation Authority Paper 2005/04: Aircrew Fatigue: A Review of Research Undertaken on Behalf of the UK [United Kingdom] Civil Aviation Authority. (October 2005): 27-30. 98 See T. Akerstedt, “Review Article: Shift Work and Disturbed Sleep/Wakefulness,” Sleep Medicine Reviews, Vol. 2, No. 2 (1998): 117-128.

Factual Information 40 Aircraft Accident Report Research shows that fatigue can cause pilots to make risky, impulsive decisions, become fixated on one aspect of a situation, and react slowly to warnings or signs, which could result in an approach being continued despite evidence that it should be discontinued.99 Additionally, research shows that people who are fatigued become less able to consider options and are more likely to become fixated on a course of action or a desired outcome.100 For example, in its report on the June 1, 1999, accident involving American Airlines flight 1420 at Little Rock, Arkansas, the Safety Board noted that the pilots had been awake for more than 16 hours and on duty for 14 hours and that they demonstrated deficiencies that included failing to discontinue the approach in deteriorating weather conditions (in the Little Rock case, thunderstorms). The report concluded that, “the flight crew’s impaired performance resulting from fatigue and the situational stress associated with the intent to land under severe meteorological circumstances contributed to the accident.” Figure 8. Aviation accident data from 55 accidents involving U.S. air carriers between 1978 and 1999, indicating that accidents are more prevalent as the length of the pilots’ duty period increases. For additional information, see J.H. Goode, “Are Pilots at Risk of Accidents Due to Fatigue?” Journal of Safety Research, 34 (2003): 309-313. 99 See M.R. Rosekind, K.B. Gregory, D.L. Miller, E.L. Co, J.V. Lebacqz, and M. Brenner, “Evaluating Fatigue Factors in Accident Investigations: Description and Application of a Structured Approach,” (2005): Special Supplement of Aviation, Space Environmental Medicine, in preparation. For additional information, see a) Aircraft Accident Report NTSB/AAR-01/02; (b) Aircraft Accident Report NTSB/AAR-00/01; (c) National Transportation Safety Board, Uncontrolled Collision With Terrain, American International Airways Flight 808, Douglas DC-8-61, N814CK, U.S. Naval Air Station, Guantanamo Bay, Cuba, August 18, 1993, Aircraft Accident Report NTSB/AAR-94/04 (Washington, DC: NTSB, 1994); and d) Safety Study NTSB/SS-94/01. 100 J.A. Caldwell, “Fatigue in the Aviation Environment: An Overview of the Causes and Effect as well as Recommended Countermeasures,” Aviation, Space, and Environmental Medicine, Vol. 68 (1997): 932-938.

Factual Information 41 Aircraft Accident Report 1.18.5.2 Previously Issued Fatigue-Related Recommendations Safety Recommendations A-94-5 and A-94-73 recommended that the FAA: Require U.S. air carriers operating under 14 CFR Part 121 to include, as part of pilot training, a program to educate pilots about the detrimental effects of fatigue, and strategies for avoiding fatigue and countering its effects. (A-94-5) Require that 14 CFR Part 135 air carriers provide aircrews, as part of their initial and recurrent training, information on fatigue countermeasures relevant to the duty/rest schedules being flown by the company. (A-94-73) In response to these Safety Recommendations, on September 8, 1995, the FAA revised AC 120-51, Appendix 3, “Appropriate CRM Training Topics,” to encourage operators to provide pilots with “factual information about the detrimental effects of fatigue and strategies for avoiding and countering its effects” as part of their pilot training programs.101 Further, in December 1995, the FAA issued NPRM 95-18, “Flight Crewmember Duty Period Limitations, Flight Time Limitations and Rest Requirements,” proposing to amend existing regulations to establish flight and duty time limitations and rest requirements for flight crewmembers. On January 16, 1996, Safety Recommendations A-94-5 and A-94-73 were classified “Closed—Acceptable Action.” 1.18.5.3 Department of Transportation Operator Fatigue Management Program The FAA recently participated (with other transportation modal administrations) in a DOT Human Factors Coordinating Committee, which led the DOT’s Operator Fatigue Management Program effort to develop practical tools for use by individuals and industries to better maintain vigilance and alertness on the job. One such tool is a fatigue management reference guide.102 The reference guide was intended to provide basic information to operators in all transportation modes on how to develop an effective fatigue management program using available scientific evidence and best industry practices. For example, the reference guide notes that one of the important components of a fatigue management training program is its ongoing evaluation and refinement. Further, the guide suggests that conducting pilot surveys and monitoring objective safety data to refine existing programs are among the best procedures for such evaluation and refinement. In addition, the DOT program has developed additional products for industry use, including: 101 Although fatigue-related training is recommended in AC 120-51, it is not required by current regulations. 102 U.S. Department of Transportation, (in draft 2003). Commercial Transportation Operator, Fatigue Management Reference. Washington, D.C.: DOT Research and Special Programs Administration. This work follows, in part, from previous Safety Board recommendations that the DOT develop and disseminate educational material for transportation industry personnel and management regarding shift work; work and rest schedule; and proper regimens of health, diet, and rest (Safety Recommendation I-89-2, which was classified, “Closed—Acceptable Action” on May 25, 2001).

Factual Information 42 Aircraft Accident Report • A fatigue management reference guide: a compendium of current science and practical information on approaches to fatigue management and countermeasure usage; • A fatigue model validation procedure: a practical and methodologically sound approach for validating output from fatigue modeling software being tailored for transportation application; • Work schedule representation and analysis software: a software tool to aid managers and schedulers in evaluating and designing ergonomic work schedules to promote on-duty alertness; and • Program evaluation framework: a cross-modal fatigue management research logic model that provides a blueprint for evaluating current knowledge, information needs, and points of leverage between DOT agencies. Further, the DOT is currently developing the following: • Business case development tool suite: a documented methodology and supporting analytical tools to aid company safety managers in building a case for senior management support of fatigue management activities. Recent interviews with DOT personnel indicated that the Federal Railroad Administration has begun validation tests on some of these tools in operational settings within the railroad industry. DOT personnel indicated that they would like future efforts to involve aviation and other transportation modes.

43 Aircraft Accident Report 2. Analysis 2.1 General The captain and first officer were properly certificated and qualified in accordance with, and had received the training and rest time prescribed by, Federal regulations and company requirements. The flight crewmembers possessed valid and current medical certificates appropriate for 14 CFR Part 121 flight operations. The accident airplane was properly certificated and maintained and was equipped and dispatched in accordance with applicable regulations and industry practices. There was no evidence of any preexisting powerplant, system, or structural failure. Loading for the accident flight was routine; no passenger or cargo anomalies were observed, and the airplane was operating within the prescribed weight and center of gravity limits. No hazardous materials were on board the airplane. The accident airplane’s cargo and its loading were not factors in the accident. The pilots received thorough, accurate, and pertinent weather information for their destination airport and were well aware that they would likely not descend beneath the clouds until at or near the MDA. Further, they had been flying in similar weather conditions (IMC with low ceilings and reduced visibilities in fog and mist) all day throughout the region. Although the weather conditions deteriorated slightly since they flew the approach earlier in the day, the CVR indicated that the pilots were aware of and prepared for the deteriorating conditions. In addition, airplanes landed in similar weather conditions without incident about an hour before and about an hour after the accident. Therefore, the Safety Board concludes that, although the weather did not cause this accident, the low ceiling and reduced visibility at IRK made the nonprecision approach more challenging. Corporate Airlines pilots (former and current) and FAA inspectors provided positive comments about the company and its procedures and training. The company’s training program included CFIT and CRM training and was described as tough and thorough. Although Corporate Airlines’ schedules occasionally resulted in long duty days, they satisfied Federal flight and duty time requirements.103 There was no evidence of company-wide deficiencies or company pressure on pilots to fly fatigued or to complete difficult approaches. Therefore, the Safety Board concludes that Corporate Airlines’ policies, procedures, and training were consistent with industry standards. The accident occurred after ATC had cleared the pilots for a nonprecision approach to an uncontrolled airport. ATC was not a factor in the accident. Because of the rural location of the accident site and the communication challenges inherent in off-airport accidents involving uncontrolled airports, emergency 103 For additional information, see section 2.5.

Analysis 44 Aircraft Accident Report response personnel arrived at the accident site about 40 minutes after the accident. The cause of death for all fatally injured airplane occupants was determined to be multiple blunt force injuries experienced during the impact sequence. It is likely that the two survivors were less severely injured because of their seat locations in the airplane (over the main wing spar near a postaccident break in the fuselage); as a result, they were able to promptly exit the burning airplane.104 The Safety Board concludes that the emergency response did not adversely affect the survivability of this accident. The Safety Board notes that the GPWS installed on the accident airplane provided a “sink rate” alert about 3 seconds before initial impact, which was consistent with the unit’s design. By contrast, an EGPWS, which is now required by Federal regulations would have provided a “too low terrain” alert about 10 seconds before impact (shortly after the airplane descended through the MDA) and would have repeated this alert every 3 seconds until the airplane’s descent profile was corrected. Corporate Airlines had equipped 2 of its 12 operating airplanes (but not the accident airplane) with EGPWS when the accident occurred and equipped its remaining fleet with EGPWS before March 29, 2005, in compliance with FAA requirements. The Safety Board concludes that an EGPWS (required by Federal regulation since March 29, 2005), would have provided the pilots with a “too low terrain” alert in sufficient time to avoid collision with the trees. This analysis will focus on the pilots’ decisions and performance to consider why neither pilot recognized and/or took action to correct the airplane’s descent rate and proximity to the ground during the later stages of the approach to IRK. Specifically, this analysis will evaluate operational and human factors issues, including: pilot professionalism and sterile cockpit procedures, nonprecision instrument approach procedures, flight and duty time regulations, fatigue, and FDR/image recorder requirements. 2.2 The Accident Sequence Examination of the CVR and FDR data indicated that the en route portion of the accident flight from STL to IRK was routine. The captain had thoroughly briefed the nonprecision, instrument approach, including the MDA and missed approach procedures. The initiation of the approach was consistent with company procedures; when the airplane passed the FAF on the approach, the pilots began a 1,200 fpm rate of descent to the MDA. The Safety Board notes that Corporate Airlines’ flight manual indicates that a 1,200 fpm descent rate from 1,000 feet agl down to 300 feet agl is consistent with a stabilized approach. Although this descent rate is not prohibited by the FAA, it is not consistent with the FAA’s guidance, which indicates that one of the criteria for a stabilized approach is a descent rate no greater than 1,000 fpm below 1,000 feet agl. The Safety Board concludes that although the accident airplane’s 1,200 fpm rate of descent was consistent with company procedures, it varied from current FAA guidance that recommends a descent rate of no more than 1,000 fpm below 1,000 feet agl. 104 Although emergency response communication and coordination issues were identified (for example, the initial LPFD responders and IC were operating on a different radio frequency than law enforcement personnel), the issues were not causal to this accident and have since been addressed.

Analysis 45 Aircraft Accident Report As the approach continued, however, neither pilot followed standard company nonprecision approach procedures. Table 5 lists proper procedural requirements and callouts (with the acting pilot, if applicable), the accident pilots’ actions and responses, and pertinent remarks where applicable. Table 5. Proper procedural requirements and callouts (with the acting pilot, if applicable), the accident pilots’ actions and responses, and pertinent remarks where applicable. Italics text indicates deviations from procedures. Procedural requirements/callouts (acting pilot, if applicable) Accident pilot actions and responses Pertinent remarks Regulations and procedures prohibit non-essential flight crew conversation below 10,000 feet msl See CVR transcript in appendix B. “Flaps 10” callout (flying pilot) “Flaps 10” callout (flying pilot) “Flaps 10” response (nonflying pilot, after flaps 10 were selected) “Course alive, crosschecked, no flags” callout (nonflying pilot) “Course alive, cross check, no flags except for the vertical” callout (nonflying pilot) “Gear down, flaps 20, before landing check” callout (flying pilot) “Gear down, flaps 20, before landing check” callout (flying pilot) The nonflying pilot then performed the before landing checklist “100 feet above minimums” callout (nonflying pilot) No such callout was recorded by the CVR. “Minimums” callout and look for pertinent ground references (nonflying pilot) “Thirteen twenty” - callout (nonflying pilot) 1,320 feet msl was the MDA If pertinent ground references are not clearly visible to the nonflying pilot level off at the MDA and monitor cockpit flight instruments (flying pilot) As the airplane continued its descent to and through the MDA, the flying pilot stated, “I can see ground there” and “what do you think?” Contrary to procedures and training, the flying pilot was looking for external visual references during the approach, rather than leveling off and monitoring the flight instruments If pertinent ground references are not clearly visible to the nonflying pilot continue to look for pertinent ground references (nonflying pilot). After the flying pilot said he saw the ground, the nonflying pilot stated, “I can’t see [expletive].” • Consistent with procedures, the nonflying pilot was looking for pertinent ground references. • The nonflying pilot did not challenge the flying pilot’s continued descent. “Runway in sight” callout (nonflying pilot) “Yeah, oh there it is, approach lights in sight” statement (flying pilot) Contrary to procedures, the flying pilot was the first to say that he had visual cues allowing descent below MDA. Further, this nonstandard callout was recorded after the airplane was below the MDA. Company procedures dictate descent rates of no more than 900 fpm below 300 feet agl. The accident airplane’s descent rate was consistently about 1,200 fpm until immediately before it struck the trees. The first officer failed to challenge the continued 1.200 fpm rate of descent below 300 feet agl. “Going visual, leaving minimums, flaps 35” callout (flying pilot) No such callout was recorded by the CVR; however,the first officer offered and the captain declined selection of flaps 35 about 4 seconds before impact.

Analysis 46 Aircraft Accident Report CVR evidence indicated that just before the GPWS announced that the airplane was at the MDA (at 1936:36.8), the captain stated, “I can see ground there.”105 About 6 seconds later, the captain stated that he could see the approach lights. The captain’s statements indicated that, contrary to company procedures, he was looking outside the cockpit for visual references. Corporate Airlines’ procedures dictated that if the nonflying/monitoring pilot (the first officer) did not see the required visual cues when the airplane reached the MDA (and in this case, his comment at 1936:41.9 indicated that he did not), the flying pilot (the captain) should level off and remain at the MDA until those cues came into sight or until the airplane reached the MAP.106 As the airplane was about 170 feet below the MDA (about 194 feet agl, 8 seconds after the airplane descended through the MDA), the first officer stated, “in sight…continue.” CVR evidence clearly indicates that both pilots were referring to external cues and not referencing the necessary cockpit instrumentation. In fact, although company procedures dictated descents of no more than 900 fpm below 300 feet agl, the airplane was still descending at a rate of about 1,200 fpm as it descended through about 100 feet agl. As the airplane descended through about 100 feet agl, the first officer suggested selecting landing flaps (35°); the captain turned down the suggestion. The decision not to extend landing flaps suggests that the captain was not completely committed to a landing, although he said he saw the approach lights. However, the captain’s failure to stop or slow the airplane’s descent indicates that he was not aware of the airplane’s excessive descent rate and/or significantly misjudged its proximity to the ground. Although current FAA regulations permit pilots to descend below the MDA to 100 feet above the TDZE after they observe the approach lights,107 such a descent may not be advisable under all circumstances. During an approach at night, in reduced visibility, approach lights alone would not provide an adequate sight picture for the pilots to make an appropriate approach to the runway. With only an approach light or lights for approach path reference, a pilot could focus on those lights while flying into the ground. Pilots who had flown into IRK at night told investigators that, other than the airport’s lighting systems, there were minimal lights or ground references beneath the approach course that would have helped the pilots judge the airplane’s position relative to the runway or height above terrain.108 105 It is not clear what the captain was looking at when he reported seeing the ground. On the basis of IRK ASOS weather observations and other pilot reports, it is likely that the airplane was skimming the bottom of the clouds as it descended through the MDA. The approach path was over farmland and woods, and postaccident interviews with local residents and other pilots indicated that there were few, if any, light sources (except the airport lights) or other ground references that were visible at night in the area. 106 At the MAP, if the pilots do not see the approach lights or runway environment, company and published approach procedures require a missed approach. 107 For additional information, see section 2.4. 108 On the basis of the airplane’s altitude, its distance from the runway, the relative brightness of the approach lights, and the fact that the VASI glidepath does not intercept the MDA until closer to the airport, the VASI lights would have appeared solid red and therefore would not have provided the pilots with much usable information.

Analysis 47 Aircraft Accident Report The Safety Board concludes that the pilots failed to follow established procedures to effectively monitor the airplane’s descent rate and height above terrain during the later stages of the approach and relied too much on minimal external visual cues. Although descent rate and altitude information were readily available through cockpit instruments, both pilots were largely preoccupied with looking for the approach lights. 2.3 Crew Performance/Professionalism Cockpit communications recorded by the CVR indicated that the pilots frequently engaged in conversation that lacked a professional tone during the accident flight. The Board considered whether these unprofessional communications (some of which were made during a critical phase of flight below 10,000 feet msl and therefore were not consistent with FAA and Corporate Airlines sterile cockpit procedures) were a factor in this accident. CVR evidence indicated that the pilots appeared to be comfortable with each other and enjoyed flying and joking together. To an extent, this working relationship might have been a benefit in the cockpit. Humor can play an important function in promoting crew cohesion, coordination, and tension reduction; it is reasonable to expect that a crew that works together for several days may develop an effective interaction style that involves humor. However, research has shown that flight crews that focus more on social cohesion than on-task team work may not perform as effectively as other flight crews and may be distracted from standard procedures.109 When the relationship between colleagues is excessively relaxed, there may be a tendency for professionalism to be compromised and pilot responsibilities to be adversely affected. Flight crewmembers must be alert to these possibilities to avoid degraded situational awareness and adhere to standard operating procedures and professionalism. Also, in an excessively relaxed relationship, there may be a tendency for overconfidence and over-reliance on each other. The pilots’ professional demeanor was probably degraded as a result of their relationship and relaxed behavior; these factors may also have detracted from the pilots’ adherence to company standard procedures and callouts. Federal regulations regarding sterile cockpit procedures are intended to prevent casual crew interactions from interfering with the careful execution of critical pilot actions, such as altitude and course control during nonprecision instrument approaches. These rules allow more casual flight crew interactions during operations above 10,000 feet msl, when the workload is relatively low, while expressly prohibiting nonessential flight crew conversations/interactions below 10,000 feet msl, when the workload is relatively high. 109 D. Druckman and J.A. Swets, Enhancing Human Performance: Issues, Theories, and Techniques, National Academy Press (1988): 159-163.

Analysis 48 Aircraft Accident Report The captain, as the pilot-in-command, had the authority and responsibility to set the cockpit tone for the approach. However, the accident captain was known among coworkers for his sense of humor and CVR evidence indicated that he emphasized fun in the cockpit. Had he emphasized the pilots’ goals and strategies as they prepared for the nonprecision approach in night IMC conditions, it is likely that the accident pilots would have suspended their humorous banter and engaged in only operationally relevant conversation below 10,000 feet msl. The captain’s continued joking during this period established an inappropriate cockpit orientation for this phase of the flight and was not consistent with standard operating procedures. Both pilots’ attitudes and inattention during subsequent operations demonstrated a lack of regard/respect for their responsibilities and duties. Despite the pilots’ unprofessional verbal behavior throughout much of the flight, CVR, FDR, ATC, and radar information indicated that they were generally attentive to required flight-related duties until shortly before the accident. For example, the pilots were very attentive to the weather conditions (low ceilings and reduced visibility) at IRK, checking and rechecking the IRK ASOS observations as they approached the airport. Additionally, the captain provided a thorough landing briefing in which he stated the MDA and runway TDZE (1,320 and 964 feet, respectively) and reviewed the missed approach procedures. He also restated the MDA as he began the approach. However, despite their apparent awareness of proper approach procedures and altitudes, the pilots continued their 1,200 fpm descent below the MDA without an appropriate visual reference. The captain should have leveled off and focused on the flight instruments and the first officer should have instructed him to level off. It was apparent that they did not have the requisite visual cues needed to descend further at that time. Instead, about 2 seconds after the airplane descended through the MDA, still descending about 1,200 fpm, the captain asked the first officer, “what do you think?” About 4 seconds later, the first officer responded, “I can’t see [expletive].” Corporate Airlines’ procedures dictated that the first officer was to monitor the approach and report deviations from standard company approach procedures. During the accident approach, the first officer occasionally provided the captain with appropriate nonflying/monitoring pilot support (such as when he prompted the approach checklist, provided DME callouts, repeated the MDA altitude, and prompted landing flaps). However, there were several instances in which the first officer failed to provide company-required callouts or provided nonstandard callouts. For example, he was required to callout “100 feet above minimums” and “minimums,” as the airplane descended through those altitudes, but instead he made a single callout of “thirteen twenty” as the airplane approached the MDA. Most significantly, the first officer did not challenge the captain’s failure to level off at or reduce the airplane’s rate of descent around the MDA, despite the fact that the first officer did not see any ground references and was responsible for monitoring the progress of the approach.110 110 The Safety Board notes that careful adherence to standard procedures and division of responsibility in the cockpit can significantly help pilots limit the degrading effects of fatigue. The role of fatigue in this accident is discussed in section 2.5.

Analysis 49 Aircraft Accident Report The first officer appeared to be engaged in appropriate nonflying/monitoring pilot activities during the later stages of the approach; he was looking for external visual references and stated, “in sight, continue” when he eventually observed the approach lights (about 11 seconds after the airplane descended through the MDA). He also prompted the captain regarding the landing flap configuration late in the approach. However, when the descent continued below the MDA, the first officer did not aggressively express concern even though he did not yet see the approach lights. It is possible that the first officer was not aware that the airplane had not leveled off at the MDA because, as the nonflying/monitoring pilot, he was primarily looking for external visual references. However, it is also possible that the first officer did not challenge the captain because he was hesitant to be perceived as criticizing him. The Safety Board’s 1994 safety study showed that accidents that involve human performance deficiencies are much more likely to occur when the captain is the flying pilot. This finding has been widely interpreted as indicative of the difficulty that first officers may have in challenging a captain because of the difference in experience and cockpit authority gradient between the two crewmembers. The Safety Board concludes that the pilots’ nonessential conversation below 10,000 feet msl was contrary to established sterile cockpit regulations and reflected a demeanor and cockpit environment that fostered deviation from established standard procedures, CRM disciplines, division of duties, and professionalism, reducing the margin of safety well below acceptable limits during the accident approach and likely contributing to the pilots’ degraded performance. Further, the Safety Board concludes that compliance with sterile cockpit rules likely would have resulted in an increased focus on standard procedures and professionalism during the accident flight. Further, there is no evidence to indicate that this flight crew was unique in their behavior. Therefore, the Safety Board believes that the FAA should direct the POIs of all 14 CFR Part 121 and 135 operators to reemphasize the importance of strict compliance with the sterile cockpit rule. 2.4 Nonprecision Instrument Approach Techniques Industry nonprecision instrument approach practices include two basic techniques: a traditional technique in which pilots descend rapidly to the MDA, level off, and fly to the MAP; and a constant-angle-of-descent technique in which the pilots establish a more moderate rate of descent calculated to reach the MDA just before the MAP. Corporate Airlines trained its pilots to use a traditional approach technique when performing nonprecision instrument approaches. Thus, when the airplane crossed the FAF, the pilots were to establish the airplane in a descent that allowed it to reach the MDA well before the MAP, then level off. The approach flown by the accident pilots was consistent with a traditional method nonprecision instrument approach until they continued their descent below the MDA. The Safety Board reviewed the constant-angle-of-descent approach technique (which is recommended where practicable by the FAA and FSF) to determine whether it might have helped the pilots avoid this accident.

Analysis 50 Aircraft Accident Report Unlike a traditional approach, a constant-angle-of-descent approach technique involves establishing and maintaining a constant descent angle and moderate descent rate from the FAF toward the approach end of the runway and arriving and leveling off at the MDA at a point at or slightly before reaching the MAP. (Although the accident pilots maintained a relatively consistent angle of descent, their descent was steeper than that involved in a constant-angle, moderate-rate descent; as a result, the airplane reached the MDA almost 2 miles before the MAP and then did not level off.) The use of the constant-angle-of-descent technique is typically dependent on the use of position and altitude information (for example, DME and the altimeter) to determine the necessary vertical flightpath. If used for the accident approach, the constant-angle-of-descent approach would likely have provided a stabilized flightpath with a relatively shallow angle of descent such that the airplane would reach the MDA at or slightly before the MAP.111 The accident captain would likely have needed only minimal adjustments to maintain the correct descent profile to land within the touchdown zone on the runway. The pilots would have been closer to the airport when they reached the MDA, which would have facilitated their acquisition of visual cues indicating the airport environment, so they could maintain a normal descent to the runway and thus avoid obstacles during the descent from the MDA to the runway. The Safety Board concludes that the use of a constant-angle-of-descent approach technique, with its resultant stabilized, moderate rate-of-descent flightpath, and obstacle clearance, would have better positioned the accident airplane for a successful approach and landing. Therefore, the Safety Board believes that the FAA should require all 14 CFR Part 121 and 135 operators to incorporate the constant-angle-of-descent technique into their nonprecision approach procedures and to emphasize the preference for that technique where practicable. 2.4.1 Descent Below the Minimum Descent Altitude on Nonprecision Approaches Current Federal regulations permit pilots to descend below the MDA to 100 feet above the runway TDZE if the airport approach lights are in sight.112 However, the pilots must positively maintain obstacle clearance without the electronic vertical profile guidance that they would receive during a precision approach or the proper vertical profile they would maintain if performing a nonprecision constant-angle-of-descent approach. According to the FAA, published nonprecision approach procedures ensure obstacle clearance throughout the descent to the MDA but do not ensure obstacle clearance below this altitude. Therefore, it is critical that pilots refrain from descending 111 Additionally, use of the constant-angle-of-descent approach technique would eliminate the need to descend to 100 feet above the touchdown zone before reaching the runway. In marginal weather conditions, the procedure permitting descent to 100 feet above the TDZE could have a potential for attracting pilots into an unsafe environment. 112 Evidence (interviews with other Corporate Airlines pilots, examination of Corporate Airlines’ operations, and review of FDR data from the accident pilots’ previous approach to IRK) indicates that the accident pilots were aware of the Federal regulations allowing them to descend below the MDA if they had the approach lights in sight and took advantage of it if necessary.

Analysis 51 Aircraft Accident Report below the MDA unless at least one of several very specific approach lighting or runway environment items is “distinctly visible and identifiable” to them, to provide guidance to the runway. This accident occurred after the pilots continued their descent through the MDA and even through 100 feet above the TDZE (1,064 feet msl), without adequate visual reference to the approach lights or runway environment. At night with low ceilings, reduced visibility, and limited visual cues (ground lights, etc.), it would have been very difficult for the pilots to detect obstacles along the approach path through external visual cues, let alone visually assess the airplane’s descent rate, distance from the airport, and height above the ground. The pilots (whom CVR evidence indicated wanted to land at IRK at the end of a long day and who likely began to see that they were breaking out of the clouds around the MDA) were apparently motivated to descend below the MDA to acquire visual cues that would allow them to continue the approach. The accident airplane initially impacted trees about 996 feet msl, which was about 62 feet below the “100 feet above TDZE” altitude. The Safety Board concludes that current regulations permitting pilots to descend below the MDA into a region where obstacle clearance is not assured results in reduced margins of safety for nonprecision approaches, especially in conditions of low ceilings, reduced visibility, and/or at night. Further, these regulations can have the unintended effect of encouraging some pilots to descend below the MDA in an attempt to acquire visual cues that will permit them to continue the approach, as occurred in this case. Therefore, the Safety Board believes that the FAA should revise applicable 14 CFR Part 121 and 135 regulations to prohibit pilots from descending below the MDA during nonprecision instrument approaches unless conditions allow for clear visual identification of all obstacles and terrain along the approach path or vertical guidance to the runway is available and being used. 2.5 Pilot Flight and Duty Time and Fatigue Issues The Safety Board evaluated fatigue as a possible factor in this accident and looked at the various circumstances present the day of the accident that may have contributed to the pilots’ fatigue, including hours of rest, waking time, length of the duty day, and workload. The pilots’ available rest time (from about 2100 to about 0400) did not correspond favorably with either pilot’s reported usual sleeping hours, resulting in much earlier than normal times to go to sleep and awaken.113 Additionally, the early wakeup call times114 would have been challenging to both pilots because the human body is normally physiologically primed to sleep between 0300 and 0500. 113 According to the captain’s fiancée, when he did not have work demands, the captain normally went to sleep about midnight and awoke about 0630 or 0700; further, he had indicated that he had difficulty sleeping the night before the accident. The first officer’s mother reported that when he did not have work demands, the first officer’s sleep schedule was variable, depending on social and flight instruction obligations; however, she was often asleep before he returned home. 114 Records indicate that the captain and first officer received hotel wakeup calls at 0410 and 0430, respectively.

Analysis 52 Aircraft Accident Report Other important factors that would facilitate the development of fatigue in the accident pilots included the length of their duty day and the type of flying throughout that day (and the two previous days). At the time of the accident, it had been more than 15 hours since the pilots’ last significant sleep period, and they had been on duty for 14 1/2 hours. The captain was observed resting on a small couch in the company crew room in STL between flights; however, the quality of rest the captain obtained during this time could not be determined, and company pilots stated that the crew room was a noisy meeting area that was not ideal for sleeping. Further, although naps are a recognized countermeasure for fatigue, research indicates that the effect of a nap would only last a few hours. Therefore, any sleep the captain got during this rest period probably had little fatigue-reducing effect by the time of the accident.115 The Safety Board’s 1994 study of flight crew-related major aviation accidents indicated that fatigue related to lengthy periods of wakefulness can contribute to accidents. Specifically, the Board’s study found that captains who had been awake for more than about 12 hours made significantly more errors than those who had been awake for less than 12 hours; such errors included failing to discontinue a flawed approach.116 Further, accident data show that long duty days significantly increase the likelihood of human factors-related accidents. Pilots who flew schedules involving 13 or more hours of duty time had accident rates several times higher than pilots who flew shorter schedules. Additionally, the pilots’ high workload during their long day may have increased their fatigue. The accident occurred during the sixth flight segment of the day while the pilots were performing a nonprecision approach in low ceilings and reduced visibility. The pilot deficiencies observed in this accident could be consistent with fatigue impairment. Research and accident history indicate that fatigue can cause pilots to make risky, impulsive decisions, to become fixated on one aspect of a situation, and to react slowly to warnings or signs that an approach should be discontinued. Fatigue especially affects decision making, and research shows that people who are fatigued become less able to consider options and are more likely to become fixated on a course of action or a desired outcome. Among pilots, this may appear as errors such as failing to discontinue a flawed approach. Consistent with the degrading effects of fatigue, the captain made a risky decision to continue the approach based on inadequate visual cues, fixated on visual information to the exclusion of critical information on descent rate and altitude available on the airplane’s instruments, and failed to discontinue the flawed approach although he was unable to acquire external visual cues that would assure a safe landing. Similarly, although the first officer’s junior status with the company may have been an issue in his failure to challenge 115 As previously mentioned, the CVR recorded yawning sounds from both the captain (about 1915:03) and the first officer (about 1923:43, 1925:44, and 1929:27) during the flight. 116 For example, in its investigation of the June 1, 1999, accident involving American Airlines flight 1420 at Little Rock, Arkansas, in which the pilots continued a flawed approach, the Safety Board noted that the pilots had been continuously awake for at least 16 hours.

Analysis 53 Aircraft Accident Report the captain during the approach, he may also have been suffering from fatigue; his failure to monitor and react to the captain’s deviations from nonprecision approach procedures was consistent with the degrading effects (slowed reactions and/or tunnel vision) of fatigue. The Safety Board concludes that, on the basis of the less than optimal overnight rest time available, the early reporting time for duty, the length of the duty day, the number of flight legs, the demanding conditions (nonprecision instrument approaches flown manually in conditions of low ceilings and reduced visibilities) encountered during the long duty day (and the two previous days), it is likely that fatigue contributed to the pilots’ degraded performance and decision-making. Despite repeated recommendations from the Safety Board (including Safety Recommendation A-99-45), the FAA has not revised its pilot flight and duty time regulations. The Safety Board notes that regulations such as those adopted by Great Britain provide clear, easy-to-understand limits with which industry can develop schedules to optimize pilot utilization while respecting factors identified in current scientific literature as conducive to fatigue. The Safety Board concludes that existing FAA pilot duty regulations do not reflect recent research on pilot fatigue and sleep issues, increasing the possibility that pilots will fly in a fatigued condition. Therefore, the Safety Board believes that the FAA should modify and simplify the flight crew hours-of-service regulations to take into consideration factors such as length of duty day, starting time, workload, and other factors shown by recent research, scientific evidence, and current industry experience to affect crew alertness. Further, because the FAA has not taken suitable action regarding Safety Recommendation A-99-45 since it was issued in 1999, the Safety Board classifies Safety Recommendation A-99-45 “Closed—Superseded.” 2.5.1 Training Although the FAA revised AC 120-51, “Crew Resource Management Training,” Appendix 3, “Appropriate CRM Training Topics,” to encourage operators to provide pilots with information about the detrimental effects of fatigue and strategies for avoiding and countering its effects as part of their CRM training programs, such training is not required by current regulations. Although many airlines have incorporated such training into their programs, at the time of the accident, Corporate Airlines did not provide its pilots with fatigue-related instruction in its CRM or other training modules.117 The Safety Board notes that the FAA participated (with other transportation modal administrations) in a DOT Operator Fatigue Management Program effort to develop a fatigue management reference guide. The reference guide was intended to provide basic information to operators in all transportation modes about how to develop an effective fatigue management program using available scientific evidence and industry best 117 As previously stated, Corporate Airlines’ CRM training was a 6-hour session that addressed CRM concepts and policies of cockpit responsibility and duties during flight, as required by regulation.

Analysis 54 Aircraft Accident Report practices. In addition, the DOT program has developed additional products for industry use, such as software to aid in designing work schedules that promote alertness. Such products can provide useful guidelines and tools for companies that are willing to go beyond current regulations by developing and implementing a fatigue management program. DOT personnel are currently developing a tool to aid company safety managers in building a case for support of fatigue management activities. The circumstances of this accident demonstrate the continuing need for fatigue management in the aviation industry. The Safety Board concludes that providing pilots with additional fatigue-related training, such as that being developed by the DOT Operator Fatigue Management Program, may increase their awareness and use of fatigue avoidance techniques and thus improve safety margins. Therefore, the Safety Board believes that the FAA should require all 14 CFR Part 121 and 135 operators to incorporate fatigue-related information similar to that being developed by the DOT Operator Fatigue Management Program into their initial and recurrent pilot training programs; such training should address the detrimental effects of fatigue and include strategies for avoiding fatigue and countering its effects. 2.6 Flight Recorder Requirements Current 14 CFR Part 121 FDR standards for newly manufactured airplanes require FDRs to record 88 parameters of data. The accident airplane was in a category that was not required to be so equipped. Given the limited predicted life of these airplanes, the FAA allowed exceptions to this rule, indicating that upgrading existing FDR equipment to record additional parameters on older airplanes would require extensive modifications and was not cost effective. The Safety Board notes that the FDR is an important investigative tool that can be used to determine operational actions and an airplane’s performance. Because the information that investigators learn from FDR data can help prevent accidents and incidents from recurring, FDRs that record only a limited number of parameters can adversely affect safety. However, new technology (specifically, onboard image recorders) provides an economical means of supplementing parametric information on airplanes operating with FDRs recording fewer parameters. Image recorders have the added advantage of providing additional information that would not be readily obtained from the CVR and/or FDR, such as the environment within the cockpit and outside the cockpit window and the manipulation of controls and switches in the cockpit. In April 2000, the Safety Board issued Safety Recommendation A-00-30 to the FAA, asking the FAA to require that all aircraft operated under 14 CFR Parts 121, 125, or 135 and currently required to be equipped with a CVR and FDR be retrofitted by January 1, 2005, with a crash-protected cockpit image recording system. (See section 1.11.2.1 for more information about this recommendation.) Despite the Board’s recommendation, a February 2005 NPRM titled, “Revisions to Cockpit Voice Recorder and Digital Flight Data Recorder Regulations,” did not address image recorders.

Analysis 55 Aircraft Accident Report During this investigation, the Safety Board learned that several aircraft like the BAE-J3201 are currently used in Part 121 passenger-carrying operations with minimal, if any, recorded data,118 which is unacceptable. The Safety Board understands that the cost of retrofitting these aircraft with FDRs to meet the current standard for newly manufactured aircraft may be cost-prohibitive. However, image recorder technology that is currently available offers a cost-effective solution and would capture important data that would otherwise be lost in an investigation. For example, in this accident an image recorder might have provided information regarding where the pilots were looking and what they might have seen through the windshield as they descended below the MDA. The Safety Board concludes that capturing the maximum recorded data possible is necessary for a more effective reconstruction of the events that lead to accidents and the issuance of more timely safety recommendations to prevent similar accidents from recurring. Therefore, the Safety Board reiterates Safety Recommendations A-00-30 for airplanes that are currently required to be equipped with both a CVR and FDR and Safety Recommendation A-03-65 for airplanes that are required to be equipped with a CVR. 118 It is possible that some airplanes that entered the U.S. registry before October 11, 1991, and are currently used in Part 121 passenger-carrying operations might only be equipped with a CVR and not an FDR. The Safety Board previously recommended image recorders for airplanes that are only equipped with a CVR in Safety Recommendation A-03-65.

56 Aircraft Accident Report 3. Conclusions 3.1 Findings 1. The captain and first officer were properly certificated and qualified in accordance with, and had received the training and rest time prescribed by, Federal regulations and company requirements. The flight crewmembers possessed valid and current medical certificates appropriate for 14 Code of Federal Regulations Part 121 flight operations. 2. The accident airplane was properly certificated and maintained and was equipped and dispatched in accordance with applicable regulations and industry practices. There was no evidence of any preexisting powerplant, system, or structural failure. 3. The accident airplane’s cargo and its loading were not factors in the accident. 4. Although the weather did not cause this accident, the low ceiling and reduced visibility at Kirksville Regional Airport made the nonprecision approach more challenging. 5. Corporate Airlines’ policies, procedures, and training were consistent with industry standards. 6. Air traffic control was not a factor in the accident. 7. The emergency response did not adversely affect the survivability of this accident. 8. An enhanced ground proximity warning system (required by Federal regulation since March 29, 2005), would have provided the pilots with a “too low terrain” alert in sufficient time to avoid collision with the trees. 9. Although the accident airplane’s 1,200 feet per minute (fpm) rate of descent was consistent with company procedure, it varied from current Federal Aviation Administration guidance that recommends a descent rate of no more than 1,000 fpm below 1,000 feet above ground level.

1. The pilots failed to follow established procedures to effectively monitor the airplane’s

descent rate and height above terrain during the later stages of the approach and relied too much on minimal external visual cues. Although descent rate and altitude information were readily available through cockpit instruments, both pilots were largely preoccupied with looking for the approach lights.

Conclusions 57 Aircraft Accident Report

1. The pilots’ nonessential conversation below 10,000 feet mean sea level was contrary

to established sterile cockpit regulations and reflected a demeanor and cockpit environment that fostered deviation from established standard procedures, crew resource management disciplines, division of duties, and professionalism, reducing the margin of safety well below acceptable limits during the accident approach and likely contributing to the pilots’ degraded performance.

1. Compliance with sterile cockpit rules may have resulted in an increased focus on

standard procedures and professionalism during the accident flight.

1. The captain should have, but did not, arrest the airplane’s rapid descent when they

reached the minimum descent altitude (MDA), and the first officer should have, but did not, challenge the captain’s descent below the MDA.

1. The use of a constant-angle-of-descent approach technique, with its resultant

stabilized, moderate rate-of-descent flightpath, and obstacle clearance, would have better positioned the accident airplane for a successful approach and landing.

1. Current regulations permitting pilots to descend below the minimum descent altitude

(MDA) into a region where obstacle clearance is not assured may result in reduced margins of safety for nonprecision approaches, especially in conditions of low ceilings, reduced visibility, and/or at night. Further, these regulations can have the unintended effect of encouraging some pilots to descend below the MDA in an attempt to acquire visual cues that will permit them to continue the approach, as occurred in this case.

1. On the basis of the less than optimal overnight rest time available, the early reporting

time for duty, the length of the duty day, the number of flight legs, the demanding conditions (nonprecision instrument approaches flown manually in conditions of low ceilings and reduced visibilities) encountered during the long duty day (and the two previous days), it is likely that fatigue contributed to the pilots’ degraded performance and decisionmaking.

1. Existing Federal Aviation Administration pilot duty regulations do not reflect recent

research on pilot fatigue and sleep issues, increasing the possibility that pilots will fly in a fatigued condition.

1. Providing pilots with additional fatigue-related training, such as that being developed

by the Department of Transportation Operator Fatigue Management Program, may increase their awareness and use of fatigue avoidance techniques and thus improve safety margins.

1. Capturing the maximum recorded data possible is necessary for a more effective

reconstruction of the events that lead to accidents and the issuance of more timely safety recommendations to prevent similar accidents from recurring.

Conclusions 58 Aircraft Accident Report 3.2 Probable Cause The National Transportation Safety Board determines that the probable cause of the accident was the pilots’ failure to follow established procedures and properly conduct a nonprecision instrument approach at night in instrument meteorological conditions, including their descent below the minimum descent altitude (MDA) before required visual cues were available (which continued unmoderated until the airplane struck the trees) and their failure to adhere to the established division of duties between the flying and nonflying (monitoring) pilot. Contributing to the accident were the pilots’ failure to make standard callouts and the current Federal Aviation Regulations that allow pilots to descend below the MDA into a region in which safe obstacle clearance is not assured based upon seeing only the airport approach lights. The pilots’ failure to establish and maintain a professional demeanor during the flight and their fatigue likely contributed to their degraded performance.

59 Aircraft Accident Report 4. Recommendations 4.1 New Recommendations As a result of the investigation of the Corporate Airlines flight 5966 accident, the National Transportation Safety Board makes the following recommendations to the Federal Aviation Administration: Direct the principal operations inspectors of all 14 Code of Federal Regulations Part 121 and 135 operators to reemphasize the importance of strict compliance with the sterile cockpit rule. (A-06-7) Require all 14 Code of Federal Regulations Part 121 and 135 operators to incorporate the constant-angle-of-descent technique into their nonprecision approach procedures and to emphasize the preference for that technique where practicable. (A-06-8) Revise applicable 14 Code of Federal Regulations Part 121 and 135 regulations to prohibit pilots from descending below the minimum descent altitude during nonprecision instrument approaches unless conditions allow for clear visual identification of all obstacles and terrain along the approach path or vertical guidance to the runway is available and being used. (A-06-9) Modify and simplify the flight crew hours-of-service regulations to take into consideration factors such as length of duty day, starting time, workload, and other factors shown by recent research, scientific evidence, and current industry experience to affect crew alertness. (A-06-10) (This recommendation supersedes Safety Recommendation A-99-45.) Require all 14 Code of Federal Regulations Part 121 and 135 operators to incorporate fatigue-related information similar to that being developed by the Department of Transportation Operator Fatigue Management Program into their initial and recurrent pilot training programs; such training should address the detrimental effects of fatigue and include strategies for avoiding fatigue and countering its effects. (A-06-11) 4.2 Previously Issued Recommendations Reiterated in This Report Require that all aircraft operated under Title 14 CFR Part 121, 125, or 135 and currently required to be equipped with a cockpit voice recorder (CVR) and flight data recorder (FDR) be retrofitted…with a crash-protected

Recommendations 60 Aircraft Accident Report cockpit image recording system. The cockpit image recorder system should have a 2-hour recording duration, as a minimum, and be capable of recording, in color, a view of the entire cockpit including each control position and each action (such as display selections or system activations) taken by people in the cockpit. The recording of these video images should be at a frame rate and resolution sufficient for capturing such actions. The cockpit image recorder should be mounted in the aft portion of the aircraft for maximum survivability and should be equipped with an independent auxiliary power supply that automatically engages and provides 10 minutes of operation whenever aircraft power to the cockpit image recorder and associated cockpit camera system ceases, either by normal shutdown or by a loss of power to the bus. The circuit breaker for the cockpit image recorder system, as well as the circuit breakers for the CVR and the digital FDR, should not be accessible to the flight crew during flight. (A-00-30) Require all turbine-powered, nonexperimental, nonrestricted-category aircraft that are manufactured prior to January 1, 2007, that are not equipped with a flight data recorder, and that are operating under 14 Code of Federal Regulations Parts 135 and 121 or that are being used full-time or part-time for commercial or corporate purposes under Part 91 to be retrofitted with a crash-protected image recording system by January 1,

1. (A-03-65)
2. 3

Previously Issued Recommendation Classified in This Report The following previously issued recommendation is classified “Closed— Superseded” in this report: Establish, within 2 years, scientifically based hours-of-service regulations that set limits on hours of service, provide predictable work and rest schedules, and consider circadian rhythms and human sleep and rest. (A-99-45) BY THE NATIONAL TRANSPORTATION SAFETY BOARD MARK V. ROSENKER Acting Chairman ELLEN ENGLEMAN CONNERS Member DEBORAH A. P. HERSMAN Member KATHRYN O. HIGGINS Member Adopted: January 24, 2006

61 Aircraft Accident Report 5. Appendixes Appendix A Investigation and Public Hearing The National Transportation Safety Board was initially notified of this accident on the evening of October 19, 2004. A full go-team was assembled in Washington, DC, and traveled to the accident scene. The go-team was accompanied by representatives from the Safety Board’s Offices of Transportation Disaster Assistance and Public Affairs. Board Member Carol Carmody traveled to the accident site. The following investigative groups were formed during the course of this investigation: Structures, Systems, Powerplants, Maintenance Records, Air Traffic Control, Meteorology, Operations, Human Performance, Airport/Survival Factors, Airplane Performance, and Cockpit Voice Recorder. A specialist was also assigned to analyze the flight data recorder. In accordance with Annex 13 to the Convention on International Civil Aviation, an accredited representative from the United Kingdom’s Air Accident Investigation Branch and two advisors participated in this investigation. Parties to the investigation were the Federal Aviation Administration, Corporate Airlines, BAE Systems, Cessna/McCauley, and Honeywell. The Safety Board received submissions on this accident from Corporate Airlines (now named RegionsAir) and BAE Systems. Public Hearing No public hearing was held for this accident.

62 Aircraft Accident Report Appendix B Cockpit Voice Recorder Transcript The following is a transcript of the Fairchild model A100 CVR installed on the accident airplane. Only radio transmissions to and from the accident airplane were transcribed. The CVR transcript reflects the 30 minutes and 12 seconds before power was lost to the CVR.1 All times are central daylight time, based on a 24-hour clock. 1 Timing errors related to tape speed irregularities were observed and corrected after the initial transcript was issued, resulting in the revised transcript that is provided herein. LEGEND HOT Crewmember hot microphone voice or sound source RDO Radio transmission from accident aircraft CAM Cockpit area microphone voice or sound source CTR1 Radio transmission from first Kansas City center controller ACFT? Radio transmission from unidentified aircraft CTR2 Radio transmission from second Kansas City center controller AWOS Radio transmission from Kirksville Automated Weather Observation System KOPS Radio transmission from Kirksville operations -1 Voice identified as Pilot-in-Command (PIC) -2 Voice identified as Co-Pilot (SIC) -3 Voice identified as aircraft mechanical voice -B Sound heard over both pilot channels -? Voice unidentified * Unintelligible word @ Non-pertinent word # Expletive

Break in continuity ( ) Questionable insertion [ ] Editorial insertion ... Pause Note 1: Times are expressed in central daylight time (CDT). Note 2: Generally, only radio transmissions to and from the accident aircraft were transcribed.

Appendix B 63 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1906:46 START of RECORDING START of TRANSCRIPT 1906:48 HOT-B ****. 1906:50 HOT-1 hello. 1906:51 HOT-2 [sound of laughter] 1906:52 HOT-1 there, my hair was down to my breast pockets. 1906:55 HOT-2 are you serious? 1906:56 HOT-1 right here, I could hold my hair like this. 1906:58 HOT-2 I cannot see you with long hair like.... 1906:59 HOT-1 just, just like that. 1907:01 HOT-2 [sound of laughter] 1907:01 HOT-1 I used to wear this black derby, with the uh, rim turned down. it was my concert hat. had a Fu Manchu.

Appendix B 64 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1907:08 HOT-2 [sound of laughter] ohhh. 1907:11 HOT-1 [sound of laughter] yeah, it was, it was fun. 1907:13 HOT-2 [sound of laughter] I cannot imagine you being like that. 1907:16 HOT-1 yeah, when I show people the pictures they say, who is this? 1907:19 HOT-2 that's me. 1907:20 HOT-1 who's this freak? that's me. no way. 1907:23 HOT-2 d', no way. I was gonna say. we're gonna have to have a fifteen fifteen five card. 1907:29 CTR1 CorpEx fifty nine sixty six, climb and maintain one two thousand, twelve thousand. 1907:34 RDO-2 one two thousand, Corporate Ex fifty nine sixty six. 1907:37 HOT-2 twelve 'er, thousander 'er, 'er. 1907:38 HOT-1 twelve 'er thousander 'er. I detected a slight attitude on his part.

Appendix B 65 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1907:44 HOT-2 I know I didn't miss a call the first time. 1907:46 HOT-1 I'd might have to call him a #. 1907:49 HOT-2 uh, better yet, QB. 1907:51 HOT-1 yeah, you # QB. 1907:57 HOT-1 hey no #. 1908:09 HOT-1 no pilots. 1908:16 HOT-1 I guess I could give it a little juice. 1908:18 HOT-2 [sound of chuckle] that might help it a little bit. 1908:21 HOT-1 I say, why's this # climb performance blows? it's pretty tough when you got a torque setting around eighteen. 1908:28 HOT-2 [sound of chuckle] 1908:30 HOT-1 yeah, you ##.

Appendix B 66 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1908:32 HOT-2 this # thing ain't climbing.... 1908:33 HOT-1 [sound of chuckle] 1908:34 HOT-2 ...what the hell. 1908:35 HOT-1 dowee. 1908:36 HOT-1 oh yeah, now you're going to burn up on me you #. you # #. 1908:43 HOT-2 [brief humming sound] 1908:48 HOT-1 I keep pushing the call button. I don't know if it's ringing. 1908:51 HOT-2 [makes verbal ringing sound] 1908:52 HOT-1 give 'em something to think about. oh, something * pinging back here. 1908:55 HOT-2 [makes verbal ringing sound] 1908:56 HOT-1 oh, that's the shut up uh.... 1908:58 HOT-2 the shut up bell.

Appendix B 67 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1908:58 HOT-1 yeah, that's it. 1908:59 HOT-2 the shut up bell. 1909:00 HOT-1 that's the shut the # your mouth, you #. go turbulence. 1909:08 HOT-2 [sound of chuckle] 1909:13 HOT-1 eleven thousand twelve thousand. 1909:14 HOT-B [sound similar to altitude alerter] 1909:15 HOT-2 eleven for twelve. 1909:18 HOT-2 'er thousander. 1909:19 HOT-1 'er thousander. 1909:23 HOT-1 [several grunting sounds] 1909:24 HOT-2

• have a good time flying with you.

1909:26 HOT-1 yeah, me too.

Appendix B 68 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1909:27 HOT-2 just let you know that. 1909:30 HOT-1 gotta have fun. 1909:31 HOT-2 that's truth man. gotta have the fun. 1909:35 HOT-1 too many of these # take themselves way too serious, in this job. I hate it, I've flown with them and it sucks. a month of # agony. 1909:39 HOT-B [sound similar to frequency change alert] 1909:47 HOT-1 all you wanna do is strangle the ## when you get on the ground. 1909:50 HOT-2 oh'.,.. @ [sound of laughter] 1909:52 HOT-1 oh *, yeah, oh well, he was one but I didn't, I didn't have to fly with him that much 'cause.... 1909:56 HOT-2 I know. 1909:57 HOT-1 it was kinda a fluke. but uh, some of the guys that aren't here any more you wanted to just # kick 'em in the #. lighten the # up #. 1910:09 HOT-2 have you ever flown with @?

Appendix B 69 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1910:11 HOT-1 yeah. 1910:12 HOT-2 how's he? 1910:12 HOT-1 a #. 1910:13 HOT-2 is he? 1910:14 HOT-1 yeah. at least he was, three and a half years ago. 1910:21 HOT-2 see, I'm glad I'll never have to fly with him 'cause he's a Nashville guy. but for being a Nashville guy, he's up in St. Louis all the time. 1910:29 HOT-1 yeah, the difference between Nashville and the rest, lot of those guys, @ uh.... well not @@, @@and @ and @ uh.... can't think of his last name. there's three @ that were from Nashville that were in the crew room today. 1910:45 HOT-2 oh God. 1910:46 HOT-1 and uh, @@@@ whatever the hell they call them. 1910:51 HOT-2 blow me.

Appendix B 70 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1910:52 HOT-1 blow me. yeah, lotta guys were Nashville based. @, it just really doesn't mean anything. I mean they they come out of Nashville but they fly a lot of the routes up here. same # routes. the only difference is that you may get an Atlanta run and a Tri-Cities run, which is kinda fun. that's like working for a different company, 'cause you fly over slightly mountainous area, which is kinda cool. 1911:04 HOT-B [sound of tone similar to altitude alerter] 1911:19 HOT-2 yeah, we get the shaft. 1911:21 RDO-1 ####. 1911:25 ACFT? nice tone. 1911:26 HOT-1 [sound of chuckle] 1911:30 HOT-2 that was a good one. 1911:32 HOT-1 [sound of chuckle] yeah, I had to share that. 1911:44 HOT-2 [sound of sigh] 1911:47 HOT-1 cruise power cruise check. you push his foot away?

Appendix B 71 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1911:52 HOT-2 trying to # close it up. all right. stop # around with it. 1911:59 HOT-1 cruise power, cruise check. 1912:08 HOT-2 all you do is push the curtain to the side a little bit. it's like man.... 1912:15 HOT-1 some people I invite their feet up to make them comfortable but # I'll, I, I've dropped my book on em purposely one time, right on the top part of the arch of the foot. 1912:26 HOT-2 oooh. 1912:27 HOT-1 oh yeah, they were #. I told 'em to remove his foot twice. and then I dropped them the uh, red book.... 1912:33 HOT-2 [sound of grunting] your power levers. 1912:34 HOT-1 ...right on 'em. 1912:35 HOT-2 [sound of laughter] the power spiked up a little bit. 1912:41 HOT-1 yyyeeeaa. 1912:43 HOT-2 you want it at ninety seven not ninety seven and a quarter.

Appendix B 72 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1912:46 HOT-1 yeah. 1912:47 HOT-2 oh well. tough #. 1912:49 HOT-1 that will do. 1912:51 HOT-2 cruise power. 1912:51 HOT-1 all I'm thinking of is a Philly # cheese steak and an iced tea. 1912:55 HOT-2 sounds good. cruise power's set. altimeters are two niner niner zero, set and cross-checked. 1913:00 CAM [sounds similar to CVR tape splice] 1913:02 HOT-2 how did I get two niner niner zero? 1913:03 HOT-1 cause you're a #. 1913:04 HOT-2

• two niner niner two?

1913:06 HOT-1 'cause you never set it when we changed it to Alpha or whatever it was. soon as he was telling us that they cleared us onto the runway.

Appendix B 73 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1913:16 HOT-2 and I've been sitting here living a lie for the rest for the the last twenty minutes. 1913:21 HOT-1 yeah, you lying scum bucket. 1913:22 HOT-2

boost pumps are off, pressurization's checked and external

lights.... 1913:25 HOT-1 you blustering scabby pustuile. 1913:27 HOT-2 are externalized. your # cruise checklist is # done. 1913:31 HOT-1 thank you. 1913:32 HOT-2 you're welcome. 1913:33 HOT-B [sound of tone similar to frequency change alert] 1913:34 AWOS not available.... 1913:36 HOT-1 you get a ##.

Appendix B 74 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1913:37 AWOS ...Kirksville Regional Airport automated weather observation zero zero one three Zulu. wind zero four zero at zero six. visibility four. mist. sky condition overcast three hundred.... 1913:54 HOT-1 ahh. 1913:55 AWOS ...temperature zero niner Celsius. dew point zero niner Celsius. altimeter two niner niner five. remarks.... 1914:06 HOT-1 we're not getting in. 1914:10 HOT-2 Kirksville uh.... that was Quincy that the ILS... was out of service. 1914:18 HOT-1 we don't have an ILS. 1914:19 HOT-2 I know. 1914:20 HOT-1 three hundred sixty feet. 1914:21 HOT-2 Jesus Christ. [spoken in a whispered voice] 1914:26 HOT-2 go all this # way. 1914:30 HOT-2 well, let's try it.

Appendix B 75 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1914:31 HOT-1 yeah, we'll try it. 1914:39 HOT-2 that # sucks. 1914:41 HOT-1 does suck. 1914:42 HOT-2 [sound of sigh] 1914:45 HOT-1 [sound of humming] 1914:49 HOT-1 so it went down. 1914:50 HOT-2 [sound of humming] 1914:51 HOT-1 but that's a # a # AWOS there anyway.... we'll see what happens. 1915:03 HOT-1 [sound of humming, yawning and tapping] I don't want to get, go all the way out here for nothing tonight. it's gonna blow #..... it's gonna blow the butt, blow the butt, blow the butt. what have we got here. three sixty, thirteen twenty. 1915:32 HOT-1 I'll be so happy when we have an ILS everywhere we go. 1915:42 HOT-2 what'd you say?

Appendix B 76 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1915:43 HOT-1 one twenty one. I said I'll be so happy we'll have an ILS, the next job everywhere we go will be an ILS. 1915:47 HOT-2 yep. 1915:48 HOT-1 [sound of burp] I thought we were gonna have it easy tonight. it was gonna be.... 1915:58 CTR1 **** fifty nine sixty six, contact Kansas City center one three two point six. 1916:02 HOT-2 I, I don't know if that was us. 1916:04 HOT-1 yeah. 1916:04 HOT-2 it was? 1916:05 HOT-1 one two three point six. 1916:06 RDO-2 Kansas City one thirty two point six, CorpEx fifty nine sixty six. 1916:13 HOT-B [sound similar to frequency change alert] 1916:17 HOT-2 man, I'm glad I caught that. man this frequency's way too loud.

Appendix B 77 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1916:23 HOT-1 turn it down. we don't give a # about company. 1916:24 RDO-2 Kansas City, CorpEx fifty nine sixty six is checking in with you one two thousand. good evening. 1916:28 CTR2 CorpEx fifty nine sixty six, Kansas City center, good evening. uh, do you have the Kirksville weather yet? 1916:34 RDO-2 yes sir, we do. 1916:36 CTR2 CorpEx fifty nine sixty six, roger. uh, what approach you want over there? 1916:41 RDO-2 we'd like vectors for the localizer DME runway three six into Kirksville. 1916:45 CTR2 roger. have your request. 1916:50 HOT-2 ah, I remembered. 1916:50 HOT-1 very good. 1917:06 HOT-2 I'm a #.

Appendix B 78 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1917:10 HOT-2 all right, we got supposedly six miles before we have to flip it up. want me to flip it. 1917:17 CTR2 CorpEx fifty nine sixty six, descend at pilots discretion maintain eight thousand. 1917:20 HOT-1 sure. 1917:19 RDO-2 pilot's discretion down to eight thousand, CorpEx fifty nine sixty six. 1917:23 HOT-1 discretion eight thousand. 1917:25 HOT-2 discretion eight thousand my friend. [sound of humming] 1917:28 HOT-1 descent checklist when you get a chance. 1917:28 CTR2 CorpEx fifty nine sixty six, fly your present heading vectors for localizer three six approach.

Appendix B 79 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1917:35 RDO-2 present heading vectors for a localizer, fifty nine sixty six. 1917:49 HOT-2 one ten.... would be that one... that. okay, your descent check- list. [sound of humming] altimeters are... two niner niner.... five... set right. 1918:21 HOT-1 niner five. set. left. 1918:24 HOT-2 okay, altimeters are set and crosschecked. fuel pres, pressuriza- tion is set and checked. fuel balance is .... go ahead and do it.... checked. and seat belt sign/external lights are on. your descent checklist is complete. one ten. one eleven point five. 1918:48 HOT-1 thank you. 1918:51 HOT-2 well you got it *, up already? 1918:53 HOT-1 DME on uh, three if you want it. I guess there's DME on the localizer. looks like there's a D there is there? 1919:04 HOT-2 yeah, there's a localizer DME. 1919:06 HOT-1 yeah. that would make sense, wouldn't it? 1919:09 HOT-2 yes it would.

Appendix B 80 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1919:09 HOT-1 yes it would. 1919:11 HOT-2 yes in deede doody, daudy, deede. 1919:13 HOT-1 yes in deede doody, daudy. 1919:20 HOT-1 [sound of humming] 1919:37 AWOS wind zero four zero at zero five.... 1919:39 HOT-1 the one bad thing about these covers is they reflect the light off of this of thing too much and you can't see #. thirteen twenty. oh shut the # up back there. 1919:42 AWOS ...visibility three. mist. sky condition overcast three hundred. temperature zero niner Celsius. dew point zero niner Celsius. al- timeter two niner niner five. 1920:05 HOT-2 [sound of sigh] 1920:20 HOT-2 it's three miles and mist now. [sound of sigh] 1920:22 HOT-1 *. really? 1920:25 HOT-2 yep.

Appendix B 81 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1920:25 HOT-1 so it's going down the tubes.... #. 1920:35 HOT-2 [sound of whistling] 1921:27 HOT-1 Charlie India. 1921:44 HOT-2 you know, I think you're gonna need to just shut the # up. 1921:49 HOT-1 love to poke my head back around and say that. you know ladies and gentlemen uh, we've thought about it.... 1921:55 HOT-2 [sound of laughter] it was unanimous up here. 1921:57 HOT-1

• we've come to the conclusion that you people should all shut the

up.

1921:59 HOT-B [tone similar to altitude alerter] 1922:02 HOT-2 niner thousander for eight thousander. 1922:04 HOT-1 niner thousander for eight thousander. today er. tonight er. 1922:06 HOT-2 tonight er.

Appendix B 82 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1922:07 HOT-B [continuation of above sentences for several repetitions] 1922:16 HOT-2 five point to KEMMY, huh? 1922:17 HOT-2 on the Richter scale. 1922:20 HOT-1 five point two is KEMMY, correct? 1922:22 HOT-2 that is correct. 1922:22 HOT-1 roger. 1922:23 HOT-2 roooooooooger.... almost sounded like a burp, didn't it? 1922:34 HOT-1 did. 1922:36 HOT-2 amazing. we're forty three point eight miles from IRK, eye rk. 1922:44 HOT-1 "e kirk". 1922:59 HOT-2 [sound of sigh] let's see. speeds are off the fifteen five card. fifteen, twenty one and thirty. be darned. I already had that in there.

Appendix B 83 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1923:16 HOT-1 thank you.... localizer DME runway three six. one eleven five. 1923:117 CTR2 CorpEx fifty nine sixty six, descend at pilot's discretion, maintain three thousand. 1923:23 RDO-2 pilot's discretion maintain three thousand, CorpEx fifty nine sixty six. 1923:27 HOT-1 discretion three thousand. 1923:28 HOT-2 three thousand. 1923:29 HOT-1 one eleven point five, three fifty seven's the inbound. twenty five hundred at KEMMY. thirteen twenty is our MDA. and we have a three hundred sixty foot approach set in the radar altimeter. 1923:43 HOT-2 three sixty. [sound of yawn] aw, I had it on three sixty. 1923:47 HOT-1 thank you. 1923:48 HOT-2 you're welcome.

Appendix B 84 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1923:50 HOT-1 nine sixty six for the appr, airport elevation. nine sixty four is the touchdown zone elevation. speeds as previously briefed, fifteen, twenty one and thirty. if we have to go missed we'll set max power, flaps ten positive rate, gear up.... and we'll climb to three thousand feet then direct Kirksville VOR, and hold, and that will be a parallel.... parallel entry, or teardrop, either one. 1924:17 HOT-2 oh, I was being.... teardrop. 1924:18 HOT-1 it's probably a teardrop, I'll go with teardrop.... and I'll have you walk me through that if we need it. 1924:25 HOT-2 no problem. 1924:26 HOT-1 and that's it. questions? 1924:34 HOT-2 negative. [sound of humming] 1924:36 HOT-1 negative, we're going into the crap. look, ooh, it's so eerie and creepy. 1924:38 HOT-2 ooh, negative. 1924:40 HOT-1 get a suffocating feeling when I see that.

Appendix B 85 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1924:48 HOT-2 [pilot makes barking sound followed by groan] 1924:58 HOT-1 I'm drowning.... MSA is thirty one hundred. 1925:00 HOT-2 correcto mundo. 1925:02 HOT-1 how is he able to put us down at three thousand? 1925:05 HOT-2 beats the # out of me. 1925:16 HOT-1 thirty five miles from the, east. 1925:19 HOT-2 well we can level off at thirty one hundred feet. how about that? 1925:26 HOT-1 yeah... yeah baby. 1925:44 HOT-2 cause we know our #.... [sound of yawn] 1925:46 HOT-1 [sound of humming] 1925:53 HOT-2 [sound of humming] and they have a VASI on the left hand side. 1926:00 HOT-1 yeah. wish we had an ILS on the front hand side.

Appendix B 86 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1926:00 HOT-2 [sound of laughter] yeah, that'd be nice. 1926:03 HOT-1 nice. 1926:52 CTR2 CorpEx fifty nine sixty six, turn ten degrees right now vectors to localizer uh, uh, runway three six final approach course. 1927:01 RDO-2 ten right for vectors for final approach course for runway three six, CorpEx fifty nine sixty six. 1927:05 CTR2 CorpEx fifty nine sixty six, say your new heading. 1927:10 HOT-1 three one zero. 1927:10 RDO-2 three one zero, CorpEx fifty nine sixty six. 1927:13 CTR2 thank you. 1927:15 HOT-1 new heading. 1927:18 HOT-2 just ask, say new heading. 1927:19 HOT-1 new heading.

Appendix B 87 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1927:20 HOT-2 [sound of chuckle] I'd like to do that just once to see if I'd get a crack. 1927:29 HOT-2 all right smart ass. I need you to hold. [sound of chuckle] 1927:34 HOT-1 no say uh, cancel IFR. 1927:38 HOT-2 yeah, noooooo. [sound of whistling] all right, we're within range, again. 1927:53 HOT-1 again. 1927:55 HOT-2 got one? 1927:55 HOT-1 I got one. 1928:03 RDO-2 Kirksville ops, CorpEx fifty nine sixty six. 1928:11 KOPS fifty nine sixty six.

Appendix B 88 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1928:11 RDO-2 yeah, we're within range. it's gonna be about one point seven on the fuel. 1928:15 KOPS one point seven. 1928:18 RDO-2 see ya a little bit. 1928:23 HOT-2 back on one. 1928:25 HOT-1 no changes. 1928:26 HOT-2 no, no a changeee. 1928:33 HOT-2 [sound of humming] 1928:46 HOT-1 how's uh, Kirksville looking weather wise? getting' any worse? 1928:50 AWOS ... niner Celsius. dew point zero niner Celsius. altimeter two niner niner five. remarks, thunderstorm, information not avail- able.... 1929:00 HOT-1 temp 'n dew point's right where you don't want it.

Appendix B 89 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1929:01 HOT-2 yeah, dead nuts. 1929:03 AWOS ... Kirksville Regional Airport, Automated Weather Observation zero zero two eight Zulu. wind zero three zero at zero six. visibil- ity three. mist. sky condition overcast three hundred. temp.... 1929:19 HOT-2 still three hundred. 1929:21 HOT-1 yep. 1929:27 HOT-2 [sound of yawn] *. how would you like approach checklist? 1929:33 HOT-1 that would be a beautiful thing. 1929:36 HOT-2 all right, approach briefing? 1929:37 HOT-1 complete. 1929:39 HOT-2 ah let's see, landing data. we briefed, right? 1929:41 HOT-1

• left.

1929:41 HOT-2 flight instruments and radios, set checked on the right?

Appendix B 90 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1929:43 HOT-1 set checked left. 1929:45 HOT-2

• * crossfeed on normal. passenger briefing is started. approach

checklist is complete. 1929:50 HOT-1 thanks. 1929:51 HOT-2 sure. 1929:57 HOT-B [tone similar to altitude alerter] 1929:59 HOT-2 four thousand three thousand. 1930:00 HOT-1 four thousand for three thousand. 1930:13 HOT-2 actually we should do thirty-one hundred. 1930:15 HOT-1 yeah, that's what I'm gonna do. 1930:17 HOT-2 should I put it on here? 1930:18 HOT-1 yep. is a good thing.

Appendix B 91 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1930:30 CTR2 CorpEx fifty nine sixty six uh, one one miles south of uh, KEMMY. turn right heading three, three zero. maintain three thousand until established on the localizer. cleared localizer DME runway three six approach at Kirksville. 1930:41 RDO-2 three thousand feet 'til established uh, heading three three zero. cleared for the localizer DME runway three six into Kirksville Cor- pEx fifty nine sixty six. 1930:50 HOT-2 thirty three, three thousand til established. cleared for the ap- proach. 1930:54 HOT-1 cleared the approach. 1931:00 HOT-2 cleared for the approach. 1931:01 HOT-1

the approach. you're #. approach #. [sound of chuckle]

1931:11 HOT-2 [sound of chuckle] ** [vibrating lip noise] that's funny when it happens too. [vibrating lip noise] is that a #? yeah. [sound of laughter] he #. thirty one. 1931:27 HOT-1 thirty *. 1931:30 HOT-1 [humming sound] thank you.

Appendix B 92 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1931:34 HOT-2 course alive. cross check, no flags except for the vertical. 1931:41 HOT-1 the wertical. get up there ##. keep it slow. all the time we need. [sound of humming] 1932:06 HOT-1 let's go flaps ten and we'll configure early too. 1932:11 HOT-2 all right. flaps ten.... 1932:12 HOT-1 give ourselves as much time as we can. 1932:13 HOT-2 selected indicating ten.... since we're not going to doing holds like that one #. 1932:22 HOT-1 right. 1932:24 HOT-2 **. 1932:30 HOT-1 and it, was it five point? 1932:31 HOT-2 five point two. 1932:32 HOT-1 five point two.

Appendix B 93 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1932:33 HOT-2 I'll call it out for you. 1932:35 HOT-1 okay. we can go to what, twenty five right now? 1932:37 HOT-2 twenty five right now. 1932:38 HOT-1 okay, gear down, flaps twenty, before landing check. 1932:45 HOT-2 [sound of a sigh] all right. 1932:46 HOT-2 dow, gear down, three green. 1932:48 HOT-1 three green. 1932:49 HOT-2 uh, prop syncs are off, speeds are high. flaps selected indicating twenty. hydraulic brake pressure normal. standing by the flows. 1933:07 HOT-1 [sound of humming] 1933:17 HOT-2 twenty five. 1933:41 CTR2 CorpEx fifty nine sixty six, frequency change approved. report the down time on this frequency or through flight service.

Appendix B 94 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1933:46 RDO-2 all right, frequency change approved. we'll cancel with you on the ground, CorpEx fifty nine sixty six. so long. 1933:51 CTR2 roger. 1933:52 HOT-B [sound similar to frequency change alert] 1933:55 HOT-1 make sure those lights are up please. 1933:56 HOT-2 all right. 1933:57 HOT-1 thanks. 1933:57 RDO-2 [sound similar to seven microphone clicks] 1934:04 HOT-2 seven times I clicked it. I cleeted it. 1934:08 HOT-1 what we can do is, well is call Kirksville ops and ask them to con- firm that they're up. 1934:13 HOT-2 all right. 1934:13 HOT-1 that would be kinda nice.

Appendix B 95 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1934:14 RDO-2 Kirksville ops, CorpEx fifty nine sixty six. 1934:22 HOT-2 aw speeds. 1934:21 KOPS fifty nine sixty six. 1934:23 RDO-2 yeah, can you tell me if uh, the approach lights are up? 1934:37 KOPS lights are on. 1934:39 RDO-2 cool, thanks. 1934:51 HOT-1 come on you ##. 1934:52 HOT-2

it. pig, isn't it?

1934:55 HOT-1 sure is. 1935:06 HOT-1 what happened to our identifier? 1935:09 HOT-B [sound of Morse code identifier] R-K. 1935:10 HOT-1 I don't have it any more. do you? localizer?

Appendix B 96 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1935:16 HOT-B [sound of Morse code identifier] I-I-R-K. 1935:19 HOT-2 I got it. 1935:20 HOT-1 okay. 1935:22 HOT-1 DME went off line. 1935:26 HOT-2 not on my side. five point seven. 1935:28 HOT-1 okay. 1935:29 HOT-2 five point six. 1935:30 HOT-1 okay, mine's back. 1935:31 HOT-2 five point five. 1935:38 HOT-1 I can hear it. 1935:39 HOT-2 there you go, KEMMY. down to thirteen twenty. 1935:42 HOT-1 thirteen twenty, here we go.

Appendix B 97 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1936:02 HOT-1 when we get within a hundred feet if you'd uh, arm that uh.... 1936:06 HOT-2 disarm it? 1936:06 HOT-1 ... director again yeah uh, altitude. 1936:08 HOT-2 oh for * [one member heard "altitude"], okay. 1936:18 HOT-1 c'mon, go down there. 1936:23 HOT-2 five hundred, four hundred feet to go. 1936:24 HOT-1 *. 1936:30.6 HOT-3 five hundred. 1936:33.9 HOT-2 thirteen twenty. 1936:35.7 HOT-1 what do you think? 1936:35.9 HOT-1 thank you. 1936:36.8 HOT-1 I can see ground there.

Appendix B 98 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1936:37.2 HOT-3 minimums, minimums. 1936:41.9 HOT-2 I can't see #. 1936:43.5 HOT-1 yeah, oh there it is. approach lights in sight. 1936:44.2 HOT-3 two hundred. 1936:44.7 HOT-2

• in sight.

1936:46.6 HOT-2 continue. 1936:47.7 HOT-1 we get rid of the director. 1936:48.6 HOT-B [sound of beep] 1936:50.5 CAM [sound similar to increase in engine RPM] 1936:50.5 HOT-1 getting a little slow. 1936:50.6 HOT-2 flaps thirty five? 1936:51.9 HOT-1 no....

Appendix B 99 Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CDT) TIME (CDT) & SOURCE CONTENT & SOURCE CONTENT 1936:52.2 HOT-3 sink rate. 1936:52.8 HOT-1 ...no. 1936:53.2 HOT-2 trees. 1936:54.0 HOT-B [sound similar to stall warning horn] 1936:54.4 HOT-1 no, stop. 1936:55.2 CAM [sound of impact] 1936:56.6 HOT-1 oh, my God. 1936:57.0 CAM [sounds of numerous impacts] 1936:57.5 HOT-2 holy #. 1936:58.6 END of TRANSCRIPT END of RECORDING

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FD07314 ｜ 2006_美国_AAR0602.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2006 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

Controlled Flight Into Terrain Era Aviation Sikorsky S-76A++, N579EH Gulf of Mexico, About 70 Nautical Miles South-Southeast of Scholes International Airport, Galveston, Texas March 23, 2004 Aircraft Accident Report NTSB/AAR-06/02 PB2006-910402 Notation 7646B National Transportation Safety Board Washington, D.C.

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Aircraft Accident Report Controlled Flight Into Terrain Era Aviation Sikorsky S-76A++, N579EH Gulf of Mexico, About 70 Nautical Miles South-Southeast of Scholes International Airport, Galveston, Texas March 23, 2004 NTSB/AAR-06/02 PB2006-910402 National Transportation Safety Board Notation 7646B 490 L’Enfant Plaza, S.W. Adopted March 7, 2006 Washington, D.C. 20594 E

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National Transportation Safety Board. 2006. Controlled Flight Into Terrain, Era Aviation, Sikorsky S-76A++, N579EH, Gulf of Mexico, About 70 Nautical Miles South-Southeast of Scholes International Airport, Galveston, Texas, March 23, 2004. Aircraft Accident Report NTSB/AAR-06/02. Washington, DC. Abstract: This report explains the accident involving an Era Aviation Sikorsky S-76A++ helicopter, N579EH, which crashed into the Gulf of Mexico about 70 nautical miles south-southeast of Scholes International Airport (GLS), Galveston, Texas. Safety issues discussed in this report focus on terrain awareness and warning systems for helicopters, flight control system training, flight-tracking technology for low-flying aircraft in the Gulf of Mexico, and preflight testing and maintenance checks for cockpit voice recorders. Safety recommendations concerning these issues are addressed to the Federal Aviation Administration. The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Web at http://www.ntsb.gov. Other information about available publications also may be obtained from the Web site or by contacting: National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (800) 877-6799 or (202) 314-6551 Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2006-910402 from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605-6000 The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

iii Aircraft Accident Report Contents Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii

1. Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2. 1

History of Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.2 Injuries to Persons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.3 Damage to Aircraft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.4 Other Damage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.5 Personnel Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.5.1 The Captain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.5.2 The Copilot. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 1.6 Aircraft Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 1.6.1 Main Rotor and Tail Rotor Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 1.6.2 Powerplants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1.6.3 Flight Control Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1.6.3.1 Cyclic, Collective, and Tail Rotor Pedal Control Systems . . . . . . . . . . . . . . . . . . 8 1.6.3.2 SPZ-7000 Dual Digital Automatic Flight Control System . . . . . . . . . . . . . . . . . . 8 1.6.3.2.1 Autopilots . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 1.6.3.2.2 Flight Directors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 1.6.3.2.3 Coupling Function. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 1.6.3.3 Electronic Flight Information System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 1.6.4 Maintenance Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 1.6.5 Previous Flights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 1.7 Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 1.8 Aids to Navigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1.9 Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1.10 Airport Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 1.11 Flight Recorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 1.11.1 Cockpit Voice Recorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 1.11.2 Flight Data Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 1.12 Wreckage and Impact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 1.12.1 Main Rotor and Tail Rotor Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 1.12.2 Powerplants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 1.12.3 Landing Gear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 1.13 Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 1.14 Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 1.15 Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 1.16 Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 1.16.1 Cockpit Voice Recorder Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 1.16.2 Actuator Testing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 1.17 Organizational and Management Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 1.17.1 Era Aviation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Contents iv Aircraft Accident Report 1.17.1.1 S-76A Configurations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 1.17.1.2 Ground and Flight Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 1.17.1.3 Visual Flight Rules Flight Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 1.17.1.4 Federal Aviation Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 1.18 Additional Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 1.18.1 Flight Simulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 1.18.2 Gulf of Mexico Helicopter Operations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 1.18.3 Automatic Dependent Surveillance–Broadcast Technology . . . . . . . . . . . . . . . . . . 31 1.18.4 Controlled Flight Into Terrain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 1.18.5 Comparison of SPZ-7000 and SPZ-7600 Dual Digital Automatic Flight Control Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 1.18.5.1 Federal Aviation Administration SPZ-7000 Evaluation . . . . . . . . . . . . . . . . . . . 37 1.18.6 Previous Flight Recorder Safety Recommendations . . . . . . . . . . . . . . . . . . . . . . . . 38 1.18.6.1 Safety Recommendation A-02-25 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 1.18.6.2 Safety Recommendations A-06-17 and A-06-18. . . . . . . . . . . . . . . . . . . . . . . . . 39

1. Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
2. 1

General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 2.2 Accident Sequence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 2.2.1 Accident Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 2.2.2 Indications of Descent and Proximity to the Water . . . . . . . . . . . . . . . . . . . . . . . . . 42 2.2.3 Human Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 2.2.3.1 Flight Crew Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 2.2.3.2 Crew Coordination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 2.2.3.3 Use of Automated Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 2.3 Cockpit Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 2.3.1 Terrain Awareness and Warning System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 2.3.2 Dual Digital Automatic Flight Control System . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 2.4 Tracking of Gulf of Mexico Helicopter Flights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 2.5 Lack of Adequate Cockpit Voice Recorder Information for This Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 2.6 Lack of Flight Data Recorder Information for Helicopter Operations . . . . . . . . . . . . . . 56

1. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
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Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 3.2 Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

1. Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
2. 1

New Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 4.2 Additional Recommendations Resulting From This Accident Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 4.3 Previously Issued Recommendation Classified in This Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

1. Appendixes

A: Investigation and Public Hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 B: Cockpit Voice Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 C: Flight Simulation Scenarios . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 D: Gulf of Mexico Helicopter Accident Data March 2000 Through February 2006 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

v Aircraft Accident Report Figures

1. Location of DDAFCS Components and Indications in the

Accident Helicopter’s Cockpit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

1. Autopilot Controller. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2. Flight Director Mode Selector. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3. Electronic Attitude Director Indicator. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
4. Indications of Descent on the Attitude Direction Indicator. . . . . . . . . . . . . . . . . . . . . . . . . . 27
5. Altitude Alert Light. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
6. SPZ-7000 Dual-Cue Format. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
7. SPZ-7000 Single-Cue Format. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
8. Indications of Descent in the Accident Helicopter’s Cockpit . . . . . . . . . . . . . . . . . . . . . . . . 43

vi Aircraft Accident Report Abbreviations ADI attitude direction indicator ADS-B automatic dependent surveillance–broadcast agl above ground level ALT altitude ALT PRE altitude preselect AP autopilot ASOS automated surface observing system ASR airport surveillance radar ATT attitude BEA Bureau d’Enquêtes et d’Analyses pour la Sécurité de l’Aviation Civile CAM cockpit area microphone CFIT controlled flight into terrain CFR Code of Federal Regulations CLTV collective CPL couple CPLT FD copilot flight director CRM crew resource management CVR cockpit voice recorder DAFCS digital automatic flight control system DCPL decouple DDAFCS dual digital automatic flight control system DFDR digital flight data recorder DH decision height EFIS electronic flight instrument system EMS emergency medical services FAA Federal Aviation Administration

Abbreviations vii Aircraft Accident Report FD flight director FDR flight data recorder FOU Port Fourchon, Louisiana fpm feet per minute GLS Scholes International Airport GPS global positioning system GPWS ground proximity warning system HDG heading HSAC Helicopter Safety Advisory Conference HSI horizontal situation indicator IAS indicated airspeed IFR instrument flight rules LCH Lake Charles Regional Airport METAR meteorological aerodrome report msl mean sea level NAV navigation nm nautical mile NWS National Weather Service PIC pilot in command POI principal operations inspector RA radar altitude S/N serial number SAS stability augmentation system SBY standby TAWS terrain awareness and warning system UTC coordinated universal time VFR visual flight rules VHF very high frequency VMC visual meteorological conditions VS vertical speed VSI vertical slope indicator

viii Aircraft Accident Report Executive Summary On March 23, 2004, about 1918:34 central standard time, an Era Aviation Sikorsky S-76A++ helicopter, N579EH, crashed into the Gulf of Mexico about 70 nautical miles south-southeast of Scholes International Airport (GLS), Galveston, Texas. The helicopter was transporting eight oil service personnel to the Transocean, Inc., drilling ship Discoverer Spirit, which was en route to a location about 180 miles south-southeast of GLS. The captain, copilot, and eight passengers aboard the helicopter were killed, and the helicopter was destroyed by impact forces. The flight was operating under the provisions of 14 Code of Federal Regulations Part 135 on a visual flight rules flight plan. Night visual meteorological conditions prevailed at the time of the accident. The National Transportation Safety Board determines that the probable cause of this accident was the flight crew’s failure to identify and arrest the helicopter’s descent for undetermined reasons, which resulted in controlled flight into terrain. The safety issues discussed in this report focus on terrain awareness and warning systems for helicopters, flight control system training, flight-tracking technology for low-flying aircraft in the Gulf of Mexico, and preflight testing and maintenance checks for cockpit voice recorders. Safety recommendations concerning these issues are addressed to the Federal Aviation Administration.

1 Aircraft Accident Report 1. Factual Information 1.1 History of Flight On March 23, 2004, about 1918:34 central standard time,1 an Era Aviation Sikorsky S-76A++ helicopter, N579EH, crashed into the Gulf of Mexico about 70 nautical miles (nm) south-southeast of Scholes International Airport (GLS), Galveston, Texas. The helicopter was transporting eight oil service personnel to the Transocean, Inc., drilling ship Discoverer Spirit, which was en route to a location about 180 miles south-southeast of GLS. The captain, copilot, and eight passengers aboard the helicopter were killed, and the helicopter was destroyed by impact forces. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 135 on a visual flight rules (VFR) flight plan.2 Night visual meteorological conditions (VMC) prevailed at the time of the accident. The accident helicopter had been operated out of Era Aviation’s flight and maintenance facility at Port Fourchon (FOU), Louisiana, as part of its contract with Union Oil Company of California for day and night aviation support operations. On March 22, 2004, two Era Aviation pilots repositioned the accident helicopter from FOU to GLS because the Discoverer Spirit was going to be operating from a location in the Gulf of Mexico that was closer to GLS. On March 22, the copilot drove his personal vehicle from FOU to GLS. On March 23, the captain drove his personal vehicle from his home to GLS.3 An Era Aviation captain stated that he saw the accident captain briefing the accident copilot and both pilots obtaining weather information from the Internet. The Era Aviation captain also stated that he saw the accident captain, in the right pilot seat,4 taxi the helicopter to the site where the copilot and passengers would board.5 The Era Aviation captain further stated that one box of cargo and the passengers’ baggage were loaded on the helicopter. 1 All times in this report are central standard time based on a 24-hour clock. 2 This flight plan was maintained by the company and was followed by the company dispatcher. The flight plan was not filed with the Federal Aviation Administration. See section 1.17.1.3 for more information. 3 The accident captain, who normally worked the day shift, had been off duty during the previous 5 days but was aware that he would need to replace the on-duty night captain because of a scheduling conflict. During a postaccident interview, the captain’s wife stated that he had changed his sleep pattern during the previous 72 hours so that he could handle the job requirements for this work assignment. 4 The captain normally occupies the right seat in a helicopter. 5 Each passenger viewed a videotaped safety briefing before boarding the helicopter.

Factual Information 2 Aircraft Accident Report A dispatcher located at Era Aviation’s Gulf Coast headquarters was responsible for communicating by radio with the accident flight and entering information about the flight in a computerized log after each radio transmission. The dispatcher’s records showed that the helicopter departed GLS at 1845 on an estimated 45-minute flight to an en route refueling stop at High Island A-557.6 The records also showed that the helicopter had 2 hours of fuel on board at the time of departure. The cockpit voice recorder (CVR) recording began at 1847:42. The recording was mostly unintelligible, but conversational-tone voices were discernible during parts of the recording.7 Radar data from the Airport Surveillance Radar-9 (ASR-9) at the George Bush Intercontinental Airport in Houston, Texas,8 showed that the helicopter flew on a south-southeasterly course after takeoff and climbed to 1,800 feet mean sea level (msl). The radar data also showed that the helicopter remained at 1,800 feet msl until about 1858:10 and then started to descend at a rate of about 300 feet per minute (fpm). A radar return that was received about 1900:21 showed that the helicopter was at an altitude of 1,100 feet msl and that its rate of descent was about 250 fpm. No radar returns were received after that time because the helicopter was no longer within the range of radar coverage.9 At that point, the helicopter was about 35 nm south-southeast of GLS. According to company procedures, the flight crew was responsible for providing the dispatcher with a position report every 15 minutes.10 During its 1914 position report,11 the flight crew told the dispatcher that the helicopter had enough fuel on board (1.6 hours) to continue directly to the Discoverer Spirit.12 Also, the flight crew asked the dispatcher to provide updated coordinates to the Discoverer Spirit.13 The dispatcher received no further

6 A lighted fixed oil and gas platform with refueling capability was located in U.S. Gulf Coast VFR Aeronautical Chart reference area High Island A-557, which was about 80 nm south-southeast of GLS and slightly to the east of a direct course from GLS to the reported location of the Discoverer Spirit (U.S. Gulf Coast VFR Aeronautical Chart reference area Alaminos Canyon 738). 7 See section 1.11.1 for more information. 8 The National Transportation Safety Board obtained these data from the U.S. Air Force 84th Radar Evaluation Squadron. 9 ASRs are designed to provide short-range radar coverage within the general vicinity of an airport. The maximum radar coverage is about 60 nm. At the time of the last radar return, the accident helicopter was about 58 nm southeast of the Houston ASR-9 radar site. 10 The standard position report at the time of the accident consisted of the helicopter’s distance to its destination and the amount of fuel on board the aircraft. After the accident, the position reports also included the helicopter’s altitude. 11 The flight crew had provided two previous position reports—at 1850 and 1902. Both reports indicated that the helicopter would stop at High Island A-557 for refueling. 12 The CVR recording captured the copilot stating, in part, “we [have] enough to ah fly to ah spirit.” 13 The Discoverer Spirit was lighted, and its helideck had refueling capability.

Factual Information 3 Aircraft Accident Report communications from the flight crew.14 About 1918:25, the CVR recorded the sound of decreasing background noise. The CVR stopped recording about 1918:34. The dispatcher’s records showed that, at 1923, she tried to make radio contact with the flight crew to provide updated coordinates to the Discoverer Spirit but received no response from the crew. The records also showed that, at 1931, 1934, 1946,15 and 2008, the dispatcher continued to try to make radio contact with the helicopter. The 1931 entry indicated that the dispatcher would call the Discoverer Spirit to see if someone aboard the ship could make radio contact with the helicopter,16 and the 1934 entry indicated that someone aboard the ship was trying to contact the helicopter. During a postaccident interview, the dispatcher stated that, in her communications with the flight crew, everything sounded normal with no strange background noises. Also, the dispatcher received no emergency or distress calls from the helicopter. Seven vessels (from the U.S. Coast Guard and Union Oil) and nine aircraft (from the Coast Guard; Era Aviation; Petroleum Helicopters, Inc. [PHI]; and Evergreen Helicopters) were activated for search and rescue operations.17 Pilots aboard these aircraft observed debris floating near the area that was believed to be the location of the helicopter after its last communication with the dispatcher. The helicopter wreckage was located about 70 nm south-southeast of GLS and 10 nm northwest of High Island A-557 at a depth of about 186 feet. 14 If a flight crew position report is not called in within 15 minutes of the last report, the helicopter’s tail number on the flight plan line (which is displayed on the dispatcher’s screen) turns from white to yellow. If the position report is still not called in within the next 5 minutes, the entire flight plan line turns to yellow. If the flight crew has not called in to close out or extend its flight plan at the estimated time of arrival for the helicopter’s destination, the entire flight plan line turns red. 15 The dispatcher’s records indicated two entries for 1946. 16 The Discoverer Spirit had two-way FM radio communications capability with the helicopter. 17 According to an Era Aviation vice president, five aircraft were dispatched on the night of the accident for search and rescue operations: a helicopter from PHI was deployed from GLS about 2150; an Era helicopter was deployed from Houma, Louisiana, about 2209; two U.S. Coast Guard aircraft were deployed about 2210; and a helicopter from Evergreen Helicopters was deployed from GLS sometime before 2230. By 0515 on March 24, 2004, four vessels had joined the search and rescue operations. By 1000 on March 24, three additional vessels and four additional aircraft had joined the search and rescue operations.

Factual Information 4 Aircraft Accident Report 1.2 Injuries to Persons Table 1. Injury chart. 1.3 Damage to Aircraft The helicopter was destroyed as a result of impact forces with the water. 1.4 Other Damage No other damage was reported. 1.5 Personnel Information 1.5.1 The Captain The captain, age 50, held an airline transport pilot certificate with a rotorcraft-helicopter rating. The captain also held a Federal Aviation Administration (FAA) first-class medical certificate dated May 12, 2003, with a limitation that required him to wear lenses to correct for distant vision and possess glasses to correct for near vision. The captain served in the U.S. Army from July 1977 to August 1988, during which time he graduated from Army flight training and became an Army pilot (December 1980). From October 1988 to October 1999, the captain served in the U.S. Coast Guard as a pilot. The captain was hired by Era Aviation in November 1999. According to company records, the captain had accumulated 7,288 hours total flying time, including 5,323 hours as pilot-in-command (PIC) of multiengine helicopters, 1,489 hours aboard S-76 helicopters, and 1,028 hours at night. Company records also showed that the captain had accumulated 3,913 hours total flying time in the Gulf of Mexico. Further, the captain had flown in the Gulf of Mexico 389, 64, and 32 hours in the Injuries Flight Crew Cabin Crew Passengers Other Total Fatal 2 0 8 0 10 Serious 0 0 0 0 0 Minor 0 0 0 0 0 None 0 0 0 0 0 Total 2 0 8 0 10

Factual Information 5 Aircraft Accident Report 12 months, 90 days, and 30 days, respectively, before the accident. The 32-hour flight time (for the 30 days before the accident) included about 3 hours at night. Between March 1, 2003, and March 23, 2004, the captain accumulated 344 total flight hours (764 flights) in Era Aviation S-76A helicopters, 335 hours of which were flown during the day and 9 hours of which were flown at night. Of his 344 total flight hours, the captain flew 276 hours in S-76As with an analog flight control system and 68 hours in S-76As with a digital flight control system.18 Of the 68 hours in a digital S-76A, 1 hour was flown at night, and 17 hours (43 flights) were flown in the accident helicopter (with 0.4 hour—the accident flight—at night). The captain completed initial ground and flight training for the S-76A on November 17, 1999; a flight check on January 30, 2004, in an analog S-76A; recurrent instrument training on February 18, 2003; and recurrent ground training on February 26,

1. The captain was also rated in the Bell 212/412 helicopter. FAA records indicated no

accident or incident history or enforcement action, and a search of the National Driver Register indicated no record of driver’s license suspension or revocation. The captain’s wife reported that he was in good health and that his financial situation was good. She also reported that he was not taking any prescription or nonprescription medications. In addition, she stated that he did not smoke and that he consumed alcohol occasionally at home. The captain normally worked the day shift (0530 to 1930). The captain was on duty from March 4 to 17, 2004,19 and was off duty from March 18 to March 22, 2004. Before the captain went off duty, he was made aware that he would need to cover the upcoming night shift. On March 23, 2004, the captain drove his personal vehicle from his home to GLS (about 30 miles) and reported for duty about 1700. The accident flight was his first flight. The accident flight was also the first one that paired the captain and the copilot. The captain’s wife stated that, during the 72 hours before the accident, his activities included doing yard work and “stuff around the house.” She also stated that, on the morning of the accident, the captain slept until 1100. The captain’s wife further stated that she spoke with him during the afternoon and indicated that he sounded fine. An Era Aviation captain (who was formerly the company’s chief pilot) stated that the accident captain was always an extremely conscientious pilot and that he trusted him implicitly. The captain also stated that he never heard any complaints about the accident captain. 18 All Era Aviation S-76A pilots are trained to fly both the analog and digital flight control system versions of the helicopter. The accident helicopter had a digital flight control system. See section 1.17.1.1 for information about the S-76A analog flight control system and sections 1.6.3.2 and 1.17.1.1 for information about the S-76A digital flight control system. 19 Era pilots were generally scheduled to be on duty for 2 weeks and then off for 2 weeks.

Factual Information 6 Aircraft Accident Report 1.5.2 The Copilot The copilot, age 46, held a commercial pilot’s license with a rotorcraft-helicopter rating. The copilot also held an FAA first-class medical certificate dated March 15, 2004, with a limitation that required him to wear corrective lenses while exercising the privileges of the certificate. The copilot received flight training at Versatile Aviation, Ardmore, Oklahoma, from August 1999 to April 2000, during which time he received his flight instructor certificate (October 1999). From April 2000 to March 2001, the copilot was a flight instructor at Versatile Aviation. From March to June 2001, he was a line pilot at Kenai Helicopters, Grand Canyon, Arizona. The copilot was hired by Era Aviation in August 2001. According to company records, the copilot had accumulated 1,941 hours total flying time, including 1,371 hours as “PIC Helicopters,” 534 hours as “SIC (second-in-command) Helicopters,” 483 hours aboard S-76 helicopters, and 63 hours at night. Company records also showed that the copilot had accumulated 1,027 hours total flying time in the Gulf of Mexico. Further, the copilot had flown in the Gulf of Mexico 678, 14, and 4.5 hours in the 12 months, 90 days, and 30 days, respectively, before the accident. The 4.5-hour flight time (for the 30 days before the accident) included 3.6 hours at night. Between March 1, 2003, and March 23, 2004, the copilot accumulated 451 total flight hours (608 flights) in Era Aviation S-76A helicopters, 434 hours of which were flown during the day and 17 hours of which were flown at night. Of his 451 total flight hours, the copilot flew 314 hours in S-76As with a digital flight control system and 137 hours in S-76As with an analog flight control system. Of the 314 hours in a digital S-76A, 9 hours were flown at night, and 79 hours (97 flights) were flown in the accident helicopter (with 5.4 hours flown at night between January 20 and March 23, 2004). The copilot completed initial ground and flight training for the S-76A on December 12, 2002, and his first S-76A flight occurred on February 11, 2003. The copilot completed recurrent ground training on February 12, 2004; recurrent instrument training on February 17, 2004; and a flight check on February 20, 2004, in the accident helicopter (a digital S-76A). The copilot was also rated in the Bell 212/412 helicopter. FAA records indicated no accident or incident history or enforcement action, and a search of the National Driver Register indicated no record of driver’s license suspension or revocation. The copilot had been assigned to the night shift during his previous several duty periods, the last of which ended on March 3, 2004. The copilot had been off duty from March 4 to 17, 2004. He began his most recent duty schedule on March 17, 2004. From March 18 to 20, the copilot attended training (ground school for the Boelkow 105 helicopter)20 at Lake Charles Regional Airport (LCH), Lake Charles, Lousiana, from 0800 20 Era Aviation training records showed that the copilot was in the process of upgrading to PIC of the Boelkow 105 helicopter, which has analog instrumentation and no autopilots or flight directors.

Factual Information 7 Aircraft Accident Report to 1700. On March 21, the copilot drove his car from LCH to FOU (about 230 miles); on March 22, he drove his car from FOU to GLS (400 miles). The copilot returned to the night shift on March 23, and the accident flight was his first flight during the duty period. An Era Aviation captain who shared an apartment with the copilot when they were scheduled for duty indicated that he and the copilot would arrive at work about 1630 and that the night shift would begin about 1700 and end about 0500. The captain also indicated that he and the copilot would typically go to sleep immediately after their shift ended and that they would wake up about 1400. The captain described their schedules as “eat, sleep, work, eat, sleep, work for 14 days and then you go home.” The Era Aviation captain stated that the copilot’s health was excellent and that his financial situation was unremarkable. The captain also stated that, on the day of the accident, the copilot was not suffering from a cold or allergies, and his mood was fine. Another Era Aviation captain stated that the copilot smoked and that he consumed alcohol only outside of work. The Era Aviation captain who shared an apartment with the copilot when they were on duty stated that the copilot did not have any problems flying the S-76A and that he was interested in moving up in the company. The captain had previously flown 11 hours with the copilot and stated that the copilot had volunteered to do all of the flying. The captain further stated that he knew of no complaints about the copilot’s flying abilities and that he had not experienced any emergencies or other problems during previous flights with the copilot. In addition, the Era Aviation captain who was formerly the company’s chief pilot stated that the copilot was very keen and very conscientious, and another Era Aviation captain stated that the copilot was extremely competent. 1.6 Aircraft Information The accident helicopter, a Sikorsky S-76A++, serial number (S/N) 760274, was a transport-category, twin-engine, single main rotor helicopter that was configured to carry 2 pilots and up to 12 passengers. Aircraft records showed that the helicopter was manufactured in 1984 and was issued an export airworthiness certificate to Court Aviation Company of South Africa. Aircraft records also showed that the helicopter was transferred to Era Aviation in June 2001, at which time the helicopter received a new registration number, and that the helicopter received its U.S. airworthiness certificate in August 2001. At the time of the accident, the helicopter had accumulated 10,075 total flight hours and 2,882 total cycles.21 1.6.1 Main Rotor and Tail Rotor Systems The S-76A main rotor system provides the aerodynamic forces that make the helicopter fly. The main rotor system includes the main rotor drive shaft, which is attached 21 An aircraft cycle is one complete takeoff and landing sequence.

Factual Information 8 Aircraft Accident Report to a main transmission gearbox and a main rotor head,22 and four main rotor blades, which are installed on a main rotor hub. Three hydraulic actuators (forward, aft, and lateral) control the movement of the swashplate, which changes the pitch angle of the main rotor blades. The S-76A tail rotor system is used to control torque (that is, the tendency of helicopters with a single main rotor system to turn in the opposite direction of the main rotor rotation). The tail rotor system includes a tail rotor drive shaft with five sections that run through the tail cone, an intermediate gearbox, a tail rotor gearbox, and four tail rotor blades. The tail rotor drive shaft is attached to the main transmission gearbox. The tail rotor blades are integrated into two paddles so that each paddle has one blade on each end. 1.6.2 Powerplants Aircraft records showed that the accident helicopter was initially installed with two Rolls Royce (formerly Allison) 250-C30 engines. The records also showed that, on June 19, 1998, Keystone Helicopters of West Chester, Pennsylvania, installed two Turbomeca Arriel 1S1 engines aboard the helicopter. (The designation for S-76A helicopters that are equipped with Arriel 1S1 engines is S-76A++.) At the time of the accident, the left engine, S/N 3015, had accumulated 4,519 hours and 7,633 cycles, and the right engine, S/N 15109, had accumulated 2,052 hours and 3,161 cycles. 1.6.3 Flight Control Systems 1.6.3.1 Cyclic, Collective, and Tail Rotor Pedal Control Systems The accident helicopter was equipped with cyclic, collective, and tail rotor pedal control systems. Moving the cyclic forward or aft causes the helicopter to pitch up or down;23 moving the cyclic left or right causes the helicopter to roll in the commanded direction.24 Raising or lowering the collective results in a simultaneous increase or decrease, respectively, in the lift produced by the main rotor blades. Moving the tail rotor pedals (which are similar to airplane rudder pedals) positions the tail rotor blades to cause the helicopter to yaw.25 Either pilot can control the cyclic, collective, and tail rotor pedal control systems. 1.6.3.2 SPZ-7000 Dual Digital Automatic Flight Control System The accident helicopter was equipped with a Honeywell SPZ-7000 Dual Digital Automatic Flight Control System (DDAFCS), which was specifically designed for helicopters to provide full four-axis (longitudinal, lateral, vertical, and yaw) flight control. The DDAFCS includes the autopilots (see section 1.6.3.2.1); flight directors (see 22 The main rotor head has four spindles and four blade dampers. 23 Pitch is the movement of the helicopter about its lateral (side to side) axis. 24 Roll is the movement of the helicopter about its longitudinal (nose to tail) axis. 25 Yaw is the movement of the helicopter about its vertical axis.

Factual Information 9 Aircraft Accident Report section 1.6.3.2.2); flight control computers, which provide all computations for autopilot and flight director operation; air data components,26 which provide the flight control computers with information about the helicopter’s airspeed, altitude above sea level, vertical speed, and radar altitude (that is, the helicopter’s altitude above the surface);27 and an autotrim system. Figure 1 is a preaccident photograph of the helicopter’s cockpit that shows the location of DDAFCS components and indications. 26 The air data components include an air data command display known as the AL-300. 27 Radar altitude is computed by the radar altimeter system. The radar altimeter receiver/transmitter box sends a signal to the ground through a transmitter antenna. The receiver/transmitter box receives an echo through a receiver antenna. The receiver/transmitter box then measures the phase or time difference between the two signals and transmits this information to the cockpit in terms of feet above the ground. Radar altitude is also referred to as radio altitude. Figure 1. Location of DDAFCS Components and Indications in the Accident Helicopter’s Cockpit Source: Era Aviation.

1. Air data command display (AL-300)
2. Captain’s electronic flight information system (EFIS) displays
3. Captain’s digital automatic flight control system (DAFCS) caution panel

and decouple (DCPL) indication

1. Captain’s flight director mode selector
2. Autopilot controller
3. Copilot’s flight director mode selector
4. Copilot's EFIS displays
5. Copilot’s DAFCS caution panel and DCPL indication
6. Copilot’s flight director indication
7. DAFCS indication

2 3 4 5 6 7 8 9 10 1

Factual Information 10 Aircraft Accident Report 1.6.3.2.1 Autopilots Dual autopilot systems provide stability to the S-76 helicopter through a stability augmentation system (SAS) and an attitude retention mode (ATT). Both SAS and ATT modes provide heading hold,28 yaw damping and autotrim, and automatic turn coordination. The SAS mode provides short-term rate damping during manual flight and is selected when extensive maneuvering is required; this mode is commonly used during the initial and final phases of flight and while hovering. The ATT mode provides pitch and roll attitude retention, through the autotrim system, during manual flight. Thus, after an in-flight disturbance, the helicopter will automatically return to the reference attitude. The ATT mode engages automatically when either autopilot is selected. Upon initial ATT mode engagement, the helicopter’s reference attitude is its current attitude. The reference attitude can be reset by pressing a button on the cyclic. Only one of the stability modes (SAS or ATT) can be engaged at a time. The autopilot controller is used to engage SAS or ATT and autopilots No. 1 and No. 2 (AP1 and AP2). (Autopilot coupling, which refers to automatic flight, is discussed in section 1.6.3.2.3.) When selected, the SAS button illuminates in amber, the ATT button illuminates in green, and the AP1 and AP2 buttons illuminate in green and indicate “ON.” Figure 2 shows the autopilot controller, which is located on the center pedestal (as shown by number 5 in figure 1). 1.6.3.2.2 Flight Directors The flight directors assist pilots in maintaining a specified flightpath or attitude through the presentation of command cues29 on the attitude director indicators (ADI).30 28 SAS provides heading hold when the helicopter’s airspeed is below 60 knots; ATT provides heading hold at all airspeeds. Figure 2. Autopilot Controller Note: The “FD1/2” button allows the pilot to select flight director 1 or 2 (as discussed in section 1.6.3.2.2). The “CPL” button automatically illuminates when the autopilot and the flight director are coupled (as discussed in section 1.6.3.2.3). The “HOV” button allows the pilot to select the hover mode. The “COLL” button allows the pilot to select either the flight director or the radar altimeter to provide collective commands. The “TEST” button allows the pilot to test the autopilots before they are engaged. Source: Honeywell. 29 Additional information about command cues appears in section 1.18.5. 30 The ADIs are the top screens of the EFIS displays (as shown by numbers 2 and 7 in figure 1). Information about the ADIs appears in section 1.6.3.3. ON RAD FD ON ATT SAS AP1 SAS/ATT TEST COLL CPL AP2 HOV FD 1/2 ON ON ON 1 2

Factual Information 11 Aircraft Accident Report Flight director 1 is used when the left seat pilot is flying the helicopter, and flight director 2 is used when the right seat pilot is flying the helicopter. Flight director selection is made on the autopilot controller (see figure 2) with the FD1/2 button, which illuminates in white and indicates “1” or “2” depending on which flight director was selected. (Each press of the FD1/2 button alternates between flight directors 1 and 2.) When FD1 is selected, a “CPLT FD” light illuminates in green on the caution/advisory panel on the front instrument panel (see number 9 in figure 1). No light illuminates on the caution/advisory panel when FD2 is selected. The command cues that are presented on the ADIs generally correspond to the selected flight director modes, which include heading (HDG), vertical speed (VS), altitude (ALT), navigation (NAV), altitude preselect (ALT PRE), and standby (SBY). Figure 3 shows the flight director mode selector, which is located on the front instrument panel (as shown by numbers 4 and 6 in figure 1). 1.6.3.2.3 Coupling Function For the SPZ-7000 DDAFCS, whenever a flight director mode is selected, FD1 or FD2 becomes automatically coupled to the autopilot as long as AP1, AP2, and the autopilot’s ATT mode are engaged. Coupling allows the flight director’s computed pitch and roll attitude corrections to be input to the autopilot so that the pilot does not have to manually control the helicopter according to the command cues on the ADIs. The CPL button on the autopilot controller (see figure 2) automatically illuminates in green and Figure 3. Flight Director Mode Selector Note: Other buttons on the flight director mode selector are ILS, instrument landing system mode; DECEL, deceleration mode; VOR APR, very high frequency omnidirectional range approach mode; IAS, indicated airspeed mode; BC, instrument landing system backcourse; and GA, go-around mode. Source: Honeywell. HDG ON ON ON ARM ARM ARM CAP ARM CAP ARM CAP ARM CAP GS ON ON ON CAP NAV VOR APR IAS ALT PRE BC SBY GA ILS DECEL VS ALT

Factual Information 12 Aircraft Accident Report indicates “ON” when the autopilot and the flight director are coupled.31 The primary method to decouple the autopilot and the flight director is by pushing the CPL button.32 Once decoupling occurs, the pilot is required to fly the helicopter manually. No aural warning occurs when the autopilot and flight director become decoupled. During normal operations, the illumination, or absence of illumination, of the CPL button is the only direct annunciation of the status of the couple function.33 Because of its location on the center pedestal, the CPL button is out of the pilots’ routine instrument scan. During abnormal operations,34 a DCPL (decouple) warning indicator on the pilots’ digital automatic flight control system (DAFCS) caution panels35 illuminates in amber whenever the autopilot and flight director are not coupled for an activated mode.36 The DAFCS caution panels are located in front of the pilots above the barometric altimeters (as shown by numbers 3 and 8 in figure 1). 1.6.3.3 Electronic Flight Information System The DDAFCS interfaces with an analog electronic flight information system (EFIS), which receives inputs from attitude, heading, navigation, and flight director sources to provide information to four cathode-ray tube flat-panel screens on the front instrument panel (two for each pilot position). The top screens are the electronic ADIs, which display pitch and roll attitudes via a blue and brown sphere that moves with respect to a stationary aircraft symbol to display actual pitch and roll attitudes. The bottom screens are the electronic horizontal situation indicators (HSI), which display the helicopter’s position in relation to the selected course and heading or actual heading. The ADIs display numerous items in addition to the attitude sphere and command cues (if selected). For example, the ADIs annunciate, at the top of the display, the flight director mode (or modes) that has been selected. The ADIs also annunciate the radar altitude 31 During postaccident interviews, Era Aviation S-76A pilots indicated that the CPL button had to be selected to couple the autopilot and flight director. However, pressing the CPL button actually decouples the two systems. 32 An alternate method of decoupling is by pressing a quick release button on the bottom of the cyclic. When this button is pressed, the CPL button’s ON annunciation no longer illuminates, all modes selected on the flight director mode selector disengage and return to standby, and command cues are no longer shown on the ADI. 33 Indirect indications of the couple function are shown by course deviation on the ADIs and the horizontal situation indicators and changes displayed on mechanical instruments, such as the barometric altimeter, heading indicator, and vertical speed indicator. 34 Abnormal refers to an aircraft-induced decouple resulting from a malfunction of a sensor, which causes an activated mode to decouple. 35 The DAFCS caution panels annunciate malfunctions related to the autopilot and coupling function. The panel has three other warning indications besides DCPL: AP1, AP2, and CLTV (collective). The AP1 and AP2 warnings illuminate in amber when an autopilot failure, a hardover, or an oscillatory malfunction occurs. The CLTV warning illuminates in amber when the collective trim switch is off or the collective command limit has been exceeded. 36 Whenever any DAFCS caution panel warning is annunciated, the abbreviation “DAFCS” illuminates in amber on the caution/advisory panel (see number 10 in figure 1), and a red “MASTER WARNING” light under the glareshield panel (the top rim portion of the front instrument panel) illuminates.

Factual Information 13 Aircraft Accident Report in blue in the lower right corner37 and the pilot-selected decision height38 in blue in the lower left corner.39 Figure 4 shows an electronic ADI and its various displays. The ADIs do not show which flight director has been selected or whether it has been coupled to the autopilot. 1.6.4 Maintenance Records Maintenance records for the accident helicopter indicated that it was being maintained in accordance with an FAA-approved Continuous Airworthiness Maintenance Program. This program consists of regularly scheduled inspections, parts replacements, and tests and uses a computer database to track an aircraft’s flight and maintenance activities. The database also tracks the requirements for inspections, overhauls, retirement of components, airworthiness directives, service bulletins, and survival equipment. 37 The radar altitude readouts, which range from -20 to 2,500 feet, appear numerically in 10-foot increments between 200 and 2,500 feet and 5-foot increments below 200 feet. 38 The decision height is the height at which a decision must be made either to continue the approach or execute a missed approach. The decision height is selected in 5-foot increments from 0 to 200 feet and 10-foot increments from 200 to 990 feet. The decision height knob is located on a display controller on the center pedestal. 39 According to Era Aviation’s Operations Manual (Operating Procedures section, chapter 5, page 11, dated December 23, 2002), “an operating radar altimeter is required for all night flights and for all day flights when the ceiling is less than 400 feet and/or the visibility is less than 2 miles. The DH [decision height] shall be set to 200 feet.” Figure 4. Electronic Attitude Director Indicator Source: Honeywell. 200 DH 140 RA HDG Roll attitude pointer Roll scale Flight director mode annunciation Flight director mode annunciation Pitch and roll command bars Decision height box and indication Aircraft symbol Radar altitude display Rising runway Decision height display Pitch scale 20 20 10 10 10 10 20 20 DH ALTP

Factual Information 14 Aircraft Accident Report On March 22, 2004, a main rotor blade inspection (performed every 300 hours) was conducted at LCH. On March 23, 2004 (the accident date), a tail rotor spar inspection (performed every 25 hours) was conducted at GLS. The aircraft maintenance log for March 22 and 23, 2004, indicated “preflight inspection made this date, A/C [aircraft] deemed Airworthy and Satisfactory for operational flight.” The last recorded flight control maintenance action occurred on March 15 and 16,

1. The maintenance action involved replacing the helicopter’s trim relay assembly (a

minimum equipment list [MEL] item)40 because of an inoperative relay, performing an operational check, and clearing the helicopter for flight. The replacement of the helicopter’s trim relay assembly was the final corrective action for a series of discrepancies concerning the flight director that occurred between March 9 and March 16, 2004.41 1.6.5 Previous Flights On March 22, 2004, two Era Aviation pilots repositioned the accident helicopter from FOU to GLS. During a postaccident interview, the copilot who repositioned the accident helicopter stated that the captain of the repositioning flight tested the DDAFCS before departure and found it to be functioning properly. This copilot also stated that the DDAFCS was engaged during the flight and that the flight director ALT mode had been selected. Further, the copilot stated that he did not recall anything being wrong with the helicopter during the flight and that the helicopter performed as expected. On March 23, 2004, the helicopter flew 5.4 hours before the accident flight with no reported discrepancies. The captain of these flights stated, during a postaccident interview, that the helicopter flew well and experienced no problems. The DDAFCS was used during this flight. 1.7 Meteorological Information Weather observations at GLS are made by an automated surface observing system (ASOS), which is maintained by the National Weather Service (NWS). The ASOS records 40 According to the FAA, an MEL is an inventory of instruments and equipment that may legally be inoperative with the specific conditions under which an aircraft may be flown with such items inoperative. 41 On March 9, 2004, the aircraft maintenance log indicated that the copilot’s flight director did not hold altitude when the navigation and heading modes were selected and that the helicopter pitched nose down and descended when the collective was lowered manually. The log also indicated that, to correct this discrepancy, the pilot’s and copilot’s flight control computers were swapped; however, because this action only transferred the problem to the pilot’s side, the flight control computers were switched back, and the copilot’s computer was replaced. An operational check was performed, but the copilot’s flight director still responded as before. On March 10, 2004, the copilot’s flight director was placed on the MEL. To address the problem, the pitch trim actuator was replaced on March 12, 2004. A ground check of the pitch trim actuator was then performed, which was successful. On March 15, 2004, the trim relay assembly was replaced because of an inoperative relay. On March 16, 2004, paperwork was updated to indicate that the trim relay assembly had been replaced and that this corrective action had cleared the discrepancy. As a result, the flight director was removed from the MEL, and the helicopter was cleared for flight.

Factual Information 15 Aircraft Accident Report continuous information on wind speed and direction, cloud cover, temperature, precipitation, and visibility42 and transmits an official meteorological aerodrome report (known as a METAR) each hour in coordinated universal time (UTC). (Central standard time is 6 hours behind UTC time.) The 0052Z43 METAR (1852 local time), which was issued 7 minutes after the helicopter departed from GLS, indicated the following: winds 110º at 11 knots, visibility 10 miles, few clouds at 2,800 feet, overcast at 4,000 feet, temperature 19º C (66º F), dew point 16º C (61º F), and altimeter setting 30.25 inches of mercury. The NWS surface analysis chart for 0000Z (1800 local time) showed a ridge of high pressure extending over the area with winds from the east-southeast at 10 to 20 knots. Buoy reports indicated winds from the east-southeast to southeast at 17 to 21 knots. Satellite imagery depicted no cumulonimbus clouds or thunderstorms over the region but depicted a scattered to broken layer of low stratiform clouds over the Gulf of Mexico south of GLS. The Galveston weather service radar identified no weather echoes near the accident site. Sunset occurred about 1833, and the end of evening civil twilight44 was about 1856, which was 11 minutes after the flight’s departure from GLS. According to the U.S. Naval Observatory, 8 percent of the moon disk was illuminated at the time of the accident. 1.8 Aids to Navigation Not applicable. 1.9 Communications During a postaccident interview, the Era Aviation dispatcher reported that the flight crew called her after takeoff. The dispatcher stated that she was able to hear the pilots but that they were unable to hear her, even after they changed frequencies. The dispatcher thought that the reason for this lack of communication was because the helicopter had just taken off and had not reached a sufficient altitude. No other communications problems between the dispatcher and the flight crew were reported. No audio record of the conversations between the dispatcher and the accident flight crew was available.45 Such conversations are normally recorded on a very high 42 Cloud cover is expressed in feet above ground level. Visibility is expressed in statute miles. 43 The “Z” designation that follows the time in a weather observation stands for Zulu, which indicates UTC time. 44 The U.S. Naval Observatory explains evening civil twilight as follows: “to end in the evening when the center of the Sun is geometrically 6 degrees below the horizon. This is the limit at which twilight illumination is sufficient, under good weather conditions, for terrestrial objects to be clearly distinguished...Complete darkness, however...begins sometime after the end of evening civil twilight.” 45 The only record of the communications between the dispatcher and the pilots was a three-page printout containing nine entries (as described in section 1.1). The printout was generated from the dispatcher’s computerized log at Era Aviation’s Gulf Coast headquarters.

Factual Information 16 Aircraft Accident Report frequency (VHF) tape deck system in Era Aviation’s Gulf Coast headquarters operations center; however, on the night of the accident, the tape deck system was not working.46 1.10 Airport Information Not applicable. 1.11 Flight Recorders 1.11.1 Cockpit Voice Recorder The helicopter was equipped with an L-3 Communications solid-state model FA2100 CVR, S/N 118739. The exterior of the CVR did not appear to have any heat or structural damage, but it had been submerged in salt water. The CVR memory module was removed, restacked using dry components, and installed on a Safety Board FA2100 CVR chassis in the Board’s audio laboratory. The CVR audio data was successfully downloaded. The CVR recording contained four channels of audio data. The first audio channel, which was not required by Federal regulations, did not contain any usable audio information. The second and third audio channels recorded information from the pilot and copilot stations but did not contain any usable audio information. The fourth audio channel contained poor quality47 audio information from the cockpit area microphone (CAM). A transcript was prepared of the entire 30-minute 52-second digital recording (see appendix B), but most of the recording was obscured by a high level of background noise. The manufacturer of the CVR evaluated the main chassis to determine if the CVR was functioning properly at the time of the accident. The evaluation determined that the CVR was operating within its design specifications. The Safety Board evaluated the internal communications system units from the pilot (captain) and copilot stations. On the left side of each unit was a white notched switch, labeled model 105/103, that could slide up or down to be set in the top (105) or the bottom (103) positions. According to CVR installation documentation provided by Era 46 During a postaccident interview, Era Aviation’s director of operations stated that the system had been unhooked 1 or 2 days earlier for the installation of new furniture but that the system was accidentally not hooked up again. Once the problem was discovered, the system was hooked up again. In addition, a computer-based backup system for audio recordings was installed a few weeks after the accident. 47 The Safety Board rates the quality of CVR recordings according to a five-category scale: excellent, good, fair, poor, and unusable. Poor quality CVR information is characterized by the following traits: extraordinary means had to be used to make some of the crew conversations intelligible. The transcript that was developed may indicate fragmented phrases and conversations and may indicate extensive passages where conversations were missing or unintelligible. This type of recording is usually caused by a combination of a high cockpit noise level with a low voice signal (poor signal-to-noise ratio) or by a mechanical or electrical failure of the CVR system that severely distorts or obscures the audio information.

Factual Information 17 Aircraft Accident Report Aviation, the switches determine the internal configuration for the CVR output, and failure to set the switches to the correct model position results in a lack of audio input to the respective CVR channels. The helicopter’s CVR installation required that the switches be set to the bottom (103) position, but the switches were found set to the top (105) position. (These switches were not visible to the pilots.) After this accident, Era Aviation checked the CVRs installed on its remaining S-76A helicopters and found that the switches were set to the correct position. According to FAA Form 337, “Major Repair and Alteration,” the installation of the CVR and the pilot and copilot audio panels on the accident helicopter was performed at an FAA-certified repair station and was approved by the FAA on August 2, 2001. FAA Form 337 also stated, “an operational test of the CVR system was complied with.” 1.11.2 Flight Data Recorder The accident helicopter was not equipped with a flight data recorder (FDR) because, in August 2003, the S-76A became permanently exempt from Federal regulations requiring the helicopter to be so equipped. Before the permanent exemption was granted, Era Aviation had petitioned the FAA for an exemption from 14 CFR 135.152, “Flight Recorders,” paragraph (a), to permit the company to operate two of its newly acquired S-76A helicopters—N575EH and N579EH (the accident helicopter)—under Part 135 without an FDR installed.48 Section 135.152(a), stated the following at the time of the petition: No person may operate under this part a multi-engine, turbine-engine powered airplane or rotorcraft having a passenger seating configuration, excluding any required crewmember seat, of 10 to 19 seats, that was either brought onto the U.S. register after, or was registered outside the United States and added to the operator’s U.S. operations specifications after October 11, 1991, unless it is equipped with one or more approved flight recorders that use a digital method of recording and storing data and a method of readily retrieving that data from the storage medium. In its June 11, 2001, letter, Era Aviation stated that operations without FDRs “do not degrade safety.” The letter also stated that the Safety Board’s accident data for rotorcraft operated under Part 135 with seating of 10 to 19 passengers do not indicate “that the cause of accidents is in question or that the investigative process would have been improved by the requirement for a DFDR [digital flight data recorder].” In an August 17, 2001, letter to Era Aviation, the FAA stated that it had previously issued grants of exemption to petitioners with circumstances similar to those presented in Era’s petition. The letter referred to Grant of Exemption No. 6785, dated June 12, 1998, in which the FAA (specifically, the Director, Flight Standards Service) stated that the petitioners had demonstrated “valid reasons” for exempting several helicopter models, 48 In its letter, Era Aviation stated that it currently operated 37 other helicopters (with seating for 10 to 19 passengers) without FDRs installed.

Factual Information 18 Aircraft Accident Report including the S-76A, from the FDR requirements,49 but the letter did not explain what these reasons were. The letter also stated that the FAA had found that “exempting certain helicopters from the FDR requirements would be in the public interest and would not adversely affect safety.” The letter further stated that Era Aviation’s reasons for requesting an exemption did not materially differ from those presented by the petitioner in Grant of Exemption No. 6785. As a result, the FAA granted Era Aviation an exemption from 14 CFR 135.152(a) for N575EH and N579EH (Grant of Exemption No. 7605), which allowed the company to continue to operate the helicopters without an FDR installed. The FAA’s letter stated that the exemption would terminate on January 31, 2004, unless it was superseded or rescinded sooner. On August 18, 2003, the S-76A helicopter became permanently exempt from the requirements of 14 CFR 135.152. Title 14 CFR 135.152(k) stated the following: For aircraft manufactured before August 18, 1997, the following aircraft types need not comply with this section: Bell 212, Bell 214ST, Bell 412, Bell 412SP, Boeing Chinook (BV-234), Boeing/Kawasaki Vertol 107 (BV/KV-107-II), deHavilland DHC-6, Eurocopter Puma 330J, Sikorsky 58, Sikorsky 61N, Sikorsky 76A.[50] The final rule, which was issued on July 18, 2003 (and became effective 1 month later), focused primarily on 14 CFR Part 121 parameter accuracy issues with large transport-category Boeing and Airbus airplanes. The Safety Board commented on those issues before the issuance of the final rule. The FAA did not notify the Board of its intent to include the rotorcraft exemptions as part of the final rule and did not provide a comment period for the final rule.51 Thus, the Board did not have the opportunity to formally state its position on the rotorcraft exemptions before the issuance of the final rule. The Era Aviation S-76A accident highlighted the problems associated with rotorcraft exemptions from FDR requirements. As a result, on March 7, 2006, the Safety Board issued Safety Recommendation A-06-18, which asked the FAA to remove the current rotorcraft exemptions to 14 CFR 135.152(a). This recommendation is further discussed in section 1.18.6.2. 49 The FAA stated the following in Grant of Exception No. 6785: “following the August 18, 1997, effective date of Amendment No. 135-69, ‘Revisions to Digital Flight Data Recorder Rules; Final Rule’ (62 FR 38362, July 17, 1997), the FAA received requests from several helicopter operators for exemption from the new DFDR requirements. The FAA found that the petitioners demonstrated valid reasons for exempting the following helicopters from the DFDR requirements: Bell 212, Bell 214ST, Bell 412, Bell 412SP, Sikorsky 61N, and Sikorsky 76A. Because the material presented by the petitioners concerning those helicopters supported the FAA’s finding of an exception to the rule, the exemptions were issued until §135.152(k) could be changed to include the affected helicopters as exceptions to the DFDR requirements.” 50 After the accident, Sikorsky began voluntarily equipping all of its new commercial aircraft, including the S-76, with FDRs. 51 Title 14 CFR 11.29 states that the FAA may issue a direct final rule without first issuing a notice of proposed rulemaking (NPRM) if (1) an NPRM is “impracticable, unnecessary, or contrary to the public interest” or (2) the agency does not expect any adverse comments to the changed rule.

Factual Information 19 Aircraft Accident Report 1.12 Wreckage and Impact Information The helicopter wreckage was found on March 25, 2004. The wreckage was recovered from the sea floor (a depth of about 186 feet) at a location about 70 nm south-southeast of GLS in U.S. Gulf Coast VFR Aeronautical Chart reference area High Island A-508. The helicopter fuselage showed severe accordion-type crushing. The fuselage was fragmented with pieces of structure attached to helicopter components. About 95 percent of the structure was recovered. The structure showed no evidence of bird strikes, fatigue fractures, or other anomalies. The nose cone had separated from the fuselage and showed minor damage. The lower fuselage showed upward compression fractures. The tailboom (the structure that connects the helicopter’s fuselage to its tail rotor) had separated from the helicopter fuselage. Inward crushing was found on the lower part of the structure that attached the fuselage and tailboom, and tearing was found on the upper part of the attachment structure. The bottom of the tailboom was undamaged. The front instrument panel was intact, and most instruments remained in their respective mounting areas. The EFIS displays were shattered. No useful instrument data were available. Continuity of the cyclic, collective, and tail rotor pedal control systems could not be established because of the breaks in the systems. All of the breaks were examined, and no evidence of malfunction or failure was found. 1.12.1 Main Rotor and Tail Rotor Systems The main rotor drive shaft remained attached to the main transmission gearbox and main rotor head. Two of the five sections of the tail rotor drive shaft were fractured, and the other three sections of the tail rotor drive shaft were attached to the tail cone structure. All four main rotor blades were found fractured and with their blade roots still attached to the main rotor hub. All blade fracture surfaces were consistent with static bending overload and showed no evidence of fatigue. The rotor tips had separated from the blades but were recovered in the main debris field. Two of the tail rotor blades separated from the tail rotor just outboard of the rotor cuff.52 The third tail rotor blade remained intact on the spar but had a flatwise spar fracture near the root. The fourth tail rotor blade had fractured, and the outboard portion of the blade was not recovered.53 52 The rotor cuff is located at the root end of the blade spar and attaches the blade to the rotor head. 53 Because a tail rotor blade is much smaller and flatter than a main rotor blade, the underwater recovery of a tail rotor blade can be more difficult than that for a main rotor blade.

Factual Information 20 Aircraft Accident Report The main, intermediate, and tail rotor gearboxes were examined at Sikorsky’s facility. The gearboxes showed no evidence of malfunction or failure, and none of the components showed evidence of heat distress, warping, discoloration, or other signs of stress. 1.12.2 Powerplants The left and right engines were found attached to the helicopter structure that surrounds the engine compartment. The engines were found in their normal operating position but had separated from their engine mounting points. The engines showed no evidence of fire damage. The left and right engines were examined at the Turbomeca facility in Grand Prairie, Texas. The examination revealed torsion fractures to both drive shafts.54 Evidence (turbine blades on the left engine that had completely shed from the disk) showed that the right engine had sensed an overspeed condition and activated its overspeed protection, which included shutting down the fuel to the right engine and removing all overspeed protection for the left engine. According to Turbomeca, during an accident sequence in which both engines become decoupled from the transmission, one engine will overspeed, and the other engine will not overspeed. Examination of the overspeed protection boxes found that both boxes had minor external damage. One of the boxes (referred to as box A) was inscribed with the number 2, but the wiring bundle connected to the box was labeled with the number 1. The other box (referred to as box B) had no inscribed number to indicate its position, and no wiring bundle was connected to the box. The boxes’ electrical connecting pins were tested for continuity, and the pins indicated that both boxes were not in an overspeed condition. The overspeed protection boxes were disassembled and examined at Turbomeca’s facility in Tarnos, France. The internal examination of both boxes found no evidence of soot, arcing, or overheating but found damage that appeared to be the result of seawater immersion. A pin continuity test of box A showed that it was not in the overspeed position but that its relay was found in the overspeed position. A pin continuity test of box B showed that it was not in the overspeed position and that its relay also was not in the overspeed position. 1.12.3 Landing Gear The main landing gear was found intact but heavily damaged. The main landing gear doors were pushed upward and showed fractures that were consistent with the doors being closed at impact. The main landing gear floats were folded inside the wheel wells, and the floats were ripped. The main landing gear wheels, tires, and brakes were intact. The nose landing gear was attached to its respective mounting area but had severe structural deformation throughout the assembly. The nose gear support structure was in the up position. The landing gear control valve was intact and in the up position. 54 The drive shafts transmit power from the engines to the main rotor blades.

Factual Information 21 Aircraft Accident Report The electrical wiring for the landing gear warning system was examined for proper routing, component placement, and evidence of anomalies. The wiring matched the manufacturer’s schematic drawing, which showed that the landing gear warning system was configured to activate red “LDG GEAR UP” lights under the glareshield panel and an aural warning (a gear warning horn) over the pilots’ headsets when (1) the helicopter’s height above the ground, as measured by the radar altimeter, decreased below a pilot-set decision height55 with the gear up or (2) the helicopter’s airspeed was at or below 60 knots indicated airspeed with the gear up. The landing gear warning relay was found with damage that appeared to be the result of seawater immersion. The relay was not functional and thus could not be tested after the accident. A postaccident test flight aboard an Era Aviation S-76A helicopter showed that its landing gear warning system (which was similar to that installed on the accident helicopter) worked as indicated on the manufacturer’s wiring diagram. Specifically, the aural tone sounded until one of the LDG GEAR UP warning lights was pressed, and the lights remained illuminated until the landing gear was lowered.56 The test flight also demonstrated that the landing gear warning system’s lights were among the brightest, and the aural warning was among the loudest, in the cockpit. The landing gear warning lights were examined at the Safety Board’s metallurgical laboratory in Washington, D.C. The light bulb filaments showed no evidence of stretching.57 1.13 Medical and Pathological Information Remains of both pilots and all eight passengers were recovered. Autopsies were performed on both pilots, and no drugs of abuse were detected in either pilot. 1.14 Fire The helicopter wreckage showed no evidence of an in-flight or a postcrash fire. 1.15 Survival Aspects According to the County of Galveston Medical Examiner’s Office, the cause of death for the flight crew and passengers was multiple blunt force trauma injuries. 55 Because it is possible for the pilots to select different decision heights, the landing gear warning system will activate at the higher of the two decision heights. 56 The aural tone and the warning lights could also be cleared if the helicopter’s airspeed increased above 60 knots and the helicopter’s altitude increased above the higher pilot-selected decision height. 57 Stretching is the elongation of individual coils in light bulb filaments when the filaments are hot and subjected to impact forces.

Factual Information 22 Aircraft Accident Report 1.16 Tests and Research 1.16.1 Cockpit Voice Recorder Study The Safety Board conducted a CVR study to detect any aircraft system noise on the recording, including the noise produced by the helicopter’s rotor, engine, and transmission. Numerous signals were evident on the CAM, but the following five signals were prominent: tail rotor, bull gear mesh (in the main rotor transmission), piston passing frequency of the hydraulic pump, bevel gear mesh (in the main rotor transmission), and input helical mesh (in the main rotor transmission). These five signals remained constant in frequency throughout the recording, which indicated that the system producing the noise remained at a constant speed throughout the recording. The amplitudes of the bull gear mesh and the bevel gear mesh changed toward the end of the recording, which indicated a change in the signal strength.58 The signals that were evident in the recording indicated that, at the time of the accident, the main rotor and the tail rotor were operating at a constant rotor speed. According to Sikorsky Aircraft, the simultaneous changes in signal strength of the bull and bevel gear meshes (at 1918:15) indicated that an increase in torque was applied to the transmission. The Safety Board’s CVR study was also conducted to evaluate the background noise recorded on the CAM channel. Generally, the noise of air flowing over the fuselage directly influences the loudness (amplitude) of the broadband background noise of a CAM recording. About 1918:25, the overall background noise level recorded on the CAM decreased.59 The decrease in the background noise level continued until the end of the CVR recording at 1918:34. 1.16.2 Actuator Testing The Safety Board identified airworthiness concerns about S-76 actuators during the investigation of the August 2005 accident involving an S-76C that crashed into the Baltic Sea shortly after takeoff from Tallin, Estonia.60 As a result, the Safety Board examined the three main rotor actuators installed on the Era Aviation S-76A accident helicopter at HR Textron (the actuator manufacturer), Santa Clarita, California. The examination showed that most of the actuator seals were intact with no damage61 and that 58 Specifically, the signal for the bull gear mesh began to decrease in strength until the signal disappeared into the background noise at 1917:28. The signal reappeared at 1917:43 and increased in strength at 1918:15. The signal for the bevel gear mesh decreased in strength beginning at 1918:15. 59 It was not possible for the Safety Board to correlate the noise level to a specific airspeed because the accident CVR recording levels could not be calibrated to an external source. 60 In accordance with the provisions of Annex 13 to the International Convention on Civil Aviation, the Safety Board has been assisting the Aircraft Accident Investigation Commission of Estonia with this accident investigation. For more information, see DCA05RA089 and Safety Recommendations A-05-33 through -35 at the Safety Board’s Web site at http://www.ntsb.gov. 61 Only the forward actuator’s balance tube seals were worn, and one of the actuator’s seal caps had fractured.

Factual Information 23 Aircraft Accident Report the control valves moved freely with no blockages or restrictions. The piston head’s plasma coating was not flaked. Because of the condition of the actuators, they could not be functionally tested. 1.17 Organizational and Management Information 1.17.1 Era Aviation Era Aviation, LLC, is headquartered in Anchorage, Alaska.62 Era Aviation began operations in the Gulf of Mexico in 1979. The accident helicopter was based at GLS, and its operations and maintenance were managed by the company’s Gulf Coast headquarters at LCH. At the time of the accident, Era Aviation had 7 S-76A helicopters in its Gulf of Mexico fleet63 (including the accident helicopter) and employed 87 pilots who flew in the Gulf of Mexico (including the accident flight crew). 1.17.1.1 S-76A Configurations At the time of the accident, four of the seven S-76A helicopters in Era Aviation’s Gulf of Mexico fleet, including the accident helicopter, were digital and were configured with an EFIS and a DDAFCS (as described in section 1.6.3).64 These helicopters provided pilots with landing gear warnings when the helicopters’ airspeed was at or below 60 knots or when the helicopter was at or below the decision height with the gear retracted.65 The other three S-76A helicopters in Era Aviation’s Gulf of Mexico fleet were analog and were equipped with a Phase II automatic flight control system that was installed by the manufacturer.66 These helicopters provided pilots with landing gear warnings only when the helicopters’ airspeed was at or below 60 knots with the gear retracted.67 62 At the time of the accident, Era Aviation, Inc., was a subsidiary of Rowan Companies, Inc., of Houston. In January 2005, Era Aviation, LLC, became a subsidiary of SEACOR Holdings, Inc., of Houston. 63 Other helicopters in the company’s Gulf of Mexico fleet at the time of the accident included the Sikorsky 61, Bell 212/412, Boelkow 105, Agusta 109, and Eurocopter 332L (Super Puma) and 350. 64 The accident captain completed EFIS-DDAFCS training in December 2001. The accident copilot received EFIS-DDFACS training as part of initial training. For information about Era Aviation’s training program, see section 1.17.1.2. 65 As stated in section 1.12.3, the accident helicopter’s landing gear warning lights were located under the glareshield panel. The landing gear warning lights for the other three digital helicopters were located at the bottom of the front instrument panel near the center pedestal. 66 The Phase II automatic flight control system maintains selected attitudes and provides stabilization in the pitch, roll, and yaw axes. The Phase II system consists of two separate but identical systems that introduce signals into the flight control system through the pitch, roll, and yaw operational channels to correct any difference between a preset flight attitude and the actual flight attitude. The helicopters equipped with a Phase II automatic flight control system do not have EFIS or flight directors. 67 The landing gear warning lights on two of the analog helicopters were also located under the glareshield panel. The warning lights on the other analog helicopter were located above each pilot’s airspeed indicator.

Factual Information 24 Aircraft Accident Report 1.17.1.2 Ground and Flight Training Era Aviation’s S-76A initial ground training consisted of 40 hours of classroom training during a 5-day period. During a postaccident interview, Era Aviation’s director of training at LCH stated that the primary instructors for initial ground training were check airmen, who followed the FAA-approved curriculum and prepared a syllabus, lesson plans, pilot training manuals, PowerPoint presentations, and other needed materials. The director of training stated that he was responsible for overseeing the format of the training information. The initial ground training syllabus listed 14 lessons that were presented during the course “to provide the ground training necessary to familiarize and train each crewmember in the operation of the Sikorsky S76 helicopter and to assure that the crewmember can completely and safely perform his/her assigned duties.” The 14 lessons included 4 hours of instruction for the flight control and automatic flight control systems; 2 hours of instruction for the avionics system; 3 hours of instruction for familiarization with aircraft flight manuals; and 4 hours of instruction on the caution warning, electrical power, and lighting systems. A quiz was given at the end of each lesson, and an examination was given at the end of the course; each pilot had to receive a minimum score of 80 percent on all of the quizzes and the examination. Initial ground training was delivered in lecture format using information from Era Aviation training manuals and PowerPoint presentations. The Era Aviation S-76 Pilot Training Manual included detailed descriptions of the analog and digital flight control systems, and the Era Aviation S-76 Training Flight Manual included all operating handbooks and required supplements. Pilots were provided with copies of the manuals during the training. The PowerPoint presentations included schematics and photographs of the various components of the analog and digital flight control systems. The training included limited information on flight director and coupling status annunciations and command cue presentations. During initial ground training, pilots also received a copy of Era Aviation’s Operations Manual. This manual contained guidelines for Era Aviation’s operations, which were not specific to any aircraft type in the company’s fleet. Pilots receive revisions to the manual as they are printed. Part of initial ground training was dedicated to controlled flight into terrain (CFIT)68 and crew resource management (CRM). All Era Aviation pilots were required to watch a 30-minute videotape on CFIT prepared by Boeing. The videotape emphasized the importance of communication and crosscheck procedures in preventing CFIT. The director of training at LCH stated that, during the CFIT portion of his training, the accident captain spoke about his flight experiences with the Coast Guard, discussed the risk factors associated with flying to an offshore platform at night, and was “the most vocal and active participant in the class.” Also, Era Aviation pilots were required to view a 45-minute PowerPoint presentation on aeronautical decision-making. The presentation cautioned pilots about becoming overly confident with increased experience and provided information about various helicopter 68 For more information about CFIT, see section 1.18.4.

Factual Information 25 Aircraft Accident Report accidents. In addition, pilots watched three videotapes about pilot decision-making, one of which discussed the human factor considerations present in aviation safety. Initial flight training consisted of 10 hours of flight time. This flight time was divided into six 90-minute periods and one 2-hour period during which pilots were given a Part 135 flight check.69 Era Aviation’s S-76A recurrent ground and instrument training was conducted at its headquarters during a 6-day period (6 hours each day). The training was presented along with recurrent ground and instrument training for the Sikorsky S-61 and the Bell 412. Topics covered during the training for all three helicopter models included aircraft flight manual and flight standards guide information, systems training (flight control and hydraulic systems), navigation, meteorology, instrument flight rules (IFR) procedures, maintenance, CFIT, CRM, situational awareness, and safety (accident and incident review). Examinations were given for each training subject. Era Aviation required its S-76A pilots to attend a minimum of 6 hours of recurrent simulator flight training each year. This training was conducted during four 1.5-hour sessions at FlightSafety International, West Palm Beach, Florida, in an S-76A simulator equipped with an EFIS and a DDAFCS. The first session consisted of simulator familiarization, including normal approaches to oil rigs, and selected malfunctions and emergencies. The second session consisted of instrument procedures and weather considerations. The third session consisted of a review of VFR and IFR procedures and CRM procedures. Each of these sessions concluded with a debriefing. The fourth session consisted of a Part 135 flight check and a question-and-answer period. An Era Aviation captain stated that the simulator sessions included at least 2 hours of night flying under IFR. He also stated that at least two offshore approaches to an oil rig were conducted down to 200 feet with 0.6 mile visibility. Era Aviation’s simulator coordinator (who was also an S-76A check airman) stated that, before the accident, coupling indications and related issues were not a focus of the DDAFCS portion of ground or simulator flight training. He also stated that, after the accident, Era Aviation focused the DDFACS portion of the training on improving a pilot’s situational awareness regarding the system and decreasing the possibility of confusion between pilots. Era Aviation’s check airmen provided annual flight checks to company PICs. According to an Era Aviation vice president, the flight checks generally involved flights to offshore platforms or ships or flights near LCH for checks of emergency procedures. 1.17.1.3 Visual Flight Rules Flight Plans As stated in section 1.1, the accident helicopter’s VFR flight plan was not filed with the FAA. In a July 12, 2004, letter to the Safety Board, an Era Aviation vice president 69 These flight checks were conducted pursuant to 14 CFR 135.293, “Initial and Recurrent Pilot Testing Requirements,” 14 CFR 135.297, “Pilot in Command: Instrument Proficiency Check Requirements,” and/or 14 CFR 135.299, “Pilot in Command: Line Checks: Routes and Airports.”

Factual Information 26 Aircraft Accident Report stated that about 600 helicopters fly in the Gulf of Mexico, many of which fly numerous flight segments each day, and that it would therefore be “impractical” and “overwhelming” to file every VFR flight plan with the FAA. This vice president stated that the company adhered to 14 CFR 135.79(a), “Flight Locating Requirements,” for its VFR flight plans. Title 14 CFR 135.79(a) states the following: Each certificate holder must have procedures established for locating each flight, for which an FAA flight plan is not filed, that – (1) provide the certificated holder with at least the information required to be included in a VFR flight plan; (2) provide for timely notification of an FAA facility or rescue facility, if an aircraft is overdue or missing; and provide the certificate holder with the location, date, and estimated time for reestablishing radio or telephone communications, if the flight will operate in an area where communications cannot be maintained. 1.17.2 Federal Aviation Administration The principal operations inspector (POI), assistant POI, principal maintenance inspector, and principal avionics inspector at the FAA’s Anchorage office provided oversight for Era Aviation. Flight checks for check airmen at Era Aviation’s Gulf Coast headquarters were conducted by the assistant POI or by designated examiners from the FAA’s Baton Rouge, Louisiana, office. Era Aviation’s director of operations stated that the flight checks were performed on shore and near LCH. 1.18 Additional Information 1.18.1 Flight Simulations Safety Board staff members evaluated the flight characteristics of the accident helicopter using a full-motion, FAA-certified flight check S-76A simulator at FlightSafety. The simulator’s cockpit configuration replicated, as much as possible, that of the accident helicopter (as determined by preaccident photographs of the helicopter’s front instrument panel).70 The simulator’s mechanical radar altimeter indicator was not used because the accident helicopter was not equipped with a mechanical radar altimeter indicator. Also, the simulator’s landing gear warning system triggered only when airspeed decreased below 60 knots with the gear up.71 The Safety Board examined numerous possible scenarios that could lead to an inadvertent descent to understand the systems and annunciations that were available to the 70 Although the simulator’s cockpit configuration did not exactly replicate that of the accident helicopter, the simulator’s flying characteristics closely resembled those of the accident helicopter. 71 As stated in section 1.17.1.2, Era Aviation S-76A pilots received recurrent training using this S-76A simulator. Even though this simulator had a landing gear warning system that triggered only when the helicopter’s airspeed was 60 knots or below with the gear retracted, the predominant method of flight training was actual flights aboard company helicopters, during which the pilots would have been trained on helicopters with both landing gear warning system configurations.

Factual Information 27 Aircraft Accident Report flight crew. As shown in figure 5, the following indications of descent were seen on the pilots’ ADIs during the scenarios: • The radar altitude appeared in blue at the bottom right of the ADIs followed by an “RA” indication in white. • The decision height was displayed in blue at the bottom left of the ADIs followed by a DH indication in white. A white square box appeared above the radar altitude (at the bottom right of the ADIs) when the helicopter was 100 feet above the decision height (based on the radar altimeter). When the decision height was reached, an amber DH indication appeared inside the box and remained there as the helicopter continued to descend. • A yellow rising runway symbol appeared at the bottom center of the ADIs at 180 feet (based on the radar altimeter). As the helicopter’s altitude decreased, this symbol ascended until it met the aircraft symbol at 0 feet. Other indications of descent seen on the pilots’ instrumentation during the scenarios were the following: • The barometric altimeters showed decreasing altitude by the counterclockwise rotation of the needle.72 • The vertical speed indicators (VSI) showed a rate of descent of 250 to 300 fpm, which placed the needle below the centerline position.73 Figure 5. Indications of Descent on the Attitude Direction Indicator 72 The barometric altimeters are located directly to the right of the ADIs (see figure 1). 73 The VSIs are located directly below the barometric altimeters and directly to the right of the HSIs (see figure 1). The VSI tick marks between 0 and 1,000 feet represent increments of 100 fpm, and the tick marks between 1,000 and 3,000 feet represent increments of 500 fpm.

Factual Information 28 Aircraft Accident Report In addition, for one scenario, an altitude of 900 feet was selected on the air data command display (the AL-300).74 At an altitude of 600 feet (300 feet below the preselected altitude), an amber altitude alert light at the top left of the barometric altimeters illuminated,75 and a 1-second aural tone sounded over the pilots’ headsets. The light remained illuminated for the rest of this simulation.76 Figure 6 shows the amber altitude alert light on one of the simulator’s barometric altimeters. Of the numerous possible scenarios that could lead to an inadvertent descent, the Safety Board focused on the four scenarios that were deemed to be the most likely to have occurred during the accident flight if the flight crew had engaged the DDAFCS. For detailed information about each of the four scenarios, see appendix C. 74 The altitude preselect value is entered by turning the “set” knob until the AL-300 shows the desired value. The selected altitude is shown on the display until the altitude is captured. The AL-300 also displays commanded vertical speed, airspeed, and radar altitude depending on the mode (VS, IAS, or ALT) selected on the flight director mode selector. The parameters are displayed during the time that each is being adjusted by the pilot and for 7 seconds after the adjustment. 75 When the helicopter is descending, the altitude alert light illuminates at 1,000 feet above the preselected altitude. The light does not illuminate from about 300 feet above the preselected altitude to about 300 feet below the preselected altitude. Afterward, the light illuminates again until the helicopter descends beyond 1,000 feet below the preselected altitude, at which point the light is no longer illuminated. 76 The accident helicopter was equipped with two barometric altimeters, but only the captain’s barometric altimeter had an altitude alert light at the top left of the instrument. Figure 6. Altitude Alert Light

Factual Information 29 Aircraft Accident Report 1.18.2 Gulf of Mexico Helicopter Operations According to the latest statistics from the Helicopter Safety Advisory Conference (HSAC),77 561 oil industry helicopters (single engine, light twin, medium twin, and heavy twin) operated in the Gulf of Mexico during 2004, transporting more than 2.3 million passengers aboard 1.3 million flights. Table 2 shows the 2004 Gulf of Mexico oil industry helicopter accident rate and fatal accident rate per 100,000 flight hours compared with the same information for all U.S. air carrier operations under on-demand Part 135 (charter and air taxi).78 (Even though the FAA’s General Aviation and Air Taxi Survey79 distinguishes between fixed-wing airplane and rotorcraft flight hours, the survey estimates of flight hours for rotorcraft do not reliably compare to HSAC’s flight hour estimates for offshore helicopter operations. Thus, only the overall rates for on-demand Part 135 accidents are reported.) Table 3 shows this information for the 5-year period between 2000 and 2004. Appendix D provides a list of Gulf of Mexico helicopter accidents from March 2000 to February 2006. Table 2. 2004 Accident Rates for Gulf of Mexico Helicopter Operations and On-Demand Part 135 Air Carrier Operations a The Gulf of Mexico estimate of flight hours was obtained from the HSAC’s Gulf of Mexico Offshore Helicopter Operations and Safety Review. b Accident rate calculations for on-demand Part 135 operations (fixed-wing airplanes and rotorcraft) were estimated using data from the FAA’s General Aviation and Air Taxi Survey. 77 According to its Web site, the HSAC was formed in January 1978 to promote improved communication and safe practices within the Gulf of Mexico offshore community. The HSAC consists of representatives from major petroleum companies; drilling companies; helicopter operators; oil industry service companies; helicopter manufacturers; and U.S. Federal agencies, including the FAA, the Army, the Air Force, the Navy, the Coast Guard, the Department of the Interior, and the Customs Service. Since 1998, HSAC has annually surveyed 22 helicopter operators that provide on-demand Part 135 helicopter services in the Gulf of Mexico. The survey compiles operational and flight activity data, including fleet size and characteristics; number of passengers, flights, and flight hours; and accident statistics. These data are published annually in HSAC’s Gulf of Mexico Offshore Helicopter Operations and Safety Review. 78 On-demand Part 135 air carrier operations include rotorcraft and fixed-wing airplanes. 79 Data for the General Aviation and Air Taxi Survey are compiled annually by the FAA based on voluntary data from Part 135 operators. Operation Number of flight hours Accident rate per 100,000 flight hours Fatal accident rate per 100,000 flight hours Gulf of Mexico helicopters 362,000a 2.77 1.11 On-demand Part 135 aircraftb 3,238,000 2.10 0.74

Factual Information 30 Aircraft Accident Report Table 3. Accident Rates for Gulf of Mexico Helicopter Operations and On-Demand Part 135 Aircraft Operations for 2000 Through 2004 a The Gulf of Mexico accident rates were calculated using estimates of flight hours from the HSAC’s Gulf of Mexico Offshore Helicopter Operations and Safety Review. b Accident rate calculations for on-demand Part 135 operations (fixed-wing airplanes and rotorcraft) were estimated using data from the FAA’s General Aviation and Air Taxi Survey. Safety Board staff members visited two Gulf of Mexico helicopter operators—PHI of Lafayette, Louisiana, and Air Logistics of New Iberia, Louisiana—to compare and contrast their operations with Era Aviation’s operations. Although each company’s fleet consists of similar helicopter models, PHI and Air Logistics operate a larger fleet of helicopters than Era Aviation (more than 220 at PHI and more than 170 at Air Logistics compared with about 100 helicopters at Era Aviation). Also, PHI and Air Logistics operate both domestically and internationally, whereas Era Aviation operates domestically in Alaska, the West Coast, and the Gulf Coast. All three operators’ helicopters fly at low altitudes while en route. All three operators have dispatchers at their Gulf Coast headquarters (Era Aviation has 3 dispatchers, PHI has between 8 and 12 dispatchers, and Air Logistics has 2 dispatchers), but only Air Logistics has additional dispatchers at all of the locations where the company’s helicopters are operating (one dispatcher per location). All three operators currently use flight-tracking software and hardware purchased from commercial vendors.80 The software displays chevrons to indicate aircraft in flight and their direction along with weather overlays, and the hardware allows company pilots and dispatchers to relay text messages to each other. As with Era Aviation pilots, Air Logistics pilots call a company dispatcher to provide a position report every 15 minutes and to close out the flight plan; PHI pilots do not call a company dispatcher with position reports unless the Year Gulf of Mexico helicoptersa On-demand Part 135 aircraftb Accident rate per 100,000 flight hours Fatal accident rate per 100,000 flight hours Accident rate per 100,000 flight hours Fatal accident rate per 100,000 flight hours 2000 2.04 0.68 2.04 0.56 2001 1.77 0.22 2.40 0.60 2002 1.49 0.25 2.06 0.62 2003 3.93 1.84 2.56 0.61 2004 2.77 1.11 2.10 0.74 Average 2.40 0.82 2.22 0.62 80 At the time of the accident, Era Aviation did not have this flight-tracking capability. As stated in section 1.1, dispatchers at Era Aviation’s Gulf Coast headquarters entered information about company flights in a computerized log after each radio transmission. This information was displayed on a screen showing each helicopter’s tail number in black, the departure location in yellow, the destination location in red, and the helicopter’s flight plan between the two locations.

Factual Information 31 Aircraft Accident Report customer requests so, but the pilots do call the dispatcher to close out the flight plan. All three operators stated that they did not receive weather information or flight-tracking services from the FAA. All three companies conduct training at their headquarters and at FlightSafety. Era Aviation does not have simulators on site, but PHI and Air Logistics have two fixed-base simulators on site that have similar instrumentation and performance capabilities as most of the aircraft in their fleets. All three companies conduct daily maintenance at their bases of operation and heavy maintenance at their headquarters. 1.18.3 Automatic Dependent Surveillance–Broadcast Technology In 1998, the FAA developed an initiative under the Safe Flight 21 program for the Gulf of Mexico. The Safe Flight 21 program focused on providing pilots with radar-like information (navigation, air traffic, terrain, and weather) in the cockpit and enabling air traffic controllers and operators to provide surveillance of low-flying aircraft in those areas with limited or no radar coverage. The Safe Flight 21 Gulf of Mexico initiative included plans to provide a ground- and satellite-based infrastructure called automatic dependent surveillance–broadcast (ADS-B), which relies on position information that is transmitted by individual aircraft based on global positioning system (GPS) technology. Each ADS-B-equipped aircraft has the capability to broadcast its position using a digital data link that provides information on the aircraft’s airspeed and altitude and an indication of whether the aircraft is turning, climbing, or descending. This information can be directly transmitted from one aircraft to another, or the information can be transmitted to an ADS-B ground station,81 combined with other aircraft data, and transmitted back to any aircraft within range of an ADS-B ground station. The information can also be transmitted by landlines or other means to air traffic controllers in distant locations. In addition, ADS-B can be used as the enabling technology that will allow weather, traffic, conflict alert, and other information available to personnel on the ground to be provided to pilots. The Safe Flight 21 Gulf of Mexico initiative also included a network of ADS-B ground stations that were tested on offshore platforms. These ground stations transmitted and received high accuracy, radar-like flight-tracking information for ADS-B-equipped aircraft. In addition, data received by these ground stations were transmitted and processed at the Houston Air Route Traffic Control Center and the Lafayette Terminal Radar Approach Control so that controllers at these locations had real-time positional data on test ADS-B-equipped aircraft operating in the Gulf of Mexico. This test was conducted by the National Aeronautics and Space Administration between 2001 and 2004 with the use of 81 A ground station is a site equipped with a device that transmits and receives signals.

Factual Information 32 Aircraft Accident Report several ADS-B-equipped aircraft,82 and the test data were provided to the FAA. The ADS-B infrastructure in the Gulf of Mexico was removed in 2005 because of the lack of funding. Another initiative under the Safe Flight 21 program was the Capstone program in Alaska, which was developed to improve aviation safety in areas of Alaska with a high accident rate. The FAA planned to implement the Capstone program in three phases (based on geographic area). According to the FAA, at the beginning of March 2006, 341 aircraft in Alaska had been equipped with ADS-B technology during the first two phases of the program. The FAA also indicated that the final Capstone phase was currently under development with funding for site surveys but not construction. Information from the FAA’s November 2005 Flight Technologies and Procedures New Technologies Workshop showed that the FAA did not plan to implement the Safe Flight 21 Gulf of Mexico initiative until fiscal year 2013. In January 2006, the FAA announced that the Safe Flight 21 program was being transitioned to the National ADS-B Program. Although the content of both programs was basically the same, the implementation dates for the National ADS-B Program were moved forward. Specifically, the FAA proposed fiscal year 2007 to begin implementation of the program and fiscal year 2010 to complete the first segment of ADS-B infrastructure deployment. On March 1, 2006, the FAA informed the Safety Board verbally that the Gulf of Mexico would be among those areas in the first segment of ADS-B deployment. The FAA also informed the Board that it planned to seek budget approval for the National ADS-B Program in June 2006. 1.18.4 Controlled Flight Into Terrain CFIT occurs when a controlled, serviceable aircraft is flown into terrain, obstacles, or water with no prior awareness by the flight crew of the impending collision.83 Between 1987 and 2004, 56 (25 percent) of the 226 worldwide fatal accidents involving large commercial jet aircraft were classified as CFIT, resulting in 3,631 fatalities.84 Most CFIT accidents occurred with poor visibility conditions and during the approach and landing phases of flight.85 Although the number of CFIT accidents has markedly declined in recent years for U.S. transport-category airplanes,86 CFIT remains a major aviation problem in foreign countries and for general aviation aircraft and helicopters. A Flight Safety Foundation study indicated that about 75 percent of all CFIT accidents in commercial aircraft occurred in those that were not equipped with a 82 These aircraft were an FAA Boeing 727, an FAA Convair, a Piper Aztec from the Department of Transportation’s Volpe National Transportation Systems Center, and a PHI helicopter. 83 E.L. Weiner, “Controlled Flight Into Terrain: System Induced Accidents,” Human Factors Journal Vol. 19 (1977). 84 Boeing Commercial Airplane Group, “Statistical Summary of Commercial Jet Aircraft Accidents, Worldwide Operations 1959-2004,” (Seattle, WA: May 2005). 85 R. Khatwa and R. Helmreich, “Analysis of Critical Factors During Approach and Landing in Accidents and Normal Flights,” Flight Safety Digest (November 1998–February 1999): Flight Safety Foundation. 86 The Safety Board issued numerous safety recommendations to prevent CFIT.

Factual Information 33 Aircraft Accident Report traditional ground proximity warning system (GPWS).87 A traditional GPWS uses the radar altimeter to calculate closure rate with terrain to predict a potential collision threat. Although a traditional GPWS can help prevent CFIT, a traditional GPWS cannot provide a timely warning to the flight crew if the terrain rises steeply. As a result, on October 16, 1996, the Safety Board issued Safety Recommendation A-96-101,88 which asked the FAA to do the following: Examine the effectiveness of the enhanced ground proximity warning equipment and, if found effective, require all transport-category aircraft to be equipped with enhanced ground proximity warning equipment that provides pilots with an early warning of terrain. Enhanced GPWS is also referred to as a terrain awareness and warning system (TAWS). These systems have the ability to look ahead of an aircraft to determine the terrain or other obstruction along the flightpath, thereby providing pilots with more time to determine the necessary corrective actions than with a traditional GPWS. When used for helicopter operations, TAWS can include a forward-looking terrain awareness display, which provides aural alerts and visual indications of terrain and obstacles. The aural alerts are “caution terrain,” “warning terrain,” “caution obstacle,” and “warning obstacle.” The visual indications of terrain and obstacles can be displayed on one or two screens on the front instrument panel or can be incorporated into EFIS displays. In addition, TAWS for helicopters can include aural alert modes 1 through 6, which are excessive descent rate, excessive terrain closure rate, descent after takeoff, terrain clearance, deviation below glideslope, and autorotation and altitude,89 respectively. The accident helicopter was not equipped with a TAWS and was not required by Federal regulations to so be equipped.90 Specifically, a March 23, 2000, final rule issued by the FAA required all U.S.-registered turbine-powered airplanes configured with six or more passenger seats to be equipped with a TAWS by March 29, 2002 (new-production airplanes), and March 29, 2005 (existing airplanes). As a result of the FAA’s action, Safety Recommendation A-96-101 was classified “Closed—Acceptable Action” on February 15, 2001. 87 R. Khatwa and A.L.C. Roelen, “An Analysis of Controlled-Flight-Into-Terrain (CFIT) Accidents of Commercial Operators, 1988 Through 1994,” Flight Safety Digest (April–May 1996): Flight Safety Foundation. 88 This recommendation was issued in response to the December 20, 1995, accident involving American Airlines flight 965, which struck trees and crashed into a side of a mountain near Cali, Colombia, during night VMC. The airplane was equipped with a traditional GPWS. About 12 seconds before impact, the GPWS began issuing the aural warnings “terrain” and “pull up,” but these warnings were not provided in time for the flight crew to avoid crashing into the mountainous terrain. 89 If a decision height is set, the mode 6 “altitude altitude” aural alert would occur at that height unless a higher priority alert, such as “caution terrain” or “warning terrain” takes precedent. 90 In May 2004, Sikorsky announced that it would voluntarily equip its new S-76 helicopters with TAWS. Sikorsky subsequently announced that it would offer a TAWS/CVR/FDR retrofit program for all S-76 helicopters built before 2005.

Factual Information 34 Aircraft Accident Report As part of this investigation, the Safety Board requested that Honeywell (the manufacturer of TAWS for helicopters) perform simulations of a 150- and 250-fpm descent into water to determine what alerts could have been expected if a TAWS had been installed aboard the accident helicopter.91 For a descent rate of 150 fpm, the simulation showed that the “caution terrain” alert would have occurred 97 seconds before impact, along with a water indication that changed from blue to yellow on the forward-looking terrain awareness display.92 The simulation also showed that the “warning terrain” alert would have occurred 84 seconds before impact, along with a water indication that changed from yellow to red on the forward-looking terrain awareness display. For a descent rate of 250 fpm, the simulation showed that the caution terrain alert would have occurred 68 seconds before impact and that the warning terrain alert would have occurred 55 seconds before impact (along with the water indication color changes on the forward-looking terrain awareness display). In January 2006, the Safety Board adopted a special investigation report on emergency medical services (EMS) aircraft accidents.93 According to the report, 55 EMS accidents occurred between January 2002 and January 2005; these accidents involved 41 helicopters and 14 airplanes and resulted in 55 fatalities and 18 serious injuries. The Board found that TAWS might have helped pilots avoid terrain in 17 of the 55 accidents. (Thirteen of these 17 accidents involved helicopters.) As a result, the Board issued Safety Recommendation A-06-15, which asked the FAA to do the following: Require emergency medical services (EMS) operators to install terrain awareness and warning systems on their aircraft and to provide adequate training to ensure that flight crews are capable of using the system to safely conduct EMS operations. 1.18.5 Comparison of SPZ-7000 and SPZ-7600 Dual Digital Automatic Flight Control Systems The SPZ-7000 DDAFCS, which was installed on the accident helicopter, is no longer in production. Its successor is the SPZ-7600 DDAFCS, which was originally designed for the S-76C.94 Although the SPZ-7000 and the SPZ-7600 are similar, there are differences between the systems, including the display presentation of command cues for an unselected axis and the indications for system coupling and decoupling. 91 Radar data showed that the helicopter’s descent rate at an altitude of 1,100 feet was 250 fpm. The Safety Board estimated that the helicopter impacted the water at a descent rate of 150 fpm. 92 The color change would have occurred because the TAWS would have detected that the closure rate to the water was a concern. 93 National Transportation Safety Board, Special Investigation Report on Emergency Medical Services Operations, Aviation Special Investigation Report NTSB/SIR-06/01 (Washington, DC: NTSB, 2006). 94 The FAA issued a supplemental type certificate to allow the S-76A to be retrofitted with the SPZ-7600.

Factual Information 35 Aircraft Accident Report Both the SPZ-7000 and the SPZ-7600 have the capability to display pitch and roll command cues in either a dual- or a single-cue format. With the dual-cue format, pitch attitude is represented by a horizontal line, and roll attitude is represented by a vertical line, as shown in figure 7. With the single-cue format, angular bars integrate pitch and roll guidance, as shown in figure 8. When both pitch and roll commands are selected in either mode, the guidance provided by the command cues is intuitive and well understood by pilots who have been trained on either flight control system. Figure 7. SPZ-7000 Dual-Cue Format Figure 8. SPZ-7000 Single-Cue Format

Factual Information 36 Aircraft Accident Report Also, both the SPZ-7000 and the SPZ-7600 have the capability for the pilot to select a command cue for only one axis, either pitch or roll, at a time. The displayed cue for the selected axis is functionally the same as when command cues for both axes are selected. However, depending on the system and the command cue format, the command cue for the unselected axis may or may not be displayed. In addition, no annunciation appears on the ADIs regarding the source of guidance for the unselected command cue presented in the SPZ-7000 dual- and single-cue formats and the SPZ-7600 single-cue format. Table 4 summarizes the command cues presented on the SPZ-7000 and SPZ-7600 DDAFCS and highlights the differences in attitude synchronization between the two systems. These differences, which are not intuitive, are analyzed in section 2.3.2. Table 4. Command Cues Presented on the SPZ-7000 and SPZ-7600 DDAFCS With Single-Axis Command Selections In addition, the indications for coupling and decoupling are distinctly different between the SPZ-7000 and SPZ-7600 DDAFCS. As stated in section 1.6.3, the SPZ-7000 does not annunciate the coupling status on the front instrument panel, and the SPZ-7000 DCPL warning indicator on the DAFCS caution panels illuminates only during abnormal operations. For the SPZ-7600, the DCPL warning indicator on each DAFCS caution panel illuminates during normal and abnormal operations whenever the autopilot and flight director become decoupled for an activated mode. Once the DCPL warning indicators are annunciated, annunciations can be cleared by either coupling the autopilot and flight director or resetting the couple logic by disengaging and reengaging one or both of the autopilots. Finally, the SPZ-7600, as delivered from the manufacturer (Honeywell), is not equipped with an aural alert to indicate system decoupling under normal operations. Operators that use the SPZ-7600 can install an after-market product to provide this aural Display format Axis selected SPZ-7000 unselected axis SPZ-7600 unselected axis Dual cue Pitch only Roll indication is synchronized to the trimmed roll attitude. Roll indication is not shown. Roll only Pitch indication is synchronized to the trimmed pitch attitude. Pitch indication is not shown. Single cue Pitch only Roll indication is synchronized to the trimmed roll attitude. Roll indication is centered. Roll only Pitch indication is synchronized to the trimmed pitch attitude. Pitch indication is centered at the horizon.

Factual Information 37 Aircraft Accident Report alert as either a chime or a verbal annunciation (“decouple”).95 One manufacturer (Sikorsky) installs this aural alert (manufactured by Keystone Helicopters) on all of its helicopters that are equipped with the SPZ-7600. 1.18.5.1 Federal Aviation Administration SPZ-7000 Evaluation As a result of the Safety Board’s investigation of this accident, and to ensure the safety of the S-76 fleet, the FAA evaluated the SPZ-7000 DDAFCS to determine whether “hazardously misleading” flight director data were being presented on EFIS displays. The evaluation was conducted during February 2005 in an S-76A simulator and helicopter that were similarly configured to the accident helicopter. The FAA provided notes about its evaluation to the Board. The notes indicated the following observations: There is no aural or visual annunciation of a pilot-induced decouple. The only cues that the flight director is not coupled on the selected side are the lack of FD mode selections and the disappearance of FD mode annunciations on the corresponding EADI [electronic ADI]. With cross-needle FD cues selected on the EADI, single-axis FD modes (HDG only, ALT only, etc.) caused both pitch and roll cue needles to be displayed. With only HDG mode selected, the pitch cue bar apparently provides guidance only to retain the aircraft’s existing pitch attitude when HDG mode was selected. It did not provide guidance to maintain a selected altitude. A vertical mode (ALT, VS, ILS) must be selected for the pitch bar to provide vertical navigation steering commands. This is apparently different from other S-76 DAFCS systems such as the SPZ-7600, and from some Part 23 or Part 25 fixed-wing flight director systems. In general, the indications of either a pilot-induced or self-induced FD decouple were not particularly compelling. In its notes, the FAA recommended that the certification basis for the SPZ-7000 DDAFCS be reviewed to ensure that, at the time of certification, the system met all requirements for coupled flight director disconnect annunciations. Also, the FAA recommended that the presentation of single-cue flight director commands by the SPZ-7000 be further examined in the context of certification requirements and continued operational safety. In November 2005 correspondence, the FAA stated that it reviewed the certification basis of the SPZ-7000 DDAFCS and determined that, at the time of certification, the system did meet the requirements of 14 CFR 29.1335 and 14 CFR 29.1329. Also, the FAA stated that it found no evidence to indicate that the SPZ-7000’s disconnect annunciations were inadequate or that the SPZ-7000 was a factor in previous S-76 accidents. 95 This alert can be configured (according to customer preference) to provide an aural annunciation in pilots’ headsets, the cabin, or both.

Factual Information 38 Aircraft Accident Report 1.18.6 Previous Flight Recorder Safety Recommendations 1.18.6.1 Safety Recommendation A-02-25 On August 29, 2002, the Safety Board issued Safety Recommendation A-02-25 as a result of its long-standing concerns about the availability of CVR information after reportable accidents or incidents. Safety Recommendation A-02-25 asked the FAA to do the following: Require that all operators of airplanes equipped with a cockpit voice recorder (CVR) test the functionality of the CVR system prior to the first flight of each day, as part of an approved aircraft checklist. This test must be conducted according to procedures provided by the CVR manufacturer and shall include, at a minimum, listening to the recorded signals on each channel to verify that the audio is being recorded properly, is intelligible, and is free from electrical noise or other interference. On December 12, 2002, the FAA responded that current regulations (14 CFR 23.1457 and 25.1457) require CVR equipment to have “an aural or visual means for preflight checking of the recorder for proper operation.” The FAA also stated that it would survey current maintenance practices of air carrier and general aviation aircraft to determine if corrections to the operators’ maintenance programs were necessary to ensure expected recorder reliability. On January 16, 2003, the Safety Board replied, stating its concern that the FAA’s maintenance survey would address only one part of the CVR reliability problem. The Board’s safety recommendation letter stressed that it was the flight crew’s responsibility to check the CVR for proper operation each day before the first flight; consequently, the Board encouraged the FAA to include maintenance procedures and crew checklist operational procedures in its survey. On March 5, 2004, the Safety Board reiterated Safety Recommendation A-02-25 as a result of its investigation of the January 8, 2003, Beech 1900D accident (Air Midwest flight 5481) in Charlotte, North Carolina.96 The Board’s investigation found that the captain’s and the copilot’s audio panel information was fair to poor quality with respect to the audio captured from the accident airplane’s VHF radio systems. As a result, important CVR information from the accident flight might not have been available if the audio information from the captain’s and the copilot’s hot microphones had not been excellent to good quality. On June 7, 2005, the FAA responded that, even though CVRs on all equipped airplanes were tested daily, the level of testing that the Safety Board was seeking could not be universally accomplished because of implementation or design limitations imposed by the regulations that govern CVR requirements. The FAA also stated that it issued Notice N8000.292, “Clarification of Recommendations for Cockpit Voice Testing” 96 For more information, see National Transportation Safety Board, Loss of Pitch Control During Takeoff, Air Midwest Flight 5481, Raytheon (Beechcraft) 1900D, N233YV, Charlotte North Carolina, January 8, 2003, Aircraft Accident Report NTSB/AAR-04/01 (Washington, DC: NTSB, 2004).

Factual Information 39 Aircraft Accident Report (January 18, 2005), for operators of those airplanes equipped with CVRs that can be tested before the first flight of the day. The FAA indicated that the intent of the notice was to persuade the operators to configure the CVRs during future major maintenance cycles so that flight crews would be able to test them. Further, the FAA stated that it made a change to FAA Order 8300.10, Airworthiness Inspector’s Handbook, Chapter 143, “Monitor Cockpit Voice Recorders” (March 4, 2004). According to the FAA, the change tasked airworthiness aviation safety inspectors to evaluate maintenance programs that require maintenance technicians to perform a thorough test of the CVR at appropriate intervals. The FAA explained that the test should include listening to the recorder signals on each channel to verify that the audio is properly recording, is intelligible, and does not contain electrical noise or other interference. On January 4, 2006, the Safety Board stated that, even though Notice N8000.292 asked for the recommended action, a notice was not a requirement, and it would expire after 1 year. The Board added that the need for a functional check of the CVR before the first flight of each day would remain after Notice N8000.292 was canceled. Also, the Board stated that the change to FAA Order 8300.10 would not ensure that a CVR functional test would be performed before the first flight of each day and that there must be a permanent change to the FAA’s operational requirements to ensure this CVR functional test; such a change could be achieved by a revision to FAA Order 8400.10, Air Transportation Operations Inspector’s Handbook. Pending this permanent change, Safety Recommendation A-02-25 was classified “Open—Acceptable Response.” 1.18.6.2 Safety Recommendations A-06-17 and A-06-18 On March 7, 2006, the Safety Board issued Safety Recommendations A-06-17 and A-06-18, which asked the FAA to do the following: Require all rotorcraft operating under 14 Code of Federal Regulations Parts 91 and 135 with a transport-category certification to be equipped with a cockpit voice recorder (CVR) and a flight data recorder (FDR). For those transport-category rotorcraft manufactured before October 11, 1991, require a CVR and an FDR or an onboard cockpit image recorder with the capability of recording cockpit audio, crew communications, and aircraft parametric data. (A-06-17) Do not permit exemptions or exceptions to the flight recorder regulations that allow transport-category rotorcraft to operate without flight recorders, and withdraw the current exemptions and exceptions that allow transport-category rotorcraft to operate without flight recorders. (A-06-18)

40 Aircraft Accident Report 2. Analysis 2.1 General The captain and the copilot were properly certificated and qualified under Federal regulations. No evidence indicated any medical or behavioral conditions that might have adversely affected their performance during the accident flight. Flight crew fatigue was not a factor in this accident. The accident helicopter was properly certified, equipped, and maintained in accordance with Federal regulations. The recovered components, with the exception of the CVR,97 showed no evidence of any structural, engine, or system failures. The engines were found attached to the helicopter with no evidence of fire, uncontainment, structural damage, or foreign object damage. The torsion fractures to the drive shafts and the water impact damage to the helicopter fuselage indicated that both engines were producing power at the time of impact. During the helicopter’s impact with the water, the engines became decoupled from the transmission. As a result, the right engine sensed an overspeed condition, shut down, and removed the overspeed protection from the left engine, which, in turn, caused the left engine to overspeed. All four main rotor blades were found fractured but with their root ends still attached to the main rotor hub. All of the main rotor blade tips were recovered in the main debris field. Two of the tail rotor blades were fractured just outside of the tail rotor cuff, and a third tail rotor blade had fractured near the root but was still attached to the spar. The fourth tail rotor blade had an outboard portion that was not recovered. None of the tail rotor tips were recovered. However, because of the paddle design of the tail rotor blades, if a tail rotor blade tip had separated in flight, a whole paddle (two tail rotor blades) would be missing, which did not occur in this accident. Weather was not a factor in this accident. The dispatcher who handled the accident flight provided appropriate flight-tracking services. The search and rescue effort for this accident was timely. The accident was not survivable for the helicopter occupants because they were subjected to impact forces that exceeded the limits of human tolerance. This analysis discusses the accident sequence, cockpit systems, tracking of Gulf of Mexico helicopter flights, the lack of adequate CVR information for this accident investigation, and the lack of FDR data for helicopter operations. 97 This issue is discussed in section 2.5.

Analysis 41 Aircraft Accident Report 2.2 Accident Sequence 2.2.1 Accident Summary The Era Aviation dispatcher’s records showed that the accident helicopter departed GLS about 1845 with 2 hours of fuel on board. The helicopter’s initial destination was High Island A-557, a refueling platform about 80 nm south-southeast of GLS, and its final destination was the Discoverer Spirit, a drilling ship that was en route to a location about 180 miles south-southeast of GLS. It is reasonable to assume that the captain was the flying pilot because, according to the CVR recording, the copilot was making the radio calls to the dispatcher (which is the duty of the nonflying pilot) through the time of the destination change. (The CVR did not record any pilot transmissions after that time.) ASR-9 radar data showed that the helicopter began to descend from an altitude of 1,800 feet at 1858:10 at a rate of 300 fpm. The last radar return that was received while the helicopter was still within the range of radar coverage was at 1900:21; this return showed that the helicopter was at an altitude of 1,100 feet msl and that its rate of descent was 250 fpm. At the time, the helicopter was located 35 nm south-southeast of GLS. If the helicopter had continued its 250-fpm descent from 1,100 feet msl, it would have crashed into the water within 5 minutes. However, the helicopter flew for another 18 minutes. During its 1914 position report, the flight crew told the dispatcher that the helicopter had enough fuel on board (1.6 hours) to continue directly to the location of the Discoverer Spirit. The CVR study for this accident found that, at 1918:15, an increase of torque was applied to the main rotor transmission and that the background noise level on the CVR recording decreased from about 1918:25 to the end of the recording at 1918:34 (the time of the accident). Although an increase in torque can be the result of a pilot input to the flight control system (increased collective or movement of the cyclic) and the decrease in background noise level can be directly related to a decrease in forward airspeed, the available evidence prevented further evaluation of the CVR study’s findings. Evening civil twilight (sometime after which complete darkness occurs) ended about 22 minutes before the accident. Also, the moon illumination (only 8 percent of the moon disk) and the starlight were affected by a scattered to broken layer of low stratiform clouds over the Gulf of Mexico south of GLS. The Safety Board concludes that, even though VMC prevailed at the time of the accident, few, if any, references outside of the helicopter would have been available to the flight crew. The severe accordion-type crushing found on the helicopter fuselage was consistent with a water impact at a high airspeed. The upward compression fractures found on the lower fuselage were consistent with a level (or very shallow) bank attitude at impact. The lack of damage to the lower part of the tailboom was consistent with a shallow descent angle and pitch attitude at impact. The damage to the cyclic, collective, and tail rotor pedal control systems was consistent with static overload fractures as a result of water impact. As a result, the Safety Board concludes that the helicopter crashed into

Analysis 42 Aircraft Accident Report the water at a high airspeed, a shallow descent angle, and a near-level roll attitude. Also, because the main landing gear floats were found folded, which was consistent with the floats not being inflated and being in the stowed position inside the wheel wells at impact, and no emergency or distress calls were received by the dispatcher from the flight crew, the Safety Board concludes that the pilots were not attempting an emergency landing on the water. In addition, because of the inward crushing that was found on the lower part of the structure that attached the fuselage and tailboom and the tearing that was found on the upper part of the attachment structure, the Safety Board concludes that, after the helicopter crashed into the water, the fuselage pitched nose down, and the tailboom broke off in a downward direction. Because no evidence showed any problems with the helicopter’s engines, systems, or structures during the accident flight, the Safety Board’s investigation focused on the pilots’ actions during the 4 minutes between their last radio call to the dispatcher and the time of the accident. The Board did not have FDR, CVR, or air traffic control information98 to help determine what transpired during that portion of the flight. However, with the use of an S-76A simulator that was similarly configured to the accident helicopter, the Board examined numerous possible scenarios in which the flight crew’s actions could have inadvertently led to a controlled descent into water. The Board then focused on the four scenarios that were the most likely to have occurred (see appendix C). The scenario results, along with preaccident photographs of the accident helicopter’s front instrument panel and manufacturer and company manuals, showed the indications of descent that would have been available to the flight crew. These indications are discussed and analyzed in section 2.2.2. 2.2.2 Indications of Descent and Proximity to the Water Cockpit instrumentation at both pilot stations would have shown indications of the helicopter’s descent and proximity to the water. These indications, which are shown in figure 9 and described in this section, were located in front of the pilots and within their routine instrument scan. Three indications would have been available on a continuous basis throughout the flight and did not require previous pilot action. First, the VSI needles (numbers 4 and 6 in figure 9) would have been consistently below the centerline position, indicating a descent. Second, the barometric altimeter needles (numbers 3 and 8 in figure 9) would have been indicating a decreasing altitude. Third, the radar altitude readout on the ADIs (numbers 2 and 7 in figure 9) would have shown numbers that decreased in 10-foot increments through 200 feet and 5-foot increments afterward. 98 As stated previously, the accident helicopter was not equipped with an FDR. Also, although the helicopter was equipped with a CVR, three channels (including the pilot and copilot stations) contained no usable information, and the fourth channel (the CAM) contained information that was mostly obscured by a high level of background noise. In addition, no radar data were available after the helicopter descended below 1,100 feet msl.

Analysis 43 Aircraft Accident Report Another indication, a rising runway symbol on the ADIs (numbers 2 and 7 in figure 9), did not require previous pilot action but would not have appeared until 180 feet above ground level (agl). The rising runway symbol would have continued upward until it met the aircraft symbol on the ADIs at 0 feet. In addition to the indications of the helicopter’s descent and proximity to the water that would have been present regardless of pilot action, several indications could have been present depending on the actions taken by the pilots during the accident flight. For example, if the flight crew had set a decision height above 0 feet (a decision height of Figure 9. Indications of Descent in the Accident Helicopter’s Cockpit Source: Era Aviation.

1. Landing gear warning light
2. Captain’s ADI, showing radar altitude readout, rising runway symbol, decision height box,

decision height indication, and command cues

1. Captain’s barometric altimeter and altitude alert light
2. Captain’s VSI
3. Landing gear warning light
4. Copilot’s VSI
5. Copilot’s ADI, showing radar altitude readout, rising runway symbol, decision height box,

decision height indication, and command cues

1. Copilot’s barometric altimeter

5 2 3 4 6 7 8 1

Analysis 44 Aircraft Accident Report 200 feet was required by Era Aviation for nighttime flights), two additional indications of the helicopter’s descent and proximity to water would have been available. First, a decision height box would have appeared on the ADIs (numbers 2 and 7 in figure 9) at 100 feet above the set decision height. Second, the letters DH would have appeared inside the decision height box as the helicopter descended through the decision height. If the decision height was set to 0 feet, a decision height box would have appeared on the ADIs at 100 feet agl, and the letters DH would have appeared inside the decision height box about the time that the helicopter was contacting the water. If the pilots had set different decision heights, then the decision height box and the letters DH would have appeared when the helicopter descended through the higher of the two decision heights. 99 Also, if either pilot had set a decision height above 0 feet, both pilots would have seen conspicuous (very bright) landing gear warning lights under the glareshield panel100 (numbers 1 and 5 in figure 9) and would have heard a tone over their headsets when the helicopter descended below the decision height.101 The aural tone was not detected on the CVR recording. However, as stated previously, audio information from the pilot and copilot stations was unusable because of the faulty installation of the CVR. Also, the CAM would not have recorded the aural tone because the tone is sent to the pilots’ headsets only and not to a cockpit speaker. In addition, if the pilots had entered a preselected altitude on the AL-300, an altitude alert light would have illuminated on the captain’s barometric altimeter (number 3 in figure 9) at 1,000 feet above the preselected altitude. The light would have extinguished from about 300 feet above to about 300 feet below the preselected altitude. The light would again have illuminated from about 300 to 1,000 feet below the preselected altitude. The pilots would have also heard a 1-second tone over their headsets each time that the light illuminated. Finally, if the pilots had selected an altitude-related flight director mode (altitude or altitude preselect and vertical speed)102 but had not coupled the flight director to the engaged autopilot, the pitch command cue would have been displaced above the centerline on the ADIs (numbers 2 and 7 in figure 9). Displacement of the pitch command cue above the centerline would have indicated that the helicopter was below the desired altitude, and movement of the pitch command cue toward the top of the display would have indicated 99 If the accident flight crew had not changed the decision height from the previous flight, then the altitude at which the decision height box and the DH indication appeared would have been based on the decision height set by the previous flight crew. 100 The results of the landing gear warning light bulb examination were inconclusive regarding whether the lights had illuminated. It is possible that the helicopter fuselage absorbed a large amount of impact energy at the time of the collision with the water and that a reduced amount of impact energy was transferred to the light bulbs within the helicopter. Thus, if the lights were illuminated at the time of impact, the impact might not have been severe enough to stretch the filaments. 101 As stated in section 1.12.3, the landing gear relay could not be functionally tested after the accident to determine if the system did in fact trigger because of damage to the relay that appeared to be the result of seawater immersion. 102 If the pilots had selected the altitude preselect and vertical speed modes, they would also have had to enter the desired altitude on the AL-300.

Analysis 45 Aircraft Accident Report the helicopter’s continued descent. Displacement of the pitch command cue in these cases would have occurred regardless of whether a flight director heading mode was engaged and the decision not to couple was intentional. The Safety Board cannot determine the sequence of events that led to the helicopter’s inadvertent descent.103 It is clear, however, that the flight crew should have been actively monitoring cockpit instrumentation showing the helicopter’s altitude, especially because of the lack of outside visual references. The flight crew would have been presented with salient cues to detect the helicopter’s descent and proximity to the water. Thus, the Safety Board concludes that the flight crew was not adequately monitoring the helicopter’s altitude and missed numerous cues to indicate that the helicopter was inadvertently descending toward the water. 2.2.3 Human Factors The Safety Board examined possible factors to explain why the flight crew missed indications of the helicopter’s descent and proximity to the water. Three of these factors— flight crew experience, crew coordination, and use of automated systems—are discussed in sections 2.2.3.1 through 2.2.3.3, respectively. 2.2.3.1 Flight Crew Experience The accident flight crew had adequate experience in the accident helicopter and other similar S-76A helicopters in Era Aviation’s fleet to safely conduct the accident flight. The captain and the copilot completed recurrent training and flight checks during the month before the accident. Even though the captain completed his flight check in an S-76A analog helicopter, he had line experience during the 12 months before the accident with the S-76A EFIS-DDAFCS configuration, including experience with the accident helicopter. The copilot completed his flight check in the accident helicopter and had additional line experience during the 12 months before the accident with the EFIS-DDAFCS configuration and the accident helicopter. Also, both pilots had adequate experience at night to safely conduct the accident flight. In addition, both pilots received adequate CFIT training. 2.2.3.2 Crew Coordination The accident occurred about 4 minutes after the flight crew notified the dispatcher of the change in destination. Under most conditions, a change in destination increases pilot workload depending on the tasks that need to be completed and the flight conditions. The accident flight crew’s decision to proceed directly to the reported location of the Discoverer Spirit required the pilots, at a minimum, to coordinate a change in course and communicate with the dispatcher to receive updated coordinates for the ship, which would have been programmed into the GPS after the course change. It is also possible that the 103 Even though an FDR was not required to be installed on the accident helicopter, an FDR would have provided investigators with pertinent information to help determine the sequence of events that led to this accident. The lack of a requirement for FDRs aboard helicopters is discussed in section 2.6.

Analysis 46 Aircraft Accident Report flight crew initiated a change in control from one pilot to the other or a change in flight control method from automatic (coupling of the autopilot and flight director) to manual flight or vice versa. Such changes require effective crew coordination, including continuous crosschecking and monitoring of instruments to ensure that the intended system inputs have correctly been made. The accident flight was the first one that paired the captain and the copilot. Coordinating with a new flight crewmember can require more effort than coordinating with a previous crewmember. Also, new crew pairings have been associated with increased errors and less effective communication patterns than crew pairings with crewmembers who have previously flown together.104 During critical phases of flight, a lack of familiarity can affect a flight crew’s ability to coordinate effectively. However, because of the poor quality of the CVR recording, it was not possible for the Safety Board to determine whether crew coordination was a factor in this accident. 2.2.3.3 Use of Automated Systems The accident helicopter’s flight control system allowed the pilot to couple the autopilots and flight director so that the helicopter would automatically carry out pilot-set flightpath commands. The pilots might have intended to use this feature to automatically maintain heading and altitude while they completed some immediate manual tasks related to the change in destination. However, the pilots could have incorrectly programmed the flight director mode selector and either not have detected this situation or have misinterpreted it given the available system feedback (as discussed in section 2.3.2). It is also possible that the pilots were in the process of reprogramming the flight director mode selector. Research on the use of automated flight systems in transport-category aircraft found that the reprogramming of automated flight control systems is prone to human error because reprogramming involves multiple, complex steps.105 The accident pilots might not have chosen to use the coupling feature when changing destinations and instead might have chosen to rely on their ability to manually maintain the appropriate flightpath. The helicopter’s ATT mode provides stability to the helicopter during manual flight and reduces a pilot’s manual control requirements. If the helicopter were descending at a shallow rate, the ATT mode would have maintained this trajectory with minimal, if any, physical cues. One of the most critical issues associated with flight deck automation is “automation misuse,” that is, pilot overreliance on automation, because it can lead to deficiencies in monitoring an aircraft’s performance.106 Pilots may become complacent if 104 H.C. Foushee, J.K. Lauber, M.M. Baetge, and D.B. Acomb, Crew Factors in Flight Operations: III. The Operational Significance of Exposure to Short-Haul Air Transport Operations, National Aeronautics and Space Administration Technical Memorandum 88322 (August 1986). 105 R.O. Besco and K. Funk, “Conceptual Design Guidelines to Rediscover Systems Engineering for Automated Flight Decks,” International Journal of Aviation Psychology, Vol. 9, No. 2 (2000): 189-198. 106 R. Parasuraman and V. Riley, “Humans and Automation: Use, Misuse, Disuse, Abuse,” Human Factors, Vol. 39, No. 2 (1997): 230-253.

Analysis 47 Aircraft Accident Report they are overconfident in automation and may fail to exercise appropriate vigilance.107 As a result, significant deviations in altitude or flightpath, if controlled by automation, may develop without detection by the flight crew, especially when the flight crew is focused on other tasks. The only reliable way for pilots to detect such deviations is through continuous monitoring of cockpit instrumentation. Although the opportunity for successful monitoring would be increased with two flight crewmembers rather than an individual pilot, research indicated that an overreliance on automation and a failure to monitor were unaffected by the presence of a second pilot in the cockpit.108 Evidence was not available for the Safety Board to determine whether the accident pilots were relying on an automated system for altitude and flightpath control. Nevertheless, the Board notes that, because the possibility exists for monitoring errors when using automated systems (and from distractions during times of increased workload), other systems have been developed to provide pilots with warnings of impending conditions that require corrective actions. One such system is TAWS, which alerts flight crews to a potential collision with terrain or water. Helicopters are not currently required to be equipped with TAWS; this issue is discussed and analyzed in section 2.3.1. 2.3 Cockpit Systems 2.3.1 Terrain Awareness and Warning System TAWS has the ability to look ahead of an aircraft to detect the terrain or other obstructions along a flightpath. However, none of the S-76A helicopters in Era Aviation’s fleet were equipped with a TAWS or were required to be so equipped. At the time of the FAA’s March 2000 final rule requiring that a TAWS be installed aboard all turbine-powered airplanes configured with six or more passenger seats, TAWS technology had not been specifically developed for the unique flightpaths of rotorcraft compared with fixed-wing aircraft (that is, lower altitudes and the ability to land at off-airport sites). Thus, the installation of TAWS aboard helicopters at that time would have likely resulted in numerous false warnings; systems with this tendency typically prompt a lack of operator trust and result in the failure to respond to the systems’ warnings. However, TAWS technology is now available for helicopters,109 and this technology can include warnings for terrain, obstacles, landing gear, excessive bank and sink rates, tail low attitudes, and below glideslope (on an instrument approach). 107 K. Funk, B. Lyall, J. Wilson, R. Vint, M. Niemczyk, C. Suroteguh, and G. Owen, “Flight Deck Automation Issues,” International Journal of Aviation Psychology, Vol. 9, No. 2 (2000): 109-123. 108 L.J. Skitka, K.L. Mosier, M. Burdick, and B. Rosenblatt, “Automation Bias and Errors: Are Crews Better Than Individuals?,” International Journal of Aviation Psychology, Vol. 10, No. 1 (2000): 85-97. 109 For example, Honeywell’s Mark XXII enhanced GPWS, which was certified in 2001, contains an obstacle database that includes locations of more than 5,000 oil platforms and structures in the Gulf of Mexico. Also, during its visit to PHI, the Safety Board learned that the company equipped its helicopters with TAWS upon customer request.

Analysis 48 Aircraft Accident Report A simulation by the manufacturer of TAWS for helicopters showed that, if a TAWS had been installed aboard the accident helicopter and the helicopter were descending toward the water at a rate of 150 fpm, the “caution terrain” alert would have occurred 97 seconds before impact at an altitude of about 240 feet, along with a water indication that changed from blue to yellow on the system’s forward-looking terrain awareness display. The simulation also showed that the “warning terrain” alert would have occurred 84 seconds before impact at an altitude of about 210 feet, along with a water indication that changed from yellow to red on the forward-looking terrain awareness display. If the helicopter were descending toward the water at a rate of 250 fpm, the caution terrain alert would have occurred 68 seconds before impact at an altitude of about 270 feet, and the warning terrain alert would have occurred 55 seconds before impact at an altitude of about 215 feet (along with the water indication color changes on the forward-looking terrain awareness display). The Safety Board concludes that, if a TAWS had been installed aboard the accident helicopter, the system’s aural and visual warnings should have provided the flight crew with ample time to recognize that the helicopter was descending toward the water, initiate the necessary corrective actions, and recover from the descent. Therefore, the Safety Board believes that the FAA should require all existing and new U.S.-registered turbine-powered rotorcraft certificated for six or more passenger seats to be equipped with a TAWS. As part of its special investigation report on EMS aircraft accidents, the Safety Board issued Safety Recommendation A-06-15, which asked the FAA to require EMS operators to install TAWS on their aircraft. It is important to provide the same level of safety for other helicopter operations, including the transportation of oil service personnel to and from offshore platforms. 2.3.2 Dual Digital Automatic Flight Control System The accident helicopter was equipped with an SPZ-7000 DDAFCS. Although the Safety Board found no evidence to indicate that the SPZ-7000 contributed to this accident, the Board noted three characteristics about this flight control system that have safety-of-flight implications if pilots are not familiar with the system. First, the SPZ-7000 does not provide an indication on the ADIs showing which flight director (FD1 or FD2) has been engaged. The SPZ-7000 has two independent flight control computers; one computer provides commands to the autopilot and flight director at the pilot’s station, and the other computer provides commands to the autopilot and flight director at the copilot’s station (referred to as a split cockpit). Thus, it is possible for the pilot and copilot ADIs to simultaneously present a different set of pitch and roll command cues.110 This situation can be beneficial if the nonflying pilot 110 In contrast, many of the flight control systems currently in use in transport-category fixed-wing aircraft have dual but dependent flight control computers. In such systems, only one set of commands guides flight director command cues, which are presented simultaneously for both pilot stations.

Analysis 49 Aircraft Accident Report wants to program the flight director in advance of the subsequent phase of flight. However, only one pilot station can be coupled at a time, and a lack of pilot awareness regarding which set of command cues is coupled to the autopilot can lead to automation mode confusion.111 Two indications in the cockpit provide the pilot with direct feedback regarding the flight director status: the FD1/2 button on the autopilot controller on the center pedestal (see figure 2), which shows the flight director that has been engaged, and the CPLT FD light (see number 9 in figure 1), which illuminates on the caution/advisory panel on the center of the front instrument panel when FD1 is selected. No similar light illuminates when FD2 is selected, and the only indication in front of the pilots that FD2 is selected is the absence of illumination of the CPLT FD light. Neither the FD1/2 button nor the CPLT FD light is located near either pilot’s ADI or the flight director mode selector, where other indications regarding flight director mode selections are presented. Second, the SPZ-7000 does not annunciate the coupling status on the front instrument panel and does not provide an aural alert when the autopilot and flight director have become decoupled. As a result, the only direct indication of the coupling status is the illumination, or absence of illumination, of the CPL light on the autopilot controller on the center pedestal (see figure 2). Although indirect indications of the flight director source and coupling status can be determined through monitoring cockpit instrumentation, the possibility of automation mode confusion increases when pilots are required to search multiple locations for information pertaining to the same system.112 Displays for many newer flight control systems, including those used on the Sikorsky S-92 and Agusta AB-139 helicopters, annunciate the flight director source and the coupling status directly on the ADIs. Third, when only one flight director mode (either pitch or roll) is selected, both pitch and roll command cues appear simultaneously on the SPZ-7000, but no annunciation appears on the ADIs regarding the source of guidance for the unselected command cue. Because the SPZ-7000 allows for independent engagement of flight director mode selections (referred to as split-axis engagement), the system can be coupled to the longitudinal (pitch), lateral (roll), and vertical axes individually, two at a time, or all three simultaneously. The ability to engage only one or two axes, instead of all three, can be beneficial in certain circumstances, such as search and rescue, when a pilot may engage a roll function on the flight director mode selector (such as heading) but need to make pitch control inputs to maintain a certain height above varying terrain. However, the simultaneous presentation of command cues for both selected and unselected axes allows for the possibility of pilot misinterpretation of the command cue for the unselected axis. Specifically, a pilot may be unaware that a flight director mode has not been selected for 111 Automation mode confusion is a lack of awareness of the current mode of an automated system. It can result from inadequate feedback about the automated system’s actions and intentions. 112 R. Parasuraman and V. Riley, “Humans and Automation: Use, Misuse, Disuse, Abuse,” Human Factors, Vol. 39, No. 2 (1997): 230-253.

Analysis 50 Aircraft Accident Report both axes (because of the presence of two command cues)113 and thus not realize that the command cue for the unselected axis is not synchronized to a selected pitch or roll function. Even if a pilot were aware that a flight director mode had not been selected for both axes, the lack of an annunciation on the ADIs regarding the source of guidance for the unselected axis might also result in pilot misinterpretation of the command cue. The source of guidance for an unselected command cue varies between flight control system models and may or may not be synchronized to the helicopter’s attitude. For the SPZ-7000, the command cue for an unselected axis is synchronized to the helicopter’s attitude. As a result, the command cue for the unselected axis will indicate a deviation from attitude rather than a deviation from altitude (when a flight director roll function is selected) and heading (when a flight director pitch function is selected). Some of the FAA’s observations of the SPZ-7000 DDFACS (see section 1.18.5.1) were consistent with those made by the Safety Board. Specifically, the FAA found that (1) no aural or visual annunciations occurred for a pilot-induced decouple, (2) the only cues that the flight director was not coupled on the selected side were the lack of flight director mode selections and the lack of flight director mode annunciations on the ADIs, (3) both pitch and roll command cues were displayed when only one axis was selected, and (4) the decoupling indications were not particularly compelling. Although the SPZ-7000 is no longer in production, it is still in use on numerous helicopters.114 The SPZ-7000’s successor is the SPZ-7600, which is installed in S-76C helicopters.115 Although the SPZ-7600 has many of the same components and operations as the SPZ-7000, the SPZ-7600 has key differences regarding coupling status annunciation, which promotes pilot mode awareness. For example, although the SPZ-7000 and the SPZ-7600 both have a DCPL warning indicator on the DAFCS caution panels (which are in direct view of the pilots and are next to the ADIs) to indicate when the autopilot and flight director have become decoupled, the SPZ-7000 DCPL warning indicators illuminate only during abnormal operations, whereas the SPZ-7600’s DCPL warning indicators illuminate during both normal and abnormal operations. Also, although both the SPZ-7000 and the SPZ-7600 are not manufactured with an aural alert to indicate system decoupling, operators of helicopters that are equipped with the SPZ-7600 can install an after-market product that provides this alert to the pilots’ headsets, the cabin, or both. The SPZ-7600 also has a key difference regarding command cue guidance for the dual-cue format. With the SPZ-7000, both command cues appear simultaneously when only one axis is engaged. However, with the SPZ-7600 dual-cue format, the command cue for only the selected axis will appear on the pilots’ ADIs. Specifically, if a flight director 113 For the dual-cue format, pitch attitude is represented by a horizontal command bar, and roll attitude is represented by a vertical command bar (see figure 7). For the single-cue format, pitch and roll guidance is integrated into angular bars in the shape of a chevron (see figure 8). 114 According to a Honeywell official, more than 300 SPZ-7000s were manufactured. 115 A Honeywell official stated that more than 850 SPZ-7600s have been manufactured to date.

Analysis 51 Aircraft Accident Report roll function, such as heading, is selected and no flight director pitch function is engaged, only the vertical command bar (roll attitude) will appear. Likewise, if a flight director pitch function, such as altitude, is selected and no flight director roll function is engaged, only the horizontal command bar (pitch attitude) will appear. Thus, with the SPZ-7600 dual-cue format, pilots cannot misinterpret command cue guidance for the unselected axis, which also promotes pilot mode awareness. Despite the improvements present in the SPZ-7600 (compared with the SPZ-7000), two issues exist with the single-cue format for that system. One issue is that the guidance for the unselected axis is still presented without annunciation. As a result, pilots could still misinterpret the status of the command cue for the unselected axis when using the SPZ-7600 single-cue format. The other issue is that the command cue for the unselected axis for the SPZ-7600 is not synchronized to attitude (as with the SPZ-7000); instead, the single-cue format symbol maintains a centered or neutral position regardless of pilot input. Thus, pilots may mistake a centered (pitch attitude) or neutral (roll attitude) command cue as feedback that the aircraft is either on a commanded flightpath or is synchronized to attitude (as with the SPZ-7000).116 Pilot mode awareness is a critical aspect associated with reducing errors from the use of automated flight control systems.117 During postaccident interviews, Era Aviation pilots (including the chief pilot and director of training) were not able to fully explain the flight director and coupling status annunciations and command cue presentations associated with the SPZ-7000 and SPZ-7600. Additional training on these systems could help improve pilot understanding of the systems’ capabilities, which is especially critical for pilots who operate both the SPZ-7000 and SPZ-7600. The Safety Board concludes that additional pilot training on the SPZ-7000 and SPZ-7600 DDAFCSs would promote automation mode awareness for pilots operating helicopters equipped with these systems. Therefore, the Safety Board believes that the FAA should ensure that all operators of helicopters equipped with either the SPZ-7000 or SPZ-7600 DDAFCSs provide training that includes information on flight director and coupling status annunciations; the command cue presentations when only the pitch or the roll mode is engaged; and, if applicable, the differences between the SPZ-7000 and the SPZ-7600. 2.4 Tracking of Gulf of Mexico Helicopter Flights The FAA cannot currently provide flight-tracking services for low-flying aircraft in the Gulf of Mexico beyond the capabilities of existing FAA land-based radar sites. For example, during the accident flight, radar data were available until the helicopter was about 58 nm southeast of the Houston ASR-9 radar site, which provides maximum radar coverage of about 60 nm. The helicopter flew for another 18 minutes, traveling an additional 35 nm to the southeast, but no radar data were available for that portion of the 116 Displays for some newer flight control systems annunciate the source of guidance for the unselected axis (for example, “ROLL” or “PTCH”) when the unselected axis is synchronized to attitude. 117 U.S. Department of Transportation, Federal Aviation Administration, Report on the Interfaces Between Flightcrews and Modern Flight Deck Systems (Washington, DC: FAA, 1996).

Analysis 52 Aircraft Accident Report flight. In addition to the lack of radar data for low-flying aircraft in the Gulf of Mexico, only helicopter dispatchers are aware of the status of their respective company’s flights because there is no direct communication between pilots of such aircraft and air traffic controllers.118 The FAA’s Safe Flight 21 Gulf of Mexico initiative (see section 1.18.3) was developed to determine whether ADS-B technology would be effective in providing pilots with navigation, air traffic, terrain, and weather information in the cockpit and enabling air traffic controllers and operators to provide surveillance (including position and altitude) of low-flying aircraft in those areas with limited or no radar coverage. The ADS-B infrastructure included ground-based transceivers, weather sensors, and communications outlets that would be used along with ADS-B monitors installed by operators on aircraft that fly in the Gulf of Mexico. ADS-B technology had already been successfully deployed in Alaska as part of the Safe Flight 21 Capstone program. The FAA’s Capstone Web site indicated that, according to a 2004 safety study by the University of Alaska, the accident rate for aircraft under the Capstone program had decreased by 47 percent from 2000 to 2004. Also, according to a 2003 safety study contracted by the Capstone program,119 the ADS-B technology used in the Capstone program would have been effective in preventing about 80 percent of the en route CFIT accidents that occurred in southwest Alaska (the Phase I Capstone area) between 1990 and 1999.120 The Capstone program and the Safe Flight 21 Gulf of Mexico initiative were both intended to benefit pilots of low-flying aircraft in areas of limited radar coverage. The final phase of the Capstone program is currently being developed with funding for site surveys (but not for construction of the sites). However, in November 2005, the FAA indicated that implementation of the Safe Flight 21 Gulf of Mexico initiative would not begin until fiscal year 2013. As a result, helicopter pilots transporting oil service personnel to and from offshore platforms would not be afforded the same level of safety as general aviation pilots operating in Alaska. ADS-B technology has many potential benefits for flight operations in the Gulf of Mexico. For example, if the ADS-B infrastructure had been operational in the Gulf of Mexico at the time of the accident, (1) the Era Aviation dispatcher would have had better flight-tracking and communication capabilities and thus could have monitored the accident helicopter’s flightpath and provided an alert to the flight crew about the descent 118 For some helicopter operators, the status of their company’s flights is transmitted only intermittently (as with Era Aviation, whose pilots provide dispatchers with position reports every 15 minutes.) As a result, no continuous flight tracking is provided for such flights. 119 University of Alaska Anchorage, Capstone Phase I Interim Safety Study, 2002 (Anchorage, Alaska: University of Alaska, 2003). 120 According to the study, the ADS-B technology should prevent en route CFIT accidents by providing the pilot with information about the aircraft’s proximity to high ground. Specifically, the technology compares information about nearby terrain (stored in an on-board database) with the aircraft’s altitude and GPS location and then presents the information on a cockpit display. Terrain that is 500 feet or less below the aircraft is shown in yellow, and terrain that is level with or higher than the aircraft is shown in red.

Analysis 53 Aircraft Accident Report and (2) the pilots would have received a warning in the cockpit about the descent. Also, ADS-B technology has many potential benefits for search and rescue operations in the Gulf of Mexico. For example, in September 2005, a Houston Helicopters S-76A helicopter was ditched in the Gulf of Mexico after an in-flight fire.121 The 2 pilots and 10 passengers escaped from the helicopter but remained in the water for about 7 hours until they were located by U.S. Coast Guard personnel using night vision goggles.122 ADS-B technology would have facilitated the search and expedited the rescue of the helicopter occupants. In addition, ADS-B technology would benefit accident investigations because information on an aircraft’s airspeed, altitude, and position (that is, whether the aircraft was turning, climbing, or descending) would be available to investigators. In January 2006, the FAA announced that the Safe Flight 21 program was being transitioned to the National ADS-B Program. At that time, the FAA proposed fiscal year 2007 for the start date for implementation of the program and fiscal year 2010 as the target date for completion of the first segment of ADS-B infrastructure deployment. On March 1, 2006, the FAA verbally informed the Safety Board that the Gulf of Mexico would be among those areas in the first segment of ADS-B infrastructure deployment; however, this information has not been confirmed. It is critical that the milestones for the National ADS-B Program in the Gulf of Mexico are achieved on or ahead of time and that the fiscal year 2010 completion date for ADS-B deployment in the Gulf of Mexico not slip. This matter is especially important given the number of passengers and flights in the region (in 2004, more than 2.3 million passengers were transported aboard 1.3 million flights) and the inherent risks of offshore helicopter operations, as indicated by the FAA’s Aeronautical Information Manual, section 10-2-1, “Offshore Helicopter Operations,” which states the following: The offshore environment offers unique applications and challenges for helicopter pilots. The mission demands, the nature of oil and gas exploration and production facilities, and the flight environment (weather, terrain, obstacles, traffic), demand special practices, techniques and procedures not found in other flight operations. Because of the limited radar services in the Gulf of Mexico, some helicopter operators, including Era Aviation, PHI, and Air Logistics, have purchased flight-tracking systems from commercial vendors. These commercial systems allow dispatchers to track aircraft in flight and the weather along the flightpath and to relay text messages to company pilots (and vice versa). Thus, as with ADS-B technology, a commercial 121 For more information about this accident, see DFW05MA230 at the Safety Board’s Web site. 122 The pilot of the helicopter declared “MAYDAY” but did not provide position information. Pilots of several aircraft in the area overheard the emergency distress call and immediately notified various FAA facilities of the situation. A ground search for the helicopter was then conducted based on the reported locations of the aircraft pilots who had overheard the emergency distress call. After the helicopter was overdue at its destination by more than 2 hours, the company coordinated with the FAA and the Coast Guard to determine the helicopter’s likely location, and the Coast Guard then began its search for the helicopter. Because of damage to the communication infrastructure from Hurricane Katrina, company and FAA communications were not available for the flight.

Analysis 54 Aircraft Accident Report flight-tracking system could have provided the Era Aviation dispatcher with information about the accident helicopter’s descending altitude, which she could have communicated to the flight crew. However, the ADS-B technology would offer an additional level of safety for pilots flying at low altitudes in the Gulf of Mexico by providing them with navigation, air traffic, terrain, and weather information in the cockpit. The Safety Board concludes that the National ADS-B Program technology would help Gulf of Mexico aircraft operators mitigate the inherent risks associated with offshore operations by providing pilots with terrain, weather, and other flight information in the cockpit and dispatchers with current location information. Therefore, the Safety Board believes that the FAA should ensure that the infrastructure for the National ADS-B Program in the Gulf of Mexico is operational by fiscal year 2010. The Safety Board further believes that, until the infrastructure for the National ADS-B Program in the Gulf of Mexico is fully operational, the FAA should require POIs of Gulf of Mexico aircraft operators to inform the operators about the benefits of commercial flight-tracking systems and encourage the operators to acquire such systems. 2.5 Lack of Adequate Cockpit Voice Recorder Information for This Investigation The accident helicopter was equipped with a CVR that had been improperly installed. Specifically, the helicopter’s CVR installation required that white notched switches (within the internal communications system units for the pilot and copilot stations) be set to the bottom position, but the switches were found set to the top position. The failure to set the switches to the correct position resulted in a lack of audio input to those CVR channels. The functional check of the CVR after installation did not detect the faulty installation. The CAM was the only source of audio information recorded for the accident flight. However, because of the high noise level within the helicopter cockpit, the flight crew’s conversation was mostly unintelligible. The lack of audio information significantly hindered the investigation of this accident. On August 29, 2002, the Safety Board issued Safety Recommendation A-02-25, which asked that the FAA require operators to implement daily CVR test procedures to prevent the lack of CVR data after aviation accidents and incidents (see section 1.18.6.1). On March 5, 2004, the Safety Board reiterated Safety Recommendation A-02-25 as a result of its investigation of the January 2003 Air Midwest Beech 1900D accident in Charlotte. The Board’s investigation of that accident found that the captain’s and the copilot’s audio information captured from the airplane’s VHF radio systems was fair to poor quality. In its response to Safety Recommendation A-02-25, the FAA stated that it issued Notice N8000.292, “Clarification of Recommendations for Cockpit Voice Recorder Testing,” for operators of those airplanes equipped with CVRs that could be tested before

Analysis 55 Aircraft Accident Report the first flight of the day. The FAA indicated that the intent of the notice was to persuade the operators to configure the CVRs during future major maintenance cycles so that flight crews would be able to test them. The FAA also stated that it made a change to chapter 143, “Monitor Cockpit Voice Recorders,” of FAA Order 8300.10. According to the FAA, the change tasked airworthiness aviation safety inspectors to evaluate maintenance programs that require maintenance technicians to perform a thorough test of the CVR at appropriate intervals. The Safety Board classified Safety Recommendation A-02-25 “Open—Acceptable Response” pending a permanent change to the FAA’s operational requirements to ensure that a CVR functional test would be performed before the first flight of each day. Although daily preflight testing of the CVR should catch most problems encountered with poor-quality audio recordings, a review of the actual audio recorded by the CVR would ensure that the entire CVR system (including the microphones, audio/communications panels, wiring, and CVR itself) was working properly. Such a review would reveal any problems with audio quality, CVR malfunction, or lack of audio signals to the CVR. The Safety Board recognizes that a review of downloaded audio data would not be feasible on a daily preflight basis, but this review could easily be accomplished periodically during a routine maintenance check of an aircraft. A periodic maintenance check of a CVR could be similar to the periodic maintenance check that is performed on an FDR, during which the FDR is downloaded and the data are analyzed to ensure that the required parameters are being recorded correctly. The FDR maintenance check is currently being accomplished with minimal impact on the amount of time that the recorder is removed from the aircraft. With the advent of solid-state recorders, the download can be accomplished without the operator having to perform any maintenance to the recorder to comply with the download requirement. The Safety Board concludes that preflight testing and maintenance checks of an aircraft’s CVR are both necessary to ensure that audio data from CVR recordings are adequate. Therefore, the Safety Board believes that the FAA should require all operators of aircraft equipped with a CVR to (1) test the functionality of the CVR before the first flight of each day as part of an approved aircraft checklist and (2) perform a periodic maintenance check of the CVR as part of an approved maintenance check of the aircraft. The CVR preflight test should be performed according to procedures provided by the CVR manufacturer and should include listening to the recorded signals on each channel to verify that the audio is being recorded properly, is intelligible, and is free from electrical noise or other interference. The periodic maintenance check of the CVR should include an audio test followed by a download and review of each channel of recorded audio. The downloaded recording should be checked for overall audio quality, CVR functionality, and intelligibility. In addition, the FAA’s actions in response to Safety Recommendation A-02-25— the issuance of Notice N8000.292 and the change to FAA Order 8300.10—are not adequate to ensure that a CVR, once installed, will operate as required because the CVR test detailed in the notice and the order might not contain sufficient instructions to detect

Analysis 56 Aircraft Accident Report all faulty recordings. For example, although the preflight test recommended in Safety Recommendation A-02-25 might have been sufficient to discover the problem with the CVR installed on the Air Midwest accident airplane, the preflight test would not have discovered the faulty CVR installed on the Era Aviation accident helicopter. Therefore, the Safety Board classifies Safety Recommendation A-02-25 “Closed—Superseded” as a result of the issuance of Safety Recommendation A-06-23. 2.6 Lack of Flight Data Recorder Information for Helicopter Operations The accident helicopter was not equipped with an FDR. In August 2003, the S-76A and several other helicopter models became permanently exempt from 14 CFR 135.152, which required that multiengine, turbine-powered aircraft with 10 to 19 passenger seats (excluding required crewmember seats) be equipped with an FDR. In June 2001, Era Aviation requested a temporary exemption from the requirements of 14 CFR 135.152 for two of its S-76A helicopters (one of which was the accident helicopter) while the FAA was in the process of changing the regulation. In its letter, Era Aviation stated that operations without FDRs “do not degrade safety.” The letter also stated that the Safety Board’s accident data for rotorcraft operated under Part 135 with seating of 10 to 19 passengers do not indicate “that the cause of accidents is in question or that the investigative process would have been improved by the requirement for a DFDR.” In its August 2001 letter to Era Aviation that granted the exemption, the FAA cited Grant of Exemption No. 6785, which stated that the FAA had found that operators had demonstrated “valid reasons” for exempting several helicopter models (including the S-76A) from the FDR requirements, but the letter did not state what these valid reasons were. The FAA’s letter also stated, “exempting certain helicopters from the FDR requirements would be in the public interest and would not adversely affect safety.” The Safety Board does not agree with the FAA’s position that the lack of an FDR aboard helicopters is in the public interest and does not adversely affect safety. An FDR is an important investigative tool that is used to determine an aircraft’s performance. Because the information that investigators learn from FDR data can help prevent accidents and incidents from recurring, the lack of FDRs aboard helicopters undoubtedly affects safety. The Safety Board also disagrees with Era Aviation’s position that, according to helicopter accident data, the investigative process would not be improved by the requirement for an FDR. The lack of FDR information hindered the Board’s investigation of this accident, especially because of the poor quality of the CVR recording and the limited radar data. If an FDR had been installed on the accident helicopter, pertinent information would have been available to investigators, including the helicopter’s flightpath, engine operation, autopilot operation, and flight control inputs.

Analysis 57 Aircraft Accident Report The investigation of the August 2005 accident involving an S-76C that crashed in the Baltic Sea shortly after takeoff from Tallinn, Estonia, demonstrated that recorded flight data for helicopter operations are critical for effective accident and incident investigations. The S-76C had an FDR installed, and FDR data showed that the helicopter’s pitch and roll movements were severe during the accident sequence and were not consistent with the recorded cyclic inputs. It is likely that the helicopter’s movement and the cyclic’s movement would not have been known without the FDR data. As a result, investigators identified airworthiness concerns about S-76 actuators because the FDR data were consistent with a loss of control of the forward actuator. The Estonian accident was the first one involving a large helicopter for which FDR data were available. The FDR data have been extremely valuable during the investigation of that accident, which clearly demonstrates the possibility that FDR data for previous accidents would have been equally valuable if these data had been available. The Safety Board concludes that, because the FAA exempted the S-76A helicopter from the FDR requirements in 14 CFR 135.152, recorded flight data were not available to help reconstruct the events that led to this accident, which significantly hampered the investigation. To prevent a similar situation from recurring, the Board urges the FAA to act on Safety Recommendations A-06-17 and -18 (see section 1.18.6.2) in a timely manner.

58 Aircraft Accident Report 3. Conclusions 3.1 Findings 1. The captain and the copilot were properly certificated and qualified under Federal regulations. No evidence indicated any medical or behavioral conditions that might have adversely affected their performance during the accident flight. Flight crew fatigue was not a factor in this accident. 2. The accident helicopter was properly certified, equipped, and maintained in accordance with Federal regulations. The recovered components, with the exception of the cockpit voice recorder, showed no evidence of any structural, engine, or system failures. 3. Weather was not a factor in this accident. The dispatcher who handled the accident flight provided appropriate flight-tracking services. The search and rescue effort for this accident was timely. The accident was not survivable for the helicopter occupants because they were subjected to impact forces that exceeded the limits of human tolerance. 4. Even though visual meteorological conditions prevailed at the time of the accident, few, if any, references outside of the helicopter would have been available to the flight crew. 5. The helicopter crashed into the water at a high airspeed, a shallow descent angle, and a near-level roll attitude. 6. The pilots were not attempting an emergency landing on the water. 7. After the helicopter crashed into the water, the fuselage pitched nose down, and the tailboom broke off in a downward direction. 8. The flight crew was not adequately monitoring the helicopter’s altitude and missed numerous cues to indicate that the helicopter was inadvertently descending toward the water. 9. If a terrain awareness and warning system had been installed aboard the accident helicopter, the system’s aural and visual warnings should have provided the flight crew with ample time to recognize that the helicopter was descending toward the water, initiate the necessary corrective actions, and recover from the descent.

1. Additional pilot training on the SPZ-7000 and SPZ-7600 dual digital automatic flight

control systems would promote automation mode awareness for pilots operating helicopters equipped with these systems.

Conclusions 59 Aircraft Accident Report

1. The National Automatic Dependent Surveillance–Broadcast Program technology

would help Gulf of Mexico aircraft operators mitigate the inherent risks associated with offshore operations by providing pilots with terrain, weather, and other flight information in the cockpit and dispatchers with current location information.

1. Preflight testing and maintenance checks of an aircraft’s cockpit voice recorder

(CVR) are both necessary to ensure that audio data from CVR recordings are adequate.

1. Because the Federal Aviation Administration exempted the S-76A helicopter from the

flight data recorder requirements in 14 Code of Federal Regulations 135.152, recorded flight data were not available to help reconstruct the events that led to this accident, which significantly hampered the investigation. 3.2 Probable Cause The National Transportation Safety Board determines that the probable cause of this accident was the flight crew’s failure to identify and arrest the helicopter’s descent for undetermined reasons, which resulted in controlled flight into terrain.

60 Aircraft Accident Report 4. Recommendations 4.1 New Recommendations As a result of the investigation of this accident, the National Transportation Safety Board makes the following recommendations to the Federal Aviation Administration: Require all existing and new U.S.-registered turbine-powered rotorcraft certificated for six or more passenger seats to be equipped with a terrain awareness and warning system. (A-06-19) Ensure that all operators of helicopters equipped with either the SPZ-7000 or SPZ-7600 dual digital automatic flight control systems provide training that includes information on flight director and coupling status annunciations; the command cue presentations when only the pitch or the roll mode is engaged; and, if applicable, the differences between the SPZ-7000 and the SPZ-7600. (A-06-20) Ensure that the infrastructure for the National Automatic Dependent Surveillance–Broadcast Program in the Gulf of Mexico is operational by fiscal year 2010. (A-06-21) Until the infrastructure for the National Automatic Dependent Surveillance–Broadcast Program in the Gulf of Mexico is fully operational, require principal operations inspectors of Gulf of Mexico aircraft operators to inform the operators about the benefits of commercial flight-tracking systems and encourage the operators to acquire such systems. (A-06-22) Require all operators of aircraft equipped with a cockpit voice recorder (CVR) to (1) test the functionality of the CVR before the first flight of each day as part of an approved aircraft checklist and (2) perform a periodic maintenance check of the CVR as part of an approved maintenance check of the aircraft. The CVR preflight test should be performed according to procedures provided by the CVR manufacturer and should include listening to the recorded signals on each channel to verify that the audio is being recorded properly, is intelligible, and is free from electrical noise or other interference. The periodic maintenance check of the CVR should include an audio test followed by a download and review of each channel of recorded audio. The downloaded recording should be checked for overall audio quality, CVR functionality, and intelligibility. (A-06-23)

Recommendations 61 Aircraft Accident Report 4.2 Additional Recommendations Resulting From This Accident Investigation As a result of the investigation of this accident (and the August 2005 accident involving the S-76C helicopter that crashed in the Baltic Sea shortly after takeoff),123 the Safety Board issued the following recommendations to the FAA on March 7, 2006: Require all rotorcraft operating under 14 Code of Federal Regulations Parts 91 and 135 with a transport-category certification to be equipped with a cockpit voice recorder (CVR) and a flight data recorder (FDR). For those transport-category rotorcraft manufactured before October 11, 1991, require a CVR and an FDR or an onboard cockpit image recorder with the capability of recording cockpit audio, crew communications, and aircraft parametric data. (A-06-17) Do not permit exemptions or exceptions to the flight recorder regulations that allow transport-category rotorcraft to operate without flight recorders, and withdraw the current exemptions and exceptions that allow transport-category rotorcraft to operate without flight recorders. (A-06-18) 4.3 Previously Issued Recommendation Classified in This Report Safety Recommendation A-02-25 (previously classified “Open—Acceptable Response”) is classified “Closed—Superseded” as a result of the issuance of Safety Recommendation A-06-23. 123 See sections 1.16.2 and 2.6 for more information about this accident. BY THE NATIONAL TRANSPORTATION SAFETY BOARD MARK V. ROSENKER Acting Chairman ELLEN ENGLEMAN CONNERS Member DEBORAH A. P. HERSMAN Member KATHRYN O. HIGGINS Member Adopted: March 7, 2006

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63 Aircraft Accident Report 5. Appendixes Appendix A Investigation and Public Hearing Investigation The National Transportation Safety Board’s South Central Regional Office in Arlington, Texas, was initially notified of this accident. Investigators from Safety Board headquarters in Washington, D.C., arrived at LCH on March 25, 2004. A Board investigator participated in recovery operations in the Gulf of Mexico. Wreckage identification and documentation occurred at LCH. Investigators remained on scene until April 3, 2004. Four investigative teams were formed: operations, airworthiness, human performance, and cockpit voice recorder. Specialists in the areas of air traffic control, survival factors, and meteorology assisted in the investigation. Parties to the investigation were the FAA; Era Aviation, LLC; Union Oil Company of California; Sikorsky Aircraft Corporation; and Honeywell. In accordance with the provisions of Annex 13 to the Convention on International Civil Aviation, the Safety Board’s counterpart agency in France, the Bureau d’Enquêtes et d’Analyses pour la Sécurité de l’Aviation Civile (BEA) participated in the investigation as the representative of the State of Design and Manufacture (Powerplants). Turbomeca participated in the investigation as a technical advisor to the BEA, as provided in Annex 13. Public Hearing No public hearing was held for this accident.

64 Aircraft Accident Report Appendix B Cockpit Voice Recorder The following is the transcript of the L-3 Communications FA2100 cockpit voice recorder, serial number 118739, installed on an Era Aviation Sikorsky S-76A++, N579EH, which crashed into the Gulf of Mexico during controlled flight on March 23, 2004.

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67 Aircraft Accident Report Appendix C Flight Simulation Scenarios The Safety Board examined numerous possible scenarios in which the flight crew’s actions could have inadvertently led to a controlled descent into water. The Board used FlightSafety’s S-76A simulator for these tests. All of the scenarios were based on a flight that occurred at night and over water with limited visual references (sparse lighting from platforms) and a cloud ceiling of 2,000 feet agl. For each of the scenarios, the starting altitude was 1,100 feet msl, the airspeed was 130 knots, the autopilots were engaged in the ATT mode, the initial rate of descent was 200 fpm, and the decision height was 200 feet. All of the scenarios involved a change in heading of 10º to the right (to reflect the flight crew’s decision not to refuel at High Island A-557 and to proceed directly to the Discoverer Spirit) and a resulting increase in rate of descent from 200 fpm to 250 to 300 fpm, which was maintained after the helicopter rolled to a level altitude. The four scenarios that were deemed to be the most likely to have occurred during the accident flight (assuming that the flight crew had engaged the DDAFCS) were (1) pilot 2 maintained control but did not select altitude hold mode, (2) pilot 1 coupled the flight director but did not select altitude hold mode, (3) pilot 1 selected the altitude mode but did not couple the flight director, and (4) pilot 1 selected the altitude preselect mode but did not couple the flight director. A detailed description of each of these scenarios follows.124 Pilot 2 Maintained Control but Did Not Select Altitude Mode The first scenario began with FD2 engaged and coupled and with NAV and VS selected on the flight director mode selector. Pilot 2 (in the right seat) then pressed SBY on the flight director mode selector, which canceled the NAV and VS modes and decoupled FD2. With the HSI heading bug,125 pilot 2 changed the helicopter’s heading 10º to the right to reflect the flight crew’s decision not to refuel at High Island A-557 and to proceed directly to the Discoverer Spirit. Pilot 2 then pressed HDG on the flight director mode selector, coupling FD2 once again, but did not press ALT. Because the helicopter’s power setting was not changed and ALT was not selected on pilot 2’s flight director mode selector, the process of making the 10º turn to the right led to a 250- to 300-fpm descent that was maintained after rollout. 124 The abbreviations discussed in these four scenarios are defined in section 1.6.3.2. 125 The heading bug is a blue notch that is positioned around a rotating compass card to indicate the direction in which the helicopter is to be flown.

Appendix C 68 Aircraft Accident Report The following is a description of what was seen on pilot 2’s instrumentation during this scenario: • A green HDG indication appeared at the top left of the ADI after the pilot pressed the HDG button on the flight director mode selector. • No command bars appeared initially on the ADI because FD2 was automatically set to SBY before HDG was selected. Once the selection was made, the command bars appeared. The pitch command bar was centered, and the roll command bar was in the neutral position. • The radar altitude appeared in blue at the bottom right of the ADI followed by an RA indication in white. • The decision height was displayed in blue at the bottom left of the ADI followed by a DH indication in white. A white square box appeared above the radar altitude (at the bottom right of the ADI) when the helicopter was 100 feet above the decision height (based on the radar altimeter). When the decision height was reached, an amber DH indication appeared inside the box and remained there as the helicopter continued to descend. • A yellow rising runway symbol appeared at the bottom center of the ADI at 180 feet (based on the radar altimeter). As the helicopter’s altitude decreased, this symbol ascended until it met the aircraft symbol at 0 feet. • The flight director mode selector’s SBY button was initially illuminated in green. Once the HDG button was selected, it illuminated in green, and the SBY button was no longer illuminated. • The VSI showed a rate of descent of 250 to 300 fpm, which placed the needle below the centerline. • The barometric altimeter showed decreasing altitude by a counterclockwise rotation of the needle. Pilot 1 Coupled the Flight Director but Did Not Select Altitude Mode The second scenario began with FD2 engaged and coupled and with NAV and VS selected on the flight director mode selector. Pilot 2 (in the right seat) transferred control of the helicopter to pilot 1 (in the left seat). Pilot 1 then selected FD1, and the flight director mode selector was automatically set to SBY. With the HSI heading bug, pilot 1 changed the helicopter’s heading 10º to the right. Pilot 1 then pressed HDG on the flight director mode selector, coupling FD1, but did not press the ALT button. Because the power setting was not changed and ALT was not selected on pilot 1’s flight director selector mode, the process of making the 10º turn to the right led to a 250- to 300-fpm descent that was maintained after rollout.

Appendix C 69 Aircraft Accident Report The following is a description of what was seen on pilot 1’s instrumentation during this scenario: • A green CPLT FD indication appeared at the top left of the caution/advisory panel. • A green HDG indication appeared at the top left of the ADI after the HDG button on the flight director mode selector was pressed. • The command bars disappeared from the ADI when FD1 was selected. When HDG was selected, the command bars reappeared. The pitch command bar was centered, and the roll command bar was in the neutral position. • The radar altitude appeared in blue at the bottom right of the ADI followed by an RA indication in white. • The decision height was displayed in blue at the bottom left of the ADI followed by a DH indication in white. A white square box appeared above the radar altitude (at the bottom right of the ADI) when the helicopter was 100 feet above the decision height (based on the radar altimeter). When the decision height was reached, an amber DH indication appeared inside the box and remained there as the helicopter continued to descend. • A yellow rising runway symbol appeared at the bottom center of the ADI at 180 feet (based on the radar altimeter). As the helicopter’s altitude decreased, this symbol ascended until it met the aircraft symbol at 0 feet. • The flight director mode selector’s SBY button was initially illuminated in green. Once the HDG button was selected, it illuminated in green, and the SBY button was no longer illuminated. • The VSI showed a rate of descent of 250 to 300 fpm, which placed the needle below the centerline. • The barometric altimeter showed decreasing altitude by a counterclockwise rotation of the needle. Pilot 1 Selected Altitude Mode but Did Not Couple the Flight Director The third scenario began with FD2 engaged and coupled and with NAV and VS selected on the flight director mode selector. Pilot 2 (in the right seat) transferred control of the helicopter to pilot 1 (in the left seat). Pilot 1 selected FD1 and then selected CPL on the autopilot controller, which decoupled FD1. With the HSI heading bug, pilot 1 changed the helicopter’s heading 10º to the right. Pilot 1 also pressed HDG and then ALT on the flight director mode selector. Because the power setting was not altered and FD1 was not coupled, the heading change led to a 250- to 300-fpm descent that was maintained after rollout.

Appendix C 70 Aircraft Accident Report The following is a description of what was seen on pilot 1’s instrumentation during this scenario: • A green CPLT FD indication appeared at the top left of the caution/advisory panel, even after FD1 was decoupled. • After the HDG and ALT buttons on the flight director mode selector were pressed, green HDG and ALT indications appeared at the top left and top right, respectively, of the ADI. • The command bars disappeared from the ADI when FD1 was selected. When HDG was selected, the command bars reappeared. The pitch command bar appeared above the center position, and the roll command bar was in the neutral position. • The radar altitude appeared in blue at the bottom right of the ADI followed by an RA indication in white. • The decision height was displayed in blue at the bottom left of the ADI followed by a DH indication in white. A white square box appeared above the radar altitude (at the bottom right of the ADI) when the helicopter was 100 feet above the decision height (based on the radar altimeter). When the decision height was reached, an amber DH indication appeared inside the box and remained there as the helicopter continued to descend. • A yellow rising runway symbol appeared at the bottom center of the ADI at 180 feet (based on the radar altimeter). As the helicopter’s altitude decreased, this symbol ascended until it met the aircraft symbol at 0 feet. • The flight director mode selector’s SBY button was initially illuminated in green. Once the HDG and ALT buttons were selected, they illuminated in green, and the SBY button was no longer illuminated. • The VSI showed a rate of descent of 250 to 300 fpm, which placed the needle below the centerline. • The barometric altimeter showed decreasing altitude by a counterclockwise rotation of the needle. Pilot 1 Selected Altitude Preselect but Did Not Couple the Flight Director The fourth scenario began with FD2 engaged and coupled and with NAV and VS selected on the flight director mode selector. Pilot 2 (in the right seat) transferred control of the helicopter to pilot 1 (in the left seat). Pilot 1 selected FD1 and then CPL on the autopilot controller, which decoupled FD1. With the heading bug, pilot 1 changed the helicopter’s heading 10º to the right. Pilot 1 pressed HDG and ALT PRE on the flight director mode selector and entered the desired altitude (900 feet) into the AL-300. Pilot 1 also pressed VS on the flight director mode selector and entered the desired rate of descent (200 fpm) with the collective. The helicopter descended at that rate until reaching the selected altitude. However, because the power setting was not altered and FD1 was not coupled, the heading change led to a 250- to 300-fpm descent that was maintained after rollout.

Appendix C 71 Aircraft Accident Report The following is a description of what was seen on pilot 1’s instrumentation during this scenario: • A green CPLT FD indication appeared at the top left of the caution/advisory panel, even after FD1 was decoupled. • After the HDG and ALT PRE buttons on the flight director mode selector were selected, a green HDG indication appeared at the top left of the ADI, and a white ALTP (altitude preselect) indication surrounded by a white box appeared at the top right of the ADI. The white ALTP indication changed to a green ALT indication after the selected altitude was reached. • After the VS button on the flight director mode selector was selected, a green VS indication appeared on the left side of the ADI. The green VS indication disappeared after the selected altitude was reached. • The command bars disappeared from the ADI when FD1 was selected. When HDG was selected, the command bars reappeared. The pitch command bar was centered, and the roll command bar was in the neutral position. • The radar altitude appeared in blue at the bottom right of the ADI followed by an RA indication in white. • The decision height was displayed in blue at the bottom left of the ADI followed by a DH indication in white. A white square box appeared above the radar altitude information when the helicopter was 100 feet above the decision height (based on the radar altimeter). When the decision height was reached, an amber DH indication appeared inside the box and remained there as the helicopter continued to descend. • A yellow rising runway symbol appeared at the bottom center of the ADI at 180 feet (based on the radar altimeter). As the altitude decreased, this symbol ascended until it met the aircraft symbol at 0 feet. • The flight director mode selector’s SBY button was initially illuminated in green. Once the HDG button was selected, it illuminated in green, and the SBY button was no longer illuminated. Also, the flight director mode selector’s VS button illuminated in green and the ALT PRE button’s ARM light illuminated in amber to indicate that the helicopter was descending toward the preselected altitude. When the helicopter was near the preselected altitude, the ALT PRE button’s ARM light extinguished, and the CAP (captured) light illuminated in green. Once the helicopter reached the selected altitude, the CAP light extinguished, and the green ALT button illuminated. • The VSI showed a rate of descent of 250 to 300 fpm, which placed the needle below the centerline. • The barometric altimeter showed decreasing altitude by a counterclockwise rotation of the needle.

Appendix C 72 Aircraft Accident Report • At an altitude of 600 feet (300 feet below the preselected altitude), an amber light at the top left of the barometric altimeter illuminated, and an aural tone sounded over the pilots’ headsets for 1 second. The light remained illuminated throughout the rest of the flight.

73 Aircraft Accident Report Appendix D Gulf of Mexico Helicopter Accident Data March 2000 Through February 2006 The following is a list of Gulf of Mexico helicopter accidents from 2000 to February 2006: Date Operator Model Number of injuries Fatal Serious Minor None Part 135 operations 3-20-00 Horizon Helicopters Bell 206 3 5-24-00 Tex-Air Helicopters Eurocopter AS-350 2 5-31-00 Panther Helicopters Bell 206 1 12-26-00 Tarlton Helicopters Bell 206 1 3-20-01 Air Logistics Sikorsky S-76A 1 8 5-4-01 Air Logistics Bell 407 2 8-5-01 Air Logistics Bell 206 3 8-24-01 Air Logistics Bell 206 2 9-26-01 Air Logistics Bell 206 3 10-18-01 Air Logistics Bell 206 3 2 7-25-02 Air Logistics Bell 206 2 8-1-02 Go Helitrans Bell 206 4 1-9-03 Tex-Air Helicopters Aerospatiale AS-350 4 1 1-16-03 Air Logistics Bell 206 1 3 1-21-03 Air Logistics Bell 206 5 2-16-03 Houston Helicopters Bell 407 2 3 2-22-03 Petroleum Helicopters Bell 407 1 1 3-24-03 Petroleum Helicopters Bell 407 2 5-11-03 Petroleum Helicopters Bell 407 4 5-29-03 Tarlton Helicopters Robinson R44 1 7-7-03 Tex-Air Helicopters Aerospatiale AS-350 2 8-13-03 Petroleum Helicopters Bell 206 3 1 1 9-12-03 Go Helitrans Bell 206 1 3 10-10-03 Petroleum Helicopters Bell 206 3 12-1-03 Petroleum Helicopters Bell 407 1 1-28-04 Rotocraft Leasing Company Bell 206 6 3-6-04 Petroleum Helicopters Bell 206 1 2 3-23-04 Era Aviation Sikorsky S-76A 10 6-24-04 American Helicopters Bell 206 3 7-21-04 Omni Energy Services Bell 206 1 2 9-29-04 Panther Helicopters Bell 206 3 11-5-04 Rotocraft Leasing Company Bell 206 1 1 1 12-17-04 Omni Energy Services Bell 407 1 1 2 2-18-05 Rotocraft Leasing Company Bell 206 3

Appendix D 74 Aircraft Accident Report Date Operator Model Number of injuries Fatal Serious Minor None Part 91 operations 6-8-05 American Helicopters Bell 206 4 7-11-05 Chevron/Texaco USA Bell 430 3 9-6-05 Houston Helicopters Sikorsky S-76A 4 6 10-6-05 Industrial Helicopters Bell 206 3 4-29-00 Chevron USA Bell 206 2 9-7-00 Horizon Helicopters Bell 206 1 10-28-00 Tex-Air Helicopters Aerospatiale AS-350 1 12-1-00 American Helicopters Bell 206 1 12-29-00 Petroleum Helicopters Bell 407 1 7-10-01 Air Logistics Sikorsky S-76A 1 11-10-01 Industrial Helicopters Bell 407 1 1-8-02 Air Logistics Bell 206 1 3-23-02 Petroleum Helicopters Bell 206 1 6-29-02 Evergreen Helicopters Bell 206 1 12-31-02 Air Logistics Bell 206 1 3-6-03 Taylor Energy Company Eurocopter AS-350 5 7-8-03 Tex-Air Helicopters Eurocopter EC120 3 7-17-04 Rotocraft Leasing Company Bell 206 1 12-9-04 Evergreen Helicopters Bell 206 1 3-13-05 Rotorcraft Leasing Company Bell 206 1 8-17-05 Air Logistics Bell 206 1 8-18-05 Air Logistics Bell 206 2 2-19-06 Central Helicopters Bell 222 2

FD07315 ｜ 2006_美国_AAR0603.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2006 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

Crash During Approach to Landing Air Tahoma, Inc., Flight 185 Convair 580, N586P Covington, Kentucky August 13, 2004 Aircraft Accident Report NTSB/AAR-06/03 PB2006-910403 Notation 7778 National Transportation Safety Board Washington, D.C.

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Aircraft Accident Report Crash During Approach to Landing Air Tahoma, Inc., Flight 185 Convair 580, N586P Covington, Kentucky August 13, 2004 NTSB/AAR-06/03 PB2006-910403 National Transportation Safety Board Notation 7778 490 L’Enfant Plaza, S.W. Adopted May 2, 2006 Washington, D.C. 20594 E

P L U R IB US UN U M

N A T I O N A L

T R A S P O R T A T I O N

B O A R D S A FE T Y N

National Transportation Safety Board. 2006. Crash During Approach to Landing, Air Tahoma, Inc., Flight 185, Convair 580, N586P, Covington, Kentucky, August 13, 2004. Aircraft Accident Report NTSB/AAR-06/03. Washington, DC. Abstract: This report explains the accident involving Air Tahoma, Inc., flight 185, a Convair 580, N586P, that crashed about 1 mile south of Cincinnati/Northern Kentucky International Airport, Covington, Kentucky, while on approach to runway 36R. Safety issues discussed in this report focus on flight crew performance, fuel crossfeed operations, operating with different fuel boost pump output pressure settings, and cockpit voice recorder power source reliability. Safety recommendations concerning these issues are addressed to the Federal Aviation Administration. A safety recommendation concerning operating with different fuel boost pump output pressure settings is addressed to Transport Canada. The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Web at http://www.ntsb.gov. Other information about available publications also may be obtained from the Web site or by contacting: National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (800) 877-6799 or (202) 314-6551 Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2006-910403 from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605-6000 The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

iii Aircraft Accident Report Contents Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii

1. Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2. 1

History of Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.2 Injuries to Persons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1.3 Damage to Airplane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1.4 Other Damage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1.5 Personnel Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1.5.1 The Captain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1.5.1.1 Flight Test Failure History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.5.2 The First Officer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.5.2.1 Flight Test Failure History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 1.6 Airplane Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 1.6.1 Electrical System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1.6.2 Fuel System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1.6.3 Fuel System Cockpit Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 1.6.3.1 Fuel System Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 1.6.3.2 Prop-Jet Convair Bulletin Regarding Fuel Boost Pump Output Pressures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 1.6.4 Weight and Balance Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 1.7 Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 1.8 Aids to Navigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 1.9 Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1.10 Airport Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1.11 Flight Recorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1.11.1 Cockpit Voice Recorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1.11.1.1 Cockpit Voice Recorder Power Source . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 1.11.1.2 Safety Recommendation A-99-16 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 1.11.2 Flight Data Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 1.11.3 Safety Recommendation A-00-30 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 1.12 Wreckage and Impact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 1.12.1 General Wreckage Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 1.12.2 Fuel Tank System Components and Controls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 1.13 Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 1.14 Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 1.15 Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 1.16 Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 1.16.1 November 2004 Fuel Boost Pump Examinations and Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 1.16.2 April 2005 Fuel Boost Pump Testing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Contents iv Aircraft Accident Report 1.17 Organizational and Management Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 1.17.1 Flight Paperwork Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 1.17.2 Air Tahoma Fuel Crossfeed Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 1.17.2.1 Airplane Manufacturer Fuel Crossfeed Procedures. . . . . . . . . . . . . . . . . . . . . . . 25 1.17.2.2 Nolinor Aviation Fuel Crossfeed Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 1.17.3 Air Tahoma Engine Flameout Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 1.17.4 Postaccident Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 1.18 Additional Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 1.18.1 Previous Convair 580 In-Flight Fuel Imbalance Incident . . . . . . . . . . . . . . . . . . . . 27

1. Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
2. 1

General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 2.2 The Captain’s Preflight Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 2.3 Accident Sequence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 2.4 Convair 580 Fuel Crossfeed Operations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 2.5 Dual Engine Power Loss. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 2.6 Differential Fuel Boost Pump Output Pressures Settings. . . . . . . . . . . . . . . . . . . . . . . . 33 2.7 Cockpit Voice and Image Recorder Requirements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

1. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
2. 1

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 3.2 Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

1. Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
2. 1

New Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 4.2 Previously Issued Recommendation Being Reiterated in This Report. . . . . . . . . . . . . . 39

1. Appendixes

A: Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 B: Cockpit Voice Recorder Transcript . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

v Aircraft Accident Report Figures

1. Schematic of the Convair 580 fuel system. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2. The Convair 580 fuel panel.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
3. The Convair 580 fuel quantity indicators and center pedestal. . . . . . . . . . . . . . . . . . . . . . . . 11

vi Aircraft Accident Report Abbreviations A&P airframe and powerplant AFM aircraft flight manual agl above ground level ARTS automated radar terminal system ASOS automated surface observing system ATC air traffic control ATCT air traffic control tower ATP airline transport pilot CAM cockpit area microphone CFR Code of Federal Regulations CG center of gravity CVG Cincinnati/Northern Kentucky International Airport CVR cockpit voice recorder DME distance measuring equipment FAA Federal Aviation Administration FARs Federal Aviation Regulations FDR flight data recorder FOM flight operations manual fpm feet per minute GOM general operations manual GPWS ground proximity warning system lbs pounds MEM Memphis International Airport MSAW minimum safe altitude warning NDB nondirectional beacon NPRM notice of proposed rulemaking

Abbreviations vii Aircraft Accident Report PIC pilot-in-command PJCB Prop-Jet Convair Bulletin PPI Pacific Propeller, Inc. psi pounds per square inch QRH quick reference handbook SDR service difficulty report STC supplemental type certificate TC Transport Canada TRACON terminal radar approach control TSB Transportation Safety Board of Canada VOR very high frequency omnidirectional range

viii Aircraft Accident Report Executive Summary On August 13, 2004, about 0049 eastern daylight time, Air Tahoma, Inc., flight 185, a Convair 580, N586P, crashed about 1 mile south of Cincinnati/Northern Kentucky International Airport (CVG), Covington, Kentucky, while on approach to runway 36R. The first officer was killed, and the captain received minor injuries. The airplane was destroyed by impact forces. The flight was operating under the provisions of 14 Code of Federal Regulations Part 121 as a cargo flight for DHL Express from Memphis International Airport, Memphis, Tennessee, to CVG. Visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan. The National Transportation Safety Board determines that the probable cause of this accident was fuel starvation resulting from the captain’s decision not to follow approved fuel crossfeed procedures. Contributing to the accident were the captain’s inadequate preflight planning, his subsequent distraction during the flight, and his late initiation of the in-range checklist. Further contributing to the accident was the flight crew’s failure to monitor the fuel gauges and to recognize that the airplane’s changing handling characteristics were caused by a fuel imbalance. The safety issues discussed in this report include flight crew performance, fuel crossfeed operations, operating with different fuel boost pump output pressure settings, and cockpit voice recorder power source reliability. Safety recommendations concerning these issues are addressed to the Federal Aviation Administration. A safety recommendation concerning operating with different fuel boost pump output pressure settings is addressed to Transport Canada.

1 Aircraft Accident Report 1. Factual Information 1.1 History of Flight On August 13, 2004, about 0049 eastern daylight time,1 Air Tahoma, Inc., flight 185, a Convair 580, N586P, crashed about 1 mile south of Cincinnati/Northern Kentucky International Airport (CVG), Covington, Kentucky, while on approach to runway 36R. The first officer was killed, and the captain received minor injuries. The airplane was destroyed by impact forces. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 as a cargo flight for DHL Express2 from Memphis International Airport (MEM), Memphis, Tennessee, to CVG. Visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan. The flight crew was scheduled to fly the accident airplane on a roundtrip sequence from MEM to CVG.3 Flight 185 departed MEM about 2329. The first officer was the flying pilot, and the captain performed the nonflying pilot duties. During postaccident interviews, the captain stated that the takeoff and climb portions of the flight were normal. According to the cockpit voice recorder (CVR) transcript, at 0017:49, the captain stated that he was just going to “balance out the fuel here.”4 The first officer acknowledged. From 0026:30 to 0027:08, the CVR recorded the captain discussing the airplane’s weight and balance with the first officer. Specifically, the captain stated, “couldn’t figure out why on the landing I was out and I was okay on the takeoff.” The captain added, “the momentum is one six six seven and I…put one zero six seven and I couldn’t work it.” He then stated, “so…we were okay all along.”5 At 0030:40, the first officer stated, “weird.” At 0032:31, the captain stated, “okay just let me finish this [the weight and balance paperwork] off and…I’m happy,” and, about 2 minutes later, he stated, “okay, back with you here.” At 0037:08, the captain contacted Cincinnati Terminal Radar Approach Control (TRACON) and reported an altitude of 11,000 feet mean sea level.6 About 1 minute later, the first officer stated, “something’s messed up with this thing,” and, at 0039:07, he asked “why is this thing?” At 0041:21, the 1 Unless otherwise indicated, all times in this report are eastern daylight time. 2 Under a lease agreement, Air Tahoma supplied flight crews and airplanes to DHL to carry freight between several cities on a scheduled basis. 3 The roundtrip sequence departed MEM every night, Monday through Friday, about 2300. The return flight typically departed CVG about 0400. 4 Fuel crossfeeding operations are conducted by the flight crew to balance out the fuel in the airplane’s fuel tanks. For more information about fuel crossfeed operations procedures, see section 1.17.2. 5 For more information about the airplane’s weight and balance and the captain’s calculations see section 1.6.3. 6 Unless otherwise indicated, all altitudes in this report are referenced in mean sea level.

Factual Information 2 Aircraft Accident Report first officer stated that the control wheel felt “funny.” He added, “feels like I need a lot of force. it is pushing to the right for some reason. I don’t know why…I don’t know what’s going on.” The first officer then repeated twice that it felt like he needed “a lot of force.” The CVR did not record the captain responding to any of these comments. At 0043:53, when the airplane was at an altitude of about 4,000 feet, the captain reported to Cincinnati TRACON that he had the runway in sight. The approach controller cleared flight 185 for a visual approach to runway 36R and added, “keep your speed up.”7 The captain acknowledged the clearance and the instruction. The first officer then stated, “what in the world is going on with this plane? sucker is acting so funny.” The captain replied, “we’ll do a full control check on the ground.” At 0044:43, the approach controller again told the captain to “keep your speed up” and instructed him to contact the CVG Air Traffic Control Tower (ATCT). At 0045:11, the captain contacted the CVG ATCT and requested clearance to land on runway 36R, and the local control west controller issued the landing clearance. Flight data recorder (FDR) data indicated that, shortly afterward, the airplane passed through about 3,200 feet, and its airspeed began to decrease from about 240 knots indicated airspeed. At 0045:37, when the airplane was at an altitude of about 3,000 feet, the captain started the in-range checklist,8 stating, “bypass is down. hydraulic pressure. quantity checks. AC [alternating current] pump is on. green light. fuel panel. boost pumps on.” About 0046, the first officer stated, “I’m telling you, what is wrong with this plane? it is really funny. I got something all messed up here.” The captain replied, “yeah.” The first officer then asked, “can you feel it? it’s like swinging back and forth.” The captain replied, “we’ve got an imbalance on this…crossfeed I left open.” The first officer responded, “oh, is that what it is?” A few seconds later, the first officer stated, “we’re gonna flame out.” The captain responded, “I got the crossfeed open. just keep power on.” At 0046:45, the CVR recorded a sound similar to decreasing engine rpm. Immediately thereafter, the first officer stated, “we’re losing power.” At 0046:52, the first officer stated, “we’ve lost both of them. did we?” The captain responded, “nope.” FDR data showed that, about 1 second later, a momentary electrical power interruption occurred when the airplane was at an altitude of about 2,400 feet. At 0046:55, the CVR stopped recording. Airplane performance calculations indicated that, shortly after the power interruption, the airplane’s descent rate was about 900 feet per minute (fpm). According to air traffic control (ATC) transcripts, at 0047:12, the captain reported to the CVG ATCT that the airplane was “having engine problems.” The local control west controller asked, “you’re having engine problems?” The captain replied, “affirmative.” At 7 During postaccident interviews, the approach controller stated that he instructed the flight crew to “keep the speed up” because he thought that Air Tahoma flight crews had a tendency to decrease the airspeed too early in the approach and that he wanted to prevent that from occurring. 8 Air Tahoma’s Flight Operations Manual (FOM) states that the in-range checklist should be performed before “leaving 12,000 feet” and that “early completion [of the checklist] will minimize cockpit distractions.” The in-range checklist includes a step to check the fuel panel settings. For a schematic of the Convair 580 fuel panel, see section 1.6.2.1, figure 2.

Factual Information 3 Aircraft Accident Report 0047:28, the controller asked the captain if he needed emergency equipment, and the captain replied, “negative.’” This was the last transmission received by ATC from the accident flight crew. The FDR continued recording until about 0049. The wreckage was located about 1.2 miles short of runway 36R. 1.2 Injuries to Persons Table 1. Injury chart. Note: Title 14 CFR 830.2 defines a serious injury as any injury that (1) requires hospitalization for more than 48 hours, starting within 7 days from the date that the injury was received; (2) results in a fracture of any bone, except simple fractures of fingers, toes, or the nose; (3) causes severe hemorrhages or nerve, muscle, or tendon damage; (4) involves any internal organ; or (5) involves second- or third-degree burns or any burns affecting more than 5 percent of the body surface. A minor injury is any injury that does not qualify as a fatal or serious injury. 1.3 Damage to Airplane The airplane was destroyed by impact forces. 1.4 Other Damage Trees and a portion of a golf course along the wreckage path were damaged by the impact. 1.5 Personnel Information 1.5.1 The Captain The captain, age 49, was hired by Air Tahoma on July 19, 2004. The captain held both Federal Aviation Administration (FAA)- and Transport Canada (TC)-issued pilot licenses and certificates.9 The captain’s FAA-issued certificates included an airframe and powerplant (A&P) certificate (issued February 25, 1982), a flight engineer certificate (issued January 26, 1988),10 and a multiengine airline transport pilot (ATP) certificate Injuries Flight Crew Cabin Crew Passengers Other Total Fatal 1 0 0 0 1 Serious 0 0 0 0 0 Minor 1 0 0 0 1 None 0 0 0 0 0 Total 2 0 0 0 2 9 The captain is a citizen of Canada.

Factual Information 4 Aircraft Accident Report (issued February 11, 2003) with a Convair 340/440 type rating (issued May 9, 2003).11 The captain held a first-class FAA airman medical certificate, dated April 16, 2004, with the limitation that he “must possess glasses for near vision.” The captain’s TC-issued certificates included a flight engineer certificate (issued December 28, 1983) and a commercial pilot certificate (issued May 7, 1997). The captain had Canadian aircraft (type) ratings in the Convair 580 and the Lockheed L-1011. Table 2 shows the employment information reported by the captain on the job application that he filled out for Air Tahoma. Table 2. Employment information for the captain. a The captain began working for Air Transat as a flight engineer. He upgraded to first officer in May 1999. He flew a total of about 104 hours before cutbacks at Air Transat caused him to return to the flight engineer position. In December 2003, the captain failed a first officer requalification proficiency checkride, and he chose to receive a severance package from Air Transat rather than return to the flight engineer position. b While working at Air Transat, the captain took leave to fly under contract as first officer or captain for various companies. 10 The flight engineer certificate was a special purpose lessee with the limitation that the certificate was valid for U.S.-registered civil Lockheed L-1011s leased to Gulf Air Airlines, Bahrain, United Arab Emirates. The certificate was issued under and subject to 14 CFR 63.23 and subject to the privileges and limitations shown on the holder’s foreign flight engineer certificate, license, or authorization. 11 The FAA uses the rating designation “Convair 340/440” on a pilot’s airman certificate when the pilot is rated in the Convair 340/440 or the Convair 580. Employment date Employer Job position Airplane type 1981 to 1983 Chevron Corporation, Khartoum, Sudan Maintenance engineer Convair 580 1983 to 1985 Northwest Territorial Airways, Yellowknife, Northwest Territories, Canada Flight engineer Lockheed Electra 1985 to 1987 Nationair, Montreal, Canada Flight engineer Douglas DC-8 1987 to 1993 Gulf Air Airlines, Bahrain, United Arab Emirates, and All Nippon Airways, Tokyo, Japan Flight engineer Lockheed L-1011 April 1993 to December 2003 Air Transat, Montreal, Canada Flight engineer/first officera Lockheed L-1011 1998 (6 months) Air Wave Transport, Toronto, Canada First officer Convair 580 1999 to 2003 (several months per year)b Nolinor Aviation, Montreal, Canada First officer Convair 580 November 2002 to July 2003 Coastal Air Transport, Mobile, Alabama Captain Convair 580 Summer 2003 ConAir, Abbotsford, British Columbia, Canada First officer Convair 580

Factual Information 5 Aircraft Accident Report Air Tahoma records indicated that the captain had accumulated 2,500 total flight hours, including 1,337 hours in the Convair 580, 88.5 hours of which were as pilot-in-command (PIC). He had flown about 32, 28, and 2 hours in the 90 days, 30 days, and 24 hours, respectively, before the accident. The captain’s last Convair 580 proficiency and line checks occurred on July 29, 2004. In accordance with 14 CFR 121.405(d), the captain attended an FAA-approved reduced training course at Air Tahoma because of his previous Part 121 experience in the Convair 580 at Coastal Air Transport. A search of FAA records indicated no accident or incident history or enforcement action, and a search of the National Driver Register found no record of driver’s license suspension or revocation. The captain stated that, during the 72 hours before the accident, he stayed at Air Tahoma’s crew house in Memphis. He stated that he typically slept until about noon after returning from flights in the morning (about 0500 central daylight time). The captain stated that, on the day of the accident, he watched television from about 1600 to 2100 central daylight time and then checked in at MEM for the accident flight. The captain stated that he did not feel tired during the accident flight but that he was “preoccupied” with and “stressed” about calculating the airplane’s weight and balance. A company mechanic who routinely met both the captain and the first officer before and after trips stated that they both appeared normal, alert, and “not dragging” before the accident flight. The captain stated that he was in good health and that he did not take any medications. 1.5.1.1 Flight Test Failure History On February 7, 2003, the captain received a notice of disapproval from the FAA because he failed the precision instrument approach portion of the flight test for his ATP certificate. On February 11, 2003, the captain was retested successfully, and he received his ATP certificate. On May 8, 2003, the captain received a notice of disapproval from the FAA because he failed the nondirectional beacon (NDB) approach portion of the flight test for his Convair 580 type rating. On May 9, 2003, the captain was retested successfully, and he received his Convair 580 type rating. 1.5.2 The First Officer The first officer, age 37, was hired by Air Tahoma on May 5, 2004. The first officer held an A&P certificate (issued May 8, 1996), a commercial pilot certificate with single- and multiengine land ratings (issued February 7, 2002), and a flight instructor certificate (issued April 10, 2002). The first officer held a first-class FAA airman medical certificate dated December 16, 2003, with no limitations. Table 3 shows the employment information reported by the first officer on the job application that he filled out for Air Tahoma.

Factual Information 6 Aircraft Accident Report Table 3. Employment information for the first officer. a In August 2001, the first officer was laid off from Ryan International. In December 2002, Ryan International rehired him. Air Tahoma and Ryan International records indicated that the first officer had accumulated 2,488 total flight hours, 1,564 hours of which were as a flight engineer, and 924 hours of which were as PIC or first officer. The first officer had accumulated 145 hours in Convair 580 airplanes. He had flown about 145, 70, and 2 hours in the 90 days, 30 days, and 24 hours, respectively, before the accident. The first officer’s last Convair 580 proficiency and line checks occurred on May 26, 2004. FAA records indicated no accident or incident history or enforcement action, and a search of the National Driver Register found no record of driver’s license suspension or revocation. The first officer operated all of the flights from MEM to CVG from August 9 to 13, 2005, and all of these flights were in the accident airplane. According to a family member, on August 12, the first officer returned home about 0700 central daylight time and slept until about 1530 central daylight time. Later that day, he went to his son’s football practice and ate dinner before checking in for the flight. A company mechanic reported that the first officer appeared to be wide awake and alert before the flight and that he had sufficient time to complete his preflight activities. The family member reported that the first officer did not use alcohol or take any medications. 1.5.2.1 Flight Test Failure History On November 14, 2001, the first officer received a notice of disapproval from the FAA because he failed the steep turns, compliance with departure and arrival procedures, distance measuring equipment (DME) arc approach, and NDB approach portions of the flight test for his instrument rating. The first officer was retested successfully on November 19, 2001, and he received his instrument rating. On April 10, 2002, the first officer received a notice of disapproval from the FAA because he failed the ground reference maneuvers portion of the flight test for his flight instructor certificate. The first officer was retested successfully that day, and he received his flight instructor certificate. Employment date Employer Job position Airplane type January 1997 to August 2001 Ryan International Airlines, Wichita, Kansas Flight engineer Boeing 727 April 2002 to March 2004 Douglas Aviation, Olive Branch, Mississippi Flight instructor N/A July 2002 to April 2003 Air Venture Flying Club, Olive Branch, Mississippi Flight instructor Cessna 152 and 172 December 2002a to February 2004 Ryan International Airlines Flight engineer Boeing 727

Factual Information 7 Aircraft Accident Report 1.6 Airplane Information The accident airplane, serial number 068, was manufactured in 1953 by General Dynamics, Convair Division, and was originally designated “Convair 340/440.” In 1967, the airplane was made to comply with Supplemental Type Certificate (STC) SA41100,12 changing its designation to “Convair 580.”13 Air Tahoma purchased the airplane from European Air Transport in Belgium on April 27, 2004; at which time, the airplane was flown to the company’s maintenance facility at Rickenbacker International Airport, Columbus, Ohio. From April 28 to July 15, 2004, the airplane underwent a conformity and acceptance inspection, a C check (maintenance inspection), and serial number verification before being operated in the United States.14 Maintenance records indicate that, during these inspections, most of the airplane’s replaceable components were replaced because of inadequate time and service history information and that all of the fuel system components, except for the right fuel boost pump, were replaced with overhauled units.15 The FAA issued a standard airworthiness certificate for the airplane on July 14, 2004. At the time of the accident, the airplane had accumulated about 67,886 total flight hours. The accident airplane was configured with five containerized pallets in the fuselage for all-cargo operations.16 There were four cargo stops (one in each of the floor tracks) at the aft and forward ends of the fuselage. Each cargo stop was secured to floor tracks in the airplane’s interior by two latches. Four cargo locks, which raised up and locked the pallets into position, were between each pallet (16 locks total). Each lock was secured to the floor tracks by two latches. In compliance with STC SA41100, the airplane was equipped with two Rolls-Royce 501-D13D turbopropeller engines. The time since new for the left engine was 41,232 hours, and the time since overhaul was 4,808 hours. The time since new for the right engine was 24,055 hours, and the time since overhaul was 1,858 hours. The airplane was equipped with Aeroproducts model A6441FN-606A propellers. The right propeller 12 In 1960, STC SA41100 was developed to install two Rolls-Royce (formerly Allison Gas Turbines) 501-D13D turbopropeller engines on the Convair 340/440, and the airplane model’s designation was changed to Convair 580. Currently, about 26 Convair 580 airplanes are in operation in the United States. 13 General Dynamics, Convair Division, held the Convair 580 type certificate until 1995; at which time, the type certificate was transferred to Tracor Flight Systems. In 1998, the type certificate was transferred to Kelowna Flightcraft Ltd., British Columbia, Canada. 14 The conformity and acceptance inspection was conducted in accordance with Air Tahoma’s FARs [Federal Aviation Regulations] 121 Conformity Check and Acceptance Manual, dated January 8, 1999; the C check was performed in accordance with Air Tahoma’s FAA-approved maintenance program; and the serial number verification was performed in accordance with Air Tahoma’s FARs 121 Conformity CV-580 Serial Number Verification document. 15 Maintenance records indicated that the right fuel boost pump had been replaced by Canadian Aero Accessories Ltd., Calgary, Alberta, Canada, in February 2003. For more information about the airplane’s fuel system, see section 1.6.2. 16 The Convair 580 was originally configured as a 52-seat passenger airplane.

Factual Information 8 Aircraft Accident Report was overhauled in January 2002, and the left propeller was overhauled in May 2003 by Pacific Propeller, Inc. (PPI),17 Kent, Washington. 1.6.1 Electrical System The airplane had a 28-volt d.c. electrical system and a 115/200-volt a.c. electrical system. The d.c. electrical system had two engine-driven power generators, and the a.c. electrical system had two engine-driven alternators. Each engine had one d.c. generator and one a.c. alternator. The electrical system was designed to automatically revert to battery power if both d.c. generators and a.c. alternators shut down in flight. When this occurs, the a.c. electrical system is powered by the batteries through the d.c. electrical system and an inverter. 1.6.2 Fuel System The Convair 580 fuel system comprises two subsystems, one for each wing-mounted engine. Each fuel subsystem has a wing fuel tank, which is fueled through a fuel filler cap and mating adaptor located under a cover plate on the upper surface of each wing.18 Fuel is supplied from each fuel tank via fuel lines, which pass through the tank wall, a fuel tank shutoff valve, and an electric fuel boost pump, to its respective engine. (Figure 1 shows a schematic of the Convair 580 fuel system.) The electric fuel boost pump supplies pressurized fuel to its respective engine and to the crossfeed fuel line. The fuel boost pump supplies fuel at an output pressure of about 15 to 21 pounds per square inch (psi) at a rate of about 640 gallons per hour. The airplane’s two fuel subsystems are connected by a crossfeed system consisting of two electrically operated crossfeed valves, which allows both engines to be supplied with fuel from either fuel tank.19 17 PPI holds the type certificate for the propellers. 18 Each fuel tank has an 865-gallon capacity, four capacitance transmitters, and one compensator for fuel quantity indication in the cockpit. 19 For information about Air Tahoma’s fuel crossfeed procedures, see section 1.17.2.

Factual Information 9 Aircraft Accident Report

Figure 1. Schematic of the Convair 580 fuel system. 1.6.3 Fuel System Cockpit Instrumentation The airplane’s fuel system cockpit instrumentation includes the fuel panel, fuel quantity indicators, and fuel system warning annunciator lights. The fuel panel, which is located on the captain’s overhead instrument panel, has an emergency power-off switch and three cover-guarded switches: two fuel tank shutoff valve switches and one fuel crossfeed valve switch. Figure 2 shows the Convair 580 fuel panel. L.M. EMERGENCY MECHANICAL CONTROLS DRAIN LINES R.M. EMERGENCY CROSSFEED VALVE FUEL TANK SHUTOFF VALVES EMER. FIREWALL SHUTOFF VALVE ENGINE FUEL BOOST PUMP A.C. BOOST PUMP PRESSURE SWITCH LEFT WING LEFT ENGINE RIGHT WING RIGHT ENGINE ENGINE-DRIVEN FUEL PUMP

Factual Information 10 Aircraft Accident Report Figure 2. The Convair 580 fuel panel. The fuel quantity indicators are located on the lower part of the center instrument panel and behind the center pedestal, which includes the engine throttle control console and the gust lock levers. (Figure 3 shows the fuel quantity indicators behind the center pedestal.) The three fuel system warning annunciator lights for each engine (primary fuel pump failure, low engine fuel boost pressure, and aircraft fuel boost pressure) are located on the center pedestal annunciator panel. CIRCUIT BREAKERS For the respective valve. NOTE: Power for those circuit breakers comes from the Fuel Shut Off Valves Circuit Breaker on the Essential D.C. Bus. TANK SHUT OFF VALVE SWITCHES Opens and closes the respective motor acutated fuel tank shut off valve. FUEL CROSS FEED VALVE SWITCH Opens and closes both motor actuated cross feed valves. EMERGENCY POWER OFF SWITCH Turn power on and off to the cross feed and fuel tank shut off valves. Because they are motor actuated valves, these valves will remain in the position they are in at the time this switch is turned off. FUEL TRANSFER FROM TANK TO TANK IS PROHIBITED WHEN OPERATING WITH THE CROSSFEED SYSTEM. TURN OFF FUEL VALVE FOR TANK NOT BEING USED. FUEL PANEL FUEL TANK No1 FUEL TANK No2 CROSS FEED VALVES CLOSED CROSS FEED VALVES NORMAL OFF O P E N C L S E D O P E N C L S E D O P E N SHUT OFF VALVES LH RH LH RH SHUT OFF VALVES EMERGENCY POWER OFF ENG NO. 1 ENG NO. 2

Factual Information 11 Aircraft Accident Report Figure 3. The Convair 580 fuel quantity indicators and center pedestal. Postaccident interviews with Air Tahoma personnel and an inspection of another Convair 580 revealed that, at some seat positions, it was difficult to see the fuel quantity indicators. Specifically, if the seats were in an aft position, the indicators were difficult to see because the throttle control console and the gust lock lever partially blocked the indicators. The inspection revealed that, in the aft position, a pilot had to sit up and lean forward to completely see the fuel quantity indicators. 1.6.3.1 Fuel System Limitations The FAA-approved Aircraft Flight Manual (AFM), dated April 5, 1962,20 contains the following caution: DO NOT ATTEMPT TO TRANSFER FROM ONE TANK TO ANOTHER. TO DO SO MIGHT BUILD UP EXCESSIVE PRESSURE IN A TANK, WHICH COULD RESULT IN STRUCTURAL FAILURE OR CAUSE FUEL TO OVERFLOW THROUGH THE VENTS. 20 The AFM used by Air Tahoma was issued by the airplane manufacturer, General Dynamics, Convair Division. Fuel Quantity Indicators

Factual Information 12 Aircraft Accident Report The Convair 580 type certificate data sheet indicated that a placard stating, “Fuel transfer from tank to tank is prohibited. When operating with the crossfeed system, turn off fuel valve for tank not being used,” must be displayed on the instrument panel in full view of the pilot. The Air Tahoma CV-580 Flight Operations Manual (FOM), Section 1.000, “Limitations,” states that transferring fuel from one tank to another tank is prohibited and that crossfeeding fuel is prohibited during takeoff and landing (unless an engine cannot be fed from its respective tank). The manual states that the maximum permissible lateral fuel imbalance in flight is 2,080 pounds (lbs) and that the maximum demonstrated lateral fuel imbalance during takeoff and landing is 600 lbs. 1.6.3.2 Prop-Jet Convair Bulletin Regarding Fuel Boost Pump Output Pressures Prop-Jet Convair Bulletin (PJCB) 10-21, “Aircraft Fuel Boost Pump Output Pressure Limit-Reduce,” dated October 10, 1969, provided details on an optional procedure that allowed Convair operators to reduce the typical fuel boost pump output pressure setting of 21 psi to 15 psi. The bulletin stated that reducing the output pressure would “improve the service life of the aircraft fuel boost pump motors.” The bulletin also stated that the low fuel boost pump pressure warning switch would have to be replaced with a switch that would actuate at a decreasing pressure of 9 psi and an increasing pressure of 10 psi. The bulletin stated that, although aircraft could be operated with different fuel boost pump output pressure settings and switches, “preferably, aircraft should be operated with identical boost pump pressure settings and switches, of either configuration, on both sides.” Postaccident examinations revealed that the accident airplane’s right fuel boost pump was set to an output pressure of 15 psi21 and that its left fuel boost pump was set to an output pressure of 20 psi. Air Tahoma stated that it was unaware of PJCB 10-21, and, therefore, was not aware of the possibility that its Convair 580 airplanes were operating with different fuel boost pump output pressure settings. In its July 18, 2005, submission, Air Tahoma indicated that, after the accident, the company checked all of its airplanes’ fuel boost pump pressure output pressure settings and switches and set all of the output pressure settings to 21 psi. 1.6.4 Weight and Balance Information Title 14 CFR 121.665, “Load Manifest,” states, in part, the following: Each certificate holder is responsible for the preparation and accuracy of a load manifest form before each takeoff. The form must be prepared and signed for each flight by employees of the certificate holder who have the duty of supervising the loading of aircraft and preparing the load manifest forms or by other qualified persons authorized by the certificate holder. 21 Examinations also revealed that the airplane’s right low boost pump pressure warning switch was set at 9 psi. For more information about the postaccident fuel boost pump examinations, see section 1.16.1.

Factual Information 13 Aircraft Accident Report Title 14 CFR 121.693, “Load Manifest: All Certificate Holders,” states, in part, that the load manifest must contain the weight of the aircraft, fuel and oil, cargo and baggage, passengers, and crewmembers; the maximum allowable weight for the flight; the total weight calculated using FAA-approved company procedures; and evidence that the aircraft was loaded in accordance with an approved schedule that ensures that the CG is within limits. Title 14 CFR 121.695, “Disposition of Load Manifest, Dispatch Release, and Flight Plans: Domestic and Flag Operations,” states, in part, that the pilot must carry copies of the completed load manifest, dispatch release, and flight plan in the airplane. Two load manifests were found at the accident site; however, the captain did not leave a load manifest at the departure station, which is required by company procedures and Federal regulations.22 The captain stated during postaccident interviews that he usually left a yellow copy of the load manifest at the departure station. However, the captain stated that he did not leave a copy of the load manifest at MEM before the accident flight departed because he had to manually calculate the airplane’s weight and balance, and the calculations were not completed before takeoff.23 The captain left a signed copy of a load sheet,24 which showed the weight of the cargo loaded in each of the airplane’s five cargo containers (labeled A through E) and the location at which each container should be loaded on the airplane, with the cargo loaders at MEM. He stated that the total cargo weight was not near the maximum allowable. He added that the load was “an average load” and that he used his “general experience” to determine whether the airplane was within weight and balance limits before takeoff. For example, the captain stated that, during the preflight check, he noted that the airplane sat “properly” on the nose landing gear strut. Both load manifests found at the accident site had the accident flight number, accident flight date, and numerous crossouts on them. One of the manifests was not signed by the captain and indicated weights and cargo locations that corresponded to those on the load sheet he left at MEM. The other load manifest was signed by the captain and did not indicate weights and cargo locations that corresponded to those on the load sheet. Table 4 shows the information listed on each of the load manifests found at the accident site. 22 For more information about Air Tahoma’s procedures on the preparation and disposition of weight and balance paperwork, see section 1.17.1. 23 Air Tahoma’s handheld company computer was not working before the flight departed. Air Tahoma’s ground school instructor stated the captain was not trained to manually compute an airplane’s weight and balance because he had attended the company’s reduced training course. In its submission, Air Tahoma indicated that, after the accident, the company provided followup training to its flight crewmembers on how to compute weight and balance with and without the handheld computer and emphasized the importance of leaving a copy of the weight and balance paperwork at the departure station. 24 The load sheet that the captain left at MEM was not an official document nor was it mentioned in company manuals or procedures; rather, it was an informal document used between Air Tahoma flight crews and cargo loaders.

Factual Information 14 Aircraft Accident Report Table 4. Accident airplane weight and balance information. a According to Air Tahoma’s Convair 580 Cargo Weight & Balance Loading Manual, the maximum certificated takeoff weight for the accident airplane was 58,156 lbs. b A moment is a force that tries to cause rotation and is the product of weight (in pounds) and distance from the CG (in inches). c Using the CV-580 CG Limits Table contained in the Air Tahoma loading manual and assuming a takeoff weight of about 54,200 lbs, Safety Board investigators determined that the takeoff CG limits for the accident flight were about 20,408 forward and 21,127 aft. d The fuel burn moment appeared to have been written as 1,067 and then rewritten as 1,667. According to Air Tahoma’s Convair 580 Cargo Weight & Balance Loading Manual, the correct moment for a fuel burn of 4,200 lbs was 1,667. e The landing moment of 20,030 corresponds to the originally written fuel burn moment of 1,067, and the landing moment of 19,430 corresponds to the rewritten fuel burn moment of 1,667. 1.7 Meteorological Information Weather observations at CVG were made every hour by an automated surface observing system (ASOS).25 About 0015, the ASOS reported that visibility was 10 statute miles, clouds were overcast at 7,500 feet above ground level (agl), and winds were 320° at 5 knots. 1.8 Aids to Navigation The DME on the CVG VOR26 was inoperative. No problems with any other navigational aids were reported. Unsigned load manifest Signed load manifest Cargo weight (pounds) 12,400 12,400 Fuel weight (pounds) 7,600 7,900 Takeoff weight (pounds) 54,213a 54,513 Takeoff moment/1,000b 21,073 21,118 Takeoff center of gravity (CG) limits (moment/1,000)c 19,638 (forward)/20,386 (aft) 20,571 (forward)/21,283 (aft) Fuel burn (pounds) 4,200 4,200 Fuel burn moment/1,000 1,067/1,667d 1,667 Landing weight (pounds) 50,013 50,313 Landing moment/1,000 20,030/19,430e 19,451 Landing CG limits (moment/1,000) 18,752 (forward)/19,529 (aft) 18,872 (forward)/19,645 (aft) 25 ASOS is a system that continuously measures weather information, including wind speed and direction, visibility, precipitation, cloud cover, temperature, dew point, and altimeter setting. 26 VOR stands for very high frequency omnidirectional range.

Factual Information 15 Aircraft Accident Report 1.9 Communications No communications problems between the pilots and any of the air traffic controllers who handled the accident flight were reported. 1.10 Airport Information CVG is located about 9 miles south of Cincinnati, Ohio, at an elevation of 896 feet. The airport has three runways: runway 18L/36R, 18R/36L, and 9/27. All of the runways have high-intensity runway and centerline lights. Runway 18L/36R has a standard 2,400-foot, high-intensity lighting system with sequenced flashers27 and a precision approach path indicator on its right side. CVG is equipped with an automated radar terminal system (ARTS)-IIIA radar data processing system, which includes a minimum safe altitude warning (MSAW) capability that monitors aircraft separation from terrain and other obstacles. If an aircraft descends below or is predicted to descend below a prescribed minimum altitude, the MSAW provides air traffic controllers with both visual and aural alerts. The minimum altitude at which the MSAW alerts controllers varies according to geographic location. CVG’s ARTS-III system did not activate an MSAW alert around the time of the accident.28 1.11 Flight Recorders 1.11.1 Cockpit Voice Recorder The accident airplane was equipped with a Honeywell Sundstrand V557 model CVR, serial number 2372. The exterior of the CVR was not structurally damaged. The CVR was sent to the Safety Board’s laboratory in Washington, D.C., for readout and evaluation. The tape was played back normally and without difficulty. The recording started at 0016:03 and continued until 0046:55. The recording consisted of three separate channels of audio information: the captain and first officer audio panels and the cockpit area microphone (CAM). The captain audio panel information was excellent quality, the first officer audio panel information was good quality, and the CAM information was poor quality.29 A transcript was prepared of the entire 30-minute, 52-second recording (see appendix B). 27 A notice to airmen recorded by the CVR at 0030:41 indicated that the sequenced flashers on runway 36R were out of service. 28 Radar coverage of the accident airplane should have been available to the ground; however, the airplane descended below radar coverage before the ARTS-III system could detect whether the airplane was below the minimum safe altitude or predict whether it would descend below the minimum safe altitude. 29 The Safety Board rates the quality of CVR recordings according to a five-category scale: excellent, good, fair, poor, and unusable. See appendix B for a description of these ratings.

Factual Information 16 Aircraft Accident Report 1.11.1.1 Cockpit Voice Recorder Power Source Title 14 CFR 121.359(a) requires airplanes to be equipped with a CVR system that operates “continuously from the start of the use of the checklist (before starting engines for the purpose of flight) to completion of the final checklist at the termination of the flight.” The CVR on the accident airplane was installed in 1966 by Allegheny Airlines, Inc., Middleton, Pennsylvania, in accordance with Engineering Order 66-16c, Revision A, which required changing the wiring “to provide an isolated power source for the [CVR]…to comply with FAR [Federal Aviation Regulations] 121.359.” The accident CVR was designed to receive sufficient power to operate when both engine power levers are at or above flight idle. When the engine power levers are in the low-speed range or shut down and the low-rpm buttons, which are located on the center pedestal, are pushed in by the flight crew, the low-rpm relays are energized, and the batteries provide power to the CVR.30 However, when both engines are in the low-speed range or shut down and the low-rpm buttons are not pushed in by the pilot, no power is provided to the CVR. 1.11.1.2 Safety Recommendation A-99-16 On March 9, 1999, as a result of its longstanding concerns about the loss of critical flight information following interruption of electrical power to the CVR or FDR, the Safety Board issued Safety Recommendation A-99-16,31 which asked the FAA to do the following: Require retrofit after January 1, 2005, of all CVRs on all airplanes required to carry both a CVR and an FDR with a CVR that…is capable of recording the last 2 hours of audio, and…is fitted with an independent power source that is located with the digital CVR and that automatically engages and provides 10 minutes of operation whenever aircraft power to the recorder ceases, either by normal shutdown or by a loss of power to the bus. The safety recommendation letter cited the investigation of the September 2, 1998, Swissair flight 111 accident, which was conducted by the Transportation Safety Board of Canada (TSB) with the participation of the Safety Board,32 as the most recent investigation that had been “severely hampered” by the lack of critical flight information and noted that “Since 1983, there have been 52 accidents and incidents in which 30 When the engine power levers are moved from the low-speed range to a higher speed range, power is automatically removed from the low-rpm relays, the low-rpm buttons are automatically released, and the CVR transitions to electrical power from the engine alternators. Most turbopropeller airplanes have battery-operated CVR systems and are not equipped with circuitry like that installed on the accident airplane. 31 In 1999, Safety Recommendation A-99-16 was placed on the Safety Board’s List of Most Wanted Transportation Safety Improvements. For more information about Safety Recommendation A-99-16 and the Most Wanted list, see the Board’s Web site at http://www.ntsb.gov. 32 In accordance with the provisions of Annex 13 to the Convention on International Civil Aviation, the Safety Board participated in the TSB’s investigation as the representative of the State of Design and Manufacture.

Factual Information 17 Aircraft Accident Report information from either the CVR or FDR or both were lost due to interruption of electrical power following an engine or generator failure or crew action.” In a March 19, 1999, letter, the FAA stated that it would issue a notice of proposed rulemaking (NPRM) to address Safety Recommendation A-99-16. In a July 21, 2001, letter, the Safety Board stated that the FAA had made little progress to address the recommendation since its issuance 2 years previously. Therefore, the Board classified Safety Recommendation A-99-16 “Open—Unacceptable Response,” pending issuance of an NPRM and expeditious issuance of a final rule. On February 28, 2005, the FAA published an NPRM titled, “Revisions to Cockpit Voice Recorder and Digital Flight Data Recorder Regulations,” which proposed requiring that all CVRs record a minimum of 2 hours of audio information. The NPRM stated that all newly manufactured aircraft would be required to be equipped with a 2-hour CVR within 2 years of the issuance of a final rule and that all existing aircraft would be required to be retrofitted with a 2-hour CVR within 4 years of the issuance of the rule. The NPRM also proposed a requirement to install a 10-minute independent power source for CVRs on newly manufactured aircraft. In an April 29, 2005, letter, the Safety Board stated that it was pleased about the FAA’s proposed actions to require 2-hour CVRs on all aircraft within 4 years. However, the Board stated that it was disappointed that the proposed requirement to install a 10-minute independent CVR power source only applied to newly manufactured aircraft. The Board suggested that the FAA require the installation of an independent CVR power source on all aircraft within 4 years of the final rule. Safety Recommendation A-99-16 remains classified “Open—Unacceptable Response,” pending the suggested rule change. 1.11.2 Flight Data Recorder The accident airplane was equipped with a Honeywell model 980-4100 FDR, serial number 7657 that used a magnetic tape as the recording medium. The FDR system was designed to record six parameters.33 The FDR was sent to the Safety Board’s laboratory for readout and evaluation. The FDR was found to be in good condition, and the data were extracted normally. About 25 hours of data were recorded by the FDR, including data for the accident flight. About 0047, the airplane’s electrical power was interrupted, which caused a momentary dropout of the FDR data. The FDR stopped recording about 0049. 33 Turbine-powered, transport-category aircraft manufactured on or before October 11, 1991, are required to be equipped with an FDR that records a minimum of 11 parameters in accordance with 14 CFR 121.344. However, the accident FDR only recorded six parameters. The six parameters recorded and verified were time, airspeed, pressure altitude, vertical load factor, magnetic heading, and microphone keying.

Factual Information 18 Aircraft Accident Report 1.11.3 Safety Recommendation A-00-30 On April 11, 2000, as a result of longstanding concerns about the loss of critical flight recorder data, the Safety Board issued Safety Recommendation A-00-30, which asked the FAA to do the following: Require that all aircraft operated under…14 Code of Federal Regulations Part 121, 125, or 135 and currently required to be equipped with a cockpit voice recorder (CVR) and digital flight data recorder (DFDR) be retrofitted by January 1, 2005, with a crash-protected cockpit image recording system.[34] The cockpit image recorder system should have a 2-hour recording duration, as a minimum, and be capable of recording, in color, a view of the entire cockpit including each control position and each action (such as display selections or system activations) taken by people in the cockpit. The recording of these video images should be at a frame rate and resolution sufficient for capturing such actions. The cockpit image recorder should be mounted in the aft portion of the aircraft for maximum survivability and should be equipped with an independent auxiliary power supply that automatically engages and provides 10 minutes of operation whenever aircraft power to the cockpit image recorder and associated cockpit camera system ceases, either by normal shutdown or by a loss of power to the bus. The circuit breaker for the cockpit image recorder system, as well as the circuit breakers for the CVR and the DFDR, should not be accessible to the flight crew during flight. In a March 29, 2004, letter, the FAA stated that flight recorder-related safety recommendations continued to be difficult to respond to in a manner that the Safety Board would find acceptable. The FAA also stated that flight recorder-related safety recommendations presented unique challenges, including difficulties in cost/benefit analysis, technical hurdles, retrofit problems, data use issues, and privacy concerns. On June 3, 2004, FAA and Safety Board staff met to discuss previously issued flight recorder-related safety recommendations, including Safety Recommendation A-00-30. In a December 15, 2004, letter, the Safety Board noted that, although the meeting was constructive, the substance of the safety recommendations and the FAA’s planned actions in response to them were not discussed; therefore, the Board classified Safety Recommendation A-00-30 “Open—Unacceptable Response.” In its April 29, 2005, response to the February 2005 flight recorder-related NPRM, the Safety Board stated that it was disappointed that the FAA had not addressed image recorders in the NPRM. The Board also stated that image recorders would have provided in-depth information about the facts, conditions, and circumstances surrounding numerous accidents. The Board restated its opinion that image recorders could play a key role in accident investigations by providing critical human performance and cockpit environment information that would otherwise be unavailable. The Board encouraged the FAA to move 34 Image recorders obtain audio information (similar to that recorded by CVRs), event data (similar to that recorded by FDRs), and information about the environment inside the cockpit and outside the cockpit window.

Factual Information 19 Aircraft Accident Report quickly to implement Safety Recommendation A-00-30. On January 24, 2006, the Safety Board reiterated Safety Recommendation A-00-30 as a result of its investigation of the October 19, 2004, Corporate Airlines flight 5966 accident in Kirksville, Missouri.35 1.12 Wreckage and Impact Information 1.12.1 General Wreckage Description The airplane initially impacted the top of a stand of trees, which exhibited a few clean, angled cuts, about 40 feet agl. The airplane impacted the ground about 308 feet north of the initial impact point. The airplane then impacted a grove of trees about 420 feet from the initial impact point, where the aft fuselage came to rest, about 1.2 miles short of the approach end of runway 36R. The forward fuselage was scattered about 200 feet beyond the edge of the grove. The total wreckage path was about 600 feet long. The forward half of the airplane and most of the wing structure were destroyed. The airplane’s forward fuselage was found essentially split in half about a vertical plane that extended from the nose to near the wing rear spar. The right half of the forward fuselage remained partially attached to the rear fuselage but was severely damaged by impact forces. Most of the left half of the forward fuselage was found severed from the rest of the airplane and in several sections within the debris field. The section of the fuselage from the wing rear spar to the tail, which included the inboard halves of both horizontal stabilizers and the entire vertical stabilizer and rudder, was found intact, oriented on about a 60° magnetic heading, and banked about 30° left wing down. The forward portion of this section exhibited severe impact damage. The right engine remained attached to the right wing and was found embedded in a tree. The right propeller hub had separated from the engine and was found in the main debris field. The left engine remained attached to the left wing and was found adjacent to the cockpit at the forward end of the main debris field. The left propeller hub was found in the main debris field. The compressor blades showed very little evidence of tip curling or bending in the direction opposite of rotation. All of the turbine blades and nozzles were found intact and showed no signs of metal spray. The engines were disassembled at Rolls-Royce’s facility in Indianapolis, Indiana, under Safety Board direction. Examinations of both engines revealed no evidence of uncontainment or burnthrough. Several compressor blades exhibited foreign object damage on the trailing edges in the direction of engine rotation. Finely chopped or pulverized green vegetative debris was found throughout both engines. The vegetative debris showed no evidence of burning or charring. Pulverized dirt was found throughout the left engine. The turbine blades and nozzles were intact on both engines; however, the 35 For more information about this accident, see National Transportation Safety Board, Collision with Trees Short of the Runway, Corporate Airlines Flight 5966, British Aerospace BAE-J3201, N875KX, Kirksville, Missouri, October 19, 2004, Aircraft Accident Report NTSB/AAR-06/01 (Washington, DC: NTSB, 2006).

Factual Information 20 Aircraft Accident Report left engine’s turbine vanes exhibited leading and/or trailing edge damage. No evidence of any metal spray or splatter was found on any of the engines’ turbine blades. The propellers were disassembled at PPI’s facility in Kent, Washington, under Safety Board direction. Six of the eight propeller blade angles were measured to have been from about 40° to 46° at the time of impact.36 Examinations revealed that one of the four right propeller blades and three of the four left propeller blades had sheared off. All of the fracture surfaces showed signatures consistent with overload, with no leading edge or rotational damage. The airplane’s two batteries were found in the battery compartment on the underside of the left wing, and both batteries exhibited substantial impact damage. The ground proximity warning system (GPWS) unit, which is powered by the essential d.c. electrical system, was found with the Mode 4 (flight into terrain when not in landing configuration) warning button indicator activated.37 Four of the five cargo containers were destroyed by impact forces. The fifth container was found intact in the aft fuselage section, and its base was deformed upward. Three of the four forward cargo stops were found intact but separated from the floor tracks. The fourth forward cargo stop was found attached to its floor track. The four aft cargo stops were found intact and attached to their floor tracks. All of the recovered cargo locks exhibited damage consistent with impact. 1.12.2 Fuel Tank System Components and Controls Both fuel cap access doors were found closed and latched. Both fuel filler caps were found unlocked and were able to be lifted away without any counter-clockwise rotation.38 The operating mechanism for the left fuel filler cap exhibited wear. A functional check was performed on the left fuel filler cap, and, during several attempts to engage, several complete clockwise turns were required to lock the cap in place. When the cap was successfully engaged, very little counter-clockwise pressure was required to loosen the cap. A functional check was performed on the right fuel filler cap, and it operated normally. After the accident, Air Tahoma inspected the condition and installation of the fuel filler caps on its other Convair airplanes, and no discrepancies were noted. In its July 2005 submission, Air Tahoma indicated that, after the accident, all company mechanics and Air Tahoma-contracted fuel vendors were trained on over-wing fuel filler cap installation and fueling procedures. Air Tahoma indicated that the company instructed flight 36 Two of the blades’ angles could not be determined because of accident damage. 37 If a warning mode activates in flight, one of five warning mode button indicators on the annunciator panel will change from black to green and yellow. If power to the GPWS is lost, the warning button indication will remain visible. 38 Fuel filler caps are removed during fueling operations. Normal engagement of the fuel filler cap requires the cap to be rotated about a quarter turn clockwise to lock into place securely.

Factual Information 21 Aircraft Accident Report crewmembers to ensure that the proper type and amount of fuel was added and that, during preflight inspections and at intermediate stops, the fuel filler caps were secure. The fuel boost pump low and primary fuel failure warning circuit breakers were found open. The left fuel boost pump circuit breaker was found open, and the right fuel boost pump circuit breaker was found closed.39 Impact damage precluded a continuity check between the fuel tanks and the crossfeed lines. The left and right main fuel tank shutoff valve switches and the left and right crossfeed valves were found in the open position. The emergency power-off switch guard was broken off, and the switch was found in the off position. The left fuel quantity indicator was found indicating 0 lb of fuel. The right fuel quantity indicator’s glass face was broken, and the fuel quantity indicator was found indicating about 5,600 lbs of fuel. According to Kelowna Flightcraft, the Convair 580 type certificate holder, the fuel quantity indication in the cockpit can indicate a fuel quantity that is from 300 to 500 gallons greater than the actual amount, depending on the airplane’s roll attitude. The signed load manifest showed that the accident airplane had about 8,000 lbs of fuel on board at takeoff.40 The manifest showed a fuel burn of about 4,200 lbs, which would have left about 3,800 lbs of fuel on board at the time of impact. Air Tahoma provided the Safety Board with the flight releases and fueling records for the accident airplane’s 12 previous flights from MEM to CVG. Using fuel data from these records, Board investigators calculated that the fuel burn for the accident airplane’s last 12 flights ranged from about 3,500 to 4,200 lbs. 1.13 Medical and Pathological Information Fluid specimens obtained from the pilot and fluid and tissue specimens from the first officer were transported to the FAA’s Civil Aerospace Medical Institute for toxicological analysis. The specimens tested negative for alcohol and a wide range of drugs, including major drugs of abuse.41 1.14 Fire No evidence of an in-flight or a postcrash fire was found. 39 For information about postaccident examinations and bench tests of the accident fuel boost pumps, see section 1.16.1.1. 40 A copy of an Aircraft Service International Group aircraft service record indicated that, on the day of the accident, company ground personnel added 3,564 lbs of fuel to the accident airplane’s fuel tanks. 41 The drugs tested in the postaccident analysis include (but are not limited to) marijuana, cocaine, opiates, phencyclidine, amphetamines, benzodiazapines, barbiturates, antidepressants, antihistamines, meprobamate, and methaqualone.

Factual Information 22 Aircraft Accident Report 1.15 Survival Aspects According to the Boone County Coroner’s Office autopsy report, the cause of death for the first officer was “massive acute body trauma.” According to the captain’s medical records, he sustained minor injuries, including multiple lacerations, acute right lower extremity contusions, and acute bilateral forearm contusions. 1.16 Tests and Research 1.16.1 November 2004 Fuel Boost Pump Examinations and Testing On November 16 and 17, 2004, the fuel boost pump assemblies were examined and bench tests were conducted at Canadian Aero Accessories Ltd.’s facility in Calgary, Alberta, Canada, under Safety Board supervision. The exterior and the interior components of the left electrically driven fuel boost pump and respective electric pump motor exhibited no signs of damage or wear. The cooling fan on the pump motor was clean, with no visible damage. The pump motor cooling fan could be rotated by hand with no binding. The pump motor operated normally when power was applied. The top and front of the right fuel boost pump assembly exhibited some damage. The internal components of the right fuel pump exhibited no signs of damage or wear. The pump motor cooling fan cover and the fan blade directly beneath the dented portion of the cover were found bent inward. None of the other fan blades exhibited damage, nor were any rotational markings found. The pump motor cooling fan could be rotated by hand with little resistance, and the pump motor operated normally when power was applied. During the bench tests, the left fuel boost pump was determined to be operable within the manufacturer’s delivery specifications and maintained an output pressure of 20 psi. The right fuel boost pump was initially found to have an output pressure of 15 psi, which was allowed by the issuance of PJCB 10-21.42 The output pressure setting screw was then adjusted to the manufacturer’s delivery specifications; at which point, the right fuel boost pump maintained an output pressure of 20 psi. Air Tahoma indicated that the left and right fuel boost pump output pressures were not measured or altered after the company bought the airplane in 2004. 1.16.2 April 2005 Fuel Boost Pump Testing On April 12 and 13, 2005, bench tests using the accident airplane’s right fuel boost pump were conducted at Argo-Tech Corporation’s facility in Cleveland, Ohio. The fuel boost pump tests simulated crossfeed operation from the left fuel tank, through a 42 Initially, Safety Board investigators and Convair 580 maintenance personnel thought that the 15-psi output pressure setting had resulted from the impact.

Factual Information 23 Aircraft Accident Report nonoperating right fuel boost pump and an open right fuel tank shutoff valve, consistent with the airplane’s approximate fuel system configuration during the last portion of the accident flight. The tests revealed that, with the left fuel boost pump output pressure set at 21 psi, the right engine’s fuel tank shutoff valve open, and both fuel crossfeed valves open, the fuel not consumed by the right engine was allowed to flow back through the right fuel boost pump and into the right fuel tank. 1.17 Organizational and Management Information Air Tahoma began Part 121 cargo operations on May 21, 1997. At the time of the accident, Air Tahoma had 50 employees, including 15 pilots and a fleet of four Convair 240 and four Convair 580 airplanes. The company operated cargo flights daily from MEM; Cleveland and Columbus, Ohio; and Pittsburgh, Pennsylvania, to CVG. 1.17.1 Flight Paperwork Procedures Air Tahoma’s FAA-approved General Operations Manual (GOM), Section 1.617, “Disposition of Documents,” stated, in part, the following: If a flight originates at a place other than the Principal Operations Base, the Captain will fax a copy of Flight Release and the weight and balance manifest to the company…If the aircraft departs a station where there is a person authorized by the Company who manages the departure, and who does not depart on the aircraft, then that person or the crew may retain the signed copies of the required documents in a designated location. Air Tahoma’s GOM, Section 1.741, “Preflight Procedures,” stated that a flight plan form, which is incorporated in the flight release form, must be completed by the flight crew before a company aircraft departs for a flight or series of flights. The GOM stated that weight and balance calculations for the flight plan form “will be computed on an approved weight and balance form” and added the following The completed [form] will be attached to both copies of the flight release form…A copy of the Flight Release…and Weight and Balance form…will be faxed, or mailed to [Air Tahoma] Operations. If there is no fax available then…self-addressed envelopes…can be used. The envelope will be given to the FBO [fixed-base operator] to be mailed if there is no mailbox available. 1.17.2 Air Tahoma Fuel Crossfeed Procedures Air Tahoma’s CV-580 Quick Reference Handbook (QRH), dated February 5, 1997, contains fuel crossfeed procedures, which state, in part, the following: CROSSFEED FROM EITHER TANK TO OPPOSITE ENGINE 1 BOTH FUEL BOOST PUMPS.......................................................................ON

Factual Information 24 Aircraft Accident Report 2 BOTH AIRCRAFT FUEL BOOST PRESSURE LIGHTS .......................... OFF 3 CROSSFEED VALVE................................................................................ OPEN 4 FUEL BOOST PUMP FOR TANK NOT TO BE USED ............................. OFF IF EITHER OR BOTH AIRCRAFT FUEL BOOST PRESSURE LIGHTS ARE ILLUMINATED: • BOTH FUEL BOOST PUMPS.......................................................................ON • RESET AS REQUIRED CROSSFEED VALVE C/B CIRCUIT BREAKER • FUEL SHUT OFF VALVE C/B • FUEL BOOST PUMP C/B • FUEL BOOST PUMP FOR TANK NOT TO BE USED ............................. OFF IF EITHER OR BOTH AIRCRAFT FUEL BOOST PRESSURE LIGHTS ARE ILLUMINATED: • AIRCRAFT BOOST PUMPS.................................................................AS REQ • CROSSFEED VALVE........................................................................... CLOSED • DO NOT CROSSFEED • END 5 TANK SHUTOFF VALVE FOR TANK NOT USED................................... OFF During postaccident interviews, the captain stated that he had previously performed fuel crossfeed operations about 5 to 10 times in the Convair 580. The captain stated that fuel crossfeed operations were always performed to correct an in-flight fuel imbalance. The captain stated that Air Tahoma trained company pilots to use the QRH during fuel crossfeed operations.43 According to the company’s chief pilot, pilots were trained to crossfeed fuel only in safety-of-flight situations. He stated that, because the company typically operated short flights, from 1 to 1.5 hours long, any in-flight fuel imbalance could be corrected during ground fueling operations.44 Interviews of other company pilots revealed that they did not routinely crossfeed fuel in flight. However, a Safety Board review of Air Tahoma’s operations and training manuals revealed that the company had no written documentation regarding fuel crossfeed operations restrictions. 43 A company ground school instructor indicated that, because the captain attended the reduced training course, he received “more of a review” of the fuel crossfeed operations procedures. 44 Kelowna Flightcraft indicated that it also had a policy to restrict fuel crossfeed operations to safety-of-flight situations because the company only operated short flights.

Factual Information 25 Aircraft Accident Report The captain stated that he thought that the fuel tank shutoff valve should not be turned off during fuel crossfeed operations because, if the shutoff valve could not be reopened, the fuel in that tank would not be accessible. The captain thought that his two previous employers did not require that the fuel tank shutoff valve be closed during fuel crossfeed operations.45 The captain also thought that the Convair 580 had a one-way check valve that would prevent fuel from transferring from one tank to another tank during crossfeed operations.46 Postaccident interviews with Air Tahoma’s chief pilot and Nolinor Aviation personnel revealed that additional pilots believed that the Convair 580 fuel tank shutoff valve had a tendency to fail. Further, a Kelowna Flightcraft maintenance instructor stated that, during company training, he had been asked about fuel tank shutoff valve failures. He believed that this concern led many pilots to leave the fuel tank shutoff valve open. The instructor stated that he thought that the pilots’ concerns were unfounded because, in the previous 10 years, no customers had reported any fuel tank shutoff valve failures.47 1.17.2.1 Airplane Manufacturer Fuel Crossfeed Procedures The airplane manufacturer’s AFM contains the following fuel crossfeed procedures: (1) place boost pump switch for tank being used to the ON position and place the crossfeed switch to the ON position, (2) place the boost pump switch for the tank not being used to the OFF position, and (3) place the fuel shutoff valve switch for the tank not being used to the CLOSED position. As noted previously, the procedures also contain a caution stating that transferring fuel from one tank to the other is prohibited because structural failure or overflow of fuel through the vent system could occur. 1.17.2.2 Nolinor Aviation Fuel Crossfeed Procedures Nolinor Aviation, one of the captain’s previous employers, operated five Convair 580 airplanes, none of which had a one-way fuel check valve installed in the fuel system. At the time of the accident, Nolinor Aviation’s fuel crossfeed operations procedures, which were contained in the company’s FOM (dated February 14, 1998), included a step indicating that the fuel tank shutoff valve on the tank not being used should be closed, “subject to the captain’s discretion.” The company’s QRH did not 45 The investigation revealed that one of the captain’s previous employers, Nolinor Aviation, did not require that the fuel tank shutoff valve be closed during crossfeed operations. For additional information about Nolinor Aviation’s fuel crossfeed procedures, see section 1.17.2.2. 46 One-way check valves are not typically installed on airplanes, and the accident airplane did not have one installed. According to a Kelowna Flightcraft representative, one Convair 580 operator modified its fleet of about 30 Convair 580 airplanes in the 1960s under an engineering order by installing a one-way check valve, which prevented fuel from flowing back into the fuel tanks when the fuel tank shutoff valve was left open. However, the representative stated that this operator was no longer in business and that its airplanes had represented a small percentage of the entire Convair 580 fleet. 47 Further, a search of the FAA’s service difficulty reports (SDR) database revealed no history of Convair 580 fuel tank shutoff valve failures.

Factual Information 26 Aircraft Accident Report include this remark. According to Nolinor Aviation’s chief pilot, in November 2004, the company corrected the discrepancy between its QRH and FOM by removing the remark, “subject to the captain’s discretion,” from the fuel crossfeed operations procedures contained in the FOM. 1.17.3 Air Tahoma Engine Flameout Procedures The Air Tahoma CV-580 QRH contains emergency flameout procedures (loss of one or both engines), which state, in part, the following: 1. AIRSPEED........................................................................ MAINTAIN 170 KTS IF RPM 5500-6500 RPM: POWER LEVER(S)1” [INCH] ABOVE FLIGHT IDLE FUEL VALVES........................................................................................CAPPED FUEL BOOST PUMPS ..................................................................................... ON FEATHER BUTTON.....................................PUSH TO 2500 RPM, THEN PULL PRIMER......................................................................HOLD UNTIL LIGHT OFF E-HANDLE ....................................................................... IDENTIFY & GUARD When the accident airplane was about 4.5 miles from the runway and at an altitude of about 2,300 feet,48 the flight crew reported to the CVG ATCT that they were having engine problems. During postaccident interviews, the captain could not remember if the airplane had experienced an engine problem or whether he had performed any emergency or abnormal procedures during the accident flight. 1.17.4 Postaccident Actions On August 26, 2004, Air Tahoma issued Operations Memorandum 2 to all flight crewmembers to reemphasize which procedures to follow during fuel crossfeed operations. The memorandum stated, in part, that crossfeeding should only be conducted if it is necessary for the safety of flight; the QRH should be used during crossfeeding; a checklist should be placed in the throttle quadrant as a reminder that fuel crossfeeding was in progress; instruments should not be blocked by checklists; and crew resource management must be practiced and communications forceful, if necessary. Air Tahoma also stated that its captains had been instructed to physically touch the fuel panel when it is 48 The terrain height in the accident area was about 900 feet.

Factual Information 27 Aircraft Accident Report called on the checklist rather that just looking at it.49 In addition, Air Tahoma installed a breakaway wire on all of its Convair 580 fuel tank shutoff and crossfeed valve cover-guarded switches.50 Further, Air Tahoma stated that it had installed captain-side, overhead red lights, which indicate the position of the fuel crossfeed and fuel tank shutoff valve switches. When the left and/or right fuel tank shutoff valve switches are in the off (closed) position, the respective lights will illuminate, and when the fuel crossfeed valve switch is in the on (open) position, the respective light will illuminate. During normal operations, the fuel tank shutoff valve switches are on and the fuel crossfeed valve switch is off, resulting in all three lights being extinguished. Air Tahoma noted that the lights indicate crossfeed or fuel tank shutoff valve switch position not operation status. 1.18 Additional Information 1.18.1 Previous Convair 580 In-Flight Fuel Imbalance Incident On September 21, 2004, a Nolinor Aviation Convair 580 had to return to its departure airport in Montreal, Canada, because of a fuel imbalance. The incident flight crew stated that, shortly after takeoff, a flight attendant reported that a passenger had seen fuel coming out of the right wing. The flight crew reported that, about this time, they needed to move the aileron to the left to maintain level flight, which required about a 10°-left input on the control wheel, and the fuel quantity indicators showed that the left and right fuel tanks had 4,000 and 6,000 lbs of fuel, respectively.51 The flight crew stated that at this point, they noticed that the fuel crossfeed valve was open. The flight crew closed the fuel crossfeed valve and decided to return to Montreal, where they landed safely. The flight crew stated that the airplane was controllable at all times and that the fuel imbalance did not exceed the in-flight limit of 2,080 lbs. Ground maintenance personnel determined that no fuel was coming out of the airplane’s wing; however, it appeared that some fuel had been pumped overboard through the fuel vent system. The maintenance personnel also determined that the right and left fuel boost pumps had output pressure settings of 15 and 21 psi, respectively.52 According to Nolinor Aviation, the left fuel boost pump had been replaced before the incident flight. 49 Operations Memorandum 2 also stated that, if excessive trim is needed to maintain normal flight, a problem might exist. Air Tahoma’s chief pilot stated that the company did not have any training procedures related to control wheel imbalance but that he expected pilots to actively troubleshoot such a problem and to consider fuel imbalance as a possible cause. 50 A breakaway wire is a device that supplements a cover-guarded switch and passively warns pilots that using the fuel switches in flight is nonroutine. If a flight crew used the breakaway wire in flight, maintenance personnel would have to replace it. 51 According to Nolinor Aviation’s chief pilot, the incident airplane was fueled to 11,200 lbs before takeoff. 52 Nolinor Aviation indicated that it normally operated company airplanes with a fuel boost pump output pressure setting of 15 psi.

Factual Information 28 Aircraft Accident Report Nolinor indicated that company maintenance personnel did not bench check the replacement fuel boost pump before installing it on the airplane; therefore, the company did not know that the airplane was operating with different fuel boost pump output pressure settings. In addition, the maintenance personnel left the fuel crossfeed valve open after performing postinstallation checks on the left fuel boost pump.

29 Aircraft Accident Report 2. Analysis 2.1 General The captain and first officer were properly certificated and qualified under Federal regulations. No evidence indicated that flight crew fatigue was a factor in this accident, and no evidence indicated any preexisting medical or behavioral conditions that might have affected the accident flight. The airplane was properly maintained in accordance with Federal regulations and approved company procedures. The recovered components showed no evidence of any preexisting powerplant, system, or structural failures. No evidence indicated that any of the airplane’s cargo shifted during the flight. Neither the weather nor the inoperative DME on the CVG VOR was a factor in this accident. A review of the preflight fueling log, the signed load manifest found at the accident site, and previous flight information for the accident airplane revealed that there was sufficient fuel on board the airplane for the flight from MEM to CVG. This analysis discusses the captain’s preflight actions and the accident sequence, including the role of the flight crew’s performance. This analysis also discusses the Convair 580 fuel system, including fuel crossfeed operations; the dual engine power loss; operating with different fuel boost pump output pressure settings; and independent CVR power sources. 2.2 The Captain’s Preflight Actions Air Tahoma’s procedures and Federal regulations require that a flight crewmember prepare, complete, and leave a copy of the load manifest at the departure station. The captain did not leave a copy of the load manifest for the accident flight at MEM. However, two load manifests, one signed by the captain and the other unsigned, were found at the accident site. A review of the unsigned load manifest and CVR transcript information revealed that, during manual, preflight weight and balance calculations,53 the captain used the 53 As mentioned previously, the captain had to manually complete the weight and balance calculations before takeoff because the handheld computer typically used by Air Tahoma’s pilots to make these calculations was not working.

Analysis 30 Aircraft Accident Report incorrect fuel burn moment value (1,067 instead of 1,667).54 Because of this error, the captain’s calculations showed the airplane outside of acceptable weight and balance limits. The captain stated during postaccident interviews that, although his preflight calculations showed the airplane outside of weight and balance takeoff limits, he used his “general experience” (for example, he stated that he looked at the nose landing gear strut extension) to determine that the airplane was within limits. On the basis of his observations, he decided to take off and finish the weight and balance paperwork during the flight. A review of the signed load manifest and CVR transcript information revealed that the captain used the correct fuel burn moment value (1,667) on this manifest. The captain’s calculations using the correct moment value indicated that the airplane was within acceptable weight and balance limits. Safety Board investigators verified the captain’s recalculations. The Safety Board concludes that the captain’s preflight weight and balance calculations indicated that the airplane was not within takeoff limits; therefore, he should not have allowed the airplane to take off. However, the captain’s calculations were incorrect, and the airplane’s weight and balance were within limits. 2.3 Accident Sequence The accident flight departed MEM about 2329. Postaccident interviews with the captain and an examination of FDR data indicated that the takeoff, climb, and cruise portions of the flight (up to the time that the CVR transcript started) were uneventful. At 0017:49, the captain told the first officer that he was going to “balance out the fuel,”55 and the first officer acknowledged. At 0026:30, the captain told the first officer that he had been working on the weight and balance calculations since departing MEM. At 0032:31 (about 15 minutes after initiating the fuel crossfeed operations), the captain stated that he was finishing up the weight and balance calculations. Two minutes later, he stated, “okay, back with you here.” During postaccident interviews, the captain stated that, because he was busy calculating the airplane’s weight and balance, he was “preoccupied” and “stressed” during the flight. Although the weight and balance calculations were not difficult, because the captain used the incorrect fuel burn moment value, the calculations were not computing correctly, and the captain became preoccupied with trying to identify the mistake. From 0038:22 to 0044:16, the first officer repeatedly told the captain that the airplane was not handling well. Specifically, he stated numerous times that the control wheel was requiring a “lot of force.” The captain did not respond to the first officer’s first five comments regarding the airplane’s unusual handling characteristics, which occurred over a period of less than 6 minutes. The captain did not request clarification or elaboration from the first officer nor did he initiate any troubleshooting or take over the 54 The fuel burn moment value appeared to have been written as 1,067 and then rewritten as 1,667. The captain used an estimated fuel burn of 4,200 lbs in his calculations. The correct fuel burn moment value for a fuel burn of 4,200 lbs is 1,667. 55 Fuel crossfeed operations are used to balance out the fuel in an airplane’s fuel tanks.

Analysis 31 Aircraft Accident Report flight controls to independently validate the first officer’s observations; instead, the captain remained silent, changed the subject, or was distracted by normal flight communications. At 0044:32, the captain finally responded to the first officer by telling him that they would perform a “full control check on the ground.” The PIC has final command authority in the cockpit and is responsible for the safety of the flight. It is reasonable to expect that, as part of the command responsibilities, the PIC would promptly investigate a potential flight control system anomaly reported by another flight crewmember. Unusual changes in an airplane’s handling characteristics can possibly affect the safety of flight. Typically, one of the first actions taken to determine the cause of an airplane’s changing handling characteristics would be to check for a possible fuel imbalance. Because the captain did not respond promptly to the first officer’s comments, he missed several opportunities to recognize that the airplane’s fuel was imbalanced. The Safety Board concludes that the captain did not recognize the importance of the cues provided by the first officer, and he failed to perform expected PIC duties. At 0045:37, shortly after the airplane passed through 3,200 feet, the captain started the in-range checklist, which includes a step to check the fuel tank shutoff and crossfeed valve switch positions. Air Tahoma’s FOM indicates that the in-range checklist should be started before leaving 12,000 feet and that “early completion [of the checklist] will minimize cockpit distractions.” Therefore, the captain should have started the in-range checklist about 14 minutes earlier (shortly before 0035; at which time, the airplane was at an altitude of about 12,000 feet, and the first officer had not yet stated his concerns about the airplane’s unusual handling characteristics). While performing the in-range checklist, the captain stated that they had an “imbalance on this…crossfeed I left open.” This was the only comment recorded by the CVR regarding fuel crossfeed operations since the captain started the operation almost 30 minutes earlier. Further, the CVR did not record any comments by either flight crewmember indicating that they were monitoring the airplane’s fuel quantity. If the flight crewmembers had been monitoring the gauges, they would have seen unmistakable indications of a developing fuel imbalance. The fuel imbalance developed over a 30-minute period, and, as noted, during that time, the pilots had several opportunities to recognize and correct the problem; however, they failed to do so. The Safety Board concludes that the captain was preoccupied with the weight and balance calculations during critical portions of the flight and, as a result, he did not monitor the fuel crossfeed operations, which resulted in a fuel imbalance and unusual airplane handling characteristics. The Safety Board further concludes that the flight crew did not monitor the fuel quantity gauges or respond properly to the airplane’s changing handling characteristics, and the captain did not start the in-range checklist at the appropriate altitude; as a result, the crew missed several opportunities to identify the ongoing fuel crossfeed operations and determine that the airplane’s fuel was imbalanced. At 0046:35, the first officer stated, “we’re gonna flame out.” The captain responded, “I got the crossfeed open.” The first officer then stated, “we’re losing power,” and, “we’ve lost both of them [engines].” The captain replied, “nope.” The CVR stopped

Analysis 32 Aircraft Accident Report recording at 0046:55, and, about the same time, a momentary interruption in electrical power occurred. About 2 minutes later, the FDR stopped recording. Although Air Tahoma’s QRH contained engine flameout procedures, the pilots most likely would not have had sufficient time or altitude to restart the engines because they lost power during short final approach. 2.4 Convair 580 Fuel Crossfeed Operations The Convair 580 type certificate data sheet and Air Tahoma’s FOM prohibit fuel transfer from one tank to the other while the airplane is on the ground or in flight. The type certificate data sheet also states, “When operating with the crossfeed system, turn off fuel valve for tank not being used,” which would preclude fuel transfer. The AFM also prohibits the transfer of fuel from one tank to the other and cautions, “to do so might build up excessive pressure in a tank, which could result in structural failure or cause fuel to overflow through the vents.” Step 5 of Air Tahoma’s QRH fuel crossfeed procedures states that the fuel tank shutoff valve for the fuel tank not being used must be closed during fuel crossfeed operations. Further, the Convair 580’s overhead fuel panel has a placard on the bottom that states the same thing. However, the captain stated that he did not shut off the right fuel tank shutoff valve, and wreckage examinations confirmed that both the left and right fuel tank shutoff valves were open at impact. Postaccident fuel boost pump testing revealed that, in this configuration, all of the fuel from the left fuel tank not used by the engines could transfer into the right fuel tank in a relatively short period of time. During postaccident interviews, the captain stated that he was aware of the step to close the fuel tank shutoff valve for the tank not being used. However, the captain added that he intentionally kept the valve open because he thought that Convair fuel tank shutoff valves tended to fail after being shut off, preventing the use of the fuel in the closed tank.56 The captain also stated that a previous employer (Nolinor Aviation) allowed company pilots to decide whether or not to close the valve.57 The Safety Board is concerned that Convair 580 pilots’ mistaken belief that the fuel tank shutoff valves have a tendency to fail may cause these pilots to intentionally keep the fuel tank shutoff valves open during fuel crossfeed operations, which could allow fuel to transfer and cause either structural damage or fuel overflow. The Safety Board concludes that, although fuel transfer is prohibited on the Convair 580 airplane, fuel transfer can occur during fuel crossfeed operations if the fuel tank shutoff valve for the tank not being used is left open. The Safety Board further 56 During postaccident interviews, other Convair 580 pilots indicated that they also thought that Convair fuel tank shutoff valves tended to fail. However, manufacturer and FAA SDR data did not indicate a history of Convair fuel tank shutoff valve failures. 57 At the time of the accident, Nolinor Aviation’s FOM stated that the fuel tank valve on the tank to be shut off should be closed, “subject to the captain’s discretion.” After the accident, Nolinor removed this remark from the crossfeed procedures contained in its FOM.

Analysis 33 Aircraft Accident Report concludes that all of the fuel from the airplane’s left tank that was not used by the engines transferred into the right tank because the captain intentionally kept the right fuel tank shutoff valve open during fuel crossfeed operations, which was not in accordance with approved fuel crossfeed procedures. Therefore, to prevent similar accidents from occurring in the future, the Safety Board believes that the FAA should issue a flight standards information bulletin to all principal operations inspectors of Convair 580 operators that familiarizes operators with the circumstances of the Air Tahoma flight 185 accident, including the importance of closing the fuel tank shutoff valve for the tank not being used during fuel crossfeed operations. 2.5 Dual Engine Power Loss The Safety Board considered why both engines lost power even though the right fuel tank had sufficient fuel for operation. Further, after the engines failed, the flight crew was still able to make transmissions to ATC, the GPWS alerted, and the FDR continued to record, indicating that the airplane still had partial electrical power. Wreckage examinations indicated that, when the left fuel tank was exhausted of fuel, the left fuel boost pump most likely continued to operate, which allowed air to enter the fuel system and reduced the fuel pressure to the left and right engine-driven fuel pump inlets. If the captain had turned on the right fuel boost pump after he identified that he had left the crossfeed valve switch open, it is possible that the right engine would have received sufficient fuel pressure to continue to operate; however, there is no evidence that he did so. Specifically, the right fuel boost pump fan motor cooling fan cover and the blade directly beneath the cover were found bent inward, and no rotational markings were found, indicating that the right fuel boost pump was not operating at the time of impact. Postaccident testing of the left and right fuel pumps revealed no evidence of preexisting failures. The Safety Board concludes that, during the airplane’s descent to landing, the fuel in the left fuel tank, which was providing fuel to both engines, was exhausted because both engine-driven fuel pumps drew air from the left tank into the fuel system instead of fuel from the right tank, resulting in a dual-engine flameout. 2.6 Differential Fuel Boost Pump Output Pressures Settings PJCB 10-21, “Aircraft Fuel Boost Pump Output Pressure Limit-Reduce,” which was published in October 1969, provided details on an optional procedure that allowed Convair 580 operators to reduce the typical fuel boost pump output pressure setting of 21 psi to 15 psi to “improve the service life of the aircraft fuel boost pump.” The bulletin stated that, although an aircraft could be operated with different boost pump output pressure settings, “preferably, aircraft should be operated with identical boost pump

Analysis 34 Aircraft Accident Report pressure settings.” Postaccident testing of the accident fuel boost pumps revealed that the left and right fuel boost pumps had output pressure settings of 20 and 15 psi, respectively. Air Tahoma maintenance personnel reported that they were not aware of PJCB 10-21 or the provision to lower the fuel boost pump output pressure setting to 15 psi. In June 2004, Air Tahoma replaced the left fuel boost pump on the accident airplane with a pump that had an output pressure setting of 21 psi. However, Air Tahoma did not replace the right fuel boost pump and did not measure or alter the output pressure setting. As a result, Air Tahoma was unaware that it was operating the airplane with different left and right fuel boost pump output pressure settings. The Safety Board is concerned that other Convair 580 operators may not be aware of PJCB 10-21 and its provision to allow fuel boost pumps to be set at different output pressure settings. On September 21, 2004, a Nolinor Aviation Convair 580 experienced an in-flight fuel imbalance. The incident flight crew reported that a passenger had seen fuel coming from the right wing and that, about the same time, the fuel quantity indicators showed that the left and right fuel tanks had 4,000 and 6,000 lbs of fuel, respectively. The flight crew closed the fuel crossfeed valve after noticing that the valve was open. Nolinor Aviation ground maintenance personnel determined that the right and left fuel boost pumps had output pressure settings of 15 and 21 psi, respectively, and that the crossfeed valves had been left open, which allowed fuel to transfer from the left to the right fuel tank. Nolinor Aviation indicated that the incident airplane’s left fuel boost pump had been replaced and had not been bench checked before installation. As a result, the company was unaware that the incident airplane’s left fuel boost pump was operating with an output pressure setting of 21 psi. Nolinor Aviation indicated that it typically operated its Convair 580 airplanes with a fuel boost pump output pressure setting of 15 psi. Kelowna Flightcraft, the Convair 580 type certificate holder, indicated that most operators normally set the fuel boost pumps to the same output pressure settings. However, the Safety Board is concerned that PJCB 10-21 allows Convair 580 airplanes to operate with different output pressure settings. Further, given the age of the Convair 580 fleet, current operators might not have a complete history of the airplanes, including possible changes made to the fuel boost pumps in accordance with PJCB 10-21. Although operating the Convair 580 with different fuel boost pump output pressure settings does not in itself create an unsafe operating condition, the Board notes that crossfeed valves are not monitored58 and that the only indication that these valves are open is the switch position in the cockpit. Such operation did not factor in the accident; however, the Nolinor Aviation incident did reveal that, if an airplane operates with different fuel boost pump output pressure settings and with the crossfeed valves unintentionally left open, a large amount of fuel can transfer from one tank to another in a short period of time, possibly causing structural failure or fuel overflow. The Safety Board concludes that fuel transfer can occur on the Convair 580 airplane if it is operated with different fuel boost pump output pressure settings and with 58 No positive indication, such as a light, exists in the cockpit to indicate whether the crossfeed system is operating.

Analysis 35 Aircraft Accident Report the fuel crossfeed valves unintentionally left open. Therefore, the Safety Board believes that the FAA should require Convair 580 operators to set the left and right fuel boost pump output pressure settings on their airplanes to the same setting. 2.7 Cockpit Voice and Image Recorder Requirements As noted previously, whether the Convair 580’s CVR electrical relay circuitry enables battery power to the CVR when the engines are in the low-speed range or shut down (which can be caused by fuel exhaustion) depends on whether the flight crew pushes in the low-rpm buttons located on the center pedestal. If the low-rpm button are pushed in when the engines are in the low-speed range or shut down, the low-rpm relays are energized, and the batteries provide power to the CVR. However, when both engines are in the low-speed range or shut down and the low-rpm buttons are not pushed in, no power is provided to the CVR. Although electrical relay circuitry is an effective method of powering the CVR during ground operations, power to the CVR is compromised if both a.c. alternators are in the low-speed range or shut down in flight and the pilots do not push in the low-rpm buttons. Accordingly, the CVR on the accident airplane lost power when the airplane’s left fuel tank was exhausted of fuel, both engines lost power, and the pilots did not push in the low-rpm buttons. The Safety Board notes that the FDR, which did not require relay circuitry to operate at lower power settings, received electrical power throughout the entire accident sequence (except for the momentary dropout of power about 0047) and operated normally until impact. Even before this accident, the Safety Board had longstanding concerns about accidents and incidents in which critical CVR information was lost because of an electrical power interruption. As a result of its longstanding concerns about this issue and its assistance in the TSB’s Swissair flight 111 accident investigation, the Board issued Safety Recommendation A-99-16 to the FAA, which stated, in part, the following: All airplanes required to carry both a CVR and an FDR [should be retrofitted] with a CVR that…is fitted with an independent power source…that automatically engages and provides 10 minutes of operation whenever aircraft power to the recorder ceases, either by normal shutdown or by a loss of power to the bus. The Safety Board is disappointed that the FAA’s February 28, 2005, NPRM, “Revisions to Cockpit Voice Recorder and Digital Flight Data Recorder Regulations,” only proposes requiring the installation of a 10-minute independent CVR power source on newly manufactured aircraft. Therefore, in its comments on the NPRM, the Board suggested requiring the installation of a 10-minute independent CVR power source on all aircraft within 4 years of the issuance of a final rule. As a result of its investigation of the October 19, 2004, Corporate Airlines flight 5966 accident and longstanding concerns about the loss of critical flight recorder

Analysis 36 Aircraft Accident Report data, on January 24, 2006, the Safety Board reiterated Safety Recommendation A-00-30, which asked the FAA, in part, to do the following: Require that all aircraft operated under…14 Code of Federal Regulations Part 121, 125, or 135 and currently required to be equipped with a [CVR] and [DFDR] be retrofitted by January 1, 2005, with a crash-protected cockpit image recording system. The cockpit image recorder system should have a 2-hour recording duration…and be capable of recording, in color, a view of the entire cockpit including each control position and each action (such as display selections or system activations) taken by people in the cockpit. The FAA did not address cockpit image recorders in its February 2005 NPRM. In its response to the NPRM, the Safety Board stated that it was disappointed that the FAA had not addressed image recorders in the NPRM and restated its opinion that cockpit image recorders could play a key role in accident investigations by providing critical human performance and cockpit environment information that would otherwise be unavailable. If the accident airplane had been equipped with a 10-minute independent power source, the CVR would have recorded important information about the flight crew’s actions after the loss of engine power until the airplane impacted the ground. Further, if the airplane had been equipped with a cockpit image recorder, the recorder could have provided additional critical human performance and cockpit environment information. The Safety Board concludes that the accident investigation would have benefited from the retrofit of an independent CVR power source and a cockpit image recorder. Because of its continued concerns in this area, the Safety Board reiterates Safety Recommendation A-99-16 and again urges the FAA to require the retrofit of all existing aircraft required to carry both a CVR and an FDR with a CVR that is fitted with an independent power source. Further, the Board again urges the FAA to quickly implement Safety Recommendation A-00-30.

37 Aircraft Accident Report 3. Conclusions 3.1 Findings 1. The captain and first officer were properly certificated and qualified under Federal regulations. 2. No evidence indicated that flight crew fatigue was a factor in this accident, and no evidence indicated any preexisting medical or behavioral conditions that might have affected the accident flight. 3. The airplane was properly maintained in accordance with Federal regulations and approved company procedures. 4. The recovered components showed no evidence of any preexisting powerplant, system, or structural failures. No evidence indicated that any of the airplane’s cargo shifted during the flight. 5. Neither the weather nor the inoperative distance measuring equipment on the Cincinnati/Northern Kentucky International Airport very high frequency omnidirectional range was a factor in this accident. 6. Sufficient fuel was on board the airplane for the flight from Memphis International Airport to Cincinnati/Northern Kentucky International Airport. 7. The captain’s preflight weight and balance calculations indicated that the airplane was not within takeoff limits; therefore, he should not have allowed the airplane to take off. However, the captain’s calculations were incorrect, and the airplane’s weight and balance were within limits. 8. The captain did not recognize the importance of the cues provided by the first officer, and he failed to perform expected pilot-in-command duties. 9. The captain was preoccupied with the weight and balance calculations during critical portions of the flight and, as a result, he did not monitor the fuel crossfeed operations, which resulted in a fuel imbalance and unusual airplane handling characteristics.

1. The flight crew did not monitor the fuel quantity gauges or respond properly to the

airplane’s changing handling characteristics, and the captain did not start the in-range checklist at the appropriate altitude; as a result, the crew missed several opportunities to identify the ongoing fuel crossfeed operations and determine that the airplane’s fuel was imbalanced.

Conclusions 38 Aircraft Accident Report

1. Although fuel transfer is prohibited on the Convair 580 airplane, fuel transfer can

occur during fuel crossfeed operations if the fuel tank shutoff valve for the tank not being used is left open.

1. All of the fuel from the airplane’s left tank that was not used by the engines

transferred into the right tank because the captain intentionally kept the right fuel tank shutoff valve open during fuel crossfeed operations, which was not in accordance with approved fuel crossfeed procedures.

1. During the airplane’s descent to landing, the fuel in the left fuel tank, which was

providing fuel to both engines, was exhausted because both engine-driven fuel pumps drew air from the left tank into the fuel system instead of fuel from the right tank, resulting in a dual-engine flameout.

1. Fuel transfer can occur on the Convair 580 airplane if it is operated with different fuel

boost pump output pressure settings and with the fuel crossfeed valves unintentionally left open.

1. The accident investigation would have benefited from the retrofit of an independent

cockpit voice recorder power source and a cockpit image recorder. 3.2 Probable Cause The National Transportation Safety Board determines that the probable cause of this accident was fuel starvation resulting from the captain’s decision not to follow approved fuel crossfeed procedures. Contributing to the accident were the captain's inadequate preflight planning, his subsequent distraction during the flight, and his late initiation of the in-range checklist. Further contributing to the accident was the flight crew’s failure to monitor the fuel gauges and to recognize that the airplane’s changing handling characteristics were caused by a fuel imbalance.

39 Aircraft Accident Report 4. Recommendations 4.1 New Recommendations As a result of its investigation of the August 13, 2004, Air Tahoma, Inc., flight 185 accident, the National Transportation Safety Board makes the following recommendations: To the Federal Aviation Administration: Issue a flight standards information bulletin to all principal operations inspectors of Convair 580 operators that familiarizes operators with the circumstances of the Air Tahoma flight 185 accident, including the importance of closing the fuel tank shutoff valve for the tank not being used during fuel crossfeed operations. (A-06-39) Require Convair 580 operators to set the left and right fuel boost pump output pressure settings on their airplanes to the same setting. (A-06-40) To Transport Canada: Require Convair 580 operators to set the left and right fuel boost pump output pressure settings on their airplanes to the same setting. (A-06-41) 4.2 Previously Issued Recommendation Being Reiterated in This Report The Safety Board reiterates the following recommendation to the Federal Aviation Administration: Require retrofit after January 1, 2005, of all cockpit voice recorders (CVR) on all airplanes required to carry both a CVR and a flight data recorder with a CVR that (a) meets Technical Standard Order (TSO) C123a, (b) is capable of recording the last 2 hours of audio, and (c) is fitted with an independent power source that is located with the digital CVR and that automatically engages and provides 10 minutes of operation whenever aircraft power to the recorder ceases, either by normal shutdown or by a loss of power to the bus. (A-99-16)

Recommendations 40 Aircraft Accident Report BY THE NATIONAL TRANSPORTATION SAFETY BOARD MARK V. ROSENKER Acting Chairman ELLEN ENGLEMAN CONNERS Member DEBORAH A. P. HERSMAN Member KATHRYN O. HIGGINS Member Adopted: May 2, 2006

41 Aircraft Accident Report 5. Appendixes Appendix A Investigation and Public Hearing Investigation The National Transportation Safety Board was officially notified of this accident on August 13, 2004, about 0300. A full go-team was assembled in Washington, D.C. The go-team departed about 0730 and arrived on scene about 0900. The team was accompanied by Board Member Carol Carmody.1 The following investigative groups were formed: Operations, Aircraft Structures, Aircraft Systems, Aircraft Powerplants, Aircraft Maintenance Records, Meteorology, Air Traffic Control, Aircraft Performance, Cockpit Voice Recorder, and Flight Data Recorder. A Human Factors specialist was also assigned to review and analyze the flight crew’s performance during the flight. Parties to the investigation were the Federal Aviation Administration; Air Tahoma, Inc.; and Rolls-Royce. An accredited representative from the Transportation Safety Board of Canada (TSB) and the TSB’s technical advisor from Kelowna Flightcraft Ltd. also assisted in the investigation. Public Hearing No public hearing was held for this accident. 1 Ms. Carmody is no longer with the Safety Board.

42 Aircraft Accident Report Appendix B Cockpit Voice Recorder Transcript The following is the transcript of the Honeywell Sundstrand V557 model cockpit voice recorder, serial number 2372, installed on Air Tahoma flight 185, a Convair 580, which crashed while on approach for landing at Cincinnati/Northern Kentucky International Airport, Covington, Kentucky, on August 13, 2004.

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FD07316 ｜ 2006_美国_AAR0604.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2006 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

aviation Runway Overrun and Collision Platinum Jet Management, LLC Bombardier Challenger CL-600-1A11, N370V, Teterboro, New Jersey February 2, 2005 ACCIDENT REPORT NTSB/AAR-06/04 PB2007-910401

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Aircraft Accident Report Runway Overrun and Collision Platinum Jet Management, LLC Bombardier Challenger CL-600-1A11, N370V, Teterboro, New Jersey February 2, 2005 NTSB/AAR-06/04 PB2007-910401 National Transportation Safety Board Notation 7715C 490 L’Enfant Plaza, S.W. Adopted October 31, 2006 Washington, D.C. 20594 E

P L U R IB US UN U M

N A T I O N A L

T R A S P O R T A T I O N

B O A R D S A FE T Y N

National Transportation Safety Board. 2006. Runway Overrun and Collision, Platinum Jet Management, LLC, Bombardier Challenger CL-600-1A11, N370V, Teterboro, New Jersey, February 2, 2005. Aircraft Accident Report NTSB/AAR-06/04. Washington, DC. Abstract: This report explains the accident involving a Bombardier Challenger CL-600-1A11, N370V, operated by Platinum Jet Management, LLC, which ran off the departure end of runway 6 at Teterboro Airport, Teterboro, New Jersey, during a rejected takeoff. Safety issues addressed in this report include weight and balance procedures; flight crew actions, training, and procedures; company oversight and operational control; Federal Aviation Administration responsibility and oversight; cabin aide actions, training, and procedures; and runway safety areas. The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Web at http://www.ntsb.gov. Other information about available publications also may be obtained from the Web site or by contacting: National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (800) 877-6799 or (202) 314-6551 Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2007-910401 from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605-6000 The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

iii Aircraft Accident Report Contents Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

1. Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2. 1

History of Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.1.1 Flight Crew Postaccident Statements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.1.2 Cabin Aide Postaccident Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.1.3 Passenger Postaccident Statements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 1.2 Injuries to Persons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1.3 Damage to Aircraft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 1.4 Other Damage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 1.5 Personnel Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 1.5.1 The Captain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 1.5.1.1 The Captain’s Employment History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 1.5.1.2 The Captain’s 72-Hour History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 1.5.2 The First Officer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 1.5.2.1 The First Officer’s Employment History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 1.5.2.2 The First Officer’s 72-Hour History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 1.5.3 The Cabin Aide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 1.5.3.1 The Cabin Aide’s Employment History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 1.5.3.2 Federal Requirements Regarding Flight Attendant Responsibilities. . . . . . . . . . 14 1.6 Airplane Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1.6.1 General Airplane Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1.6.2 Airplane Weight and Balance Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 1.6.2.1 Actual Airplane Weight and Balance Information . . . . . . . . . . . . . . . . . . . . . . . 16 1.6.2.2 Flight Crew Weight and Balance Information. . . . . . . . . . . . . . . . . . . . . . . . . . . 17 1.6.2.3 Federal Weight and Balance Requirements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 1.6.2.4 Fuel Load Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 1.6.2.5 Airplane Pitch Trim Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 1.6.3 Longitudinal Flight Control System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 1.6.4 Main Cabin Door . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 1.7 Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 1.8 Aids to Navigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 1.9 Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 1.10 Airport Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 1.10.1 General Airport Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 1.10.2 Airport Runway Safety Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 1.11 Flight Recorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 1.11.1 Cockpit Voice Recorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 1.11.2 Flight Data Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 1.11.3 Sound Spectrum Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

iv Aircraft Accident Report 1.12 Wreckage and Impact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 1.12.1 Wreckage Path . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 1.12.2 Wreckage Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 1.12.3 Longitudinal Flight Control System Components . . . . . . . . . . . . . . . . . . . . . . . . . . 29 1.13 Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 1.14 Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 1.15 Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 1.16 Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 1.16.1 Airplane Performance Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 1.16.1.1 Rotation Characteristics Simulation Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 1.16.1.2 Rejected Takeoff Simulation Results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 1.17 Organizational and Management Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 1.17.1 Airplane Ownership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 1.17.2 Airplane Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 1.17.2.1 Platinum Jet Management, LLC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 1.17.2.2 Darby Aviation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 1.17.2.3 The Relationship Between PJM and Darby Aviation . . . . . . . . . . . . . . . . . . . . . 35 1.17.2.3.1 Operational Control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 1.17.2.3.2 Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 1.17.2.3.3 Record-keeping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 1.17.2.4 Blue Star Jets, Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 1.17.3 FAA Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 1.17.4 Federal Lease Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 1.17.5 Postaccident Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 1.17.5.1 FAA and DOT Emergency Orders to PJM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 1.17.5.2 FAA Emergency Order of Suspension to Darby Aviation . . . . . . . . . . . . . . . . . 40 1.17.5.3 Additional Postaccident DOT and FAA Actions. . . . . . . . . . . . . . . . . . . . . . . . . 41 1.18 Additional Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 1.18.1 Other Challenger CL-600 Runway Overrun Accidents . . . . . . . . . . . . . . . . . . . . . . 42 1.18.2 Previous Safety Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 1.18.2.1 Engineered Materials Arresting System Recommendation. . . . . . . . . . . . . . . . . 43 1.18.2.2 Crew Resource Management Training for Part 135 Pilots . . . . . . . . . . . . . . . . . 44 1.18.2.3 Part 135 Operator Information Recommendation . . . . . . . . . . . . . . . . . . . . . . . . 45

1. Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
2. 1

General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 2.2 The Accident Sequence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 2.3 Flight Crew and Airplane Performance Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 2.3.1 Preflight Airplane Weight and Balance Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 2.3.2 Pilot Decisions and Actions During the Rejected Takeoff . . . . . . . . . . . . . . . . . . . 51 2.3.3 Crew Resource Management Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 2.4 Operational Control and Noncertificated (Unauthorized) Carrier Issues . . . . . . . . . . . . 54 2.4.1 PJM and Darby Aviation Operational Control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 2.4.2 FAA Oversight of PJM and Darby Aviation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 2.5 Cabin Aide Actions, Performance, and Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 2.6 Runway Safety Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Contents

v Aircraft Accident Report

1. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
2. 1

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 3.2 Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

1. Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
2. Appendixes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

A: Investigation and Public Hearing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 B: Cockpit Voice Recorder Transcript . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 C: Weight and Balance Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Contents

vi Aircraft Accident Report Figures

1. The airplane wreckage partially embedded in the building after

the postimpact fire was extinguished. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

1. A diagram of the accident airplane’s cockpit and cabin configuration. . . . . . . . . . . . . . . . . . 7
2. Photograph of a CL-600 pitch trim position indicator similar

to that in the accident airplane. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

1. The accident airplane’s pitch trim position indicator display, as

documented postaccident. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

1. The side-facing, three-passenger divan from the accident airplane

with the burned seat cushions removed. Note: the arrows indicate the row of folded seatbelts that were found beneath the seatback cushions. . . . . . . . . . . . . 29

1. The accident airplane, the impacted building and several impacted

vehicles, and the HRET/skin-penetrating nozzle-equipped firefighting vehicle. . . . . . . . . 31

vii Aircraft Accident Report Abbreviations AC advisory circular AD airworthiness directive AFFF aqueous film-forming foam AFM airplane flight manual APU auxiliary power unit ARAC aviation rulemaking advisory committee ARFF aircraft rescue and firefighting ASOS automated surface observing system ATC air traffic control C Celsius CAM cockpit area microphone CAMP continuous airworthiness maintenance program CASS continued analysis and surveillance system CEO chief executive officer CFR Code of Federal Regulations CG center of gravity CIMMS computer integrated maintenance management system CRM crew resource management CVR cockpit voice recorder dba doing business as DO director of operations DOM director of maintenance DOT Department of Transportation EMAS engineered materials arresting system EWR Newark International Airport FAA Federal Aviation Administration

Abbreviations viii Aircraft Accident Report FBO fixed base operator FDR flight data recorder FLL Fort Lauderdale International Airport FMS flight management system FSDO flight standards district office GMM general maintenance manual HRET high-reach extendable turret IFR instrument flight rules LAS McCarran International Airport LGA LaGuardia Airport MAC mean aerodynamic chord MDW Chicago Midway Airport NPRM notice of proposed rulemaking NWS National Weather Service PCU power control unit PJM Platinum Jet Management PMI principal maintenance inspector POI principal operations inspector RII required inspection item RSA runway safety area RTO rejected takeoff S/N serial number SB service bulletin TEB Teterboro Airport

ix Aircraft Accident Report Executive Summary On February 2, 2005, about 0718 eastern standard time, a Bombardier Challenger CL-600-1A11, N370V, ran off the departure end of runway 6 at Teterboro Airport (TEB), Teterboro, New Jersey, at a ground speed of about 110 knots; through an airport perimeter fence; across a six-lane highway (where it struck a vehicle); and into a parking lot before impacting a building. The two pilots were seriously injured, as were two occupants in the vehicle. The cabin aide, eight passengers, and one person in the building received minor injuries. The airplane was destroyed by impact forces and postimpact fire. The accident flight was an on-demand passenger charter flight from TEB to Chicago Midway Airport, Chicago, Illinois. The flight was subject to the provisions of 14 Code of Federal Regulations (CFR) Part 135 and operated by Platinum Jet Management, LLC (PJM), Fort Lauderdale, Florida, under the auspices of a charter management agreement with Darby Aviation (Darby), Muscle Shoals, Alabama. Visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan. The National Transportation Safety Board determines that the probable cause of the accident was the pilots’ failure to ensure the airplane was loaded within weight-and-balance limits and their attempt to take off with the center of gravity well for- ward of the forward takeoff limit, which prevented the airplane from rotating at the intended rotation speed. Contributing to the accident were: 1) PJM’s conduct of charter flights (using PJM pilots and airplanes) without proper Federal Aviation Administration (FAA) certification and its failure to ensure that all for-hire flights were conducted in accordance with 14 CFR Part 135 requirements; 2) Darby Aviation’s failure to maintain operational control over 14 CFR Part 135 flights being conducted under its certificate by PJM, which resulted in an environment conducive to the development of systemic patterns of flight crew performance deficiencies like those observed in this accident; 3) the failure of the Birmingham, Alabama, FAA Flight Standards District Office to provide adequate surveillance and oversight of operations conducted under Darby’s Part 135 certificate; and 4) the FAA’s tacit approval of arrangements such as that between Darby and PJM. The safety issues addressed in this report include weight and balance procedures; flight crew actions, training, and procedures; company oversight and operational control; FAA responsibility and oversight; cabin aide actions, training, and procedures; and runway safety areas.

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1 Aircraft Accident Report 1. Factual Information 1.1 History of Flight On February 2, 2005, about 0718 eastern standard time,1 a Bombardier Challenger CL-600-1A11, N370V, ran off the departure end of runway 6 at Teterboro Airport (TEB), Teterboro, New Jersey, at a ground speed of about 110 knots; through an airport perimeter fence; across a six-lane highway (where it struck a vehicle); and into a parking lot before impacting a building. The two pilots were seriously injured, as were two occupants in the vehicle. The cabin aide,2 eight passengers, and one person in the building received minor injuries. The airplane was destroyed by impact forces and postimpact fire. The accident flight was an on-demand passenger charter flight from TEB to Chicago Midway Airport (MDW), Chicago, Illinois. The flight was subject to the provisions of 14 Code of Federal Regulations (CFR) Part 135, and operated by Platinum Jet Management, LLC (PJM), Fort Lauderdale, Florida, under the auspices of a charter management agreement with Darby Aviation (Darby), Muscle Shoals, Alabama.3 Visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules (IFR) flight plan. Postaccident interviews revealed that a brokerage company had arranged for PJM to conduct the accident flight for a charter customer.4 The accident airplane was scheduled to arrive at TEB from McCarran International Airport (LAS), Las Vegas, Nevada, early on February 2, 2005, and to depart about 0700. The accident pilots and cabin aide were assigned the flight on the afternoon of February 1.5 Later that day, they traveled on a commercial flight from Fort Lauderdale International Airport (FLL), Fort Lauderdale, Florida, to LaGuardia Airport (LGA), New York, New York, arriving about 2315. They arrived at their hotel in Hasbrouck Heights, New Jersey, slightly after midnight.6 Early the next morning, fixed based operator (FBO) personnel from TEB picked up the pilots and cabin aide at the hotel and transported them to the FBO where the airplane had been parked overnight, arriving about 0520. According to postaccident statements, when the pilots arrived at the airport, they both performed preflight inspections of the airplane and noted no discrepancies. The captain stated that there were 1 Unless otherwise indicated, all times are eastern standard time based on a 24-hour clock. 2 Federal regulations did not require a qualified flight attendant for the accident flight. For more information about the role and responsibilities of the cabin aide, see section 1.5.3.2. 3 For additional information regarding PJM, Darby, and the relationship between and responsibilities of the two entities, see section 1.17.2. 4 For additional information regarding the brokerage company, see section 1.17.2.4. 5 The arriving crew would not be available for the morning departure because of Federal flight and duty/rest regulations applicable to flights operated under Part 135. 6 Postaccident interviews indicated that, upon arrival at the hotel, the accident captain contacted one of the fixed base operators at TEB to see if the airplane had arrived, and he learned that it had not yet arrived. Records indicated that the airplane arrived at TEB from LAS about 0041 on February 2.

Factual Information 2 Aircraft Accident Report no entries in the airplane logbook and added that the airplane was “absolutely clean.” The pilots requested that line service technicians top off the fuel, and the first officer monitored the airplane as 1,842 gallons of fuel were loaded.7 The pilots stated that, after their preflight duties were performed and the airplane was refueled, they started the engines and waited for the catering to arrive. After the catering arrived (about 0608), the pilots taxied the airplane to another FBO on the airport to meet the passengers for the flight. The captain stated that he performed another “walk around” inspection of the airplane after it was repositioned because it was in better light. The passengers arrived between about 0630 and 0705. The captain stated that after all of the passengers had arrived he loaded the airplane. According to postaccident statements and physical evidence, the passengers carried only light baggage, such as coats and briefcases or laptop cases, which was stowed in various locations throughout the cabin. The only bags stowed in the aft baggage compartment were suitcases belonging to the pilots and cabin aide. The captain stated that the passengers told him that their company operated its own Challenger (a CL-601) and that they were “very familiar” with the airplane. He stated that, after briefing the passengers regarding expected turbulence during the flight to Chicago, he went to the cockpit and began the “starting engines checklist,” believing the cabin aide would finish the safety briefing.8 According to the cockpit voice recorder (CVR)9 and air traffic control (ATC) transcripts, about 0711, the first officer contacted TEB ground control and indicated that they were ready to depart. The ground controller issued instructions to taxi to runway 6. As they taxied, the pilots discussed their departure and applicable noise abatement procedures and programmed the airplane’s flight director. About 0715:43, the captain suggested that they perform the before takeoff checklist, and the first officer responded with taxi checklist items, including the trim setting and flight control checks. CVR information indicated that the pilots checked the movement of the flight controls (the elevator, rudder, and ailerons) from about 0716:09 to 0716:21. The pilots stated that the movement of the flight controls was satisfactory and unrestricted during this check. They further reported that there were no abnormal lights or indications during the performance of the checklists, the taxi, or the attempted takeoff. About 0716:22, while they were still taxiing to runway 6, ATC instructed the pilots to taxi into position on the runway and hold, pending an IFR release. The first officer acknowledged. About 0716:36, the first officer announced that the taxi checklist was completed and began the before takeoff checklist. When the first officer read the 7 According to the FBO’s records, the airplane received 1,390 gallons from one fuel truck and 452 gallons from a second fuel truck. For additional information, see section 1.6.2.4. 8 The captain told investigators that it was his understanding that the cabin aide should perform the safety briefing. However, according to PJM’s chief executive officer (CEO), it was the company’s policy to have one of the pilots brief the passengers before each flight. The PJM CEO acknowledged that the captain would not have known of this policy because he had not yet received the required Part 135 indoctrination training from Darby. For additional information on the captain’s training, see section 1.5.1. 9 A complete transcript of the CVR is included in appendix B of this report.

Factual Information 3 Aircraft Accident Report “windshield…heater” before takeoff checklist item, the captain responded “they…briefed the standard for us.” The first officer read no more checklist items aloud, but, about 0716:54, he announced that the before takeoff checklist was complete.10 About 15 seconds later, as the airplane was taxiing onto runway 6, ATC cleared the flight for takeoff, advising them to “keep it on the roll…traffic is a Learjet on 4 mile final.” The controller repeated the takeoff clearance about 0717:19, and the pilots acknowledged the clearance. About 0717:32, the captain stated, “let’s go,” and, about 1 second later, the CVR recorded sounds similar to an increase in engine power. The captain was the flying pilot for the accident flight, and he stated that he steered the airplane onto the runway with his left hand and increased engine power for the takeoff with his right hand. The captain stated that, as the airplane accelerated on the runway, he kept his left hand on the tiller and his right hand on the power levers while the first officer held the control yoke. The first officer monitored the airplane’s acceleration and announced 80 knots and V1, and VR.11 According to the captain, as the airplane accelerated, he transferred first his left and then his right hand to the control yoke to prepare for liftoff. He stated that the airplane’s acceleration to this point had seemed normal and that he did not notice anything out of the ordinary when he first grasped the control yoke. However, airport surveillance videotapes and postaccident witness statements indicated that the airplane’s nose never lifted off the runway, even at an apparently higher-than-normal liftoff speed.12 CVR evidence indicated that, about 5 seconds after the airplane accelerated through the rotation speed, the captain commanded a rejected takeoff (RTO), and the CVR recorded sounds similar to decreasing engine power. The captain told investigators that he applied brakes, speed brakes, and thrust reversers in an attempt to stop the airplane and that all of those systems appeared to be working. The airplane was decelerating as it ran off the end of the runway and hit a building. After the airplane hit the building, a postimpact fire ensued. Figure 1 shows the airplane partially embedded in the building after the postimpact fire was extinguished. 10 The CVR did not record either pilot performing a takeoff briefing or verbalizing several items on the taxi and before takeoff checklists, including items involving checking the ground spoilers and radar settings, activating the transponder, and performing an annunciator recall. (Physical evidence indicated that the ground spoiler toggle switch was in the on position, consistent with the accomplishment of that checklist item.) During postaccident interviews, the captain told investigators that he had also performed a stall protection system check and verified the target speeds before the passengers arrived. 11 V1, the takeoff decision speed, is the maximum speed during the takeoff at which the pilot must take action(s) (apply brakes, reduce thrust, deploy speed brakes) to stop the airplane within the accelerate-stop distance. For the accident flight, V1 was about 127 knots. VR, the rotation speed, is the speed to which an airplane must accelerate to become airborne when a pilot makes a control input to increase the angle of attack and allow the airplane to lift off the runway. The captain recalled that VR for the accident flight was about 133 to 134 knots. Investigators calculated it to be about 135 knots. 12 For additional information, see the docket for this accident.

Factual Information 4 Aircraft Accident Report Figure 1. The airplane wreckage partially embedded in the building after the postimpact fire was extinguished. The pilots were initially trapped in their seats by wreckage and, therefore, were unable to open the main cabin door promptly after the accident. The cabin aide failed to open the main cabin door; therefore, a passenger rotated the door handle and, with another passenger, pushed and kicked the door open.13 All of the airplane occupants successfully evacuated the airplane. 1.1.1 Flight Crew Postaccident Statements During postaccident interviews, the captain stated that, when the airplane reached the rotation speed, he attempted to pull the control yoke aft, but, even though he pulled very hard, the airplane did not lift off. The first officer told investigators that, as the airplane continued to accelerate on the runway without lifting off, he also began pulling back on the control yoke. Both pilots reported being trapped in their seats because their legs were entangled in the rudder pedals and wreckage that intruded through the cockpit floor after impact. The pilots stated that they urgently wanted to exit the airplane because fuel was spilling and 13 For additional information regarding main cabin door operation, see section 1.6.4.

Factual Information 5 Aircraft Accident Report they could see smoke and flames. The captain reported that he shut down the engines and master battery switch and that he then grabbed the first officer by the belt and pulled on his lower body while the first officer pulled on an overhead bar with his arms. Through these efforts, the pilots were able to free the first officer’s legs from the wreckage. The first officer reported that he was then able to crawl out the main cabin door. After he exited the airplane and crawled over the wing, two passengers helped pull him away from the airplane. The captain reported that he freed his legs from the wreckage by pulling himself up using the overhead bar. He stated that, after freeing his legs, he crawled through the cabin area to ensure that everyone else was out of the airplane before he exited through the main cabin door and walked away from the airplane. The captain stated that, after he exited the airplane, he located the first officer and passengers and coordinated with the aircraft rescue and firefighting (ARFF) and other emergency personnel. Although he did not see the cabin aide, the captain knew that she was no longer in the airplane because he had checked the cabin area, and several passengers told him that they had seen her outside the airplane. 1.1.2 Cabin Aide Postaccident Statement The cabin aide stated that, when the passengers boarded the airplane, she helped them with their coats and carry-on bags and provided them with refreshments. She stated that the main cabin door seemed to operate normally when the pilots closed it before takeoff.14 She stated that she did not conduct a passenger safety briefing/demonstration and added that the pilots were responsible for such briefings. The cabin aide said she thought that the captain conducted a passenger safety briefing; however, because she was standing behind him, she could not hear what he said. The cabin aide told investigators that she performed a pretakeoff cabin walkthrough and ensured that all of the passengers had fastened their seatbelts.15 The cabin aide told investigators that she was seated on the forward-facing jumpseat with her seatbelt fastened during the takeoff roll. She stated that she did not notice any problems during the takeoff until she saw that they were rapidly approaching the airport perimeter fence. She remembered the captain saying, “hold on,” as the airplane ran off the runway and closing her eyes and trying to brace for the impact as the airplane headed toward the building. The cabin aide stated that, when the airplane came to a stop and she opened her eyes, she could see that the pilots were alive but injured. She stated that the pilots were concerned about fire and told her to get the passengers out of the airplane and run. She stated that she unbuckled her seatbelt and moved to open the main cabin door.16 The cabin 14 The cabin aide indicated that she thought that the pilots were responsible for operating the main cabin door during normal and emergency operations and that a cabin aide would only operate the door in an emergency if the pilots were unable to do so. 15 Postaccident passenger statements indicated that only four of the eight passengers had their seatbelts fastened before takeoff. For additional information, see section 1.1.1.3.

Factual Information 6 Aircraft Accident Report aide told investigators that she believed she “got the lever open” and that she then tried to use the electric “lever at the top [of the bulkhead] but it was not working.” She stated that the passengers began pushing and kicking the door, which eventually opened. The cabin aide stated that she jumped out of the airplane, fell, and then got up and ran away from the airplane. She stated that she was picked up by a passerby in a car, driven to a police officer and ambulance, and subsequently taken to the hospital. 1.1.3 Passenger Postaccident Statements During postaccident interviews, the eight passengers described various aspects of the preflight, taxi, attempted takeoff, RTO, and evacuation sequence. Six of the eight passengers stated that they did not remember receiving a safety briefing before takeoff. Only two passengers remembered the captain addressing them, and only one of those passengers stated that the captain’s address was a “short briefing.” Another passenger was certain he had not received a safety briefing because he would have fastened his seatbelt immediately if told to do so. Another passenger remembered specifically that no one showed them how to open the main cabin door. Many of the passengers stated that the cabin aide offered them beverages after they boarded the airplane and that at least four accepted. The cabin aide served the beverages in glasses or ceramic/china cups except for one bottled water that was specifically requested by a passenger. (Several glasses and/or cups were recovered on or near passenger seats after the accident.) The passenger in seat 4L told investigators that he picked up his coffee cup with his right hand during the takeoff roll to prevent spillage. (Figure 2 is a diagram of the airplane’s cockpit and cabin configuration.) He added that he believed that injuries to his right hand were caused by the coffee cup breaking during the accident sequence. 16 The cabin aide indicated that she considered using the overwing emergency exit (which she was trained to use as the primary emergency evacuation route) during the evacuation but that she elected to use the main cabin door because the cabin was filling with smoke and the main cabin door was closer. Postaccident evidence showed that there were several burning vehicles near the right overwing exit.

Factual Information 7 Aircraft Accident Report Figure 2. A diagram of the accident airplane’s cockpit and cabin configuration. Postaccident interviews indicated that, at the beginning of the takeoff roll, only four of the eight passengers (in seats 1L, 1R, 2L, and 2R) had their seatbelts fastened. Two of the four remaining passengers (in seats 3L and 4L) fastened their seatbelts during the takeoff roll.17 The two passengers seated on the divan (in seats 2 and 3) could not locate and, therefore did not fasten, their seatbelts.18 Passenger statements indicated that the two unrestrained passengers were thrown to the cabin aisle floor during the RTO. Passengers indicated that it was dark and smoky in the cabin after the airplane came to a stop. The cabin aide had not opened the main cabin door, so the passenger who 17 During postaccident interviews, the passenger in seat 3L stated that he “half-heartedly” looked for his seatbelt as the airplane began rolling but that he could not immediately locate it. He stated that, moments later, when he saw the passenger in seat 4L fasten his seatbelt, he again looked for his seatbelt and then located and fastened it. 18 For additional information on the divan seatbelts, see section 1.12.2.

Factual Information 8 Aircraft Accident Report had occupied seat 1L felt around the door until he found the door handle, which he then rotated. He stated that, when the door did not open, he pushed and kicked it. He added that, with help from the passenger who had occupied seat 1R, he was able to open the main cabin door, and the passengers and cabin aide were able to evacuate the airplane. Although the cabin aide told investigators that she exited the airplane after all the passengers had evacuated, the passenger who had occupied seat 2R stated that he fell onto the cabin aide when he exited the airplane, and the passenger who had occupied seat 4L stated that he saw the cabin aide outside of the airplane before he exited. When asked, six of the eight passengers reported speaking with the captain after the accident.19 The passenger who had occupied seat 1R indicated that the captain stated, “she just wouldn’t rotate” and “she wouldn’t come over. She wouldn’t rotate.” The passenger who had occupied seat 2L told investigators that the captain stated, “I just pulled back…just didn’t have any lift,”20 and the passenger who had occupied seat 2R reported that the captain stated, “no lift, no lift.” The passenger who had occupied seat 3L stated that the captain told him that the airplane “got to a point where it should have rotated [or lifted] and nothing happened.” The passenger who had occupied divan seat 1 stated that the captain told him that he “couldn’t get it up off the ground” and that he “tried to get the plane up and it just wouldn’t get up off the ground.” The passenger who occupied divan seat 3 reported that the captain stated, “didn’t have any lift…the plane had no lift.” 1.2 Injuries to Persons Table 1. Injury chart. Note: Title 14 CFR 830.2 defines a serious injury as any injury that (1) requires hospitalization for more than 48 hours, starting within 7 days from the date that the injury was received; (2) results in a fracture of any bone, except simple fractures of fingers, toes, or the nose; (3) causes severe hemorrhages or nerve, muscle, or tendon damage; (4) involves any internal organ; or (5) involves second- or third-degree burns or any burns affecting more than 5 percent of the body surface. 19 No passengers reported speaking with the first officer. 20 The passenger who had occupied seat 2L indicated that, while the pilot made this statement, he motioned with his arms as if holding onto a control yoke and pulled and pushed back and forth. Injuries Flight Crew Cabin Crew Passengers Other Total Fatal 0 0 0 0 0 Serious 2 0 0 2 4 Minor 0 1 8 1 10 None 0 0 0 0 0 Total 2 1 8 3 14

Factual Information 9 Aircraft Accident Report 1.3 Damage to Aircraft The airplane was destroyed by impact forces and postimpact fire. 1.4 Other Damage This accident resulted in damage to airport property (a navigational system antenna and the airport perimeter fence), a vehicle on a highway, five vehicles in a parking lot, and a building across the highway from the airport. 1.5 Personnel Information 1.5.1 The Captain The captain, age 58, obtained his commercial pilot certificate in 1981. The captain held an airline transport pilot certificate, issued June 7, 1984, with airplane multiengine land ratings and a type rating in the CL-600, issued January 15, 1998. PJM retained him as a contract pilot on January 6, 2005. The captain’s most recent FAA first-class airman medical certificate was issued on August 9, 2004.21 According to information provided by the captain and obtained from PJM records and other documents, at the time of the accident, the captain had accumulated about 16,374 total flight hours, including about 3,378 hours in the CL-600/-601.22 The captain had flown about 35, 15, and 5 hours in the last 90, 30, and 7 days, respectively. In addition, the captain told investigators that he had flown about 200 total hours in the year preceding the accident. A review of Federal Aviation Administration (FAA) records found no accident, incident, or enforcement action history, and a search of records at the National Driver Register revealed no evidence of convictions or violations. The captain’s records and statements indicated that, in December 2004, he independently paid for and received CL-600/-601 ground training, differences training, and simulator flight training.23 According to PJM records, in January 2005, the captain demonstrated his proficiency as a CL-600 pilot during a preemployment evaluation flight 21 The captain’s FAA medical records indicated that he was receiving treatment for mild hypertension and that he had lost about 30 pounds during the previous year. The captain stated that, except for the hypertension, which he was able to control with medication, his health was good. 22 The captain stated that his personal flight experience records had been stored in a computer that he claimed was destroyed in the accident. Résumés submitted by the captain to various companies in February 2001, April 2004, and January 2005 indicated total flight times of 12,885+, 15,670+, and 15,902+ hours, respectively. The résumés showed that the captain’s total flight time increased by 142 hours from April 2004 to January 2005; however, they also showed that he had flown 200 hours in Raytheon King Airs and 760 hours in CL-600/-601 airplanes during that time. 23 The captain’s records did not indicate that this training included sections on cabin evacuation, emergency equipment, or hands-on emergency drills.

Factual Information 10 Aircraft Accident Report with PJM’s chief executive officer (CEO). The CEO stated that, after the evaluation flight, he approved the captain to conduct Part 91 flights in PJM airplanes and he endorsed the captain for further ground and flight training, which was required to perform Part 135 flight operations for Darby Aviation24 and would include company-specific procedures for preflight planning, cabin evacuation, emergency equipment, and hands-on emergency drills. However, the captain had not yet received the additional Darby-specific Part 135 indoctrination, ground, or flight training at the time of the accident; therefore, he was restricted to operating flights under Part 91.25 The captain told investigators that his financial situation was stable during the previous year; however, he had not maintained a consistent place of residence during that time. According to the captain, he stayed with friends and family and lived in various forms of temporary housing in Virginia, Florida, and other states. 1.5.1.1 The Captain’s Employment History Records indicated that the captain worked for a government contract airline in Germany from 1986 to 1988 and that he then worked as a senior captain for a Cincinnati, Ohio-based company until 1990. The captain’s résumé indicated that he worked as a pilot under “various part time contracts”26 from 1990 to 1998 and that he was employed as a corporate CL-600/-601 captain from 1998 to 2001. The captain’s résumé and postaccident interviews indicated that from 2001 to 2004 he was employed as a pilot in various aircraft under government subcontracts. The captain told investigators that, under one of these subcontracts, he flew Cessna Citation airplanes for a Harrisonburg, Virginia-based company from 2001 to late 2003. A review of the captain’s personnel records with that company revealed an October 3, 2003, letter written by the company’s chief pilot that described a “worsening personnel problem” involving the captain. The chief pilot indicated that the pilot had exhibited “poor judgment and decision making processes” on numerous occasions on the ground and in the air and had violated Federal regulations during an approach.27 Company records indicated that the captain submitted a letter of resignation on October 7, 2003. The captain told investigators that, in addition to his government contracts from 2001 to 2004, he worked as a temporary contract pilot for various aviation companies in 24 For additional information regarding Darby Aviation, see section 1.17.2.2. 25 Title 14 CFR Part 91 contains general operating and flight regulations for all civil airplanes and pilots operating within the United States and addresses the responsibilities and authority of the pilot-in-command. The captain told investigators that he had been scheduled to begin Part 135 indoctrination, ground, and flight training the day after the accident. 26 According to the captain’s résumé, during this time, he worked as a first officer, captain, check airman, chief pilot, director of operations, and director of training. 27 The October 3, 2003, letter described a flight that occurred on September 27, 2003, for which the captain claimed he was fit for duty when he appeared to be sick, initiated a late descent for an instrument approach, descended rapidly, and continued 1 mile beyond the missed approach point before acquiring the visual cues necessary to continue the approach. The chief pilot stated that the captain failed to initiate the required missed approach despite repeated challenges to do so.

Factual Information 11 Aircraft Accident Report Texas, Florida, California, North Carolina, South Carolina, Ohio, and Missouri.28 He stated that these assignments typically lasted a few days. The captain told investigators that, in early 2004, he began a government contract, under which he was assigned to fly for different agencies and organizations and that this government contract was scheduled to end on April 30, 2005. When asked for details, the captain stated that his work was classified, and he declined to reveal the identity of his employer or supervisor under this contract. He stated that he worked as a pilot for another Virginia-based company from January to June or July 2004 and that he left when the project for which he was hired came to an end. Representatives of the Virginia-based company told investigators that the captain had responded to an advertisement seeking pilots with security clearances and that he was hired in April 2004 to work on an aviation project in Iraq but was never sent overseas. Company documents indicated that the captain’s employment with the company was terminated on May 28, 2004, for safety-related issues, including deficiencies in aircraft knowledge, lack of adherence to company procedures, poor airmanship, and “interpersonal” problems. These documents noted that the captain claimed to have experience that was not consistent with his performance and that he was not receptive to feedback about deficiencies in his performance. 1.5.1.2 The Captain’s 72-Hour History On Sunday, January 30, 2005, the captain returned from flying a 2-day trip (documented in PJM records as several Part 91 flights with varying numbers of passengers) for PJM with the accident first officer.29 He stated that he could not recall his activities that evening or what time he went to sleep. The captain told investigators that he awoke about 0930 on January 31 and engaged in routine activities at home that day. He reported that he briefly visited PJM’s office to report on the previous days’ trip and that he went to sleep about 2130 that night, which he noted was earlier than usual for him.30 The captain stated that, on Tuesday, February 1, he awoke about 0930, relaxed and ran errands during the day, and took a nap. About 1630, PJM contacted the captain to notify him of an airplane certification test flight the following day. The captain ate dinner at home and, about 1730, was notified by PJM that the test flight had been cancelled and that he was scheduled for the accident flight. The captain stated that he traveled with the first officer and cabin aide on a commercial airline flight from FLL to LGA, where they arrived about 2315. The pilots and cabin aide were transported from LGA to their hotel in 28 During the investigation, Safety Board investigators found identification cards, ramp access passes, and patches from numerous operators and agencies in the captain’s bag, which was salvaged from the aft cargo compartment after the accident. 29 The captain told investigators that he had flown with the accident first officer several times since he was hired by PJM. He stated that the first officer was an “excellent copilot, one of the sharpest…right on top of everything.” 30 The captain stated that he usually needed about 6 hours of sleep per night to feel rested and that he usually slept about 6 hours per night during extended nonworking periods.

Factual Information 12 Aircraft Accident Report Hasbrouck Heights. The captain contacted the FBO at TEB to see if the airplane had arrived, found out that it had not, and subsequently went to sleep. The captain stated that, on February 2, he awoke about 0500 and traveled to TEB with the first officer and cabin aide for the accident flight. The cabin aide and other witnesses at both TEB FBOs indicated that the captain appeared alert and cheerful that morning and did not appear fatigued. Several passengers spoke with the captain at the FBO while waiting for other passengers to arrive, and they reported that he was friendly and did not appear fatigued. 1.5.2 The First Officer The first officer, age 31, obtained his commercial pilot certificate and instrument and multiengine ratings in 1992. PJM retained the first officer as a contract pilot on November 4, 2003. The first officer’s most recent FAA first-class airman medical certificate was issued on January 4, 2004; however, this medical certificate was not valid for commercial operations after January 31, 2005. According to PJM’s records, at the time of the accident, the first officer had accumulated about 5,962 total flight hours, including about 82 hours in the CL-600/-601. The first officer had flown about 20, 10, and 5 hours in the last 90, 30, and 7 days, respectively. In addition, the first officer stated that he had flown about 82 total hours in the year preceding the accident. A review of FAA records found no accident, incident, or enforcement action history, and a search of records at the National Driver Register revealed no evidence of convictions or violations. Darby Aviation’s records indicated that the first officer completed 22 hours of company initial indoctrination training in November 2003.31 However, Darby’s Flight Operations Manual stated that pilots are required to complete 31 hours of initial training— 14 hours of indoctrination, 15 hours of initial aircraft equipment ground training, and 2 hours of flight training. The first officer stated that he did not receive a flight check in the CL-600 until he received recurrent ground training in November 2004 because a CL-600 airplane was not available when he received his indoctrination training. Investigators found no evidence that the first officer had experienced any major life changes in the year before the accident. 1.5.2.1 The First Officer’s Employment History The first officer is a Venezuelan citizen who began his aviation career with a small Venezuelan airline. During his 9-month training period with that airline, another airline purchased the company; subsequently, that airline declared bankruptcy in 1997. The first 31 Records and postaccident interviews indicated that the first officer received emergency procedures training and performed hands-on drills related to operating the overwing exit and fire extinguishers; however, this training did not include operation of the main cabin door. There was no indication that the first officer ever received hands-on training on the operation of the main cabin door.

Factual Information 13 Aircraft Accident Report officer stated that he flew for two small aviation companies before accepting a job with a major Venezuelan airline, where he served as a flight engineer on Douglas DC-10 and Boeing 727 airplanes. After that major airline ceased operations, the first officer flew business jets for individuals and companies in Florida. The first officer stated that, in recent years, he had been working in the United States in aviation and nonaviation fields. He completed some indoctrination and ground school training for PJM/Darby Aviation in November 2003; however, PJM did not have enough work for him at the time. The first officer stated that he did some other contract flying before he began flying revenue trips for PJM/Darby in November 2004. 1.5.2.2 The First Officer’s 72-Hour History On Sunday, January 30, 2005, about 1700, the first officer returned home from flying the 2-day trip (documented as Part 91 flights with varying numbers of passengers) for PJM with the accident captain. He reported that he went to sleep about 2200 that night and awoke about 0800 on January 31. He stated that he did not work that day but that he ran errands and engaged in routine activities at home before going to sleep about 2200. The first officer reported that, on Tuesday, February 1, he awoke about 0800 and engaged in routine activities at home for most of the day. About 1400, PJM notified him that he was scheduled for the accident flight. The first officer stated that he ate dinner at FLL before departing for LGA on a commercial flight, which arrived about 2315. He stated that he checked into the hotel in Hasbrouck Heights, telephoned home briefly, and then fell asleep. He stated that he awoke about 0430 the next morning and that he felt rested. According to the cabin aide, the first officer looked alert on the morning of the accident. 1.5.3 The Cabin Aide The cabin aide was retained by PJM as a contract employee in October 2004. She stated that she received on-the-job training32 from PJM’s lead cabin aide during flights on the company’s CL-600s (including the accident airplane) in October 2004 and that she received some emergency training from PJM staff on the accident airplane in November 2004.33 The cabin aide stated that, during the emergency training, she operated each of the CL-600’s exits and was familiarized with the airplane’s emergency exits, fire extinguishers, first aid kit, oxygen masks, flashlights, life vests, and life raft. In addition, procedures regarding emergency evacuations and smoke in the airplane were discussed during PJM’s cabin aide training. The cabin aide and PJM’s lead cabin aide told investigators that the company’s cabin aide training indicated that the 32 The cabin aide stated that, during the on-the-job training, PJM addressed company policies, aircraft familiarization, and customer service. 33 Interviews with PJM management personnel and the cabin aide indicated that PJM intended to send the cabin aide for additional training after her 4-month probationary period but that she had not completed the training at the time of the accident.

Factual Information 14 Aircraft Accident Report primary evacuation route was through the emergency overwing exit and that they were required to demonstrate proper operation of this exit during training. Both cabin aides also stated that the main cabin door was a secondary emergency exit and that the pilots were responsible for operating it during normal operations and in emergencies if they were able to do so. The accident cabin aide stated that she had received verbal instruction regarding main cabin door emergency operation and that she had operated the main cabin door handle and electric toggle switch in a simulated emergency scenario during her training. She stated that the door was disarmed during this training rather than armed, as it would be during an actual emergency (and as it was for the accident flight). She stated that she had not operated the main cabin door when it was armed and that she was not familiar with the arm/disarm handle. 1.5.3.1 The Cabin Aide’s Employment History The cabin aide told investigators that before her position with PJM, she had never worked in aviation or as a flight attendant or cabin aide. She said that she had been a model and a waitress before she began working for PJM. The cabin aide indicated that, between November 2004 and the day of the accident, she worked regularly (about three times a week) as a cabin aide for PJM on an “on-call” basis.34 1.5.3.2 Federal Requirements Regarding Flight Attendant Responsibilities According to 14 CFR 135.107, “no certificate holder may operate an aircraft that has a passenger seating configuration, excluding any pilot seat, of more than 19 unless there is a flight attendant crew member on board the aircraft.” The accident airplane was equipped with only 9 passenger seats; therefore, Section 135.107 did not require that the flight have a qualified flight attendant. PJM provided the cabin aide to serve as a customer service representative on the accident flight. The cabin aide was not trained or qualified as a flight attendant; however, during postaccident interviews, several passengers referred to her as a flight attendant. According to 14 CFR 135.295, no person may serve as a flight attendant on a Part 135 flight unless the certificate holder “has determined by appropriate initial and recurrent testing that the person is knowledgeable and competent” in numerous areas, including the following: • Crewmember assignments, functions, and responsibilities during ditching and evacuation of persons who may need the assistance of another person to move expeditiously to an exit in an emergency; • Briefing of passengers; • Location and operation of portable fire extinguishers and other items of emergency equipment; and • Location and operation of all normal and emergency exits, including evacuation chutes and escape ropes. 34 The cabin aide stated that she continued to work as a model and waitress while working for PJM.

Factual Information 15 Aircraft Accident Report Further, 14 CFR 135.117 requires that, for airplanes certificated to carry 19 passengers or less, a crewmember or other qualified person must brief passengers on “smoking…the use of safety belts…location and means for opening the passenger entry door and emergency exits…location of survival equipment…location and use of fire extinguishers.” PJM’s policy required pilots to accomplish the passenger safety briefing before each takeoff, regardless of whether all of the passengers were present on previous flights. According to 14 CFR 135.122, “no certificate holder may move an aircraft on the surface, take off, or land when any food, beverage, or tableware furnished by the certificate holder is located at any passenger seat.” According to 14 CFR 135.128, “each person on board an aircraft operated under this part shall occupy an approved seat or berth with a separate safety belt properly secured about him or her during movement on surface, takeoff, and landing.” 1.6 Airplane Information 1.6.1 General Airplane Information The accident airplane, N370V, a Bombardier Challenger CL-600-1A11, serial number (S/N) 1014, was manufactured in Montreal, Canada, in November 1980 and was delivered new to TAG International.35 Records indicated that the Canadian Department of National Defense purchased the airplane in June 1984 and operated it until DDH Aviation, LLC, purchased it on March 6, 2001.36 The airplane interior was refurbished in September 2001, and the airplane was then leased and flown by various operators in the United States. In February 2004, DDH leased the airplane to PJM.37 Records indicated that, at the time of the accident, the airplane had accumulated about 6,901 flight hours and 4,314 cycles.38 The airplane was equipped with two Honeywell ALF502L-2C turbofan engines. The left engine had accumulated about 3,941 hours total flight time, including about 428 hours since its April 2004 installation on the accident airplane. The right engine had accumulated about 3,890 hours total flight time, including about 428 hours since its March 2004 installation on the accident airplane. The airplane’s most recent inspection (other than preflight inspections) was a 50-hour inspection, which was accomplished on January 14, 2005, in Fort Lauderdale, Florida. Records show that, during this inspection, a functional test of the horizontal stabilizer trim actuator brake was conducted and the pitch trim system was exercised (in accordance with airworthiness directive [AD] 95-17-14). 35 The accident airplane was 1 of 20 CL-600 airplanes that were manufactured to fill an order from Federal Express. TAG International bought the accident airplane when the original Federal Express order was cancelled. 36 The airplane was registered to 448 Alliance, which is a wholly owned subsidiary of DDH. 37 For additional information regarding PJM’s operations, see section 1.17.2.1. 38 An airplane cycle is one complete takeoff and landing sequence.

Factual Information 16 Aircraft Accident Report The accident airplane was configured with two flight crew seats in the cockpit, a forward-facing jumpseat aft of the cockpit throttle console, and nine passenger seats (six fore-or-aft-facing individual seats and a three-seat, side-facing divan) in the cabin (see figure 2). The main cabin door was located on the forward left side of the fuselage, aft of the cockpit and across from the galley. The overwing emergency exit was located on the right side of the fuselage, behind the seatbacks of the side-facing divan. 1.6.2 Airplane Weight and Balance Information 1.6.2.1 Actual Airplane Weight and Balance Information Records indicated that the airplane was most recently weighed when the interior was refurbished in September 2001. At that time, the airplane’s empty weight was 24,736.5 pounds, and its empty weight center of gravity (CG) was located at 29.3 percent mean aerodynamic chord (MAC). Review of the records revealed no indication that the airplane’s weight and balance had changed since that time. (During postaccident interviews, PJM personnel claimed that the airplane had been reweighed recently; however, neither PJM nor Darby were able to provide documentation of a more recent weighing.) During the investigation, investigators determined the weights and locations for passengers, crew, cabin aide, equipment, baggage, service items, and carry-on bags using on-scene evidence and passenger and crew statements.39 For detailed documentation of these items and additional weight and balance information, see appendix C. For additional information regarding the fuel load, see section 1.6.2.4. The calculated and maximum allowable ramp and takeoff weights and CGs for the accident flight are shown in table 2. Table 2. The calculated and maximum allowable ramp and takeoff weights and centers of gravity for the accident flight. 39 During the on-scene portion of the investigation, all of the loose and recognizable items from the airplane were documented and weighed. Due to the extensive postimpact fire and firefighting efforts, most of the items from the cockpit and main cabin were charred and/or soaked with water; items from the aft baggage compartment were damp but not sooted or charred. All of the items were weighed as recovered (without drying). Airplane Condition Calculated Ramp Maximum Ramp Calculated Takeoff Maximum Takeoff Weight in Pounds 41,620 41,400 41,320 41,250 CG in percent MAC (percent MAC forward of forward limit) 12.79 (3.21) 12.47 (3.53) CG range in percent MAC 16.0 to 33.0 16.0 to 33.0

Factual Information 17 Aircraft Accident Report 1.6.2.2 Flight Crew Weight and Balance Information During postaccident interviews, the captain and first officer told investigators that they did not perform manual balance calculations or use the airplane-specific weight and balance graph that was in the accident airplane. Darby Aviation’s Part 135 operations specifications require pilots to compute the weight and balance of the loaded airplane using actual passenger weights to ensure that the airplane is operated within safe weight-and-balance limits.40 Neither pilot recalled calculating the airplane’s CG before their attempted departure, and they stated that the only weight assessment calculated for the accident flight was performed using the flight management system (FMS) calculator. The FMS calculator totaled the passenger, fuel, and baggage weights based on input (or default) values; however, it did not calculate the balance information. The Safety Board’s examination of the weight and balance form that was completed for the inbound flight from LAS revealed that the airplane empty weight that was printed on the form had been modified by hand and that it was lower than the actual airplane empty weight. This lower airplane empty weight resulted in an incorrect (farther-aft-than-actual) empty weight CG. Further, the airplane empty weight that had previously been entered into the FMS (24,500 pounds) was incorrect (also lower than the airplane’s actual empty weight).41 The airplane’s empty weight was listed correctly (based on the September 2001 weighing) in the airplane flight manual (AFM). A review of Darby Aviation’s records showed that some PJM pilots routinely modified the printed weight and balance forms when performing preflight weight and balance calculations by reducing the airplane empty weight that was printed on the forms by various amounts. Investigators noted that all reviewed weight and balance forms reflected total weights and CGs within the airplane’s operating limits. 1.6.2.3 Federal Weight and Balance Requirements Title 14 CFR 135.185, “Empty Weight and Center of Gravity: Currency Requirement,” states, in part: (a) No person may operate a multiengine aircraft unless the current empty weight and center of gravity are calculated from values established by actual weighing of the aircraft within the preceding 36 calendar months. 40 Operations specifications contain the authorizations, limitations, and certain procedures under which operations are to be conducted by the certificate holder. 41 Review of the FMS calculator keystroke log indicated that the pilots did not enter an airplane empty weight into the system on the morning of the accident. The keystroke log reflected inputs for number of passengers (eight), 300 pounds of cargo, and 14,600 pounds of fuel on the morning of the accident. No actual passenger or crew weights were entered.

Factual Information 18 Aircraft Accident Report Additionally, 14 CFR 135.63, “Recordkeeping Requirements,” states, in part: (c) For multiengine aircraft, each certificate holder is responsible for the preparation and accuracy of a load manifest in duplicate containing information concerning the loading of the aircraft. The manifest must be prepared before each takeoff and must include: 1) The number of passengers; 2) The total weight of the loaded aircraft; 3) The maximum allowable takeoff weight for that flight; 4) The center of gravity limits; 5) The center of gravity of the loaded aircraft, … (d) The pilot in command of an aircraft for which a load manifest must be prepared shall carry a copy of the completed load manifest in the aircraft to its destination. The certificate holder shall keep copies of completed load manifests for at least 30 days… Also, according to 14 CFR 91.7, “Civil Aircraft Airworthiness,” the pilot-in-command of any civil aircraft is responsible for determining whether that aircraft is in condition for safe flight. Additionally, Section 91.9, “Civil Aircraft Flight Manual, Marking, and Placard Requirements,” states the following, in part: (a) no person may operate a civil aircraft without complying with the operating limitations specified in the approved Airplane…Flight Manual, markings, and placards. The AFM contains the airplane weight and CG limits and includes information and charts for pilots to use in determining proper loading to ensure the airplane operates within takeoff and landing limitations. 1.6.2.4 Fuel Load Information Investigators received inconsistent information about the accident airplane’s fuel load and the pilots’ planning and supervision of the airplane refueling. For example, the captain and the first officer recalled specifying the amount of fuel to add, and both pilots recalled that the total fuel weight after refueling was about 13,900 pounds (the captain estimated from 13,800 to 13,900 pounds). However, a copy of the pilots’ FBO fuel receipt showed a handwritten notation reading, “top off.” FBO records indicated that 1,842 gallons of fuel (about 12,434 pounds) were added to the approximately 2,200 pounds of fuel that remained on the airplane when it arrived from LAS, which would bring the estimated fuel load to about 14,634 pounds.42 Data downloaded from the airplane’s navigational computer unit indicated that a departure fuel weight of

Factual Information 19 Aircraft Accident Report 14,600 pounds was entered into the control display unit on the first officer’s side of the cockpit before the accident flight. During postaccident interviews, the captain was asked to perform manual weight and balance calculations for the accident flight.43 The captain acknowledged that his postaccident calculations showed that, after the airplane was fueled, its weight exceeded its maximum allowable limit, and the forward CG exceeded the forward limit. However, he stated that the operation of the auxiliary power unit (APU) and engines during ramp and taxi operations would have consumed sufficient fuel to bring the weight and CG back within limits before takeoff. He stated that they took no actions to reduce the airplane’s fuel load before takeoff. Airplane, APU, and engine performance information provided by the manufacturers indicated that the CL-600 APU and engine operation described by the captain could have resulted in sufficient fuel burn to reduce the airplane’s weight to its maximum allowable takeoff weight. However, the fuel consumed by the engines and APU during taxi operation would have come from the main fuel tanks located in the wings and would have resulted in the CG moving farther forward, thus further exceeding the forward CG limit.44 The Safety Board’s postaccident calculations (based on the completed weight and balance form for the airplane’s inbound leg and documentation regarding fuel and other preflight servicing; postaccident information regarding passenger, crew, and baggage weights; and other airplane data and performance information) indicated that the airplane might have been about 100 pounds over its maximum takeoff weight and that its CG exceeded the forward balance limits by 3.53 percent MAC, about 20 percent of the entire allowable CG envelope at takeoff (see table 2). 1.6.2.5 Airplane Pitch Trim Information Pitch trim setting guidance contained in a CL-600 training manual advises pilots to set the pitch trim “to appropriate takeoff position taking into account center of gravity.” Figure 3 shows a photograph of a CL-600 pitch trim position indicator similar to that in the accident airplane. 42 Jet fuel weights were calculated using a ratio of 6.75 pounds per U.S. gallon of fuel. The airplane’s 14,634 pound fuel load is 99 percent of the airplane’s published fuel tank capacity. According to Bombardier, the airplane’s fuel tank can only be loaded to 100 percent capacity if the airplane is parked on a slight downgrade. 43 Neither pilot had performed manual weight and balance calculations for the accident flight before the attempted takeoff. 44 CL-600 training documents state that fuel burned during start, taxi, and takeoff will come from the main tanks “because of the float mechanism on the transfer ejector.” The training documents also note the following: “Initial fuel burn will be from the main tanks. When the main tanks have burned down to 93 percent of full (less 7 percent), fuel will now be burned using the auxiliary tank… . The worst-case scenario is that all 7 percent from the mains is burned before takeoff, thus resulting in … the most forward [CG] of the flight. Ensuring proper [CG] loading in all phases of flight is essential to flight safety.”

Factual Information 20 Aircraft Accident Report Figure 3. Photograph of a CL-600 pitch trim position indicator similar to that in the accident airplane. Postaccident examination of the accident airplane’s trim position indicator showed that the needle on the stabilizer trim display was located near the middle of the green band, below the takeoff (TO) and nose-up (NUP) indicators.45 Figure 4 shows the accident airplane’s pitch trim position indicator display, as documented postaccident. Figure 4. The accident airplane’s pitch trim position indicator display, as documented postaccident. 45 As noted in table 3, the CL-600 AFM indicates that, for forward CGs within CG limits, the pitch trim should be set in the top of the display range (NUP).

Factual Information 21 Aircraft Accident Report More specific information regarding pitch trim settings for a range of CGs is contained in the CL-600 AFM and Flight Crew Operating Manual and is shown in table 3. Table 3. The accident airplane’s pitch trim settings for a range of centers of gravity as described in the CL-600 Airplane Flight Manual. aThe AFM does not list pitch trim settings for CGs forward or aft of the allowable CG limits. During postaccident interviews, the first officer stated that he typically set the stabilizer trim to the indexed takeoff position (the TO line located above the middle of the green range) when the airplane was loaded lightly but that he set it slightly above the takeoff position when the airplane was heavy. The captain told investigators that he checked the pitch trim setting selected by the first officer while they taxied and that he believed that the trim setting was satisfactory. The captain stated that he recalled a table in one of the airplane’s manuals that specified trim settings but that he thought the trim could be adjusted to various settings depending on the pilots’ preference. 1.6.3 Longitudinal Flight Control System The CL-600 is equipped with dual flight controls, such that the control wheels, control columns, and rudder pedals are interconnected and work in unison. With the exception of the flaps and trim controls, the flight control surfaces are hydraulically actuated from pilot inputs through a network of cables, pulleys, and push-pull rods. Longitudinal control is provided by two hydraulically operated elevator surfaces, which are hinged to the rear spar of the horizontal stabilizer. When the pilots move the control columns, a system of cables and pulleys activates the elevators. Each elevator is driven by two power control units (PCU), each of which is powered by two redundant hydraulic systems. A pitch feel simulator unit provides the control column with the expected “stick force,” which is varied relative to the horizontal stabilizer position. The longitudinal flight control system has a pitch disconnect mechanism (a spring-loaded locking pin and two half-shafts linking the control columns) to ensure that the control columns can be separated in case one of them jams. If a jam occurs, the elevator and control column of the unjammed system would remain normally operational. Center of gravity (within limits)a Pitch trim position on indicator Forward CG (16 to ~23 percent MAC) Top of display range (nose up [NUP]) Mid-range CG (~23 to ~28 percent MAC) Middle of display range Aft CG (~28 to 33 percent MAC) Bottom of display range

Factual Information 22 Aircraft Accident Report 1.6.4 Main Cabin Door The accident airplane’s main cabin door is located on the forward left side of the fuselage, aft of the captain’s seat and across the aisle from the galley. The top-hinged door opens upward, and entrance stairs are installed on tracks inside the cabin. An interior handle near the bottom of the door is connected to several tension fittings and latch cams by a series of pushrods and torque tubes. The interior handle is linked to the exterior handle and is stowed in a handle guard in the 10 o’clock position when the door is closed and latched. The interior handle is moved to about the 11 o’clock position when the door is opened and unlatched. The main cabin door interior also has an arm/disarm T-handle at its upper right side. After the door is closed and latched for flight, this T-handle is moved to the armed position, which disengages the T-handle from the door lift mechanism and electric motor. Before opening the door again under normal circumstances, the T-handle would be moved to the disarmed position, and the door lift mechanism and motor would reengage. There are two methods of opening the main cabin door—normal and emergency. To open the door under normal circumstances, the T-handle is moved to the disarmed position, the lower door handle is rotated clockwise from the 10 to the 11 o’clock position, the electric motor is activated via a switch on the forward bulkhead, and the door lift mechanism opens the door fully. However, to open the door in an emergency situation, the lower door handle is rotated from the 10 to the 11 o’clock position without first moving the T-handle to the disarmed position. According to the system’s design, in this case, when the tension fittings and latch cams rotate off of the door stops, a gas spring provides sufficient force to open the door and allow evacuation. 1.7 Meteorological Information The National Weather Service (NWS) surface analysis chart for the time of the accident showed an area of high pressure over the northeastern United States, including TEB. The NWS area and TEB terminal forecasts predicted clear skies and visual flight rules conditions in the area at the time of the accident. TEB is equipped with an automated surface observing system (ASOS),46 which is overseen/augmented by NWS-certificated weather observers. The ASOS continuously measures wind direction and speed, visibility, present weather (for example, precipitation and obstructions to vision), sky condition (cloud height and sky cover), temperature, dew point, and altimeter setting. The ASOS observation at 0651 (closest to the time of the accident) reported calm winds, visibility 10 miles, clear skies, temperature -6° Celsius (C), dew point -8° C, and an altimeter setting of 30.53 inches of mercury. Postaccident interviews with two NWS-certificated weather observers who worked at TEB on the morning of the accident indicated that there was no evidence of 46 The ASOS sensor suite is located near the departure end of runway 6.

Factual Information 23 Aircraft Accident Report frost on the ground or paved surfaces or on the vehicles that had been left outside overnight. Additionally, two line service technicians who handled the accident airplane on the morning of the accident told investigators that they did not observe frost on the airplane, and the pilot of an airplane that was parked adjacent to the accident airplane that morning stated that there was no frost on his airplane.47 1.8 Aids to Navigation No difficulties with the navigational aids were known or reported. 1.9 Communications No communications problems were reported between the pilots and any of the air traffic controllers who handled the flight. 1.10 Airport Information 1.10.1 General Airport Information TEB is located about 1 mile southwest of Teterboro, New Jersey, at an elevation of 9 feet above sea level. Runway 6/24 (runway 6 was used by the accident airplane) is 6,015 feet long and 150 feet wide. Runway 1/19, which was closed at the time of the accident because of a nearby construction project, is 7,000 feet long and 150 feet wide. Both runways are constructed of grooved asphalt. TEB is owned by the Port Authority of New York and New Jersey. The airport was certificated under 14 CFR Part 139, with Index A ARFF capabilities.48 According to the TEB Airport Certification Manual, the airport had three ARFF vehicles for emergency response. 47 There were, however, some reports of frost earlier that morning. For example, an ATC supervisor stated that he observed frost on car windows when he arrived at work more than an hour before the accident, a line service technician reported that there was frost on the windshield of his car when he drove to work earlier that morning, and another line service technician reported that there was light frost on an airplane that he had deiced, which had been parked outside all night. 48 Title 14 CFR 139.315, “Aircraft Rescue and Firefighting: Index Determination,” defines Index A as an airport with fewer than five average daily departures of air carrier aircraft that are more than 90 feet in length. Section 139.317 requires an Index A airport to have one ARFF vehicle carrying at least (1) 500 pounds of sodium-based dry chemical, Halon 1211, or clean agent or (2) 450 pounds of potassium-based dry chemical and water with a commensurate quantity of aqueous film-forming foam (AFFF) to total 100 gallons for simultaneous dry chemical and AFFF.

Factual Information 24 Aircraft Accident Report 1.10.2 Airport Runway Safety Areas According to Advisory Circular (AC) 150/5300-13, “Airport Design,” the TEB runway safety areas (RSA) should have extended 1,000 feet beyond the departure end of each runway and been 500 feet wide. FAA documentation indicated that the RSA at the departure end of runway 6 extended about 90 feet beyond the end of the runway and was 500 feet wide. The FAA’s RSA determination for TEB, dated September 25, 2000, indicated that it was “not practicable to improve” the TEB RSAs to the standards listed for TEB in AC 150/5300-13. Specifically, the FAA stated that the improvement of the RSA at the departure end of runway 6 was not practicable because of the “highway…and buildings along the north side of the highway.” FAA Order 5200.9, “Financial Feasibility and Equivalency of Runway Safety Area Improvements and Engineered Material Arresting Systems,” dated March 15, 2004, indicated that the maximum feasible cost for RSA improvements on both ends of a runway was $10.15 million.49 A subsequent FAA RSA determination (revised after the TEB accident and dated April 14, 2005) stated that the RSA at the departure ends of runways 6 and 24 could be enhanced with the installation of an engineered materials arresting system (EMAS). The Port Authority of New York and New Jersey contracted with a company to perform an analysis of the RSAs at airports under its purview, including TEB. After comparing each alternative’s cost, operational impact, and environmental considerations, the resultant draft report (dated March 29, 2004) recommended installing EMAS arrestor beds at both ends of the runway. The draft report stated that an EMAS arrestor bed at the departure end of runway 6 would be 265 feet long and 162 feet wide and would be capable of stopping Gulfstream III/IV, CRJ-200, Learjet 35, and Citation X airplanes at runway exit speeds from 60 to 65 knots. The estimated cost for this installation was $15.6 million. The investigation revealed that the accident airplane entered the runway overrun area at a speed of about 110 knots and ran off the far end of the runway 6 RSA at about 105 knots. Simulations performed by the EMAS manufacturer indicated that, if a 265-foot long EMAS bed had been installed at the departure end of runway 6, the accident airplane would have exited the EMAS at a speed of about 97 knots. In a late May 2005 meeting, TEB Port Authority staff reported that it would install an EMAS on the departure end of runway 6 by the end of 2006. Subsequently, the FAA granted funds to facilitate the engineering and design of the planned TEB RSA improvements. (For additional information on the Safety Board’s recommendations to the FAA regarding EMAS, see section 1.18.2.1.) 49 The FAA considers both runway ends as one project when resolving an RSA issue.

Factual Information 25 Aircraft Accident Report 1.11 Flight Recorders 1.11.1 Cockpit Voice Recorder The CVR installed on the accident airplane was an L-3 Communications/Fairchild model A-100A, S/N 55843, magnetic tape CVR. The CVR showed no significant damage, and the tape was played back successfully. The CVR recording consisted of four channels, three of which contained good quality50 audio information. One channel contained audio information recorded by the cockpit area microphone (CAM), and two other channels contained audio information recorded through the radio/intercom audio panels at the captain and first officer positions. The fourth channel was not used (nor was its usage required) on this recording. Investigators correlated the CVR to local time by establishing an offset between the CVR elapsed time and ATC local time for a radio transmission that was recorded on both the CVR and ATC audio recordings. The recording began about 0648:45 and ended at 0718:15.7, after the CVR recorded the sounds of numerous impacts. A partial transcript that included the last 13 minutes 37.7 seconds of the CVR recording was prepared (from about 0704:38 to 0718:15.7).51 See appendix B for the transcript of the CVR recording. 1.11.2 Flight Data Recorder Although Federal regulations did not require the accident airplane to be equipped with an FDR,52 it was equipped with a Lockheed Aeronautical Systems Model 319, S/N FA7438, six-track, tape-based recorder. The outer case of the FDR showed evidence of thermal damage, but the recorder was otherwise in good condition. Twenty-five hours of data were successfully extracted, and these data included portions of the accident takeoff roll and eight previous flights. The FDR recorded multiple parameters of airplane flight information, including time, altitude, indicated airspeed, vertical acceleration, heading, pitch and roll attitude, control surface positions, various engine parameters, radio transmission status, and various autopilot and trim status parameters. The FDR was correlated to local time using the ground track of the airplane and information from the CVR, which was then correlated to the ATC audio recording. Review of the accident FDR information revealed that valid data were recorded for only about 10 seconds of the accident sequence (from about 0718:04 to 0718:14). The first speed value for the accident takeoff was 153.4 knots, which was recorded about 0718:05 as the airplane decelerated during the RTO. The final speed value of 91.4 knots was recorded about 0718:14. 50 The Safety Board rates the quality of CVR recordings according to a five-category scale: excellent, good, fair, poor, and unusable. See appendix B for a description of these ratings. 51 Before the start of the transcript, the CVR recorded conversation between the first officer and the cabin aide that was not related to the flight or to the operation, control, or condition of the airplane. 52 Federal regulations require airplanes with 10 or more passenger seats to have FDRs installed and properly maintained. As noted previously, the accident airplane had only nine passenger seats.

Factual Information 26 Aircraft Accident Report According to documentation provided by Bombardier, an FDR installed on a CL-600 should begin recording when there is power to the airplane and the anticollision lights are on. The FDR should stop recording when the airplane is on the ground, the anticollision lights are off, and power is removed from the 28-volt direct current essential bus or in the event of rapid deceleration.53 The FDR stopped recording about 1 second before the CVR stopped recording, as the airplane was rapidly decelerating. The Safety Board reviewed documentation for the initial installation of an FDR on the accident airplane in 1980 and the subsequent installation of the accident FDR in 1986. The wiring diagrams from the 1980 installation supported Bombardier’s statements; however, the anticollision switch was upgraded to a three-way switch in 1986, and neither Darby nor PJM were able to provide a wiring diagram for the upgraded switch. The Safety Board’s review of the available FDR data for the accident takeoff and the eight previous takeoffs for which data were recorded revealed that the FDR began recording at different stages of airplane operation during each of those nine departures.54 In addition, the Board’s examination of FDR data relative to flight log information revealed that two of the recorded flights were shorter than the flight logs indicated. Further, three short flights were noted in the flight logs but were not reflected in the FDR data. The PJM chief operating officer could not explain these inconsistencies. 1.11.3 Sound Spectrum Study Because the FDR only recorded about 10 seconds of data, the Safety Board studied the sounds and frequencies recorded by the CVR and physical evidence to reconstruct the airplane’s ground speed, calibrated airspeed, and distance traveled during portions of the takeoff roll. As the landing gear tires roll over the lateral grooves in the runway surface, the frequency of the noise they produce is determined by the groove spacing and the airplane’s speed, and higher frequency noise corresponds to higher speeds. A review of the CVR data revealed that the CAM recorded a background noise during the attempted and rejected takeoff, the frequency and strength of which increased, peaked, and then decreased. The Board determined that this noise was produced by the tires and analyzed its frequency content to calculate the resultant airplane speed. 53 An inertia switch is used to detect significant deceleration and trigger the FDR and CVR to stop recording. 54 During one of the eight previous departures for which data were recorded, the FDR began recording when the airplane accelerated through about 157 knots, about the speed at which it began recording during the accident takeoff roll. During five of the departures, the FDR began recording during the engine start. For two of the departures, the FDR recorded continuously from the previous touchdown because the engines were not shut down between flights.

Factual Information 27 Aircraft Accident Report 1.12 Wreckage and Impact Information 1.12.1 Wreckage Path Postaccident examination of runway 6 revealed several tire marks from the accident airplane, the first of which (the left main landing gear inboard tire mark) began about 1,297 feet before the departure end of the runway. All four main landing gear tire marks started out relatively light and got heavier and darker in the direction of travel. The main landing gear tire marks remained relatively straight until about 440 feet from the departure end of the runway, where they veered slightly left. The tire marks tracked approximately parallel to the centerline striping with the right tire marks just left of the runway centerline and the left tire marks about 20 feet left of the centerline at the end of the runway. Tire marks continued through the snow and dirt off the departure end of runway 6, past the left side of the localizer structure, through the airport perimeter fence, and across a drainage ditch. Scrape marks, tire marks, and debris from the airplane, airport fence, and other vehicles were located on and across the six lanes of the highway that traversed the northeast edge of the airport. The marks and debris continued through a nearby parking lot to the airplane wreckage. The airplane came to rest after it impacted a building on a heading of about 15°, with the forward fuselage (to about the wing root area) intruding through the brick wall of the building. In addition, six vehicles on the ground were impacted and damaged—one on the highway and five in the adjacent parking lot. 1.12.2 Wreckage Documentation Postaccident examination revealed that, although some small pieces of airplane structure and other debris were found between the end of the runway and the building, all of the major pieces of the airplane were located at the main wreckage site. The fuselage, empennage, and left inboard wing remained intact. The outboard portion of the left wing separated from the inboard portion near the outboard end of the inboard flap, and there was red paint transfer and impact damage in the area of the left wing separation and on a red car adjacent to the separated portion of the wing. All of the longitudinal flight control surfaces were found intact and attached to associated mounting structures,55 and the engines remained attached to the aft fuselage. The right wing was separated from the fuselage at the wing root area but remained somewhat intact adjacent to the fuselage. The right winglet was separated from the right wing and was located near a small building at the edge of the parking lot. There was crushing damage and moderate-to-heavy fire damage to the forward fuselage and the right-wing leading edge where they impacted the building and burned. The cockpit was extensively fire damaged, and a layer of soot covered all of the interior 55 For additional information about the longitudinal flight control system components, see section 1.12.3.

Factual Information 28 Aircraft Accident Report surfaces. All of the circuit breakers located in the aft cockpit bulkhead panels were melted. All of the instrument panels and displays, including the pedestal instruments, were sooted, and some were melted. The cockpit floor in front of the crew seats was structurally deformed, with floor, rudder pedals, and other wreckage displaced aft toward the pilot seats. Deformation was more severe on the first officer’s side than on the captain’s. Both pilot seats were found attached to the floor via seat rails, and the seats and cushions were extensively charred and sooted. The jumpseat located aft of the throttle console and adjacent to the galley was found in the unstowed position. The jumpseat cushions were covered with soot but were not burned. The main cabin door was found propped open about 4 feet by a board. Continuity was established between the door’s center handle and all of the latch cams and tension fittings. When the piece of lumber was removed, the door closed; however, a 1/8- to 1/4-inch overlap between the latch cams and the aft doorframe prevented the door from closing completely. The entire passenger cabin sustained substantial postcrash fire damage and was heavily sooted. The floor remained intact but was covered by a thick layer of debris and ash. The ceiling and interior panels were consumed by fire. All of the individual passenger seats and the divan were found heavily burned and sooted but otherwise intact and in place. Investigators identified the remains of the seatbelts on the individual passenger seats (including shackles, most buckles, some insert tabs, and very little webbing), and the identified components exhibited heavy sooting and heat and fire damage. The seatbelts (webbing, buckles, insert tabs, and shoulder harness fittings) at all three divan positions were found folded beneath the divan seatback cushions and were partially sooted but showed little or no fire or heat damage. Postaccident examination of another PJM CL-600 revealed that its divan seatbelts had been placed beneath or behind the divan seatback cushions. Further, during postaccident interviews, a corporate flight attendant instructor told investigators that, “in many cases,” she had seen airplanes in which the divan seatbelts had been intentionally folded and stowed beneath the seatback cushions. She stated that some corporate airplane operators had told her that they preferred to fold and stow seatbelts beneath the seatback cushions, likely for a tidier appearance. Investigators noted that passengers would have to locate the seatbelts between the seat cushions tactilely or remove the divan seatback cushions to locate seatbelts stowed in this position. Figure 5 shows the side-facing, three-passenger divan with the burned seat cushions removed.

Factual Information 29 Aircraft Accident Report Figure 5. The side-facing, three-passenger divan from the accident airplane with the burned seat cushions removed. Note: the arrows indicate the row of folded seatbelts that were found beneath the seatback cushions. 1.12.3 Longitudinal Flight Control System Components Although postaccident examination revealed impact-related damage to the control columns and some of the forward flight control attachments among other severe impact damage at both pilot positions, investigators were able to establish longitudinal flight control continuity from the forward quadrant (just aft of the control columns) to the elevator PCU input arms. All cables appeared to be traveling over the appropriate pulleys correctly, no jams were noted, and there was no evidence of obstructions that would have prevented free cable movement during the accident sequence. When the pitch cables were pulled in the rear of the airplane, free and proper movement was seen at the damaged forward quadrants and at the PCU input arms. Examination of all of the longitudinal control system components included functional testing and disassembly, and the examination of the autopilot servo and stickpusher actuators also involved radiographic inspections. No evidence of a jammed condition or signs of a previous jam were revealed during these examinations. The Safety Board examined the autopilot system to determine whether it may have been activated inadvertently. The examination revealed that, if the autopilot had been

Factual Information 30 Aircraft Accident Report activated, the pilots would have felt additional resistance during the flight control check (the pilots reported that the controls moved freely and easily). Additionally, if the autopilot were engaged during the takeoff roll, the pilots could have overridden its effects by increasing the amount of force on the control column (about 40 pounds of aft pressure on the yoke would have been required). Further, activation of the autopilot system would have required specific selection of the autopilot engagement pushbutton (which neither pilot reported), and FDR data did not indicate that the autopilot had been activated. 1.13 Medical and Pathological Information The 11 airplane occupants were transported to local hospitals for treatment of their injuries. The flight crew’s injuries were serious and were mainly limited to lower body injuries (including fractures, dislocations, and lacerations) caused by airplane wreckage that intruded on the cockpit floor space after impact. The cabin aide and all eight passengers sustained minor injuries (including contusions, abrasions, lacerations, sprains, and strains) during the impact and evacuation. In addition, three people who were not airplane occupants were transported to local hospitals for treatment of injuries. Two of these people sustained serious head injuries when the airplane struck the automobile they occupied, and the third person, who was in the building at the time of impact, received minor injuries caused by falling debris. A blood specimen collected from the first officer about 0858 on the day of the accident tested negative for ethanol and a wide range of drugs, including drugs of abuse;56 however, the first officer’s blood specimen tested positive for morphine. Medical records revealed that the first officer was administered morphine after the accident, about 0802 and again about 0810. A blood specimen collected from the captain about 1008 was lost by a commercial shipping company while being shipped to the FAA’s Bioaeronautical Sciences Research Laboratory for toxicological analysis. Therefore, no toxicological results were obtained for the captain. 1.14 Fire A postcrash, fuel-fed fire occurred. 1.15 Survival Aspects Postaccident interviews with TEB air traffic controllers indicated that the airplane’s acceleration initially appeared normal; however, they stated that the airplane did not lift off when they expected it to do so. Air traffic controller statements indicated that they notified ARFF personnel before the airplane ran off the end of the runway. 56 The drugs tested in the postaccident analysis include, but are not limited to, marijuana, cocaine, opiates, phencyclidine, amphetamines, benzodiazapines, barbiturates, antidepressants, antihistamines, meprobamate, and methaqualone.

Factual Information 31 Aircraft Accident Report Postaccident interviews with passengers and ARFF and ATC personnel indicated that ARFF personnel responded within 1 minute of notification and reached the airplane within 3 to 4 minutes of the accident.57 Several passengers and witnesses indicated that ARFF vehicles arrived just after the occupants exited the airplane and immediately initiated efforts to extinguish the exterior airplane fires. All the airplane occupants evacuated and moved away from the airplane to await medical evaluation. Firefighting personnel from neighboring communities58 also arrived promptly to assist in the firefighting effort; however, the interior fire was not extinguished until a high-reach extendable turret (HRET) vehicle equipped with a skin-penetrating nozzle arrived from the Newark International Airport (EWR), Newark, New Jersey.59 The HRET/skin-penetrating-nozzle-equipped vehicle arrived about 0851, and the interior fire was extinguished within minutes thereafter (see figure 6). Figure 6. The accident airplane, the impacted building and several impacted vehicles, and the HRET/skin-penetrating nozzle-equipped firefighting vehicle. 57 During postaccident interviews, ARFF personnel stated that they responded to the accident site by the most expeditious routes possible. They stated that it was not feasible to follow the airplane’s path to the site because of the steep walls of the drainage ditch just outside the airport’s perimeter fence. 58 TEB has mutual aid agreements with other area fire departments, including those from Moonachie and Hasbrouck Heights, New Jersey. 59 The HRET/skin-penetrating-nozzle device is an optional piece of equipment that can be attached to some ARFF vehicles to improve interior firefighting capabilities. The device consists of an elevated extendable boom and a multifunction nozzle/turret, which can be equipped with options such as piercing tips of varying lengths, aerial nozzles, halogen lights, a color video camera, and a forward-looking infrared camera. The EWR vehicle’s HRET/skin-penetrating-nozzle turret was equipped with a color video camera, an infrared camera, and a piercing tip and was specifically requested to assist in fighting the accident airplane’s interior fire.

Factual Information 32 Aircraft Accident Report 1.16 Tests and Research 1.16.1 Airplane Performance Study The Safety Board conducted a study to determine the rotation and RTO performance that would have been expected from the airplane under the loading conditions of the accident flight and to identify the airplane’s trajectory during the RTO. The Board used the airplane’s wreckage location and condition, ground scars and markings, CVR and FDR information, weather data, airplane weight and balance information, and simulator tests for this study. 1.16.1.1 Rotation Characteristics Simulation Results The Safety Board conducted simulations in a CL-600 level C crew training simulator using various CGs and stabilizer trim settings to determine the rotation characteristics of the accident airplane during the takeoff roll and to identify the control column displacement and force and the airspeed that would have been required for rotation.60 In all cases, the simulator pilots began to move the control column aft as the airplane accelerated through the expected rotation speed (about 135 knots). The airplane performance study concluded that, during the accident sequence, the acceleration portion of the takeoff roll was normal and that the airplane reached rotation speed (VR, about 134 to 135 knots) with about 3,300 feet of the 6,015-foot-long runway remaining. However, the airplane continued to accelerate beyond VR to about 160 knots calibrated airspeed without lifting off. The results of the simulator testing indicated that, for the accident conditions, even with the control column moved to its aft limit, the accident airplane would not have started a noticeable rotation until it reached about 160 knots. A Bombardier performance study based on the accident airplane conditions estimated that the captain initiated the RTO at a speed of about 160 knots. Bombardier stated that a minimum accelerate-stop distance of 6,550 feet would be required under those circumstances.61 1.16.1.2 Rejected Takeoff Simulation Results The Safety Board used a full-motion simulator to determine the airplane’s acceleration and deceleration performance during the accident sequence and to obtain information regarding the airplane’s stopping capabilities/distances with different RTO timing and/or technique. A Bombardier test pilot and three other experienced airline transport pilots performed the simulator runs under the accident conditions. During these 60 The conditions tested included, in part, the accident conditions (CG at 12.4 percent MAC with a stabilizer trim setting of -3.9°); a CG within the CG limits but at the forward CG limit of 16.0 percent MAC with a stabilizer setting of -6° (the NUP limit of the trim display range); and the accident CG (12.4 percent MAC) with a stabilizer setting of -6°. 61 Bombardier’s report also stated that, based on the accident airplane’s weight, CG, and stabilizer trim setting, the airplane would not have started to rotate until it reached about 154 knots with full aft elevator input and about 170 knots with partial (half) aft elevator input.

Factual Information 33 Aircraft Accident Report runs, the simulator pilots rejected takeoffs at various speeds (V1, VR, VR+20 knots, etc.). All rejected takeoffs performed in the simulator involved the immediate and aggressive application of reverse thrust,62 brakes, and spoilers when the RTO was initiated. Therefore, the deceleration performance obtained during the simulator runs was considered the maximum performance available from the CL-600. According to the study, the RTO for the accident flight was likely initiated about 160 knots, and the airplane began to decelerate with about 2,100 feet of runway remaining. The study indicated that the airplane ran off the departure end of the runway at a ground speed of about 110 knots, penetrated the airport perimeter fence at a speed of about 95 knots, and was moving at a speed of about 85 knots when the FDR stopped recording about 70 feet from the airplane’s final resting place. Consistent with the 6,550-foot accelerate-stop distance calculated in the Bombardier performance study, the Safety Board’s simulator runs resulted in runway excursions beyond the end of the runway; however, in all simulator cases, the airplane left the runway at a slower speed than the accident airplane. The Board’s performance study noted that the required stopping distance and speed at runway departure depended not only on the performance available from the airplane but also greatly on pilot expectations, technique, and timing.63 The performance study also showed that the accident captain did not immediately employ all available deceleration devices, such as immediate deployment of maximum thrust reverse, to maximum effect after he decided to reject the takeoff, which resulted in the accident airplane departing the runway at a higher speed than in the simulations. 1.17 Organizational and Management Information 1.17.1 Airplane Ownership The accident airplane was owned by 448 Alliance, a wholly owned subsidiary of DDH Aviation. DDH/448 Alliance leased the airplane to PJM for its exclusive use. 1.17.2 Airplane Management 1.17.2.1 Platinum Jet Management, LLC PJM was formed as a jet management company by three partners in August 2002. It was based at Fort Lauderdale Executive Airport, Fort Lauderdale, Florida. Jet management companies typically provide administrative and logistical support for flight 62 A delay (typically about 5 seconds) is designed into the thrust reverser system. This delay is based on engine fan speeds and ensures that engine thrust decreases adequately before the thrust reversers deploy. 63 The Safety Board notes that the simulator pilots were aware that they would be performing a high-speed RTO and were therefore more likely to react immediately and perform all of the required RTO steps promptly.

Factual Information 34 Aircraft Accident Report operations, including maintenance management, flight crew scheduling, developing cost estimates, providing catering services, making hotel reservations, repositioning airplanes and crews for flights, and coordinating for services with FBOs. PJM advertised its company operations as aircraft management, jet sales, and charters. Initially, PJM did not operate any airplanes; however, in January 2003, it took over a lease agreement for a Bombardier CL-600. According to postaccident interviews with PJM’s CEO, shortly thereafter, PJM began to pursue a Part 135 certificate for this airplane and its operations, ultimately entering into a charter management agreement with Darby Aviation, which held a Part 135 certificate.64 PJM did not hold a Part 119 approval or 135 operating certificate65 or any economic authority from the Department of Transportation’s (DOT) Office of the Secretary and was therefore not authorized to advertise for or conduct Part 135 charter flights. According to 14 CFR 119.5(g), an operator must hold an appropriate air carrier certificate to operate as an air carrier and to advertise its services to the public for compensation or hire. Although PJM did not hold an appropriate certificate, the company advertised its charter services and represented itself (on its Web site, business cards, and brochures) to the public as an authorized charter operator. According to PJM’s CEO, although PJM did not hold a Part 135 certificate, it had a director of maintenance (DOM) who maintained maintenance records and coordinated maintenance on the company’s airplanes. The CEO stated that, in addition to his other business duties, he himself performed many of the functions that would normally be performed by a director of operations (DO) or chief pilot.66 At the time of the accident, the company operated three CL-600 airplanes and contracted with about five captains and five or six first officers for Part 135 flight operations. All pilots and cabin aides used by PJM were independent contractors and not direct employees. The company also used a contract employee to provide quotes, schedule flights, and notify crews. On March 3, 2005, the FAA issued a cease and desist order against PJM, which ceased operations effective March 25, 2005. For more information, see section 1.17.5.1. 1.17.2.2 Darby Aviation In 1992, Darby Aviation (a Muscle Shoals, Alabama-based operator) applied for and received a Part 135 operating certificate from the Birmingham, Alabama, Flight Standards District Office (FSDO). According to Darby’s DO, he was selected for his 64 The accident airplane was one of three CL-600 airplanes that were subsequently placed on Darby’s certificate as a result of Darby’s charter management agreements with PJM. For additional information on Darby Aviation, see section 1.17.2.2. 65 Title 14 CFR Part 135 addresses the operating requirements for commuter and on-demand flights and personnel. Title 14 CFR Part 119 provides guidance to Part 135 (and Part 121) operators regarding the certification, operational, maintenance, and other regulatory requirements with which they must comply and describes the certification process. 66 The CEO told investigators that PJM hired a DO in fall 2004 but that, shortly thereafter, the individual was fired for poor performance. The CEO assumed those responsibilities and attributed PJM’s failure to appropriately designate the accident flight as a Part 135 flight to his own failure to oversee the operation.

Factual Information 35 Aircraft Accident Report position in 1992 and had served as DO ever since. In 1994, Darby received FAA approval to conduct operations under the business name AlphaJet International. AlphaJet advertised on-demand medical evacuation and worldwide charter services in various types of jet and turbopropeller-powered airplanes. Darby also entered into lease agreements with other owners and operators (including PJM) to operate other airplanes. However, PJM was not specifically listed in Darby’s operations specifications, and there were no doing business as (dba) names similar to PJM. On March 23, 2005, the FAA issued an emergency suspension of Darby’s Part 135 operating certificate. Ultimately, the Safety Board upheld the emergency suspension in a May 26, 2005, decision, Administrator v. Darby Aviation, NTSB Order No. EA-5159 (2005).67 1.17.2.3 The Relationship Between PJM and Darby Aviation In September 2003, PJM contacted Darby Aviation about establishing a Part 135 CL-600 operation under Darby’s Part 135 certificate. PJM and Darby entered into a charter management agreement (sometimes termed “certificate sharing” or “piggybacking”) covering the accident airplane in November 2003. Similar agreements covered other airplanes operated by PJM. 1.17.2.3.1 Operational Control PJM operated all of its Part 135 flights in its CL-600 airplane(s) under Darby’s certificate, for which it paid Darby a flat monthly “certificate fee.” The PJM CEO told investigators that, under the auspices of the charter management agreements with Darby Aviation, Darby was required to maintain operational control of all on-demand Part 135 operations conducted by PJM, and PJM provided an airplane (one of its three CL-600s), a flight crew, maintenance support, and scheduling services for all of the Part 135 flights it operated under Darby’s certificate. Darby was responsible for crew training and record-keeping. Postaccident interviews with Darby personnel indicated that they were to receive a fax of the airplane’s weight and balance form, a manifest, and a cellular telephone number for the crew before any Part 135 charter flight and that this was one way that Darby maintained operational control of flights conducted under its certificate. According to 14 CFR 1.1, “General Definitions,” “operational control” is defined as the exercise of authority over the initiation, conduct, and termination of a flight. FAA Order 8400.10, “Air Transportation Operations Inspectors Handbook,” Volume 3, Chapter 6, further defines operational control as follows: Operators conduct operational control by making those decisions and performing those actions on a daily basis that are necessary to operate flights safely and in compliance with the regulations. Operational control functions include crew and aircraft scheduling, accepting charter flights from the public, reviewing weather and notices to airmen, and flight planning. Another aspect consists of developing 67 The decision can be found on the Safety Board’s Web site at http://www.ntsb.gov/alj/O_n_O/docs/aviation/5159.pdf.

Factual Information 36 Aircraft Accident Report and publishing flight control policies and procedures for flight crews and other operations personnel to follow in the performance of their duties. In addition, Order 8400.10 states that providing adequate oversight of flight operations is an integral part of the exercise of operational control. 1.17.2.3.2 Maintenance According to Darby Aviation’s general maintenance manual (GMM), the accident airplane was maintained under a continuous airworthiness maintenance program (CAMP), in accordance with Darby’s GMM and applicable airplane, engine, and APU manuals. The GMM indicated that Darby would provide each contract maintenance station with a GMM. PJM’s DOM provided investigators with PJM’s GMM, revision 11, dated March 22, 2004, which was supplied to PJM by Darby. The GMM stipulated that Darby Aviation’s DOM was responsible for planning and implementing the company’s maintenance program in accordance with Federal regulations. Title 14 CFR 135.427 required Darby to list all vendors “with whom it has arranged for the performance of any of its required inspections, other maintenance, preventative maintenance, or alterations” in its GMM. Maintenance records indicated that PJM was accomplishing most of the accident airplane’s maintenance and inspections at its maintenance facility in Fort Lauderdale. (Darby’s DOM stated that Darby did not have any maintenance personnel trained to work on the CL-600.) The investigation also revealed that, on occasion, PJM contracted with Bombardier and other third-party vendors to perform maintenance on the airplanes. However, a review of Darby’s approved vendor list revealed that it did not list PJM or Bombardier as approved vendors. Further, the investigation revealed that most, if not all, of the accident airplane’s maintenance records were maintained by PJM, not by Darby. Darby Aviation’s GMM also indicated that a continued analysis and surveillance system (CASS)68 was required to audit the effectiveness of Darby’s CAMP. During a postaccident interview, Darby’s DOM stated that he had performed quarterly audits of the PJM maintenance facility, in accordance with the GMM; however, no vendor audit forms for the PJM maintenance facility were found. PJM’s DOM told investigators that PJM personnel regularly communicated by telephone with Darby regarding maintenance and reliability issues; however, no documentation of these communications was found. Investigators also did not find any condition reports documenting PJM maintenance or administrative activities, which PJM should have been required to provide Darby under the CASS. Darby Aviation and PJM used a system known as the computer integrated maintenance management system (CIMMS) to track CL-600 airplane maintenance. A 68 As required by 14 CFR 135.431, each certificate holder shall establish and maintain a system for the continuing analysis and surveillance of the performance and effectiveness of its inspection program and the program covering other maintenance, preventative maintenance, and alterations and for the correction of any deficiency in those programs, regardless of whether those programs are carried out by the certificate holder or by another person.

Factual Information 37 Aircraft Accident Report review of the accident airplane’s CIMMS records (obtained from PJM) indicated that all required ADs and service bulletins (SB) had been complied with. However, Darby was not able to provide the Safety Board with the airplane’s original maintenance documentation describing how the ADs and SBs were accomplished or showing that they were accomplished in accordance with regulations. According to Darby Aviation’s GMM, Darby was required to ensure that maintenance technicians and required inspection item (RII) inspectors attended training before maintaining airplanes listed on Darby’s certificate (including the accident airplane). Further, Darby was required to maintain individual training records for each technician who worked on its airplanes. At the Safety Board’s request, Darby provided training records for the PJM DOM, but the company was not able to provide training records for other PJM maintenance personnel. According to the PJM DOM, he was the only PJM maintenance person provided training by Darby69 and the only RII inspector-authorized maintenance technician for Darby. However, records and postaccident interviews indicated that, in addition to its DOM, PJM had three other maintenance technicians who worked on its CL-600 airplanes. These technicians had been fully trained at FlightSafety International facilities; however, their training records were maintained by PJM, not by Darby. 1.17.2.3.3 Record-keeping Numerous record-keeping discrepancies were noted by investigators during this investigation, including flight logbook discrepancies, lack of AD and major repair and alterations records, inadequate retention of PJM maintenance documentation by Darby Aviation, no minimum equipment list for the accident airplane, incomplete CIMMS records, lack of adherence to Darby’s GMM or CAMP by PJM, and no current weight and balance information for the accident airplane. Additionally, although the accident airplane and some PJM pilots were listed in Darby’s operations specifications, PJM was not listed in Darby’s FAA-approved operations specifications (as required). 1.17.2.4 Blue Star Jets, Inc. Blue Star was formed in April 2001 as a charter broker company. Blue Star does not own or hold exclusive leases on any airplanes nor does it hold a Part 119 or 135 operating certificate or any economic authority from the DOT’s Office of the Secretary. According to the DOT, a charter broker links consumers with certificated air transportation providers that are certificated under Parts 119, 135, 121, or other parts, as appropriate, and that hold the appropriate economic authority. The DOT defines direct air carriers as operators that provide transportation on their own aircraft. Indirect air carriers contract with a customer for air transportation and then contract separately with a direct air carrier to conduct the flight. Brokers that do not hold certificates or DOT economic authority must act as (1) an agent of either the charter 69 Records indicated that the PJM DOM attended a 2-week initial CL-600 maintenance course at FlightSafety International, Montreal, Canada, in November 2002.

Factual Information 38 Aircraft Accident Report customer or the direct air carrier or (2) as an entity that simply identifies prospective charter customers for direct air carriers or vice versa and then places them in direct contact with each other. (Travel agencies typically perform this function as agents of air carriers.) Charter brokers may enter into written agreements with either the charter customer or the direct air carrier. Records indicated that Blue Star had entered into such an agreement with the charter customer for the accident flight.70 According to Blue Star representatives, at the time of the accident, the company assessed the qualifications of the operators it used by obtaining a copy of their certificates of insurance, checking quality audits from independent companies, and/or reviewing the “Air Charter Guide.”71 Blue Star representatives stated that they originally located PJM through the Air Charter Guide and obtained a copy of the airplane’s certificate of insurance before Blue Star arranged the accident flight.72 They indicated that they considered the insurance document and Air Charter Guide reference sufficient evidence that PJM was operating properly under a current Part 135 certificate. Blue Star representatives stated that, at that time, they did not specifically check a company’s Part 135 operating certificate when arranging a flight; therefore, they did not ask to see a Part 135 operating certificate for PJM when they arranged the accident flight.73 Blue Star did not maintain records on the flight crews or airplanes used by the operators it used, although the company would occasionally get an airplane registration number and/or a crewmember name and cellular telephone number before a flight for customer convenience. 1.17.3 FAA Oversight The Birmingham FSDO provided oversight of Darby Aviation’s Part 135 certificate. A principal operations inspector (POI) and principal maintenance inspector (PMI) were assigned to manage Darby’s certificate. The POI for Darby had been assigned oversight responsibility for Darby’s Part 135 certificate for about 18 months at the time of the accident. In addition to his Darby duties, the POI was responsible for oversight of 9 or 10 other Part 135 operators, 6 pilot examiners, 3 Part 141 training schools, and 1 Part 125 operator. He stated that he had an assistant POI because of the number of Part 135 operators and airplanes he oversaw. He 70 Blue Star representatives and the charter customer’s chief pilot stated that their companies had worked together regularly during the year before the accident. They indicated that the accident trip was scheduled because the charter customer had sold one of its two airplanes and the other airplane was undergoing maintenance. 71 For additional information, see http://www.aircharterguide.com. 72 DDH held a hull insurance policy on the accident airplane. PJM provided Blue Star with copies of that policy and its lease for the airplane. 73 Blue Star personnel noted that if, at the time of the booking, they had asked to see PJM’s Part 135 operating certificate and PJM had presented them with a copy of Darby’s certificate (under which PJM was operating), they would have considered that acceptable based on their practices at that time. Since the accident, Blue Star has obtained a copy of Darby’s Part 135 operating certificate and worked with a charter audit company to institute a review system to ensure use of only properly certificated Part 135 operators.

Factual Information 39 Aircraft Accident Report stated that he was aware of PJM’s charter management agreements with Darby but that he did not oversee PJM operations because PJM did not hold a Part 135 certificate. (He also claimed that budget issues and the geographical distance between the Birmingham FSDO and Fort Lauderdale-based PJM were issues.) The POI stated that all of his interactions with PJM were conducted through Darby’s DO. He indicated that he had not visited PJM’s facility at FLL nor had he requested oversight assistance from the Fort Lauderdale, Florida, FSDO. The PMI for Darby Aviation had been assigned to Darby’s Part 135 certificate for about 12 months at the time of the accident. In addition to his Darby duties, the PMI was responsible for oversight of eight Part 145 repair stations, one airframe and powerplants school, and another Part 135 operator. During postaccident interviews, the PMI told investigators that he visited Darby twice per quarter, staying 3 or 4 days per visit. He stated that he accomplished all of the required oversight and surveillance items during these visits, including ramp inspections and review of Darby’s GMM, airplane maintenance manuals, and other paperwork. The PMI stated that, although Darby was responsible for the accident airplane’s maintenance, he was aware that the maintenance was performed by PJM. He indicated that he had never visited PJM’s facility at FLL nor had he asked Fort Lauderdale FSDO personnel to visit the facility. During postaccident interviews, the PMI stated that Darby Aviation had arrangements similar to its arrangement with PJM with other operators on its Part 135 certificate and that he believed that Darby maintained operational control of all its flights. He stated that, to his knowledge, Darby maintained all original maintenance paperwork and that PJM was on Darby’s approved vendor list. He told investigators that he had not seen any recurring problems with the company. 1.17.4 Federal Lease Requirements Typical aircraft lease agreements are described by the FAA as “dry leases” or “wet leases.” In a dry lease agreement, an owner supplies an airplane to a certificated operator, typically allowing the owner to defray the costs of airplane ownership while allowing the operator to increase fleet size and/or flexibility. For a Part 135 flight under a dry lease agreement, the certificated operator supplies the flight crew and is responsible for other operational aspects of the flight. In a wet lease agreement, an airplane and a flight crew are provided as a package between Part 135- or Part 121-certificated operators and contractors, typically allowing one of the parties to temporarily increase fleet size and/or flexibility. According to 14 CFR 119.53(b), wet lease agreements are only permitted between certificated operators. However, a postaccident FAA sampling of operators indicated that charter management arrangements similar to that between PJM and Darby Aviation in which one of the operators did not have a Part 135 operating certificate (contrary to 14 CFR 119.53) were common.74 Historically, these agreements have been considered acceptable and tacitly permitted by the FAA. The Safety Board requested information from the FAA regarding the number of noncompliant arrangements between certificate

Factual Information 40 Aircraft Accident Report holders and noncertificated entities that were identified and how many of those arrangements have been amended and/or resolved;75 to date, the FAA has not provided this information. 1.17.5 Postaccident Actions 1.17.5.1 FAA and DOT Emergency Orders to PJM On March 3, 2005, the FAA issued an emergency cease and desist order to PJM as a result of an investigative report that concluded that the company “violated and threatened to violate” various Federal regulations. In part, the order indicated that PJM had agreed to operate charter flights when it did not hold an air carrier certificate under Part 119 and that PJM operated flights subject to Part 135 without appropriate operations specifications from November 17, 2003, to February 2, 2005. In addition, the order stated that PJM “violated and threatened to violate” 49 U.S.C. [United States Code] section 44711(a)(4), which states that no person may operate as an air carrier without an air carrier operating certificate. Later in March 2005, PJM ceased operations.76 On June 12, 2006, the DOT entered into a consent order with PJM to cease and desist from operating without proper licensing authority. The DOT concluded that, because PJM personnel conducted direct advertising rather than using Darby Aviation to schedule its flights, they were in violation of 49 U.S.C., sections 41301 and 41712. The DOT also noted that the owner of PJM was not a U.S. citizen; therefore, PJM could not legally operate for compensation between two points within the United States. 1.17.5.2 FAA Emergency Order of Suspension to Darby Aviation On March 23, 2005, the FAA issued an emergency (immediately effective) order of suspension to Darby Aviation as a result of an investigative report that concluded that Darby, a Part 135 operating certificate holder, had caused, permitted, or allowed PJM to unlawfully operate passenger-carrying flights for compensation or hire. The report cited the accident flight and numerous other flights as examples. In addition, the FAA’s emergency order indicated that Darby Aviation had failed to maintain responsibility for operational control of flight operations, allowing PJM to exercise such control for passenger-carrying flights for hire when PJM did not hold an appropriate air carrier operating certificate. The FAA’s order further stated that Darby had violated 14 CFR 119.5(g), which states, in part, “no person may operate as a direct air 74 In one such case, on May 19, 2006, the FAA took enforcement action against an operator and an air ambulance company for alleged violations of Section 119.53 and loss of operational control. 75 Safety Board requests for this information included a June 21, 2006, e-mail request, a July 6, 2006, follow-up e-mail, and an August 22, 2006, official investigative request (request number 06-108). 76 DOT records show that, after PJM ceased operations, the three partners involved in PJM attempted to set up a new “jet management company” in Boca Raton, Florida, in early 2005 and that the new company shut down after about 3 months.

Factual Information 41 Aircraft Accident Report carrier or as a commercial operator without, or in violation of, an appropriate certificate and appropriate operations specifications.”77 As a result of these and other circumstances set forth in the FAA’s order, the FAA required an indefinite suspension of Darby Aviation’s air carrier certificate until such time as it could demonstrate that it had not surrendered operational control of the certificate. On April 21, 2005, a Safety Board administrative law judge reversed the emergency order, finding that PJM, not Darby, was responsible for the accident flight. On May 5, 2005, the FAA Administrator appealed the initial decision of the Safety Board’s law judge. Upon further review of all of the evidence, on May 26, 2005, the Board issued Order EA-5159, which affirmed the FAA administrator’s emergency order of suspension and reversed the initial decision of the Safety Board’s law judge. Subsequently, the FAA has approved rewritten operations specifications for Darby, which include an expanded, detailed section on operational control, similar to the FAA’s draft Operations Specifications A-008. Darby’s operating certificate is no longer under suspension and the company owns all but one of the airplanes it operates. Darby has a dry lease agreement with the owners of that airplane and does not operate any airplanes under wet-lease-type agreements similar to that which it held with PJM. 1.17.5.3 Additional Postaccident DOT and FAA Actions According to the DOT, Blue Star was subject to the provisions of a DOT notice issued in October 2004, which provided guidelines for brokers to avoid giving the appearance that they were acting as air carriers. In a settlement issued in October 2005,78 the DOT found that, although there was no deception related to the accident flight, certain phrases used in Blue Star’s advertising and on its Web site gave the impression that Blue Star was operating as an air carrier and implied that the company only contracted with certificated carriers. On June 10, 2005, the FAA issued Notice 8400.83, titled “Responsibility for Operational Control During Part 135 Operations and the Use of a DBA (Doing Business As) Name.”79 This notice reiterated existing guidance to FAA inspectors regarding their certificate management and surveillance of operators that conduct Part 119 and 135 operations and directed inspectors to ensure that the operators they oversee understand their obligations to maintain operational control of flights conducted under their certificates. Additionally, on October 25, 2005, the FAA issued a public notice in the Federal Register (70 FR 61684-01) that reiterated existing guidance and regulations regarding wet 77 Title 14 CFR 135.77 states, “each certificate holder is responsible for operational control of operations conducted under its certificate and shall list, in the manual required by Section 135.21, the name and title of each person authorized by it to exercise such operational control.” 78 An electronic version of this document (Order 2005-10-24) can be found at the DOT’s Web site at http://dms.dot.gov. 79 See section 1.18.2.3 for information regarding a dba-related safety recommendation.

Factual Information 42 Aircraft Accident Report lease agreements. The notice stated, in part, “it has long been contrary to Federal Aviation Regulations for an air carrier to ‘wet lease’ an aircraft from an individual or entity that is not separately authorized to engage in common carriage.” This notice further specified that “a carrier has inadequate operational control if it lacks either timely knowledge about the flight and duty status of its pilots, the means to communicate an order to the crew to delay, cancel, or divert a flight, or sufficient leverage or authority over its crews to assure compliance with the carriers lawful instructions.” Further, between March and June of 2006, the FAA hosted 10 seminars to educate attendees on the FAA’s guidance and requirements related to wet leases and operational control, use of business names, and select case studies.80 Additionally, in concert with industry, the FAA began an expansion of the operational control section of FAA Order 8400.10, “Air Transportation Operations Inspectors Handbook,” and revision of section A-008 of the standard Operations Specifications (which pertains to operational control), which were to be accomplished by August 31, 2006. On September 19, 2006, FAA staff informed Safety Board investigators that the revisions have not yet been finalized but are now scheduled for release on or about October 31, 2006. 1.18 Additional Information 1.18.1 Other Challenger CL-600 Runway Overrun Accidents The Safety Board has investigated two other recent accidents involving CL-600 runway overruns. In one case, on December 16, 2003, the pilots of a CL-600 performed an RTO at a speed of about 139 knots when the airplane did not rotate at the expected rotation speed. The airplane came to a stop about 15 feet beyond the departure end of runway 19 at TEB. The Board determined that the airplane did not rotate at the expected speed because it was loaded such that it exceeded its maximum takeoff weight and forward CG limit.81 In the other recent CL-600 runway overrun, on March 9, 2005, a CL-600 ran off the end of a runway at Tupelo Regional Airport, Tupelo, Mississippi, after the pilots initiated an RTO at a speed of about 140 to 145 knots. The Safety Board determined that the airplane did not rotate at the expected speed because the first officer’s microphone holder, which was installed on the base of the control column, had rotated 90° and was interfering with the aft movement of the column.82 (The Board’s investigation of the February 2, 2005, Teterboro accident revealed that the microphone holder in the accident airplane had a different design and could not have caused such interference.) 80 Educational program attendance was strictly voluntary for FAA principal inspectors and industry personnel. Specific training for FAA principal inspectors has not been implemented. 81 Postaccident investigation revealed that the airplane’s CG was about 13.6 percent MAC. Additional information regarding this accident NYC04IA054, can be found on the Safety Board’s Web site at http://www.ntsb.gov. 82 Additional information regarding this accident, ATL05FA061, can be found on the Safety Board’s Web site at http://www.ntsb.gov.

Factual Information 43 Aircraft Accident Report 1.18.2 Previous Safety Recommendations 1.18.2.1 Engineered Materials Arresting System Recommendation As a result of its investigation of the May 6, 2003, accident involving a Southwest Airlines airplane that overran the end of the runway after landing at Burbank, California,83 the Safety Board issued Safety Recommendations A-03-11 and -12, which addressed RSAs. Safety Recommendation A-03-11 asked the FAA to do the following: Require all 14 Code of Federal Regulations Part 139 certificated airports to upgrade all runway safety areas that could, with feasible improvements, be made to meet the minimum standards established by Advisory Circular 150/5300-13. These upgrades should be made proactively, not only as part of other runway improvement projects. Safety Recommendation A-03-12 asked the FAA to do the following: Require all 14 Code of Federal Regulations Part 139 certificated airports to install engineered materials arresting systems in each runway safety area available for air carrier use that could not, with feasible improvements, be made to meet the minimum standards established by Advisory Circular 150/5300-13, “Airport Design.” The systems should be installed proactively, not only as part of other runway improvement projects. In an August 7, 2003, letter, the FAA indicated that it agreed with the intent of these recommendations and stated that FAA Order 5200.8, “Runway Safety Area Program,” established a program to bring all RSAs up to current standards, whenever possible. The letter stated that the FAA’s goal was to upgrade RSAs at the 456 identified affected airports by 2007 and that such improvements “may be initiated at any time.” However, with regard to Safety Recommendation A-03-12, the FAA stated that the installation of an EMAS should be a choice rather than a requirement because “there may be other systems that might be developed as technologies occur.” In late 2003, Safety Board and FAA personnel met to discuss the RSA/EMAS issue and available alternative systems that would quickly and safely stop an airplane running off the end of a runway. In a January 30, 2004, letter, the Board stated that it “did not intend to specify a single product in this recommendation and agrees that the FAA should have the flexibility to allow systems that provide an equivalent level of performance.” The Board asked the FAA to provide annual updates on RSAs that could not meet the standards and the specific alternatives that would be used to improve the safety of these RSAs.84 The Board classified Safety Recommendations A-03-11 and -12, “Open—Acceptable Response,” pending receipt of the requested information. 83For additional information, see National Transportation Safety Board, Aircraft Accident Brief NTSB/AAB-02/04 (Washington, DC: NTSB, 2002). 84 The FAA stated that its goal was to upgrade at least 65 RSAs per year through 2007 and that 71, 68, and 74 RSAs were upgraded in fiscal years 2000, 2001, and 2002, respectively. The FAA also noted that eight EMAS beds had already been installed and that several more installations were planned.

Factual Information 44 Aircraft Accident Report In a July 7, 2006, letter, the FAA indicated that 208 RSA upgrades and 15 EMAS installations had been completed though fiscal year 2005. The letter further stated that more than 90 percent of the RSA upgrades would be completed by 2010, and all RSA upgrades would be completed by 2015. The latest FAA response is under Board review at this time. The issue of RSA improvements was discussed at the Safety Board’s public hearing on the December 8, 2005, accident at Chicago Midway Airport (MDW) involving Southwest Airlines flight 1248. In response to questioning during this hearing, FAA personnel indicated that, under current FAA policy, it is possible that some RSAs will not meet the dimensional standards or have arrester beds installed even after the FAA considers its improvement projects successfully completed. 1.18.2.2 Crew Resource Management Training for Part 135 Pilots As a result of its investigation of the October 25, 2002, accident involving a Raytheon (Beechcraft) King Air A100 that crashed on approach to Eveleth-Virginia Municipal Airport, Eveleth, Minnesota,85 the Safety Board issued Safety Recommendation A-03-52 on December 2, 2003. Safety Recommendation A-03-52 asked the FAA to do the following: Require that 14 Code of Federal Regulations…Part 135 on-demand charter operators that conduct dual-pilot operations establish and implement a Federal Aviation Administration-approved crew resource management [CRM86] training program for their flight crews in accordance with 14 CFR Part 121, subparts N and O. In an April 12, 2004, response, the FAA indicated that an aviation rulemaking advisory committee (ARAC) was in session “to revise and improve 14 CFR Part 135 in many respects, including requiring crew resource management training for 14 CFR Part 135 operators of airplanes with two pilots.” The FAA indicated that it anticipated receiving recommendations from the ARAC and issuing a related notice of proposed rulemaking (NPRM) in “fiscal year 2005.” In its January 12, 2005, response letter to the FAA, the Safety Board acknowledged that the pending revisions to 14 CFR Part 135 would incorporate many operational changes, including the requirement for CRM training, and encouraged the FAA to expedite those revisions. The Board classified Safety Recommendation A-03-52 “Open—Acceptable Response,” pending completion of the 14 CFR Part 135 revisions. 85 For additional information, see National Transportation Safety Board, Loss of Control and Impact with Terrain, Aviation Charter, Inc., Raytheon (Beechcraft) King Air A100, N41BE, Eveleth, Minnesota, October 25, 2002, Aircraft Accident Report NTSB/AAR-03/03 (Washington, DC: NTSB, 2003). 86 CRM has been defined as, “the effective use of all available resources: human resources, hardware, and information” to achieve safe and efficient flight. For additional information, see FAA AC 120-51E, “Crew Resource Management Training.”

Factual Information 45 Aircraft Accident Report This issue was further addressed as a result of the Safety Board’s investigation of the November 28, 2004, accident involving a CL-600-2A12 that crashed during takeoff from Montrose Regional Airport, Montrose, Colorado.87 During this investigation, it was noted that, although the ARAC had provided the FAA with its recommendations regarding improvements to Part 135 operations, no related NPRM had yet been issued, and the Board reiterated Safety Recommendation A-03-52 and reclassified it “Open— Unacceptable Response,” on May 2, 2006. During a briefing on June 13, 2006, the FAA told Board personnel that the related NPRM would be issued in mid-2007. 1.18.2.3 Part 135 Operator Information Recommendation On May 2, 2006, also as a result of its investigation of the accident in Montrose, Colorado, the Safety Board issued Safety Recommendation A-06-43, which asked the DOT to do the following: Require that, for all 14 Code of Federal Regulations…Part 135 on-demand air taxi flights, the following information be provided to customers and passengers at the time the flight is contracted and at any point there is a substantial change: the name of the company with operational control of the flight, including any “doing business as” names contained in the operations specifications; the name of the aircraft owner; and the name(s) of any brokers involved in arranging the flight. Safety Recommendation A-06-43 is classified “Open—Await Response.” Blue Star and PJM were named on the documentation for the accident flight, and the personnel involved in scheduling the charter flight knew that PJM would be operating the flight. However, none of the charter paperwork identified Darby Aviation as the actual Part 135 certificate holder. Further, it is unclear whether any of the passengers had access to any pertinent information regarding the companies involved with the accident flight. 87 For additional information, see National Transportation Safety Board, Aircraft Accident Brief NTSB/AAB-06/02 (Washington, DC: NTSB, 2006).

46 Aircraft Accident Report 2. Analysis Title 14 CFR Part 135 charter operations comprise a growing segment of air transportation for the public. The FAA expects on-demand Part 135 charter operations to increase by about 3 percent a year from 2006 to 2017.88 However, this investigation revealed a common practice in the aviation industry that undermines the safety of Part 135 operations and the FAA’s ability to oversee them. Specifically, noncertificated (unauthorized) charter operators advertise and provide charter flight services to the public under the auspices of an FAA-certificated Part 135 operator through the use of charter management agreements. However, these noncertificated operators are not subject to FAA certification requirements or the ongoing FAA oversight processes that are applied to a Part 135-certificated operator. Under charter management agreements, oversight and operational control of the noncertificated operator is the responsibility of the Part 135 certificate holder. As a result, the oversight and operational control of such operations is performed with varying degrees of diligence. In the case of the operators involved in this accident, Darby maintained minimal oversight and operational control (see section 1.17.2.3). With the expected growth of Part 135 operations, it is now more critical than ever that the FAA provide adequate guidance and oversight to ensure that operational control is maintained by the certificated entity so that the safety of individuals traveling on Part 135 on-demand chartered aircraft is not compromised. The FAA has recognized this “loophole” in its certification and oversight system and is taking steps to address the issue and instruct the charter industry and FAA principal inspectors on the aspects of operational control and acceptable methods of demonstrating such control. However, as further discussed below, the Safety Board is concerned that the FAA’s actions to identify a lack of operational control or provide guidance on acceptable methods to demonstrate operational control to date have not been adequate to fully educate all POIs and operators to ensure compliance. The analysis and recommendations contained in this report address this lack of operational control and guidance for demonstrating operational control. In addition, this analysis addresses weight and balance procedures; flight crew actions, training, and procedures; company oversight and operational control; FAA responsibility and oversight; cabin aide actions, training, and procedures; and RSAs. 2.1 General The captain held the certificates required to act as pilot-in-command of CL-600 flights under 14 CFR Part 91, but he had not yet received the training needed to operate 14 CFR Part 135 flights for Darby Aviation. 88 For additional information, see the FAA’s General Aviation and Air Taxi Activity and Avionics Survey, CY2004 at http://www.faa.gov/data_statistics/aviation_data_statistics/general_aviation/CY2004.

Analysis 47 Aircraft Accident Report Information obtained from previous employers and postaccident interviews and the Safety Board’s review of FAA records, the captain’s rèsumès, and other documentation called into question the validity of the captain’s reported experience (his flight times and previous training) as a pilot. The first officer had received only 22 of the 31 hours of ground training required by Darby’s operations specifications to perform second-in-command duties on a CL-600 being operated under Part 135. Additionally, his FAA medical certificate had expired for the purposes of commercial operations. Therefore, he was not properly trained or certificated for the accident flight. A review of the pilots’ 72-hour histories revealed that, although they reported receiving less sleep than normal the night before the accident, they had had adequate sleep during the previous two nights. Both pilots reported feeling alert on the morning of the accident. There was no evidence that fatigue affected the pilots’ performance on the morning of the accident. The accident airplane was properly certificated and was maintained in accordance with industry practices. There was no evidence of any preexisting powerplant, system (including brakes, ground spoilers, and engine thrust reversers), or structural failures. Although the investigation revealed that the FDR did not operate as expected, evidence indicated that it was likely the result of a unique installation and not a systemic problem. The TEB ASOS was functioning at the time of the accident. Although weather conditions in the area were favorable for frost formation (and an ATC supervisor stated that he observed frost on some car windows when he arrived at work about 0600), the ASOS did not indicate the presence of frost,89 and witnesses and ground and airport personnel told investigators that they did not observe frost on the ground, paved surfaces, or vehicles that were left outside overnight, including the accident airplane. Additionally, two line service technicians who handled the accident airplane on the morning of the accident told investigators that they did not observe frost on the airplane, and the pilot of an airplane that was parked adjacent to the accident airplane that morning stated that there was no frost on his airplane. The airplane’s performance was not consistent with upper wing ice or frost contamination, and the airplane’s failure to rotate when the control column was pulled fully aft is not a performance deficiency associated with the presence of upper wing contamination. Therefore, the Safety Board concludes that weather was not a factor in the accident. The ARFF response from TEB and surrounding communities was prompt, and exterior postaccident fires were extinguished efficiently. A TEB-based HRET/skin-penetrating-nozzle-equipped vehicle, had one been available, would have reached the accident site to extinguish the interior fire more promptly than the EWR-based HRET/skin-penetrating-nozzle-equipped vehicle that responded to this accident site. However, because all airplane occupants had self-evacuated before ARFF personnel 89 The ASOS does not provide direct information regarding frost, but indirect analysis of the data can determine whether frost was present or not.

Analysis 48 Aircraft Accident Report arrived, earlier arrival of such a vehicle would not have facilitated passenger evacuation in this case. The TEB local controllers observed that the airplane was not pitching up at what they believed to be a “normal” liftoff point. Recognizing that the airplane would probably not be able to stop on the remaining runway, the controllers alerted the airport ARFF facility of the situation. The local controllers also promptly issued go-around instructions to an inbound airplane and coordinated that go-around and the cessation of further arrivals at TEB with the approach control facility. Further, the TEB ground controllers ensured that the ARFF responders were aware of the accident location and monitored their progress to the accident site. The Safety Board concludes that the air traffic controllers’ prompt and efficient reaction to this accident was exemplary and facilitated the prompt ARFF response. All eight of the passengers and the cabin aide received minor injuries (including contusions, abrasions, lacerations, sprains, and strains) during the impact and evacuation. The flight crew’s injuries (which included fractures, dislocations, and lacerations) were more serious but were mainly limited to the lower limbs. All of the passengers and crew evacuated through the main cabin door, and no attempt was made to use the overwing exit on the right side of the airplane. (Use of the overwing exit would have been ill-advised because of its proximity to burning vehicles.) Because the pilots were still trapped in their seats and the cabin aide was unable to open the main cabin door, passengers rotated the door handle and pushed and kicked the door open. A passenger reported that he fumbled to find the door handle in the postimpact darkness; however, the main difficulty opening the door was the result of the door being jammed. Postaccident investigation revealed no evidence of a preimpact door anomaly. The Safety Board concludes that doorframe and/or fuselage distortion caused by impact with the building accounted for the passengers’ difficulty opening the main cabin door. 2.2 The Accident Sequence The captain was the flying pilot during the takeoff roll/RTO. Both pilots indicated that the flight controls operated freely and normally during the preflight control checks and that no anomalies were noted before the takeoff roll was initiated about 1 minute later. Witness reports, statements from the pilots and passengers, airplane performance calculations, CVR sound spectrum analysis, and airport surveillance videotapes all indicated that the airplane accelerated for takeoff normally. The captain reported to investigators that, when the airplane accelerated through the planned rotation speed and he tried to move the control column aft, he was not able to move it far, and the airplane did not lift off. However, according to passenger statements, during discussions immediately after the accident, the captain did not report limited control column motion. Rather, he told them that the airplane “had no lift.” One passenger stated that, as he spoke, the captain motioned with his arms as if he were pushing back and forth on a control column. The first officer stated that when he added his efforts to pull

Analysis 49 Aircraft Accident Report back on the control yoke, it did not move, and the airplane did not lift off. Postaccident investigation and extensive component testing revealed no evidence of a flight control system malfunction or failure, and there was no indication of foreign-object obstruction. The airplane continued to accelerate on the runway until the captain rejected the takeoff, and the airplane never rotated. During the RTO, the airplane ran off the end of the runway, through some navigational aid equipment and an airport perimeter fence, across a six-lane highway, struck cars on the road and in a parking lot, and came to rest partially embedded in a brick building about 800 feet from the end of the runway. 2.3 Flight Crew and Airplane Performance Issues 2.3.1 Preflight Airplane Weight and Balance Issues The accident pilots told investigators that, although they obtained an estimate of the airplane’s weight by inputting fuel load information and average passenger weights into the airplane’s FMS, they did not calculate the airplane’s CG in any way for the accident flight. However, Federal regulations (14 CFR 91.9) prohibit a pilot from operating any civil airplane without complying with the operating limitations specified in the approved AFM, which includes acceptable operating ranges for both weight and CG and determining that the airplane is “in condition for safe flight.” In addition, for every charter flight conducted, Federal regulations (14 CFR 135.63) require pilots to calculate an airplane’s weight and balance and to retain a copy of that calculation. Further, in this case, the pilots should also have faxed a copy of the airplane’s weight and balance calculations to Darby before the accident flight. PJM provided its pilots with numerous aids to assist them in determining the airplane’s weight and CG and ensuring that the airplane was operating within the specified limits. For example, PJM pilots were provided with a commercially produced weight and balance graph for use in preflight calculations. Additionally, the weight and balance report in each airplane included pages with the appropriate locations and values to use in manual weight and balance calculations (in accordance with the AFM). The AFM also included quick reference guide pages that could be used to make an initial estimate of the airplane’s loading. All of these materials were available to the flight crew on the morning of the accident. During its investigation, the Safety Board noted that the airplane empty weight on the PJM weight and balance form (completed by the pilots of the previous flight from LAS to TEB) had been manually modified and indicated an airplane empty weight about 1,000 pounds less than the airplane’s actual empty weight, resulting in a baseline CG farther aft than the actual CG for that flight. The Board’s calculations indicated that the previous flight likely departed LAS for TEB slightly over its maximum takeoff weight and with a CG slightly forward of its forward limit. FDR data indicated that the airplane rotated at a higher-than-normal speed during that takeoff; however, the runway at LAS was longer than runway 6 at TEB, and there was no RTO.

Analysis 50 Aircraft Accident Report Review of other PJM weight and balance forms for the accident airplane indicated that when PJM pilots completed this form for Part 135 charter flights, they frequently modified the airplane empty weight. Examination of the modified forms revealed that the modifications involved a variety of airplane empty weights and always resulted in total weights and CGs that were within the airplane’s limits. However, if the weight and balance for the LAS-to-TEB flight is representative, it is likely that the airplane was actually operated outside its specified weight-and-balance limits on numerous previous flights.90 The Safety Board concludes that PJM pilots routinely improperly modified the airplane’s weight and balance forms, using a variety of invalid airplane empty weights to ensure that the form indicated that the airplane was operating within its limitations. The Safety Board’s postaccident weight and balance calculations—which were based on the available documentation regarding fuel and other preflight servicing; the effects of fuel burned during pretakeoff operations; postaccident information regarding the weights of the passengers, crew, and baggage; and other airplane documentation—showed that the airplane was about 100 pounds over the maximum allowable takeoff weight and that the forward CG significantly exceeded the forward CG limit. The accident airplane’s calculated CG was about 12.47 percent MAC, whereas the forward CG limit was 16 percent MAC. The Safety Board concludes that the airplane, as loaded for the accident flight, had a forward CG that was significantly forward of the airplane’s forward limit, which severely degraded the airplane’s ability to rotate. The Safety Board’s review of the pilots’ flight histories indicated that both pilots were experienced and that the captain in particular had reported significant experience in the CL-600 airplane. He was type-rated in the CL-600/-601 and told investigators that he had about 1,500 hours in the CL-600 and about 1,900 hours in the CL-601.91 (The first officer reported about 82 hours in the CL-600, some of which was recent.) In addition, the captain had attended a CL-600 recurrent training program, at which weight and balance issues were reviewed, just 2 months before the accident. Both the captain and the first officer had recent experience in the accident airplane. The Board’s review of weight and balance materials for the accident airplane indicated that, under many loading configurations, the airplane could not be loaded with full fuel without exceeding its forward CG limit. Further, investigators found that this fuel loading characteristic appeared common among corporate jet airplanes with interior cabin furnishings designed for luxury business transport. This loading characteristic is commonly addressed by varying fuel loads, ballast, and/or passenger loading to remain within operational limits. Despite their reported familiarity with the airplane and its loading characteristics, and despite Federal regulations requiring them to do so, neither pilot attempted to ensure 90 The Safety Board notes that an incorrectly modified weight and balance form was not an issue in this accident because the pilots told investigators that they did not use the form for the accident flight. 91 The Safety Board noted inconsistencies in the amount of CL-600/-601 flight experience the captain reported on résumés he submitted to various companies in the year before the accident. These inconsistencies suggest that the amount of CL-600/-601 flight time reported by the captain may be inaccurate. The Board was unable to locate documentation to verify the captain’s actual CL-600/-601 flight experience.

Analysis 51 Aircraft Accident Report that the airplane’s CG would be within limits with the intended loading of eight passengers and full fuel. To remain within the airplane’s load limitations, the accident pilots could have modified their fuel load request (if they performed weight and balance calculations before the fuel tanks were topped off) or off-loaded fuel (if the out-of-balance condition was recognized after the fuel tanks were topped off).92 Even after the accident, the captain expressed disbelief that the airplane’s CG could have exceeded the forward limit under the loading conditions present on the morning of the accident. During postaccident interviews, the first officer stated he typically set the pitch trim slightly above the indexed takeoff position (the TO line within the green range) if the airplane were “heavy.” The captain told investigators that the AFM contained a table for pitch trim settings but stated that he believed that the pitch trim could be adjusted to various settings for takeoff, depending on the pilot’s preference. However, the pitch trim settings for takeoff contained in the AFM were based on the airplane’s CG. The AFM specified using a setting in the upper third of the green band (above the indexed TO position) with CGs that were near (but within) the forward limit. The pilots’ statements that pitch trim could be adjusted based on the airplane’s weight or the pilot’s preference, rather than being selected based on the airplane’s CG, showed that they were not considering the effect of the CG on the airplane’s flight characteristics. Therefore, the Safety Board concludes that neither pilot used the available weight and balance information appropriately to determine the airplane’s weight and balance characteristics for the accident flight and the pitch trim setting selected by the pilots is further evidence that they did not consider the airplane’s CG during preflight preparations. 2.3.2 Pilot Decisions and Actions During the Rejected Takeoff The Safety Board evaluated the pilots’ decision to reject the takeoff and their actions during the RTO. Using the Safety Board’s calculated weight and balance for the accident flight, investigators reconstructed the attempted takeoff in a full-motion simulator and reviewed multiple possible scenarios. The results from the simulator sessions and the Board’s airplane performance study indicated that, under the accident airplane’s loading conditions and configuration, the airplane would likely not have achieved nose-up rotation, even with full aft control column input, until after it accelerated past about 160 knots, well in excess of normal takeoff decision or rotation speeds. Slight differences in airplane responsiveness during a normal takeoff are not uncommon because of variations in airplane loading, trim settings, rotation speed, pilot technique, and other factors during takeoff. Although RTO training is usually based on the premise that an engine failure will occur just before V1, a pilot should still reject a takeoff if convinced that an airplane is not flyable later in the takeoff roll, regardless of the airplane’s speed or the amount of runway remaining. During the accident takeoff, the airplane had accelerated beyond both its safe RTO speed for the accident runway and its expected rotation speed, and its nose never began to lift off the runway. The captain 92 The FBO’s fuel records indicated that another airplane was defueled earlier on the morning of the accident.

Analysis 52 Aircraft Accident Report concluded that the airplane was not flyable and decided to reject the takeoff (albeit at a higher-than-normal RTO speed). The Safety Board concludes that the captain’s decision to initiate the RTO was reasonable, even though the airplane had already reached a higher-than-normal RTO speed. The Safety Board also evaluated the captain’s performance during the RTO by observing numerous RTO runs in a CL-600 simulator configured to match the performance of the accident airplane. The accident airplane’s takeoff performance data indicated that the airplane required as much as 5,270 feet of runway to accelerate to V1 (about 127 knots), initiate an RTO, and come to a stop before the end of the runway. However, the captain initiated the RTO at a speed of about 160 knots (about 33 knots faster than the RTO speed identified in the airplane manuals), and runway 6 at TEB was only 6,013 feet long. RTOs attempted under these conditions in the simulator resulted in runway excursions at various speeds; however, in all cases, the simulator left the runway at a slower speed than the accident airplane. These excursions would likely have resulted in a variety of airplane stopping points at the airport perimeter, the six-lane highway, or the building impacted by the accident airplane. The deceleration levels observed in the simulator study indicated that throughout the RTO the accident pilot was not using the full capability of the airplane to stop and that the speed at which he exited the runway could have been significantly lower. It is imperative that once pilots make the decision to reject the takeoff, they immediately use all available stopping devices. However, the deceleration performance observed during the simulator runs was not necessarily a realistic representation of what might be attained in the accident scenario because the simulator pilots had several advantages over the accident pilots that could explain the increased deceleration performance during the simulator-run RTOs. First, they were aware in advance that they would be performing a high-speed RTO and were instructed to apply reverse thrust, brakes, and spoilers immediately and aggressively. Second, during these tests, the simulator pilots repeatedly performed high-speed RTOs in the simulator, and they benefited from the practice. Third, the simulator pilots were not subject to the stress that the accident pilots likely experienced in a real-world situation. (Although pilots are expected to perform an RTO expeditiously, doing so in a training simulator when the RTO is expected is very different from a real-world situation.) Considering the advantages the simulator pilots had and their lack of success during the simulator runs, the Safety Board concludes that most line pilots attempting to abort a takeoff 5 seconds after and at a speed well above the expected rotation speed, like the accident captain, would not have been able to stop the accident airplane in time to avoid departing the end of the runway. 2.3.3 Crew Resource Management Issues CRM has been defined as the use of “all available resources: human resources, hardware, and information” to achieve safe and efficient flight operations. The Safety Board’s evaluation of the accident pilots’ actions during the flight revealed CRM skill

Analysis 53 Aircraft Accident Report deficiencies in numerous areas. For example, the captain demonstrated poor leadership and failed to use all of the available resources when he failed to involve the first officer in fuel load planning and other preflight decision-making. The captain also failed to reinforce adherence to regulatory requirements and standard operating procedures in the cockpit. Most importantly, he did not ensure that the airplane’s balance was calculated to verify that the flight would be operating within the approved weight-and-balance limits, as required by regulations and company procedures. In addition, the captain rushed the checklist procedures by calling for the before takeoff checklist before the taxi checklist had been initiated and discouraging the first officer from reading the last few items of the before takeoff checklist when he stated, “they...briefed the standard for us.” The captain’s actions eliminated the protections afforded by standard checklist procedures and increased the chances of crew error. The captain also exhibited deficiencies in workload management when he failed to ensure timely completion of certain critical tasks (such as reviewing the departure procedure and programming the FMS) before requesting clearance to taxi. This resulted in a higher-than-necessary workload for the first officer as he tried to brief the captain on the departure procedure, program the FMS, communicate on the radio, and complete the required checklists during the short taxi to the runway. As a result of the captain’s poor planning, the pilots had not yet completed the taxi checklist when they were cleared to taxi into position on the departure runway. At that point, the captain should have recognized that the first officer was overloaded and told TEB ATC that they were not yet ready to depart, thus providing more time to complete the essential checks and prepare for takeoff. Instead the captain stated, “Okay, set to go,” and the first officer acknowledged ATC’s clearance. The pilots’ hurried activities during the taxi, resulting directly from the captain’s poor planning, increased the likelihood of errors during critical before-takeoff checks. In his haste to depart, the captain failed to perform an adequate takeoff briefing, as called for by the taxi checklist. A thorough takeoff briefing would have addressed the most threatening safety issues for that stage of the flight, including clearance limits, initial steps in the departure procedure, requests for callouts, and a brief review of RTO criteria and procedures. The pilots had briefly discussed the departure procedure during their taxi, but when the takeoff briefing should have occurred, the captain merely reviewed emergency evacuation procedures. The first officer also exhibited deficiencies in CRM skills, specifically in the area of crew coordination. For example, the pilots shared equal responsibility for ensuring that the airplane’s weight and CG were adequately determined during preflight planning. Evidence indicated that the first officer was aware of the airplane’s total fuel load and of the anticipated passenger load; therefore, he should have coordinated with the captain or performed calculations himself to ensure that the airplane’s weight and CG were properly evaluated before takeoff. The first officer also should have communicated with the captain when he was rushed to complete critical tasks during the short taxi to the runway to ensure that critical checks and briefings could be properly completed. The first officer’s failure to challenge the captain’s failure to follow standard procedures to determine the airplane’s

Analysis 54 Aircraft Accident Report weight and balance allowed the airplane’s improper loading to go undetected, and his failure to challenge the captain’s poor workload management and deviations from standard procedures during the taxi increased the potential for other errors to occur. On the basis of its evaluation, the Safety Board concludes that the pilots’ failure to ensure that the airplane’s weight and CG were within approved takeoff limits was symptomatic of poor airmanship and a broader pattern of deficiencies in their CRM skills (specifically in the areas of leadership, workload management, communications/briefings, and crew coordination) that were exhibited on the day of the accident. The Safety Board has previously issued recommendations regarding CRM training for Part 135 on-demand charter pilots. For example, on December 2, 2003, as a result of its investigation of the October 25, 2002, accident involving a Raytheon (Beechcraft) King Air A100 at Eveleth, Minnesota, the Board issued Safety Recommendation A-03-52, which asked the FAA to do the following: Require that 14 Code of Federal Regulations…Part 135 on-demand charter operators that conduct dual-pilot operations establish and implement a Federal Aviation Administration-approved crew resource management training program for their flight crews in accordance with 14 CFR Part 121, subparts N and O. The Safety Board reiterated this safety recommendation as a result of its investigation of the November 28, 2004, accident involving a CL-600 that crashed during takeoff from Montrose Regional Airport, Montrose, Colorado. On June 13, 2006, the FAA told Board personnel that an NPRM addressing this issue would be issued in mid-2007. 2.4 Operational Control and Noncertificated (Unauthorized) Carrier Issues 2.4.1 PJM and Darby Aviation Operational Control The accident flight was arranged through a broker agency as an on-demand charter flight, carrying eight passengers for revenue. The charter customer contacted the broker agency, which in turn booked the flight with PJM. Although PJM did not hold a Part 135 operating certificate, it had entered into a charter management agreement with a Part 135 certificate holder, Darby Aviation, which allowed PJM to operate under its certificate and operations specifications. The agreement between PJM and Darby designated Darby as the “exclusive agent” for managing on-demand charter flights conducted in PJM’s airplanes and stated that Darby would monitor the flight crews and airplanes used and provide operational control93 for all such flights. In exchange, PJM would pay Darby a “certificate fee.” The certificate fee was a flat monthly fee; therefore, Darby received no 93 Federal regulations define operational control as the exercise of authority over the initiation, conduct, and termination of a flight, and FAA Order 8400.10 specifies that providing adequate oversight of flight operations is an integral part of the exercise of operational control.

Analysis 55 Aircraft Accident Report additional funds for monitoring the daily flights and operations of PJM. PJM had been conducting on-demand charter flight operations based on its agreement with Darby (with tacit approval from the Birmingham, Alabama, FAA FSDO) since November 2003. During this investigation, the Safety Board identified deficiencies in the organizational policies and procedures of both PJM and Darby Aviation with respect to operational control. For example, their procedures indicated that PJM was required to fax an airplane manifest and weight and balance calculation forms to Darby before each on-demand charter flight it conducted. However, there was no requirement for Darby to confirm or authorize the manifest and weight and balance calculation forms before a flight. Because no preflight review was required, Darby Aviation did not recognize instances in which the weight and balance calculation forms submitted by PJM pilots showed inaccurate, modified airplane empty weights, which resulted in lower-than-actual total weights and farther-aft-than-actual CGs, as it should have if it were exercising proper operational control. If Darby had been exercising proper operational control, its review of weight and balance forms from multiple PJM flights would likely have revealed the pattern in which various inaccurate airplane empty weights were used by PJM pilots to result in weights and CGs within the airplane’s limits. Further, review of PJM and Darby documentation showed that Darby was often unaware of on-demand charter flights conducted by PJM under Darby’s certificate. For example, in some cases, including the accident flight, PJM conducted on-demand revenue flights under Part 91 when they should have been conducted under Part 135.94 PJM was using Darby Aviation’s operating certificate to represent its company (on its Web site, business cards, and brochures) to the public as a Part 135 carrier to conduct on-demand charter flights for compensation. Because PJM had not met the FAA requirements for obtaining its own certificate, the FAA was relying on Darby to maintain operational control of PJM’s operations. However, Darby was purportedly unaware of the accident flight and others. The Safety Board’s review of documentation that Darby maintained on its oversight of PJM indicated that its operational control over flights conducted by PJM was minimal at best. For example, Darby was not properly monitoring the training and certification of pilots used in PJM’s on-demand charter flight operations, as illustrated by the accident flight crew. The Safety Board also noted that PJM was not listed in Darby’s operations specifications, as required. Further, Darby did not possess/maintain the required maintenance and/or pilot records related to PJM operations and was not properly evaluating the documentation that it did receive from PJM. Additionally, Darby did not recognize that the airplane had not been weighed within the previous 3 years, as required for Part 135 operations.95 The Safety Board noted that Darby Aviation and PJM seemed to have accepted responsibility for varying aspects of operational control, depending on the flight. This 94 The accident pilots told investigators that they assumed that the accident flight was a Part 91 flight— despite clear evidence that it was a revenue flight—because they knew that the captain was not yet qualified to fly Part 135 operations under Darby’s certificate. 95 Although PJM personnel told investigators that the airplane had been more recently reweighed, neither PJM nor Darby were able to provide documentation of a more recent weighing.

Analysis 56 Aircraft Accident Report situation resulted in a diffusion of responsibility between the two companies regarding the performance of oversight functions that normally serve to ensure the safety of a flight. This lack of clarity in organizational policies and practices led to a lax safety environment in which charter flights were conducted without the safety protections expected by passengers and required under Part 135. On the basis of the many errors and lapses in operational control identified during this investigation, the Safety Board concludes that Darby failed to maintain operational control over on-demand charter flights conducted by PJM under Darby’s Part 135 certificate, as required by Federal regulations. The Safety Board notes that a certificated Part 135 operator must exercise full operational control over all maintenance and flight operations being conducted under its certificate and have the full-time personnel (for example, a DO and a chief pilot), policies, and practices to detect the routine violations of airplane weight-and-balance limits, inadequate documentation, and record-keeping and incomplete pilot training that the Board easily discovered during this investigation. However, in part because of Darby Aviation’s limited involvement in the planning, conduct, and oversight of PJM’s flights, PJM tried to develop an internal management structure that approximately paralleled the functions normally performed by a certificated Part 135 operator. During postaccident interviews, PJM’s CEO stated that he performed many functions that would normally be performed by a DO or chief pilot and attributed PJM’s failure to clearly designate the accident flight as a Part 135 charter flight to his inadequate oversight of the operation. The Safety Board concludes that because neither Darby nor PJM was rigorous about enforcing the Federal requirement for operational control, PJM pilots operated in an environment in which pilot errors and/or omissions during preflight preparation were less likely to be detected before departure. 2.4.2 FAA Oversight of PJM and Darby Aviation Postaccident interviews revealed that personnel at the FAA’s Birmingham FSDO were aware of the charter management agreement between Darby Aviation and PJM and did not object to the details of that agreement. Although Darby Aviation’s operations specifications and the charter management agreement stated that Darby would maintain operational control over all charter flights (similar to most Part 135 operations specifications), Birmingham FSDO personnel stated that they were unaware of the lack of compliance with the charter management agreement and that, in practice, the arrangement enabled PJM to operate virtually independently, without meaningful operational control from Darby, the certificate holder. A postaccident FAA survey of Part 135 operators revealed that lack of compliance with the operational control aspects of charter management agreements between certificated and noncertificated entities was not uncommon at the time of the accident. Further, like the Birmingham FSDO inspectors in this case, FSDO inspectors in general had not recognized the situation. In this case, although FAA personnel reviewed Darby’s records, they did not ensure that PJM’s airplanes were operated and maintained in accordance with Darby’s company requirements or that charter trips flown by PJM were controlled by Darby. The

Analysis 57 Aircraft Accident Report process of developing a structure and operating practices sufficient to qualify for an air carrier certificate provides a positive demonstration of an operator’s ability to safely provide transportation. Based on information obtained during this investigation, PJM was never required to demonstrate to the FAA that it was capable of providing the level of safety and service expected of certificated on-demand carriers, which led to the lapses in airmanship directly related to this accident. Additionally, the arms-length relationship with Darby shielded PJM from appropriate FAA oversight. The Safety Board concludes that the FAA’s inadequate oversight of the Part 135 charter management agreement between PJM and Darby permitted management failures and a lack of operational control to exist. In effect, this allowed PJM to operate virtually independently as an on-demand air carrier while maintaining little of the structure of a certificated carrier and without demonstrating fitness to conduct such operations. Darby Aviation’s FAA principal inspectors told investigators that, despite their responsibility for managing Darby’s Part 135 certificate, they did not oversee PJM’s operations (which were conducted under that certificate), in part, because of budget issues and the geographical distance between the Birmingham FSDO and Fort Lauderdale-based PJM. Although Fort Lauderdale FSDO personnel could have provided assistance in overseeing PJM’s operations, Darby’s principal inspectors never requested such assistance. Therefore, the Safety Board concludes that Darby’s Birmingham, Alabama, FSDO-based principal inspectors should have requested assistance from a FSDO more conveniently located to PJM’s Fort Lauderdale-based operations to ensure proper oversight of the operations conducted by PJM under the auspices of Darby’s certificate. Federal regulations (14 CFR 119.5) require an operator to hold an appropriate certificate to advertise its services to the public for compensation or hire. However, PJM routinely advertised for, accepted, and conducted on-demand revenue flights as if it were a Part 135-certificated operator, without appropriate certification or oversight to do so, circumstances of which Birmingham FSDO personnel were unaware. The Safety Board concludes that the FAA failed to perform adequate charter operator surveillance and therefore did not recognize that PJM operated as a de facto Part 135 carrier, despite the lack of necessary personnel; policies; procedures; and FAA approvals, certification, and oversight that would normally be associated with such operations. On June 10, 2005, the FAA issued a notice to its principal inspectors and, on October 25, 2005, issued a public notice in the Federal Register (70 FR 61684), both of which reiterated existing regulations regarding Part 135 certificate management and advised that operations conducted under arrangements similar to that between Darby Aviation and PJM are not permissible. The results of a postaccident review of 85 on-demand operators conducted by the FAA indicated that numerous other charter management agreements similar to the agreement between Darby and PJM likely existed. According to the FAA, the initial purpose of its postaccident review of on-demand operators was to gain an understanding of existing business practices and operations of Part 135 operators. FAA personnel told Safety Board investigators that the contracts and lease agreements they examined during this review varied significantly in size and complexity but that many were similar to the agreement between Darby Aviation and PJM

Analysis 58 Aircraft Accident Report in their failure to ensure operational control by the certificate holder. FAA personnel further stated that several of the operators that were reviewed were modifying their charter management agreements as a result of that review; however, the FAA could not provide more specific details regarding the number and nature of those modifications. FAA personnel used the information gathered during their review to develop a series of 10 educational seminars explaining the concepts of operational control to principal inspectors and charter industry representatives, which the FAA conducted between March and June 2006. Also on the basis of its review, the FAA is revising FAA Order 8400.10, “Air Transportation Operations Inspectors Handbook,” and the standard language for Operations Specifications section A-008, which addresses operational control. Although the Safety Board has reviewed several draft revisions, and final changes were due on October 31, 2006, no changes have been finalized. The Safety Board acknowledges that the FAA’s educational seminars regarding operational control should assist FAA inspectors and Part 135 certificate holders in ensuring that operational control is maintained. However, this education will only be successful if all inspectors and certificate holders participate, and the FAA has no plans to hold additional seminars. Further, attendance at these one-time seminars was strictly voluntary for FAA principal inspectors and industry personnel, and there is no additional detailed training planned for FAA principal inspectors. Therefore, the seminars did not reach all inspectors, certificate holders, or other entities. The Safety Board also agrees that the increased specificity contained in the proposed revisions will assist FAA inspectors and Part 135 certificate holders in modifying or removing charter management arrangements that allow, in effect, an unauthorized entity to act as an on-demand charter operator (similar to the arrangement between Darby and PJM). However, the Board is concerned that the FAA does not have a clear assessment of the extent to which impermissible charter arrangements exist. Without such an assessment, FAA is unable to ensure that these arrangements are terminated. Further, the Board is concerned that the proposed revisions to FAA Order 8400.10 and Operations Specifications A-008 have not yet been completed. The Safety Board concludes that without clear and specific guidance on appropriate agreements between certificate holders and other entities that provide airplanes and/or flight crews for charter flights, unauthorized entities could still be performing most, if not all, of the functions of an on-demand charter operator without the controls, oversight, and demonstration of fitness imposed by a Part 135 certificate. Therefore, the Safety Board believes that the FAA should disseminate to all principal inspectors of Part 135 certificate holders and to all Part 135 certificate holders guidance that includes specific procedures, such as those contained in the draft revisions to Operations Specifications A-008, that detail appropriate methods by which a certificate holder can demonstrate to the FAA that it is maintaining adequate operational control over all on-demand charter flights conducted under the authority of its certificate. This guidance should address operations based at locations geographically distant from the certificate holder’s base, should be included in all Part 135 certificate holders’ operations

Analysis 59 Aircraft Accident Report specifications, and should be required as periodic inspection items for principal inspectors. Further, the Safety Board is concerned that, as indicated by the results of the FAA’s postaccident review of on-demand operators, arrangements similar to that between Darby and PJM may still be common among other companies. By requiring Part 135 operators to maintain full operational control of all of their flights, the FAA will help to ensure that, when customers contract with a Part 135 carrier, they are flying with a carrier that has exhibited a level of safety that has been approved by the FAA. Therefore, the Safety Board believes that the FAA should review all charter management, lease, and other agreements between 14 CFR Part 135 certificate holders and other entities to identify those agreements that permit and/or enable a loss of operational control by the certificate holder and require revisions of any such arrangements. 2.5 Cabin Aide Actions, Performance, and Training The Safety Board evaluated the cabin aide’s actions, performance, and training during its investigation. PJM documentation and guidance regarding cabin aide and flight crew responsibilities was unclear; however, the cabin aide told investigators that she ensured that the cabin was “secure,” implying that seatbelts were used and other items secured, before the takeoff roll. Physical evidence and passenger statements indicated that this was not the case. For example, after the passengers boarded the airplane, the cabin aide offered the passengers a beverage and four accepted. The drinks were served in glasses or ceramic/china cups, several of which were recovered on or near passenger seats after the accident, which is not consistent with a secured cabin. One passenger told investigators that he had to pick up his coffee cup during the takeoff roll to prevent spillage. He believed that the lacerations on his right hand were caused by the coffee cup breaking in his hand during the accident sequence. Additionally, postaccident interviews indicated that at least four of the eight passengers were unrestrained when the takeoff roll began. Two passengers located and fastened their seatbelts during the takeoff roll; however, the other two (both seated on the side-facing divan seat) were unable to locate their seatbelts and were therefore unrestrained during the RTO. The two unrestrained passengers were thrown to the cabin floor during the accident sequence. Postaccident examinations revealed that the seatbelts at the three divan seats would not have been visible to the passengers because they had been intentionally placed beneath the seatback cushions. Postaccident examination of another PJM CL-600 revealed that its divan seatbelts had also been intentionally placed beneath the seatback cushions. Positioning the seatbelts beneath the seatback cushions resulted in a tidier passenger cabin and was reportedly not uncommon among operators of corporate and charter airplanes. However, with the seatbelts stowed in this position, passengers would have had to either reach blindly between the seatback cushions or remove the cushions to locate the seatbelts. The Safety Board concludes that the cabin aide did not perform a seatbelt compliance check before the accident flight, which resulted in two passengers being

Analysis 60 Aircraft Accident Report unrestrained during the accident sequence. Further, the Safety Board concludes that the intentional positioning of the seatbelts out of the passengers’ sight made them difficult to locate and use and resulted in reduced compliance with passenger seatbelt usage requirements. Therefore, the Safety Board believes that the FAA should require all 14 CFR Part 135 certificate holders to ensure that seatbelts at all seat positions are visible and accessible to passengers before each flight. According to Federal regulations, no person may serve as a “flight attendant” on a Part 135 flight unless that person is knowledgeable and competent in the areas of crewmember functions and responsibilities during ditching and evacuation, briefing of passengers, the location and operation of all normal and emergency exits, portable fire extinguishers, and other items of emergency equipment. Additionally, regulations require that passengers on airplanes certificated to carry 19 passengers or less must be briefed on, among other things, the use of safety belts96 and the location and operation of the main cabin door and emergency exits. Further, regulations prohibit taxiing, taking off, or landing when any beverage provided by the operator is located at any passenger seat.97 The cabin aide was not required to receive any safety-related training because she was not a required crewmember (flight attendant) for the accident flight. Nonetheless, PJM did provide its cabin aides with some training. The accident cabin aide stated that she had received verbal instruction regarding emergency main cabin door operation and had operated the main cabin door handle and electric toggle switch in a simulated emergency scenario during her training. Her description of her efforts to operate the door after the accident was consistent with the training she reported that she had received; however, it revealed that her training had not provided her with an adequate understanding of the door mechanism/operation. The cabin aide told investigators that she was not familiar with the arm/disarm handle and that she tried to use the electric switch at the top of the bulkhead to operate the door; however, this switch is not needed (nor should it be used) during emergency operations. The Safety Board is concerned that Part 135 operators and/or certificate holders may delegate important safety functions to cabin aides/customer service representatives who are not properly trained and qualified to perform those functions. For example, although PJM policy required one of the pilots to provide passengers with a safety briefing before each flight, the captain believed that the cabin aide was responsible for the preflight safety briefing.98 Further, the Board is concerned that passengers might mistakenly believe that a cabin aide/customer service representative on board an on-demand charter flight had received safety training equivalent to that received by qualified flight attendants when in fact that aide/representative might have received minimal or no safety training. Providing those individuals with basic safety training could provide valuable safety results in an emergency, especially in the event of flight crew injury. 96 Title 14 CFR 135.128 states, “each person on board an aircraft operated under this part shall occupy an approved seat or berth with a separate safety belt properly secured about him or her during movement on surface, takeoff, and landing.” 97 For additional information, see 14 CFR 135.295, 135.117, 135.122, and 135.128. 98 The captain had not yet received PJM policy training.

Analysis 61 Aircraft Accident Report On the basis of the cabin aide’s performance during this accident sequence, including the lack of a seatbelt compliance check, her failure to collect beverage service items before takeoff, and her inability to open the main cabin door and conduct a professional evacuation, the Safety Board concludes that the cabin aide’s training did not adequately prepare her to perform the duties with which she was tasked, including opening the main cabin door during emergencies. Therefore, the Safety Board believes that the FAA should require that any cabin personnel on board 14 CFR Part 135 flights who could be perceived by passengers as equivalent to a qualified flight attendant receive basic FAA-approved safety training in at least the following areas: preflight briefing and safety checks; emergency exit operation; and emergency equipment usage. This training should be documented and recorded by the Part 135 certificate holder. 2.6 Runway Safety Areas The TEB RSAs at all four runway ends did not meet existing FAA standards specifying that RSAs must extend 1,000 feet beyond the departure end of the runway and be 500 feet wide. These nonstandard RSAs had been identified long before this accident, and TEB and New Jersey DOT personnel were actively involved with the FAA in addressing the issue. A related report, contracted by the Port Authority of New York and New Jersey and drafted in 2004, presented alternatives for addressing the nonstandard RSAs, and the FAA concluded that installing a nonstandard (265 feet long by 162 feet wide) EMAS bed at the departure end of runway 6 would be the most practicable solution. In May 2005, the New York and New Jersey Port Authority (which owns TEB) committed to installing an EMAS at the departure end of runway 6. The airport has received grants from the FAA to facilitate the engineering and design of the RSA improvements. The goal for this project’s completion is the end of 2006. The issue of RSA improvements was discussed at the Safety Board’s public hearing on the December 8, 2005, accident at MDW involving Southwest Airlines flight 1248. In response to questioning during this hearing, FAA personnel indicated that it is possible that some RSAs will not meet the dimensional standards or have arrester beds installed even after the FAA considers its improvement projects successfully completed. Studies conducted during the TEB investigation revealed that, if a 265-foot-long EMAS bed had been installed at the departure end of runway 6, the accident airplane would only have been slowed about an additional 8 knots (from 105 to 97 knots) when it departed the RSA. Because of the speed at which the airplane was traveling when it left the runway and the limited EMAS bed size, the airplane would not have stopped on airport property. The Safety Board concludes that the installation of an EMAS at the departure end of runway 6 at TEB (and other similarly affected runways) would provide an additional safety margin; however, although an EMAS would have reduced the energy of the accident airplane as it departed the runway, it would not have prevented the accident because the circumstances of the runway departure exceeded the design capabilities of the EMAS.

62 Aircraft Accident Report 3. Conclusions 3.1 Findings 1. The captain held the certificates required to act as pilot-in-command of CL-600 flights under 14 Code of Federal Regulations (CFR) Part 91, but he had not yet received the training needed to operate 14 CFR Part 135 flights for Darby Aviation. 2. Information obtained from previous employers and postaccident interviews and the National Transportation Safety Board’s review of Federal Aviation Adminstration records, the captain’s resumes, and other documentation called into question the validity of the captain’s reported experience (his flight times and previous training) as a pilot. 3. The first officer had received only 22 of the 31 hours of ground training required by Darby Aviation’s operations specifications to perform second-in-command duties on a CL-600 being operated under 14 Code of Federal Regulations Part 135. Additionally, his Federal Aviation Administration medical certificate had expired for the purposes of commercial operations. Therefore, he was not properly trained or certificated for the accident flight. 4. There was no evidence that fatigue affected the pilots’ performance on the morning of the accident. 5. The accident airplane was properly certificated and was maintained in accordance with industry practices. There was no evidence of any preexisting powerplant, system (including brakes, ground spoilers, and engine thrust reversers), or structural failures. 6. Weather was not a factor in the accident. The aircraft rescue and firefighting (ARFF) response from Teterboro Airport, Teterboro, New Jersey, and surrounding communities was prompt, and exterior postaccident fires were extinguished efficiently. The air traffic controllers’ prompt and efficient reaction to this accident was exemplary and facilitated the prompt ARFF response. 7. Doorframe and/or fuselage distortion caused by impact with the building accounted for the passengers’ difficulty opening the main cabin door. 8. Platinum Jet Management pilots routinely improperly modified the airplane’s weight and balance forms, using a variety of invalid airplane empty weights to ensure that the form indicated that the airplane was operating within its limitations. 9. The airplane, as loaded for the accident flight, had a forward center of gravity that was significantly forward of the airplane’s forward limit, which severely degraded the airplane’s ability to rotate.

Conclusions 63 Aircraft Accident Report

1. Neither pilot used the available weight and balance information appropriately to

determine the airplane’s weight and balance characteristics for the accident flight and the pitch trim setting selected by the pilots is further evidence that they did not consider the airplane’s center of gravity during preflight preparations.

1. The captain’s decision to initiate the rejected takeoff (RTO) was reasonable, even

though the airplane had already reached a higher-than-normal RTO speed.

1. Considering the advantages the simulator pilots had and their lack of success during

the simulator runs, most line pilots attempting to abort a takeoff 5 seconds after and at a speed well above the expected rotation speed, like the accident captain, would not have been able to stop the accident airplane in time to avoid departing the end of the runway.

1. The pilots’ failure to ensure that the airplane’s weight and center of gravity were

within approved takeoff limits was symptomatic of poor airmanship and a broader pattern of deficiencies in their crew resource management skills (specifically in the areas of leadership, workload management, communications/briefings, and crew coordination) that were exhibited on the day of the accident.

1. Darby Aviation failed to maintain operational control over on-demand charter flights

conducted by Platinum Jet Management under Darby’s 14 Code of Federal Regulations Part 135 certificate, as required by Federal regulations.

1. Because neither Darby Aviation nor Platinum Jet Management (PJM) was rigorous

about enforcing the Federal requirement for operational control, PJM pilots operated in an environment in which pilot errors and/or omissions during preflight preparation were less likely to be detected before departure.

1. The Federal Aviation Administration’s inadequate oversight of the 14 Code of

Federal Regulations Part 135 charter management agreement between Platinum Jet Management (PJM) and Darby Aviation permitted management failures and a lack of operational control to exist. In effect, this allowed PJM to operate virtually independently as an on-demand air carrier while maintaining little of the structure of a certificated carrier and without demonstrating fitness to conduct such operations.

1. Darby Aviation’s Birmingham, Alabama, Flight Standards District Office

(FSDO)-based principal inspectors should have requested assistance from a FSDO more conveniently located to Platinum Jet Management’s (PJM) Fort Lauderdale-based operations to ensure proper oversight of the operations conducted by PJM under the auspices of Darby’s certificate.

1. The Federal Aviation Administration (FAA) failed to perform adequate charter

operator surveillance and therefore did not recognize that Platinum Jet Management (PJM) operated as a de facto 14 Code of Federal Regulations Part 135 carrier, despite the lack of necessary personnel; policies; procedures; and FAA approvals, certification, and oversight that would normally be associated with such operations.

Conclusions 64 Aircraft Accident Report

1. Without clear and specific guidance on agreements between certificate holders and

other entities that provide airplanes and/or flight crews for charter flights, unauthorized entities could still be performing most, if not all, of the functions of an on-demand charter operator without the controls, oversight, and demonstration of fitness imposed by a 14 Code of Federal Regulations Part 135 certificate.

1. The cabin aide did not perform a seatbelt compliance check before the accident flight,

which resulted in two passengers being unrestrained during the accident sequence.

1. The intentional positioning of the seatbelts out of the passengers’ sight made them

difficult to locate and use and resulted in reduced compliance with passenger seatbelt usage requirements.

1. The cabin aide’s training did not adequately prepare her to perform the duties with

which she was tasked, including opening the main cabin door during emergencies.

1. The installation of an engineered materials arresting system (EMAS) at the departure

end of runway 6 at Teterboro Airport (and other similarly affected runways) would provide an additional safety margin; however, although an EMAS would have reduced the energy of the accident airplane as it departed the runway, it would not have prevented the accident because the circumstances of the runway departure exceeded the design capabilities of the EMAS. 3.2 Probable Cause The National Transportation Safety Board determines that the probable cause of the accident was the pilots’ failure to ensure the airplane was loaded within weight-and-balance limits and their attempt to take off with the center of gravity well forward of the forward takeoff limit, which prevented the airplane from rotating at the intended rotation speed. Contributing to the accident were: 1) Platinum Jet Management’s (PJM) conduct of charter flights (using PJM pilots and airplanes) without proper Federal Aviation Administration (FAA) certification and its failure to ensure that all for-hire flights were conducted in accordance with 14 Code of Federal Regulations (CFR) Part 135 requirements; 2) Darby Aviation’s failure to maintain operational control over 14 CFR Part 135 flights being conducted under its certificate by PJM, which resulted in an environment conducive to the development of systemic patterns of flight crew performance deficiencies like those observed in this accident; 3) the failure of the Birmingham, Alabama, FAA Flight Standards District Office to provide adequate surveillance and oversight of operations conducted under Darby’s Part 135 certificate; and 4) the FAA’s tacit approval of arrangements such as that between Darby and PJM.

65 Aircraft Accident Report 4. Recommendations As a result of the investigation of this accident, the National Transportation Safety Board makes the following recommendations to the Federal Aviation Administration: Disseminate to all principal inspectors of 14 Code of Federal Regulations Part 135 certificate holders and to all Part 135 certificate holders guidance that includes specific procedures, such as those contained in the draft revisions to Operations Specifications A-008, that detail appropriate methods by which a certificate holder can demonstrate to the Federal Aviation Administration that it is maintaining adequate operational control over all on-demand charter flights conducted under the authority of its certificate. This guidance should address operations based at locations geographically distant from the certificate holder’s base, should be included in all Part 135 certificate holders’ operations specifications, and should be required as periodic inspection items for principal inspectors. (A-06-66) Review all charter management, lease, and other agreements between 14 Code of Federal Regulations Part 135 certificate holders and other entities to identify those agreements that permit and/or enable a loss of operational control by the certificate holder and require revisions of any such arrangements. (A-06-67) Require all 14 Code of Federal Regulations Part 135 certificate holders to ensure that seatbelts at all seat positions are visible and accessible to passengers before each flight. (A-06-68) Require that any cabin personnel on board 14 Code of Federal Regulations Part 135 flights who could be perceived by passengers as equivalent to a qualified flight attendant receive basic Federal Aviation Administraton-approved safety training in at least the following areas: preflight briefing and safety checks; emergency exit operation; and emergency equipment usage. This training should be documented and recorded by the Part 135 certificate holder. (A-06-69) BY THE NATIONAL TRANSPORTATION SAFETY BOARD MARK V. ROSENKER Chairman ROBERT L. SUMWALT Vice Chairman DEBORAH A. P. HERSMAN Member KATHRYN O. HIGGINS Member Adopted: October 31, 2006

66 Aircraft Accident Report Board Member Statements Member Kathryn O. Higgins’ Statement I joined my colleagues in adopting the report for the Platinum Jet accident that occurred at the Teterboro airport on February 2, 2005. While I fully support the findings, probable cause and recommendations embodied in that report, I am concerned that one aspect of this accident was not fully investigated by the Board. My concern goes to the role played by Blue Star Jets in contracting with Platinum for the accident flight. Blue Star is a large broker of charter flights. In their advertising they claim to be the largest broker in the world with an ability to arrange a flight on one of 4,000 planes to one of 5,000 airports in four hours. On their web site they offer “full service, safety, security, luxury, convenience at the best prices possible, with as little as four hours notice, access anywhere in the world….” Blue Star is just one of hundreds, perhaps thousands, of companies serving as brokers for corporate and personal jet travel. These companies are the “face” of on-demand air travel to the sector of the flying public that choose to fly by private jet. And yet, very little is known about these companies. They are essentially unregulated. As long as they don’t hold themselves out to be “airlines” they can sell flights on planes operated by companies that are regulated by the FAA under part 135. But how much do these brokers really know about the operators they do business with? How much do they know about the planes these operators fly? How old are they, when were they last inspected? How well trained are the crews, what experience does a particular crew have with the route the customer wants to fly? Have they flown into that airport before? Does this operator have a dispatch function or just flight following? What safety equipment is on the plane? Who will make the decision about de-icing? Does the operator have a safety management program? Are the crews trained in crew resource management? What does the FAA know about this operator? We saw the consequences of inexperience in the Montrose accident where the flight crew were not only unfamiliar with aircraft operations in significant winter weather conditions, but also were unfamiliar with the Montrose airport from which they departed. Significant total flight hours and significant time in the accident aircraft type did not overcome the inexperience with winter weather at an unfamiliar airport. A conscientious broker might ask the questions I have asked and might make that information available to its customers. But none of these questions are required. Customers don’t usually have direct contact with the operators. In many cases they are relying on the broker to act as their agent. They may not even know which operator they are flying.

Board Member Statements 67 Aircraft Accident Report But we have seen in both the Montrose and Teterboro accidents that the details matter. In the Montrose accident, the flight was sold by Key Air to Air Castle Corporation (doing business as Global Aviation as Glo-Air flight 73), apparently without the knowledge of the customer. In the report on the Montrose accident, the Board made a recommendation to the Department of Transportation/Office of the Secretary to require more disclosure to the public about the owners of charter aircraft and the operators of charter flights, including the name of any brokers involved in arranging a flight. The Department has replied that it will put those recommendations out for comment. In the Teterboro accident Blue Star contracted with Platinum, a carrier that did not hold a Part 135 certificate and that operated with a host of irregularities documented in the Board’s report. Blue Star is selling safety but they didn’t look behind the claims made by Platinum, nor were they required to. I believe it’s time to take a closer look at brokers in the aviation business, including those who provide air ambulance service. Concerns with broker practices in the emergency medical services industry have also been brought to my attention. The advent of very light jets that will be used in many cases for on-demand charters is just one more reason to study the role of brokers in contracting for flights. I am pleased that the Board agreed to my request to study this issue. The staff has been asked to come back to the Board with a proposal on how to conduct such a study. I look forward to working with the staff, my colleagues and others in the aviation community interested in this important issue. Vice Chairman Sumwalt and Member Hersman joined Member Higgins in this concurring statement. Kathryn O'Leary Higgins November 7, 2006

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69 Aircraft Accident Report 5. Appendixes Appendix A Investigation and Public Hearing Investigation The National Transportation Safety Board learned of this accident on the morning of February 2, 2005. A full go-team traveled to the accident scene. The go-team was accompanied by representatives from the Safety Board’s Office of Transportation Disaster Assistance and Public Affairs. Board Member Deborah A.P. Hersman traveled to the accident site. The following investigative groups were formed during the course of this investigation: Structures, Systems, Powerplants, Air Traffic Control, Meteorology, Operations, Human Performance, Airport/Survival Factors, Airplane Performance, Flight Data Recorder, Cockpit Voice Recorder, Maintenance Records, and Video. In accordance with Annex 13 to the Convention on International Civil Aviation, an accredited representative from the Transportation Safety Board of Canada and advisors from Transport Canada and Bombardier Aerospace participated in this investigation. Parties to the investigation were the Federal Aviation Administration, Platinum Jet Management (PJM), and Honeywell. Darby Aviation also participated in the investigation. Observer parties to the investigation were the Port Authority of New York and New Jersey and the Transportation Security Administration. The Safety Board received a submission on this accident from PJM. Public Hearing No public hearing was held for this accident.

70 Aircraft Accident Report Appendix B Cockpit Voice Recorder Transcript The following is a transcript of the L-3 Communications/Fairchild model A-100 cockpit voice recorder (CVR) installed on the accident airplane. Only radio transmissions to and from the accident airplane were transcribed. The CVR transcript reflects the 29 minutes 31 seconds before power was lost to the CVR. All times are eastern standard time based on a 24-hour clock.

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101 Aircraft Accident Report Appendix C Weight and Balance Information During the on-scene portion of the investigation, all of the loose and recognizable items from the airplane were documented and weighed. Due to the extensive fire and the firefighting efforts, most of the items from the cockpit and main cabin were charred and/or soaked with water. The items from the aft baggage compartment were not wet or charred. The following table lists the items weighed, their location when found, and the weight. All items were weighed as recovered without drying. The seat numbers correspond to the interior layout in Gulfstream’s “Weight and Balance Final Report,” which follows. Description Location Weight (lbs) Captain’s bag Aft baggage compartment 20 First officer’s bag Aft baggage compartment 46 Cabin aide’s bag Aft baggage compartment 26 Shoe bag Aft baggage compartment 6 Briefcase Aft baggage compartment 16 Cosmetic bag Aft baggage compartment 7 Starbucks drinks Aft baggage compartment 3 Engine oil Aft baggage compartment 17 Sweeper Aft baggage compartment 1 Floor mat Aft baggage compartment 1 Flight manuals On left wing1 30 Jacket On left wing1 7 Briefcase On left wing1 19 Miscellaneous clothes and equipment Outside cabin door 36.7 Airplane manuals Outside cabin door 16.7 Airplane manuals Beneath cockpit 36.7 Jacket, soda Seat 5 6.5 Briefcase, personal effects Seat 4 14.9 Briefcase, personal effects Seat 1 12.5 Briefcase, personal effects Seat 2 26.8 Briefcase, personal effects Seat 5 25.3

Appendix C 102 Aircraft Accident Report Briefcase, personal effects Seat 5 17.4 Food, serving ware Galley 239.8 Purse, personal effects Cockpit, floor between seats 13.5 Jacket, smoke goggles L/H forward closet 4.4 Linens Aft of first officer’s seat 5.4 Airway manuals, dispatch paperwork Right of first officer’s seat 22.5 Airway manual Left of captain’s seat 4.3 Notes: 1. Removed from the cockpit by the FAA immediately following accident. Description Location Weight (lbs)

Appendix C 103 Aircraft Accident Report In 2001, when the airplane underwent refurbishment at Gulfstream Aerospace, Gulfstream prepared two weight and balance reports for the airplane, one for two crewmembers and one for three crewmembers. The three crewmember weight and balance information is provided.

Appendix C 104 Aircraft Accident Report

Appendix C 105 Aircraft Accident Report

Appendix C 106 Aircraft Accident Report

Appendix C 107 Aircraft Accident Report

Appendix C 108 Aircraft Accident Report

Appendix C 109 Aircraft Accident Report

Appendix C 110 Aircraft Accident Report

Appendix C 111 Aircraft Accident Report

Appendix C 112 Aircraft Accident Report

FD07317 ｜ 2006_美国_HAR0601.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2006 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

Collision Between a Ford Dump Truck and Four Passenger Cars Glen Rock, Pennsylvania April 11, 2003 Highway Accident Report NTSB/HAR-06/01 PB2006-916201 Notation 7743A National Transportation Safety Board Washington, D.C.

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Highway Accident Report Collision Between a Ford Dump Truck and Four Passenger Cars Glen Rock, Pennsylvania April 11, 2003 NTSB/HAR-06/01 PB2006-916201 National Transportation Safety Board Notation 7743A 490 L’Enfant Plaza, S.W. Adopted February 7, 2006 Washington, D.C. 20594

National Transportation Safety Board. 2006. Collision Between a Ford Dump Truck and Four Passenger Cars, Glen Rock, Pennsylvania, April 11, 2003. Highway Accident Report NTSB/HAR-06/01. Washington, DC. Abstract: About 3:36 p.m. on April 11, 2003, in the Borough of Glen Rock, Pennsylvania, a 1995 Ford dump truck owned and operated by Blossom Valley Farms, Inc., was traveling southbound on Church Street, a two-lane, two-way residential street with a steep downgrade, when the driver found that he was unable to stop the truck. The truck struck four passenger cars, which were stopped at the intersection of Church and Main Streets, and pushed them into the intersection. One of the vehicles struck three pedestrians (a 9-year-old boy, a 7-year-old boy, and a 7-year-old girl), who were on the sidewalk on the west side of Church Street. The truck continued across the intersection, through a gas station parking lot, and over a set of railroad tracks before coming to rest about 300 feet south of the intersection. As a result of the collision, the driver and an 11-year-old occupant of one of the passenger cars received fatal injuries, and the three pedestrians who were struck received minor-to-serious injuries. The six remaining passenger car occupants and the truck driver were not injured. Major safety issues identified in this report include maintaining air brakes equipped with automatic slack adjusters, the knowledge and skills needed to drive air brake-equipped vehicles, and motor carrier oversight. As a result of its investigation of this accident, the Safety Board makes safety recommendations to the Federal Motor Carrier Safety Administration, the 50 States and the District of Columbia, the Commercial Vehicle Safety Alliance, manufacturers and marketers of automatic slack adjusters, manufacturers of vehicles equipped with air brakes, the National Institute for Automotive Service Excellence (ASE), and publishers of ASE certification test study guides. The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Web at http://www.ntsb.gov. Other information about available publications also may be obtained from the Web site or by contacting: National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (800) 877-6799 or (202) 314-6551 Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2006-916201 from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605-6000

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

iii Highway Accident Report Contents Acronyms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 The Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Synopsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Driver Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Truck Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Highway Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Motor Carrier Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Accident Truck Maintenance History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Motor Carrier Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Inspection Selection System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Toxicological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Commercial Driver’s License . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Canadian Air Brake Endorsement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Brake Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Automatic Slack Adjusters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Brake Information in State Driver’s Manuals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Submission to the AAMVA for the Model Commercial Driver License Manual . . . 26 Commercial Vehicle Inspection Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Inspector and Mechanic Certification Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 American Trucking Associations Technology and Maintenance Council . . . . . . . . . . 29 Owner-Operator Independent Driver Association Survey . . . . . . . . . . . . . . . . . . . . . . . 29 Operation Air Brake . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Commercial Vehicle Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 El Cerrito, California, Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Other Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Accident Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Air Brakes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Maintaining Air Brakes Equipped with Automatic Slack Adjusters . . . . . . . . . . . . . . 40 Knowledge and Skills Needed to Drive Air Brake-Equipped Vehicles . . . . . . . . . . . . 47

Contents iv Highway Accident Report Motor Carrier Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Blossom Valley . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Educating Motor Carriers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 FMCSA Carrier Safety Rating Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Appendixes A: Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 B: Results of Safety Board Computer Simulations of Accident Events . . . . . . . . 60 C: CVSA Pamphlet Air Brake Adjustment—Why is it so important? . . . . . . . . . . 61 D: Previous Safety Board Recommendations on Brake Adjustment      and Inspection Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

v Highway Accident Report Acronyms and Abbreviations AAMVA American Association of Motor Vehicle Administrators ABS antilock brake system ADT average daily traffic ASA automatic slack adjuster ASE National Institute for Automotive Service Excellence ATA American Trucking Associations, Inc. Blossom Valley Blossom Valley Farms, Inc. CCMTA Canadian Council of Motor Transport Administrators CDL commercial driver’s license CFR Code of Federal Regulations CVSA Commercial Vehicle Safety Alliance EDSMAC4 Engineering Dynamics Simulation Model of Automobile Collisions, 4th revision FHWA Federal Highway Administration FMCSA Federal Motor Carrier Safety Administration FMCSRs Federal Motor Carrier Safety Regulations GVWR gross vehicle weight rating HVE Human, Vehicle, Environment ISS-2 Inspection Selection System MCMIS Federal Motor Carrier Management Information System NHTSA National Highway Traffic Safety Administration NPRM notice of proposed rulemaking OOIDA Owner-Operator Independent Drivers Association PennDOT Pennsylvania Department of Transportation psi pounds per square inch SafeStat Safety Status Measurement System SIMON Simulation Model Non-linear SRPD Southern Regional Police Department THC tetrahydrocannabinol UMTRI University of Michigan Transportation Research Institute USDOT U.S. Department of Transportation

vi Highway Accident Report Executive Summary About 3:36 p.m., eastern daylight time, on April 11, 2003, in the Borough of Glen Rock, Pennsylvania, a 1995 Ford dump truck owned and operated by Blossom Valley Farms, Inc., was traveling southbound on Church Street, a two-lane, two-way residential street with a steep downgrade, when the driver found that he was unable to stop the truck. The truck struck four passenger cars, which were stopped at the intersection of Church and Main Streets, and pushed them into the intersection. One of the vehicles struck three pedestrians (a 9-year-old boy, a 7-year-old boy, and a 7-year-old girl), who were on the sidewalk on the west side of Church Street. The truck continued across the intersection, through a gas station parking lot, and over a set of railroad tracks before coming to rest about 300 feet south of the intersection. As a result of the collision, the driver and an 11- year-old occupant of one of the passenger cars received fatal injuries, and the three pedestrians who were struck received minor-to-serious injuries. The six remaining passenger car occupants and the truck driver were not injured. The National Transportation Safety Board determines that the probable cause of this accident was the lack of oversight by Blossom Valley Farms, Inc., which resulted in an untrained driver improperly operating an overloaded, air brake-equipped vehicle with inadequately maintained brakes. Contributing to the accident was the misdiagnosis of the truck’s underlying brake problems by mechanics involved with the truck’s maintenance; also contributing was a lack of readily available and accurate information about automatic slack adjusters and inadequate warnings about the safety problems caused by manually adjusting them. During the investigation, the Safety Board identified the following major safety issues: • Maintaining air brakes equipped with automatic slack adjusters, • Knowledge and skills needed to drive air brake-equipped vehicles, and • Motor carrier oversight. As a result of this accident investigation, the Safety Board makes recommendations to the Federal Motor Carrier Safety Administration, the 50 States and the District of Columbia, the Commercial Vehicle Safety Alliance, manufacturers and marketers of automatic slack adjusters, manufacturers of vehicles equipped with air brakes, the National Institute for Automotive Service Excellence (ASE), and publishers of ASE certification test study guides.

1 Highway Accident Report Factual Information The Accident Synopsis About 3:36 p.m., eastern daylight time, on April 11, 2003, in the Borough of Glen Rock, Pennsylvania, a 1995 Ford dump truck owned and operated by Blossom Valley Farms, Inc., (see figure 1) was traveling southbound on Church Street, a two-lane, two- way residential street with a steep downgrade, when the driver found that he was unable to stop the truck. The truck struck four passenger cars, which were stopped at the intersection of Church and Main Streets, and pushed them into the intersection. One of the vehicles struck three pedestrians (a 9-year-old boy, a 7-year-old boy, and a 7-year-old girl), who were on the sidewalk on the west side of Church Street. The truck continued across the intersection, through a gas station parking lot, and over a set of railroad tracks before coming to rest about 300 feet south of the intersection. As a result of the collision, the driver and an 11-year-old occupant of one of the passenger cars received fatal injuries, and the three pedestrians who were struck received minor-to-serious injuries. The six remaining passenger car occupants and the truck driver were not injured. Figure 1. Accident truck. (Source: Southern Regional Police Department) Narrative The 21-year-old accident truck driver worked for Blossom Valley Farms, Inc., (Blossom Valley) an agricultural nursery, making deliveries of landscaping materials, including mulch, dirt, and stone. He had been working for Blossom Valley for 10 days

Factual Information 2 Highway Accident Report when the accident occurred. According to the accident driver,1 on the day of the accident, he started work about 8:00 a.m., and his first delivery in the 1995 Ford dump truck consisted of 8 yards of mulch to an address in Parkton, Maryland. (See figure 2.) He also made his second and third deliveries, of 4 yards of mulch and 2 yards of Red Mountain Stone, respectively, to Parkton. On the way back from the third delivery, he stopped at a fast food restaurant in Shrewsbury, Pennsylvania, where he picked up food and then returned to Blossom Valley. He ate lunch in the truck while topsoil was loaded into the truck.2 The fourth delivery of the day was a load of 14 yards of unscreened topsoil, which was being delivered a day late. The driver indicated that he knew it should take three trips to complete the topsoil delivery because the truck’s capacity was limited to 5 scoops of wet topsoil3 (it was raining at the time). The employee who loaded the truck told the driver he had loaded 7 scoops4 and that the driver should go on with the delivery. Figure 2. Map of the general region of the accident site. 0 0 10 km 10 mile Shrewsbury Parkton Washington, D.C. Baltimore Philadelphia PENNSYLVANIA NEW JERSEY DELAWARE MARYLAND VIRGINIA Glen Rock York 95 95 83 1  Southern Regional Police Department (SRPD) officers interviewed the accident driver on the day of the accident. A Safety Board investigator interviewed the accident driver on April 17, 2003. 2  The truck was loaded using a front-end loader that had a bucket or scoop that held about 1 yard of material by volume. Blossom Valley charged its customers by the yard; the company loaded by the scoop; and the weight of the scoop varied depending on the material. 3  A few days before the Glen Rock accident, the driver had a minor accident. At the time, the truck had been loaded with 7 scoops of unscreened topsoil. The driver said that when he told the owner about the minor accident, the owner told him that the truck should never be loaded with more than 5 scoops of topsoil. 4  The postaccident weight of the 7 scoops was about 11,060 pounds (5.53 tons), or about 1,580 pounds (0.79 ton) per scoop. Five scoops would have weighed about 7,900 pounds (3.95 tons).

Factual Information 3 Highway Accident Report The driver indicated that he followed the directions printed on the delivery invoice given to him by his employer. He traveled north on the Susquehanna Trail and turned left on Church Street toward Glen Rock. He said he saw the “3/4 ton limit, Except Local Deliveries” signs at the beginning of Church Street but continued anyway because the directions given him by Blossom Valley told him to use that street and he thought he was making a local delivery. (See figures 3 and 4.) He said that he was traveling 25 to 35 mph on Church Street and stopped at the top of the hill near a water tower and electrical substation. (A witness following the truck indicated in a police interview that the accident truck did not stop.) Figure 3. Map of the accident area, showing the Borough of Glen Rock (shaded area), the location of Blossom Valley Farms, and the intended delivery destination. The large arrows show the direction of the accident truck’s travel. 83 616 216 216 216 Center Street Church Street Main Street 0 0 1 km 1 mile Blossom Valley Farms High Street Susquehanna Trail Delivery destination

Figure 4. Weight prohibition signs at the beginning of Church Street. (Source: Pennsylvania Department of Transportation) Factual Information 4 Highway Accident Report The accident driver stated that as he started down the hill (see figure 5), he did not select a lower gear. He said that at some point during the descent, he pumped his brakes and the truck began to speed up. He also stated that about a quarter of the way down the hill, he lost his brakes and the brake warning light in the truck began to flash. He said he knew then that he had brake problems because his boss and a coworker had told him that if the brake light flashed, he did not have enough pressure [air pressure].5 He said he could not stop the truck, and he saw children and cars at the bottom of the hill. He indicated that he leaned out the window and yelled, “No brakes, get out of the way” as the truck neared Center Street (about 3 blocks from the accident site). He said he struck the back of a black car and thought he “went airborne.” He said that he did not sound the horn and that he was not wearing a seat belt. He stated that his recollection of the events after the initial impact was “vague.” 5  The truck was equipped with air brakes, which convert compressed air into a linear force that acts upon a number of components to apply the brake shoes against the brake drum, creating friction, which stops the vehicle.

Figure 5. Descending grade on southbound Church Street. (Source: Pennsylvania Department of Transportation) Factual Information 5 Highway Accident Report Witnesses reported that just before the accident, a school bus had unloaded students on Main Street. After exiting the bus, the students crossed Church Street and, as the bus began to leave, they walked up the sidewalk on the west side of Church Street. Witnesses also reported that four passenger cars were stopped at the “STOP” sign for southbound traffic on Church Street, where it intersects with Main Street. The first car in the queue was a 1997 Pontiac Grand Prix, occupied by a driver and three passengers; the second was a 1996 Mazda Protégé, occupied by a driver; the third was a 1987 Chevrolet Nova, occupied by a driver and a front seat passenger; and the fourth was a 1993 Chevrolet Camaro, occupied by a driver. About 107 feet north of the intersection, the accident truck struck the rear of the Camaro, causing it to rotate clockwise and pushing it into the Nova. The Nova rotated counterclockwise; the rear of the vehicle climbed the 6-inch-high curb and struck three children on the sidewalk and a metal post on a fence on the west side of the sidewalk. The Nova continued to rotate counterclockwise and struck the Mazda, pushing it forward into the rear of the Pontiac. The truck pushed the passenger cars into the intersection. The Camaro came to rest near the northwest corner of the intersection of Church and Main Streets, facing south. The Nova came to rest with its front wheels on the southern sidewalk in front of the gas station, facing south. The Mazda and Pontiac came to rest in the parking area of the gas station, west of the Nova by about 25 feet and facing southeast. The accident truck proceeded across Main Street, through the western portion of the gas station parking lot, onto Water Street, across the railroad tracks, and then west

Factual Information 6 Highway Accident Report into an alley, coming to rest about 130 feet west of the intersection of the alley and Water Street. The truck traveled about 407 feet from its initial point of impact with the Camaro to its point of rest. (See figures 6 and 7.) Figure 6. Intersection of Church Street and Main Street looking southbound on Church Street. (Source: Southern Regional Police Department) Figure 7. At-rest positions of the vehicles at the accident scene. Parking Lot Gas Station CHURCH ST MAIN ST Camaro Nova Mazda Pontiac Truck N

Factual Information 7 Highway Accident Report Emergency Response SRPD, Glen Rock Fire and Ambulance, and Loganville Fire Company responders were dispatched at 3:36 p.m. Glen Rock Ambulance responders were on scene within a minute, Glen Rock Fire Department personnel were on scene by 3:39 p.m., and SRPD officers arrived on scene about 3:44 p.m. In addition, the Shrewsbury and New Freedom, Pennsylvania, fire companies responded to the accident. Glen Rock, Rose Fire Company, and Jacobus ambulance services transported patients to Penn State Hershey Medical Center and York Hospital. Injuries The following table is based on the International Civil Aviation Organization’s injury criteria, which the Safety Board uses in accident reports for all transportation modes. Table 1. Injuries. Driver Information The 21-year-old truck driver lived in White Hall, Maryland, and had been working for Blossom Valley as a truck driver since April 1, 2003. He possessed a Maryland Class “C” noncommercial driver’s license. This license permitted the driver to operate an automobile, station wagon, light truck, or any motor vehicle, except a motorcycle, with a gross vehicle weight of 26,000 pounds or less.6 A commercial driver’s license (CDL) is required to drive a single vehicle weighing 26,001 pounds or more.7 Injury typeA Drivers Passengers Pedestrians Total Fatal 1 1 0 2 Serious 0 0 1 1 Minor 0 0 2 2 None 4 2 0 6 Total 5 3 3 11 ATitle 49 Code of Federal Regulations (CFR) 830.2 defines fatal injury as “any injury which results in death within 30 days of the accident” and serious injury as “any injury which: (1) requires hospitalization for more than 48 hours, commencing within 7 days from the date the injury was received; (2) results in a fracture of any bone (except simple fractures of fingers, toes, or nose); (3) causes severe hemorrhages, nerve, muscle, or tendon damage; (4) involves any internal organ; or (5) involves second- or third- degree burns, or any burns affecting more than 5 percent of the body surface.” 6 Maryland Department of Transportation, Motor Vehicle Administration, Maryland Driver’s Handbook (Glen Burnie, MD: Maryland Department of Transportation, September 1993). 7 Title 49 CFR 383.23 and 383.91.

Factual Information 8 Highway Accident Report On the day of the accident, the driver was operating a commercial truck with a gross vehicle weight rating (GVWR)8 of 26,000 pounds that was equipped with an air brake system, which does not operate in the same way that hydraulic brake systems for automobiles do. (This report will discuss operation of air brake systems in a subsequent section.) According to the accident driver, he had no experience driving an air-braked truck before Blossom Valley hired him, and the largest vehicle he had previously driven was a pickup truck. According to the driver and his employer, he received no air brake training. He said that he had been shown how to operate the lift on the accident truck. At the time of the accident, he had been driving the accident truck for less than a week. Postaccident, he told investigators that he did not know that pumping an air brake- equipped truck’s brakes depleted the brakes’ air pressure. Three days before the accident, on April 8, 2003, the driver had a minor accident in the same truck, which he stated was due to loss of braking. (The driver’s truck rolled into the back of a stopped passenger car. Neither vehicle suffered substantial damage.) Truck Information The accident truck was a 1995 Ford Motor Company, F-800 Series, 2-axle truck with a dump body. It was equipped with a Ford FD-1060 6-cylinder diesel engine that produced 175 horsepower at 2,500 rpm, an Allison model AT-545 4-speed automatic transmission, air brakes, and a hydraulic dump bed. It did not have an antilock brake system (ABS). The truck had an odometer reading of 145,095 miles. According to the manufacturer, the truck’s GVWR was 26,000 pounds. The SRPD weighed the truck during the postaccident investigation and found the total weight to be 26,600 pounds. In July 2003, the Pennsylvania Department of Transportation (PennDOT) weighed the truck on portable scales with the load removed, and the empty weight was 15,540 pounds. The wheelbase was 207 inches, and the overall truck length was 25 feet, 5.5 inches. The truck was equipped on the front and rear axles with standard S-cam drum foundation air brakes9 with automatic slack adjusters (ASAs). A Bendix model 2150 single-cylinder, gear-driven compressor supplied air to the system. The air governor was a Bendix model D-2, permanently set at 110 pounds per square inch (psi). As part of the Safety Board’s normal protocol, investigators tested the brakes postaccident. The diesel engine was operable, and all air testing was done with air supplied by the engine-mounted Bendix compressor, using the vehicle foot valve (brake pedal) for brake testing. The diesel engine was started and full brake applications were made at about 90 psi of air pressure. No air leaks were discovered in the air brake system. 8  The GVWR is the value (based on axle ratings) specified by the manufacturer as the loaded weight of a single vehicle. 9  For the purposes of this report, the term “foundation brake system” (for cam-actuated brakes) means all mechanical components involved in providing braking force, including the brake chambers, S-cam and camshaft, brake drums, brake linings, slack adjusters, and all associated hardware, including washers, clevises, clevis pins, cotter pins, bushings, springs, and rollers.

Factual Information 9 Highway Accident Report The brake testing results, summarized in table 2, indicated that the pushrod stroke for both rear brakes exceeded the adjustment limit by 1/2 inch, resulting in little or no brake force for the rear wheels. Table 2. Accident truck brake test results summary. The truck was equipped with Gunite10 ASAs on all four brakes. After the accident, Safety Board investigators removed the automatic adjusters from the rear brakes, along with the quick-connect clevises and clevis pins,11 and took them to the Gunite facility for testing. The quick-connect clevises had wear in the clevis holes, where they attached to the slack adjusters, and some flexing was observed where the two parts met. The combination of wear in the clevis pin holes and flexing of the joints rendered the automatic feature of the ASAs inoperative. When tested with the clevises and clevis pins from the accident truck, the pushrod stroke would not go below 2 1/2 inches, at which point it produced little or no brake force. When the two rear adjusters were tested at the Gunite facility with new clevises and clevis pins, the adjusters worked correctly and kept the adjustment well under 2 inches. All four brake drums were removed, examined, photographed, and measured. The front axle had 15-inch drums and the rear axle had 16.5-inch drums. Heat cracks were present in all the drums, and some discoloration (bluing) was found on the front drums, which were smooth. The drum diameters were measured with a calibrated Central Tool digital brake drum gauge, and all were within manufacturer’s tolerances. The brake shoe widths were 4 inches for the front wheels and 7 inches for the rear wheels. The brake shoes had no observable cracks and exhibited no anomalies. All the shoes were measured and found to be within CVSA-established12 tolerances.13 Axle Air chamber size Slack arm lengthA Pushrod stroke Adjustment limitB Rated strokeC Left front T-16 5 1/2 in. 1 1/2 in. 1 3/4 in. 2 1/4 in. Right front T-16 5 1/2 in. 1 1/2 in. 1 3/4 in. 2 1/4 in. Left rear T-30 5 1/2 in. 2 1/2 in. 2 in. 2 1/2 in. Right rear T-30 5 1/2 in. 2 1/2 in. 2 in. 2 1/2 in. AThe distance from the center of the splined camshaft to the center of the clevis pin, which secures the pushrod to the slack adjuster; also known as the “lever arm length.” B The maximum pushrod stroke permitted. The values utilized for the “brake adjustment limit” are those stated in the Commercial Vehicle Safety Alliance (CVSA) North American Standard Out-of-Service Criteria. (Revised edition, April 2003.) CThe total length the pushrod can travel inside the air chamber. (When the “pushrod stroke” is equivalent to the “rated stroke,” generally no braking forces are obtained when the brakes are applied.) 10 Gunite Corporation of Rockford, Illinois, is a major manufacturer of wheel-end assemblies and components for the heavy-duty truck industry. 11 The clevis and clevis pins connect the slack adjuster to the pushrod and are considered part of the foundation brake system. A quick-connect clevis is a two-part clevis that can wear and flex. 12 The CVSA is a nonprofit organization dedicated to improving commercial vehicle safety that comprises Federal, State, and Provincial government agencies and representatives from private industry in the United States, Canada, and Mexico. The CVSA establishes and maintains commercial vehicle safety operational standards and practices, inspection procedures, out-of-service criteria, and enforcement practices and penalties that provide for uniformity, compatibility, and reciprocity among CVSA member jurisdictions and industry partners. 13 According to the CVSA North American Standard Out-of-Service Criteria, it is a violation for a lining to be 1/4 inch (8/32 inch) below the wear indicator. (Revised edition, April 2003.)

Factual Information 10 Highway Accident Report The truck was equipped with a dash-mounted red brake warning light, which illuminated when the air pressure went below 70 psi. An audible alarm accompanied this illumination. The spring brakes (parking brakes) were automatically fully applied on the rear axle when the system air reached about 40 psi. Investigators installed air gauges in all the air chambers, or in the service air line just outside the chamber, to check the amount of air going into the chamber during a service brake (foot pedal) application. When a forceful application was made at 90 psi, the chamber gauge pressure read about 75 psi on all four wheel positions (about 15 pounds less than the applied pressure). The parking brake test was conducted by pulling the parking brake valve that applied the spring brakes. The engine was started and the transmission was moved into “DRIVE” in an attempt to move the vehicle forward on a concrete floor. The truck moved forward with only a slight increase in engine rpm. The truck was then placed in “REVERSE” and, with minimal engine acceleration, it went backward, even with the parking brake applied. Highway Information Church Street (State Route 3008) is a two-lane, two-way rural road 2.7 miles long between the Susquehanna Trail (State Route 3001) to the north and Main Street (State Route 216) to the south. The Susquehanna Trail is a two-lane, north/south roadway, which parallels Interstate Highway 83 on the west between Harrisburg and the Pennsylvania/Maryland State Line. The topography of the surrounding area is rolling hills. As Church Street enters the Borough of Glen Rock, the downgrade becomes increasingly steep,14 from 3.4 percent near the top of the hill to 13 percent at the base of the hill (intersection with Main Street). According to PennDOT, the roadway width varies from 20 feet before entering the borough to 26 feet inside the borough. There is an 8-foot- wide parking lane on the west side of Church Street in the borough, next to housing, and the travel lanes are 9 feet wide. Solid, double, yellow lines separate the north/south lanes. Main Street is a two-lane, two-way, east/west roadway traversing the Borough of Glen Rock. Immediately to the east of the intersection between Main Street and Church Street, a painted pedestrian crosswalk traverses Main Street. A gas station is located on the south side of the T-intersection of Church Street and Main Street. The speed limit on Church Street traveling south from the Susquehanna Trail is 55 mph. The speed limit changes 1.2 miles south of the intersection to 40 mph and again 1.8 miles south of the intersection, as Church Street enters the Borough of Glen Rock, to 25 mph. The speed limit at the accident site (intersection of Church Street and Main Street) is 25 mph. 14  On June 10, 2003, Safety Board investigators measured the descending grade on Church Street using a surveyor’s transit at 32 points (every 50 feet) over a 3,300-foot distance to determine the grades on the roadway.

Factual Information 11 Highway Accident Report According to PennDOT, the average daily traffic (ADT) on Church Street in 1998 was 3,213, of which 8 percent was trucks and buses. In 2001, the ADT was 3,915, of which 9 percent was trucks and buses. PennDOT data indicated that from January 1999 to December 2002, 11 traffic accidents occurred on Church Street within the Borough of Glen Rock. Of the 11 accidents, 1 involved a fatality, 1 a major injury, 4 moderate injuries, and 5 minor injuries. Two of the 11 accidents involved trucks. According to PennDOT, in 1965, after a fatal accident involving a truck at or near the April 11, 2003, accident intersection, the Borough of Glen Rock requested and obtained a weight restriction of 1,500 pounds (load capacity) on Church Street, and the street was so posted. At the intersection of the Susquehanna Trail and Church Street are R5-2 signs conforming to the Manual on Uniform Traffic Control Devices indicating that Church Street is a weight-restricted street. The signs indicate that the load weights are limited to 3/4 ton (1,500 pounds), except for local deliveries. The weight restriction applies only in the Borough of Glen Rock. (Refer to figures 3 and 4.) For traffic traveling northbound on the Susquehanna Trail, an additional sign reads, “Trucks over 1 ton use [Pennsylvania State Route] 216 to Glen Rock.” (See figure 8.) Figure 8. Intersection of Susquehanna Trail and Church Street. Note the weight restriction sign directing trucks over 1 ton to use Pennsylvania State Route 216. (Source: Pennsylvania Department of Transportation)

Factual Information 12 Highway Accident Report Additional signs and updated signs have periodically been erected in an effort to keep vehicles with weights in excess of the restriction from using Church Street. The borough ordinance15 reads (in part) It shall be unlawful for any person to operate a motor vehicle, trailer, or semi- trailer, as defined in The Vehicle Code, having a load capacity in excess of fifteen hundred (1,500) pounds, on Church Street ….except Delivering goods or supplying services to any location on said street or accessible only by the use of said street; and (b) Moving any such vehicle to the residence of the owner of such vehicle or to the customary place of parking such vehicle at any location on said Street or accessible only by the use of said Street. PennDOT officials indicated that the restriction applies to vehicles “having a load capacity” in excess of 1,500 pounds; many of today’s vehicles, including many pickup trucks, have a load-carrying capacity in excess of 1,500 pounds. According to PennDOT and the SRPD, enforcement of the weight restriction on Church Street is sporadic and complicated due to the wording of the ordinance and a local magistrate’s interpretation of the ordinance to allow use of this street for local deliveries to addresses that are not on or intersecting the street. Motor Carrier Information General At the time of the accident, Blossom Valley was a private interstate carrier located in New Freedom, Pennsylvania.16 It was registered as a motor carrier with the U.S. Department of Transportation (USDOT). The carrier began operations in 1987; it transported building and construction materials, agricultural and farm supplies, and nursery stock. Blossom Valley trucks covered about 16,000 miles a year, including about 2,500 interstate miles. The majority of the interstate miles involved delivery of mulch, topsoil, stone, and nursery items. According to Blossom Valley’s owner, before the accident, he was unaware of many of the Federal regulations and requirements concerning motor carrier operations. The Blossom Valley fleet consisted of five trucks—two straight trucks,17 a 1994 Chevrolet dump truck, a 1995 Ford utility dump truck (the accident truck), and a 1990 International18 truck tractor with a 1997 Reit flatbed semitrailer. The tractor-semitrailer combination truck was the only vehicle in the fleet that required a driver with a CDL. It had a combined GVWR of 80,000 pounds and, like the accident truck, was air brake- equipped. The Chevrolet dump truck was equipped with hydraulic brakes. The carrier 15  Ordinance 150 of the Council of the Borough of Glen Rock, York County, Pennsylvania, August 4, 1965. 16  According to the York Daily Record, “News Section,” for Tuesday, May 31, 2005, the business was sold in May 2005, and the new nursery does not make deliveries. 17  A straight truck is a single-unit truck with two or more axles. 18  International Truck and Engine Corporation of Warrenville, Illinois.

Factual Information 13 Highway Accident Report employed two drivers, one with a CDL and one without (the accident driver). The driver with a CDL drove the two straight trucks and the tractor-semitrailer. According to statements made during Safety Board interviews with the accident driver, the motor carrier owner, and the other driver, Blossom Valley did not give the accident driver a road test. Title 49 CFR 391.31–33, “Road test,” specifies that “a person shall not drive a commercial motor vehicle unless he/she has first successfully completed a road test and has been issued a certificate of driver’s road test….” Title 49 CFR 390.5 defines a commercial motor vehicle as “any self-propelled motor vehicle… used on a highway in interstate commerce…[with] a gross vehicle weight rating of… 10,001 pounds or more….” The road test certificate or a copy of a valid CDL is to be retained in the driver’s qualification files. The accident driver operated within a 100-mile radius of the home terminal and returned to that location every night, so, according to 49 CFR 395.1(e), he was not required to keep a record of duty status. However, as a motor carrier, Blossom Valley was required to maintain driver time records. After the accident, Blossom Valley was unable to provide investigators with the required time records. The accident driver’s actual hours of service are unknown. On March 10, 2004, another Blossom Valley truck, driven by a different driver, was ticketed for traveling down Church Street, because the vehicle was in violation of the weight restriction. Accident Truck Maintenance History At the time of the accident, Blossom Valley did not have a regular, scheduled vehicle maintenance program in place as required by 49 CFR 396.3. Safety Board investigators obtained maintenance records from four facilities that serviced Blossom Valley’s vehicles: RG Group and Beasley Ford, both in York, Pennsylvania; Truck Specialties, Inc., in Shrewsbury, Pennsylvania; and C & T Transport in Parkton, Maryland. The service facilities did not have preventative maintenance agreements with Blossom Valley. Rather, they serviced the carrier’s vehicles when Blossom Valley brought them in for repairs. Truck Specialties completed Pennsylvania State inspections of the accident truck in 2001 and 2002. The facility had last serviced the truck in May 2002 for non-brake- related repairs. On April 10, 2002, about 1 year before the accident, the accident truck was stopped in Maryland and subjected to a CVSA level 1 inspection,19 which included 19  A CVSA level 1 inspection (North American Standard Inspection) includes examination of the driver’s license and medical examiner’s certificate and waiver, if applicable; the driver for alcohol and drug use; and the driver’s record of duty status, as required, and hours of service. With respect to the vehicle, it includes inspection of the seat belt, vehicle inspection report, brake system, coupling devices, exhaust system, frame, fuel system, turn signals, brake lamps, tail lamps, head lamps, lamps on projecting loads, loading procedures, steering mechanism, suspension, tires, van and open-top trailer bodies, wheels and rims, windshield wipers, and emergency exits (on buses). In addition, during a level 1 inspection, adherence to hazardous materials regulations is checked.

Factual Information 14 Highway Accident Report checking the brakes for adjustment. At that time, the pushrod stroke for the left rear brake was 2 1/4 inches and the pushrod stroke for the right rear brake was 2 1/2 inches. The adjustment limit is 2 inches, so the brake condition resulted in the truck being placed out of service. Safety Board investigators interviewed the driver who was operating the truck at the time of this inspection. (Blossom Valley no longer employs this driver.) He stated that he [manually] adjusted the brakes before departing the inspection site. He also indicated he had adjusted the accident truck’s brakes three or four times during his seasonal employment with Blossom Valley during 2002. He further stated that he had worked full-time as a mechanic for a construction company, was a Pennsylvania State- certified truck inspection mechanic, and had been a truck mechanic for more than 20 years. On January 20, 2003, the accident truck underwent a Pennsylvania State annual inspection performed by the Beasley Ford dealership in York, Pennsylvania. According to the service manager, the truck mechanics at Beasley are certified by the National Institute for Automotive Service Excellence (ASE). (For more information, see the section in this report on “Inspector and Mechanic Certification Requirements” under “Other Information.”) The dealership pays the expenses of acquiring and maintaining certification. The mechanic who performed the annual inspection was a Pennsylvania State-certified truck inspector. He told Safety Board investigators that the rear brakes were out of adjustment and that he had [manually] adjusted them. According to the dealer’s service manager, ASAs, which work “pretty well,” still require inspection and manual adjustment, particularly if the vehicle operates in hilly or mountainous areas, or in dirt, gravel, or mud. The Ford owner’s manual for a year 2003 model F650/750 (a vehicle similar to the accident truck) states Inspect standard air brakes equipped with automatic slack adjusters for proper brake adjustment every 4 months or 20,000 miles, and more frequently if operated in hilly or mountainous regions or in mud. At the time of the January 2003 inspection, the recorded mileage on the truck was 142,810. The accident occurred less than 3 months later, at which time the odometer read 145,095 miles. No manual adjustments are known to have been made to the brakes between the January 20 inspection and the April 11 accident. The truck had traveled a total of 2,285 miles during that period. Table 3 summarizes the inspection history of the accident truck, indicating the date of each inspection, the type of inspection performed, and whether the brakes were adjusted.

Factual Information 15 Highway Accident Report Table 3. Glen Rock accident vehicle inspection history. Motor Carrier Oversight General At the time of the accident, Blossom Valley had not undergone a Federal Motor Carrier Safety Administration (FMCSA) compliance review or been assigned a safety rating, so it was considered an unrated carrier. Because the carrier had been involved in this multiple-fatality accident, the FMCSA conducted a compliance review of Blossom Valley’s safety management controls on May 2, 2003. The compliance review revealed discrepancies in the areas of drug/alcohol testing, driver qualification files, records of duty status, vehicle inspection record-keeping, and driver/vehicle inspection reports. The compliance review resulted in a safety rating of “Conditional”20 for Blossom Valley. As of October 13, 2005, the FMCSA safety rating had not changed. FMCSA standards require a motor carrier to have adequate management controls in place to comply with applicable safety requirements. The FMCSA uses a rating formula to determine a motor carrier’s safety fitness. The safety fitness rating methodology begins with an FMCSA-conducted compliance review,21 applying the six factors shown in table 4 that rate the carrier’s compliance with the Federal Motor Carrier Safety Regulations (FMCSRs). Date Type of inspection Comments August 2, 2001 Pennsylvania State annual Inspection and subsequent repairs performed by Truck Specialties mechanics; no brake problems noted March 27, 2002 Pennsylvania State annual Inspection and subsequent repairs performed by Truck Specialties mechanics; no brake problems noted April 10, 2002 Roadside, CVSA level 1 Placed out of service for out-of- adjustment brakes; driver adjusted brakes and left inspection site January 20, 2003 Pennsylvania State annual Inspection and subsequent repairs performed by Beasley Ford; rear brakes out of adjustment April 15–18, 2003 Postaccident inspection (CVSA level 1) Placed out of service for out-of- adjustment brakes, a loose brake component, and an inoperative turn signal 20 A “Conditional” rating means a carrier does not have adequate safety management controls in place to ensure compliance with the Safety Fitness Standards defined in 49 CFR Part 385, but the carrier is still allowed to operate. 21 Title 49 CFR Part 385, appendix A.

Factual Information 16 Highway Accident Report Table 4. Factors for FMCSA safety compliance and the results of Blossom Valley’s compliance review. Factors 1–General, 2–Driver, 3–Operational, 4–Vehicle, and 5–Hazardous Materials are rated “Satisfactory,” “Conditional,” or “Unsatisfactory.” Factor 6–Accident is rated either “Satisfactory” or “Unsatisfactory”; a “Conditional” rating is not given. The ratings are defined as follows: • “Satisfactory”—Carrier has not violated any acute regulations or shown a pattern of noncompliance with critical regulations for that factor. • “Conditional”—Carrier has violated an acute regulation or had a pattern of noncompliance with critical regulations. • “Unsatisfactory”—Carrier has violated two or more acute regulations or has patterns of noncompliance with two or more critical regulations. After the FMCSA May 2003 compliance review, two other vehicles in Blossom Valley’s fleet underwent roadside inspections and were placed out of service. (See table 5.) Table 5. Other Blossom Valley vehicle inspections. Inspection Selection System The Inspection Selection System (ISS-2) is an FMCSA computer program designed to assist the inspector in the field in selecting vehicles for inspection. The intent of the program is to identify vehicles and carriers that have a history of unsafe practices and poor safety performance. An ISS-2 inquiry provides three types of guidance Factors Applicable FMCSRs and other criteria Results of May 2, 2003, Blossom Valley compliance review 1–General Parts 387 and 390 Satisfactory 2–Driver Parts 382, 383, and 391 Satisfactory 3–Operational Parts 392 and 395 Satisfactory 4–Vehicle Parts 393 and 396 and out-of- service rate Unsatisfactory 5–Hazardous materials Parts 107, 171, 172, 173, 177, 180, and 397 Not applicable 6–Accident Recordable accident rate Satisfactory Date Type of inspection Comments June 3, 2003 Roadside Chevrolet pickup with a trailer: trailer brakes inoperative (no actuator switch); breakaway brake device not connected; vehicle placed out of service June 27, 2003 Roadside International tractor with Reit trailer: 4 of 10 brakes out of adjustment; vehicle placed out of service

Factual Information 17 Highway Accident Report (recommendations) to the inspector: “Inspect,” “Optional,” and “Pass.” (See table 6.) The ISS-2 criteria are based on data analysis from the Federal Motor Carrier Management Information System (MCMIS) and the Safety Status Measurement System (SafeStat)22 ratings in crash, vehicle, driver, and safety management history. If there is insufficient information about the carrier in the SafeStat system, the ISS-2 inspection values are based on the carrier’s size and number of past inspections. Table 6. ISS-2 inspection values and recommendations. When an inspector accesses the ISS-2 for a carrier, the system displays an inspection value, as well as the source of the value. If the ISS-2 indicates insufficient data to provide an inspection value, this means there is a lack of SafeStat or PRISM23 data on that carrier. The ISS-2 also displays the carrier’s “Violation Details,” which provide information about the carrier’s violation history compared to the national violation- warning threshold24 in specific categories. Carriers with a violation history greater than the warning threshold are highlighted in that category, alerting the inspector to concentrate on or pay particular attention to items in that category during the inspection process. An ISS- 2 inquiry also yields the latest MCMIS data (results of roadside inspections, compliance reviews, and accident information) and carrier information, based on the most recent updated carrier registration information. As of March 24, 2003,25 Blossom Valley had an ISS-2 inspection value of 65, based on insufficient data in the system regarding the carrier. As of September 19, 2003, 5 months after the accident, its inspection value was 82, based on the result of the FMCSA compliance review safety rating of “Conditional.” As of September 23, 2005, the carrier’s inspection value was 73. (The ISS-2 system automatically reduces the severity of an infraction over time.) 22 The FMCSA’s SafeStat analysis program uses data from Federal and State sources, including roadside inspections, accident data, and enforcement actions for all carriers, to develop a safety fitness assessment for a motor carrier. ISS-2 inspection value Recommendation 75–100 Inspect (inspection warranted) 50–74 Optional (may be worth a look) 1–49 Pass (no inspection required) 23 PRISM is a Federal and State program that correlates motor carrier safety fitness to State commercial vehicle registrations. See . 24 This is an FMCSA algorithm that uses national inspection histories and carrier census information to develop thresholds. 25 On May 24, 2003, investigators accessed the ISS-2 system to query the status of Blossom Valley. At that time, the ISS-2 system stated that, as of March 24, 2003 (about 3 weeks before the accident), Blossom Valley’s inspection value was 65.

Factual Information 18 Highway Accident Report Meteorological Information The nearest National Oceanic and Atmospheric Administration weather-reporting station to the accident site was the Automated Surface Observing System in York, Pennsylvania. At the time of the accident, the temperature was 45° F, the skies were overcast, and the winds were 7 knots from the west. There was a mist and light rain. According to SRPD investigators, the roadway was wet at the time of the accident. Toxicological Information The accident truck driver told police that he began using illicit drugs in October 2002 (about 6 months before the accident). He acknowledged use of cocaine, marijuana, heroin, rock cocaine, and hydrocodone. (The driver did not have a prescription for the prescription medication hydrocodone.) He admitted using marijuana 2 days before the accident and estimated that he had last used cocaine about 2 weeks before the accident. He denied use of any controlled substance on the day of the accident. Blood and urine specimens were collected from the driver at 6:33 p.m. and 6:55 p.m., respectively (about 3 and 3 1/4 hours postaccident). At the request of the York County, Pennsylvania, District Attorney, National Medical Services of Willow Grove, Pennsylvania, conducted postaccident toxicological testing of the truck driver’s blood and urine. Postaccident urinalysis showed the presence of methylecgonine and benzoylecgonine26 (both metabolites of cocaine), morphine,27 and Δ9-carboxy-tetrahydrocannabinol,28 an inactive metabolite of Δ9-tetrahydrocannabinol (THC, the active hallucinogenic compound in marijuana). Blood was tested only for THC and metabolites; test results were negative.29 Urinalysis testing results for ethyl alcohol and cocaethylene30 were also negative. Tests and Research To evaluate the effectiveness of the truck’s brakes, the Safety Board conducted computer simulations of the truck’s descent on Church Street to the accident site and its impact with the four passenger cars. Investigators used a Human, Vehicle, Environment (HVE)31 system that employed two physics modules, the Simulation Model Non-linear 26  Benzoylecgonine, 4,900 nanog/mL. 27  Testing was positive for both total morphine (conjugated and unconjugated, 970 nanog/mL) and free morphine (unconjugated, 150 nanog/mL). Free morphine is the active biologic agent. 28  91 nanog/mL. 29  Laboratory reporting limits of >1.0 nanog/mL (Δ9-THC) and >5.0 nanog/mL (11-hydroxy-Δ9-THC and Δ9-carboxy-THC). 30  Cocaethylene is a compound formed when cocaine and alcohol are present simultaneously. 31  The Engineering Dynamics Corporation, Beaverton, Oregon, developed the HVE system for engineers and scientists to use as a simulation tool to study vehicle and occupant kinematics.

Factual Information 19 Highway Accident Report (SIMON)32 for the truck descent and EDSMAC433 for the impact. The driver estimated his speed at the time of impact at 40 to 45 mph but stated that when he last looked at the speedometer, the truck was going 25 mph. The speed at impact was needed to determine a target speed for the truck at the bottom of the hill. SIMON uses Brake Designer to assess the effects of temperature on the brake drums and linings. The HVE system has a Ford F-800 truck in its vehicle library. The size and adjustment of the brakes, the engine power curve, the transmission ratios, the differential ratio, and the load of the vehicle were set to replicate the accident truck in the simulation. Using the simulation tools, the brakes could be applied and released at different intervals as the vehicle descended the hill. SIMON does not model the compressor output and determine the available air pressure, but the force applied to the brake pedal can be varied. SIMON does model aerodynamic drag and rolling resistance. For the simulation, the downgrade was modeled as one grade that was 3,350 feet long at an average grade of 7.7 percent. This is equivalent to the grade at the accident site hill, which varied continuously. Based on the physical evidence (including tire marks and final vehicle positions) and HVE default vehicles for the 1993 Chevrolet Camaro, 1996 Mazda Protégé, 1987 Chevrolet Nova, and 1997 Pontiac Grand Prix, the EDSMAC4 simulations of the vehicle collisions near the intersection indicated that the speed of the truck at impact with the Camaro was about 35 mph. The impact speed of 35 mph was used as a target for the SIMON downhill final speed. Witness statements concerning the speed of the truck on the hill varied. The driver stated that he stopped near the water tower and electrical substation at the top of the hill. He indicated that he pumped the brakes and that a quarter of the way down the hill, he lost the brakes. He said that as he was traveling about 25 mph, the brake warning light on the dashboard began to flash.34 A witness following the truck, however, stated that the truck did not stop and was traveling 25 to 30 mph at the top of the hill and then increased speed as it went down the hill. Numerous scenarios were simulated, including having the accident truck stop at the top of the hill and having it crest the hill at 25, 35, 45, and 55 mph. Simulations were made with and without sufficient brake pressure, for a total of 35 simulation runs. The simulations showed that the front brake drums could have heated from 615° F to 1,441° F. (At temperatures in excess of 900° F, brakes fade35 rapidly.) See appendix B for information on the simulations. 32  SIMON allows users to simulate the response of one or more vehicles to driver inputs and environmentally related factors. It is designed to fully utilize HVE Brake Designer, which models user- defined system components to estimate their behavior. 33  EDSMAC4, or the Engineering Dynamics Simulation Model of Automobile Collisions, 4th revision, permits simulation of single- or multiple-vehicle crashes and is based on the Simulation Model of Automobile Collisions, which Calspan developed for the National Highway Traffic Safety Administration (NHTSA). 34  Testing showed that the red brake warning light came on when the brake air pressure dropped below 70 psi, and the rear parking brakes applied when the pressure dropped below 40 psi, but because the rear brakes were so far out of adjustment, the parking brakes would have had little or no effect on slowing the truck. 35  Brake fade is heating of the brake drums and linings, which causes an expansion of the drums, reducing a brake’s ability to slow or stop a vehicle.

Factual Information 20 Highway Accident Report The simulations showed that if the driver had pumped the brakes rapidly and depleted the truck’s air pressure to below 50 psi, the truck would not have been able to stop. If the driver had applied the brakes too late on the descent, the front brakes would have overheated, and the driver would not have been able to stop. If the driver had allowed the speed of the truck to exceed 38 mph on the descent, the front brakes would have overheated and faded. The simulations showed that the lowest brake drum temperatures occurred when the brakes were continually snubbed36 on and off as the truck went down the hill. The simulations indicated that the front brakes would have slowed the truck somewhat, keeping the truck to about 35 mph at the time of impact. Other Information Commercial Driver’s License The majority of States (32) have a classified license system, which is one in which the State issues different licenses for specific classes of vehicles. Before the CDL program was instituted (see below), in States that did not have a classified license system, any person licensed to drive an automobile could drive a commercial motor vehicle. The CDL requirement was established under the Commercial Vehicle Safety Act of 1986 and became effective nationwide in 1992. It established testing and license requirements for drivers of commercial motor vehicles. The main purpose of the act was to reduce or prevent truck and bus accidents and fatalities by disqualifying unsafe commercial motor vehicle drivers.37 The classifications of CDL, by vehicle group descriptions, are • Combination Vehicle (Group A)—Any combination of vehicles with a gross combination weight rating of 11,794 kilograms or more (26,001 pounds or more) provided the GVWR of the vehicle(s) being towed is in excess of 4,536 kilograms (10,000 pounds). • Heavy Straight Vehicle (Group B)—Any single vehicle with a GVWR of 11,794 kilograms or more (26,001 pounds or more), or any such vehicle towing a vehicle not in excess of 4,536 kilograms (10,000 pounds) GVWR. 36  A 1992 University of Michigan Transportation Research Institute (UMTRI) study, conducted to determine what information should be included in the CDL program on braking a truck while descending mountain roads, found that it was better to apply more pressure (about 20 pounds) for 3 seconds and then release for about 6 seconds (a procedure called a “snub”) than to apply brakes at a low level of pressure (10 pounds) and hold them on while descending the mountain. Snubbing resulted in slightly lower brake temperatures, and the hottest brakes were cooler if the snubbing strategy was used, but the difference was not large. See P. Fancher, C. Winkler, and M. Campbell, The Influence of Brake Strategy on Brake Temperatures in Mountain Descents, UMTRI-92-11, March 1992. 37  Title 49 CFR 383.91.

Factual Information 21 Highway Accident Report • Small Vehicle (Group C)—Any single vehicle, or combination of vehicles, that meets neither the definition of Group A nor that of Group B as contained in this section, but that either is designed to transport 16 or more passengers including the driver, or is used in the transportation of materials found to be hazardous for the purposes of the Hazardous Materials Transportation Act and which require the motor vehicle to be placarded under the Hazardous Materials Regulations. Any CDL driver operating a commercial motor vehicle equipped with air brakes must pass an air brake test indicating that the driver has specific knowledge about air brake systems, inspection of the brakes, and “implications of low air pressure warning.”38 If a CDL driver has not passed the air brake test, the CDL will display an “L” restriction, meaning the driver is prohibited from driving air brake-equipped vehicles. A CDL driver may have this restriction removed by passing a State air brake test at a later date. Canadian Air Brake Endorsement Since 2001, Transport Canada has required all drivers to have an air brake endorsement to drive any vehicle equipped with air brakes. According to the Canadian National Safety Code #4, “Classified Driver’s Licence Program,” a driver must possess a valid driver’s license of an appropriate class to operate the assigned vehicle, including an air brake endorsement when the vehicle is equipped with air brakes. Transport Canada reports that Canada has experienced a reduction in brake-related accidents since the adoption of this requirement.39 Also, between September 1999 and September 2004, Canada experienced a 25-percent reduction in brakes found to be out of adjustment to the point of being out of service.40 Brake Systems Passenger cars are usually equipped with hydraulic brake systems. Trucks are equipped with either hydraulic brakes or air brakes. The two brake systems operate differently. A hydraulic brake system is filled with hydraulic fluid. When the brake pedal is depressed, a proportional force is applied to the fluid, which in turn forces the brake shoes against the drums, creating friction, which stops the vehicle. When the brake is released, the pressure is released, and the brakes release. Hydraulic brake systems are closed systems, so there is no depletion of the brake fluid. Also, hydraulic systems have little discernible lag time between pedal depression and brake application. An air brake system converts compressed air into a linear force that acts upon a number of components, including the pushrod, slack adjuster, and camshaft, to apply the brake shoes against the brake drum, creating friction, which stops the vehicle. The 38  Title 49 CFR 383.111(g). 39  This information was obtained through conversations between Transport Canada officials and Safety Board investigators during the April 2004 CVSA meeting in Little Rock, Arkansas. 40  From Operation Air Brake data for 1999 through 2004. (Operation Air Brake will be discussed later in this report.)

Factual Information 22 Highway Accident Report compressor provides a supply of air to the holding tanks (also known as air supply reservoirs). When the brakes are applied, the stored air is distributed in the system through relay valves to the brake chambers, which convert the air pressure to a linear force. Using this force, the pushrod moves a slack adjuster that is attached to a camshaft, which rotates and causes the brake shoes to expand and contact the brake drum. When the brakes are released, the air used to activate the brakes is exhausted to the atmosphere. (See figure 9.) Figure 9. Brake schematic. Air chamber Push rod Slack adjuster Brake lining moves outward when cam twists, contacting brake drum Rotating cam twists when brake is applied, spreading shoes Shoes push linings against drum Brake drum expands with heat The air brake system is an open system, in that the air used to apply the brakes is lost, and the air supply must be replenished before the brakes can operate. Repeated brake applications in succession (pumping the brakes) may prevent an air brake system from re- supplying the air expended during braking quickly enough to maintain a supply of air sufficient to stop the vehicle. Another distinct characteristic of an air brake system is the mechanical lag time, that is, the interval between the depression of the brake pedal and the application of the brakes. The lag time varies from about 0.20 to 0.55 second and may be longer in poorly maintained systems.41 The mechanical lag time adds to the overall stopping distance. For instance, at 50 mph, a vehicle travels at 73.30 feet per second. In a typical air brake system 41  Timing limitations are identified in 49 CFR 571.121, the course materials of the Institute of Police Technology and Management’s Commercial Vehicle Inspection and Reconstruction course, and field testing conducted by Safety Board investigators from 1989 through 1998.

Factual Information 23 Highway Accident Report for which the lag time is 0.50 second, the vehicle will travel an additional 36 feet from the moment of brake pedal depression until the brakes are fully applied. Vehicles that are typically equipped with air brakes include dump trucks, large transport trucks, and many types of buses. Some motor homes also have air brakes. Air brakes are optional on many trucks in the 19,501- to 33,000-pound weight classes. According to an article in Heavy Duty Trucking,42 an air brake system’s foundation brakes (drums and shoes) are large and can absorb a lot of heat. Hydraulic brakes typically wear out faster. In addition, air brake replacement parts are generally cheaper and more readily available than hydraulic brake system parts. Automatic Slack Adjusters ASAs, which are components of air brakes and are also known as automatic brake adjusters, have been offered as optional equipment on some commercial vehicles since the late 1960s. In 1992, the Safety Board noted, “The majority of truck tractors and about half the trailers currently being manufactured are equipped with automatic adjusters.”43 When the rule requiring automatic adjusters on all air brake-equipped vehicles built on or after October 20, 1994, was enacted,44 most heavy vehicles were already in compliance. The primary purpose of ASAs is to maintain brake adjustment levels without a mechanic or driver having to adjust the brakes manually. (See figure 10.) ASA Manufacturers’ Guidance on Manually Adjusting ASAs. The Safety Board is aware of at least six companies that market ASAs.45 The service manuals of all the ASA manufacturers reviewed suggest, implicitly or explicitly, that ASAs should not have to be manually adjusted, except at the time of initial installation or when brake components are replaced. Further, the manuals suggest that if an ASA is out of adjustment, it means that a problem exists with the installation, the slack adjuster itself, or other foundation brake components. None of the service literature reviewed suggests that routine manual adjustment of ASAs is a proper course of action for brakes found to be out of adjustment (excessive pushrod stroke). 42  “Getting the Right Truck,” Heavy Duty Trucking, October 7, 2004. See http://www.heavydutytrucking.com/200205/034a0205.asp. 43  National Transportation Safety Board, Heavy Vehicle Airbrake Performance, Safety Study NTSB/SS-92/01 (Washington, DC: NTSB, 1992) 48. 44  Title 49 CFR 393.53(b). 45  The six are Haldex Brake Products Corporation, headquartered in Kansas City, Missouri; Bendix Commercial Vehicle Systems LLC, headquartered in Elyria, Ohio; Bendix Spicer Foundation Brake LLC, headquartered in Elyria, Ohio; Gunite Corporation, headquartered in Rockford, Illinois; Rockwell Automotive, which in 1997 became Meritor Automotive, of ArvinMeritor, Inc., headquartered in Troy, Michigan; and Crewson Industries, Inc., headquartered in Buffalo, New York. (Note: Although Bendix Spicer markets an ASA, Haldex actually manufactures the Bendix Spicer adjuster.)

Figure 10. Schematic of a Gunite automatic slack adjuster. (Adapted from a figure that appears in the Gunite Corporation Automatic Slack Adjuster Service Manual, June 1994 edition.) Link Grease Fitting Hex Extension Clevis 1/2-inch or 5/8-inch Clevis Pin 1/4-inch Clevis Pin Boot Factual Information 24 Highway Accident Report The accident truck was equipped with Gunite ASAs. The Gunite service manual states (bold print in original), “An automatic slack adjuster should not have to be manually adjusted except for initial installation and at the time of brake reline.”46 This manual also explains how to troubleshoot to find the cause of excessive pushrod stroke. It does not suggest that manual adjustment is a way to correct excessive pushrod stroke. Further, according to ASA manufacturers, the adjuster will not hold adjustment as well when adjusted manually. Gunite, Haldex, and Bendix indicated to Safety Board investigators that they have not done any testing to show the relationship between manual adjustment of an ASA and the time (or number of brake applications) it may take for the adjuster to go back out of adjustment. The Haldex service manual states “Automatic adjusters should not be operated as manual adjusters except as may be necessary to get the vehicle off the road for service.”47 In the same publication, under questions and answers, the following question appears: “If automatic adjustment stops, can I operate it as a manual brake adjuster?” The answer provided in the manual is: “No. Completely check 46  Gunite Corporation, Automatic Slack Adjuster Service Manual, publication ASA-100-1, dated June 1994. 47  Haldex Service Manual for Automatic Brake Adjusters, publication L30033HBS, dated November 11, 2001.

Factual Information 25 Highway Accident Report out foundation brake and adjuster to determine the cause of the problem. Repair or replace as needed to restore automatic adjustment.” According to the ASA manufacturers, one of the reasons that ASAs should not be manually adjusted is that every time the adjusting nut is turned in a counterclockwise direction, the internal components experience additional wear. For the majority of ASAs, regular manual adjustment will cause premature wearing of the internal clutch, potentially reducing the effectiveness of the internal clutch operation, which is necessary for the automatic adjustment feature to work properly.48 Other Industry Views on Manual Adjustment of ASAs. Through the Truck Manufacturers Association, Safety Board investigators queried medium-heavy truck manufacturers to determine what information, if any, they provide about the manual adjustment of ASAs. Only Freightliner49 responded to the inquiry. Freightliner indicated that its manuals do not currently address manual adjustment of ASAs but stated that when it next updates its driver, maintenance, and service manuals, it will revise them to include warnings about manually adjusting ASAs. Over the past 2 years, Safety Board investigators have asked truck mechanics, on a random basis, whether they manually adjust ASAs. The majority indicated that they manually adjust ASAs when they are out of adjustment. Brake Information in State Driver’s Manuals Every State produces a basic driver’s handbook or manual on obtaining a driver’s license. Each State is required to produce a CDL manual to provide information, specific knowledge, and details about testing procedures.50 The State manuals are based on models developed by the American Association of Motor Vehicle Administrators (AAMVA).51 The truck driver in the Glen Rock accident had a Maryland driver’s license (not a CDL). The Maryland Driver’s Handbook provides general information about the rules of the road and the operation of passenger cars. The handbook does not address driving on hills or mountains. It does address the topic of brake failure in “Special Driving Situations,” subsection “Emergencies.”52 The action suggested in case of brake failure is pumping the 48  Manual adjustment will cause additional wear on the internal clutch on most ASAs because the adjusting hex has to be rotated counterclockwise. Rockwell (now ArvinMeritor) has a special pawl that can be removed in older adjusters or pulled in new models, which will release the clutch and no damage will occur. Crewson Industries has recently introduced a new adjuster with a “push pin” release that also releases the clutch. 49  Headquartered in Portland, Oregon, Freightliner Group is a leading North American truck and specialty vehicle manufacturer. 50  Title 49 CFR 383.131. 51  Founded in 1933, the AAMVA is a voluntary, tax-exempt, nonprofit, educational organization that develops model programs affecting motor vehicle administration, police traffic services, and highway safety and provides information concerning these disciplines. It also represents the U.S. and Canadian State and Provincial officials who administer and enforce motor vehicle laws. 52  Maryland Driver’s Handbook, 48.

Factual Information 26 Highway Accident Report brakes. (Cars are equipped with hydraulic brake systems. For a hydraulic braking system, pumping the brakes may compress air in the line or free a restricted braking component. If a hydraulic system is breached, pumping the brakes may provide some braking until there is a complete loss of fluid.) No sections in this handbook address air brakes. The Maryland CDL Manual53 addresses mountain driving, providing information about using lower gears to descend a hill and maintaining a maximum safe speed that will not exceed the vehicle braking limits. The manual states, “When you reach your maximum safe speed apply your brakes sufficiently enough to decrease your speed by 5 mph.” It also cautions about brake fade and the need for frequent brake adjustment checks. In its section on air brakes, the Maryland CDL Manual describes the air brake system and how it works. It has specific information on low air pressure warnings and air reservoir gauges, inspection of an air brake system to ensure that it is functioning and adjusted properly, and brake lag time and the additional travel distance it entails until effective braking takes place. The manual indicates that a brake lag time of 0.50 second or more is possible. The Maryland CDL Manual contains “Test Your Knowledge” features following its information sections. The “Test Your Knowledge” segment for the air brake section addresses (1) low pressure warning lights, (2) using brakes on downgrades, (3) the causes of brake failure, and (4) reducing gear before descending a hill. Submission to the AAMVA for the Model Commercial Driver License Manual The AAMVA publishes a model Commercial Driver License Manual that all 50 States use; few, if any, States make specific changes for their State manuals. The manual was last published 10 years ago.54 In August 2004, a coalition of five ASA manufacturers55 endorsed inclusion of the following language regarding ASAs in the new model Commercial Driver License Manual, which was distributed on January 3, 2006. All airbrake vehicles manufactured since October 20, 1994 are required to have automatic brake adjusters, also known as ASAs. Automatic adjusters should not have to be manually adjusted except when performing maintenance on the brakes and during the installation of the brake adjusters. In a vehicle equipped with automatic adjusters, when the pushrod stroke exceeds the legal brake adjustment limit, it is an indication that a mechanical problem exists in the adjuster itself, a problem with the related foundation brake components, or that the adjuster was improperly installed. 53  Maryland Department of Transportation, Motor Vehicle Administration, Maryland CDL Manual (Glen Burnie, MD: Maryland Department of Transportation, April 1994). 54  Commercial Driver License Manual, Version 2.0. (AAMVA, 1996). 55  The five manufacturers are ArvinMeritor, Bendix, Crewson, Gunite, and Haldex. Although Bendix Spicer markets an ASA, the adjuster is manufactured by Haldex. Bendix Spicer deferred to Haldex to comment on the proposed wording of the new text to be included in the manual.

Factual Information 27 Highway Accident Report The manual adjustment of an automatic adjuster to bring a brake pushrod stroke within legal limits is generally masking a mechanical problem and is not fixing it. Further, routine adjustment of most automatic adjusters will likely result in premature wear of the adjuster itself. It is recommended that when brakes equipped with automatic adjusters are found to be out of adjustment, that the driver take the vehicle to a repair facility ASAP to have the problem corrected. The manual adjustment of an automatic adjuster should only be used as a temporary measure to correct the adjustment in an emergency situation, as it is likely the brake will soon be back out of adjustment since this procedure usually DOES NOT fix the underlying adjustment problem. (Note: Automatic brake adjusters are made by different manufacturers and do not all operate the same. Therefore, the manufacturer’s Service Manual for the specific automatic adjuster being used should be consulted prior to troubleshooting a brake adjustment problem.) According to the AAMVA, this language is included in the new model Commercial Driver License Manual. Commercial Vehicle Inspection Programs Both the FMCSA and some States require commercial vehicle inspections. The FMCSA requires every commercial vehicle (engaged in interstate commerce) to undergo an annual inspection.56 This Federal requirement can be fulfilled in three different ways. The first method is by a State inspection. The District of Columbia and 21 States, including Pennsylvania, require commercial vehicles (engaged in intrastate or interstate operations) to undergo annual vehicle inspections; 3 States57 have voluntary commercial vehicle inspection programs. In these 25 jurisdictions that have a qualifying inspection program, the Federal requirement can be met by a State inspection.58 To implement its inspection program, the State either operates its own inspection stations or, as in Pennsylvania, the State authorizes privately owned and operated garages and repair facilities to conduct the inspections. The second method by which the Federal inspection requirement can be met applies in those States without a qualifying State inspection program. In such States, a motor carrier can either conduct the inspection itself or have it conducted at a repair facility. In either case, to meet the Federal requirement, the individuals performing the inspection must be qualified under 49 CFR 396.19. 56  See 49 CFR 396.17 and the FMCSRs, appendix G to subchapter B, Minimum Periodic Inspection Standards. 57  Arkansas, Illinois, and Oklahoma. 58  A State inspection will fulfill the Federal inspection requirement if the vehicle is inspected under a mandatory State inspection program in Alabama, California, Connecticut, Hawaii, Louisiana, Maine, Maryland, Michigan, Minnesota, New Hampshire, New Jersey, New York, Ohio, Pennsylvania, Rhode Island, Texas, Utah, Vermont, Virginia, West Virginia, Wisconsin, or the District of Columbia. (Of these, Alabama, California, Connecticut, Michigan, Minnesota, New Jersey, New York, Ohio, and Wisconsin have inspection programs that do not cover all commercial motor vehicles.) In the three States with voluntary State inspection programs—Arkansas, Illinois, and Oklahoma—the voluntary State inspection will also satisfy the Federal inspection requirement.

Factual Information 28 Highway Accident Report The third way the Federal annual inspection requirement can be fulfilled is through a State or other jurisdiction’s roadside inspection,59 as long as it meets the minimum requirements found at 49 CFR 396.17. The CVSA North American Standard Inspection procedures developed by the CVSA and the FMCSA fulfill these minimum requirements, and the CVSA procedures are to be used by all roadside inspectors. The Safety Board reviewed the North American Standard Inspection training materials developed and maintained by the CVSA and the FMCSA’s National Training Center and found that they do not address the subject of manual adjustment of ASAs. Inspector and Mechanic Certification Requirements The ASAs on the accident truck were manually adjusted at different times by at least two individuals—a former Blossom Valley driver, who was a truck mechanic with 20 years’ experience, and the mechanic from the Beasley Ford dealership in York, Pennsylvania. Both individuals were Pennsylvania State-certified truck inspection mechanics; the Ford dealership mechanic was also ASE certified. Pennsylvania State-Certified Truck Inspection Mechanics. Two classes of inspectors perform annual vehicle inspections in Pennsylvania under PennDOT direction. Class 1 inspectors inspect cars and trucks under 17,000 pounds and class 3 inspectors inspect trucks and buses over 17,000 pounds and trailers over 10,000 pounds. Community colleges and private driving schools provide inspector training. According to Pennsylvania Code Section 175.28 “Certified inspection mechanics. (d) Certification requirements,” A mechanic desiring to become certified: shall (1) be 18 years of age or older, (2) have a valid driver’s license for each class of vehicle which the mechanic will inspect, (3) have attended an approved 9-hour certification course and successfully completed the required written examination, (4) pass the required tactile test administered by a certified/qualified automotive instructor at an approved education facility. Recertification requires a mechanic to pass the required written examination every 3 years. According to PennDOT, the instruction necessary to become a class 3 truck inspector requires an additional 3 or 4 hours, includes a practical test, and gives special attention to air brake systems. PennDOT officials told Safety Board investigators that inspectors are taught to recognize whether something is broken or not functioning, but they are not taught how to diagnose brake component problems. The ASE. The ASE is an independent, nonprofit organization established in 1972 to improve the quality of vehicle repair and service through the testing and certification of repair and service professionals. According to the ASE, about 420,000 professionals hold current certifications and work in every segment of the automotive service industry, including car and truck dealerships, independent garages, fleets, service stations, and franchises. Certification requirements include passing 1 of the ASE’s 40 exams and proving relevant work experience. To remain certified, those with ASE credentials must be retested every 5 years. 59  Title 49 CFR 396.23.

Factual Information 29 Highway Accident Report The ASE medium-heavy truck test catalog contains eight tests, including test “T4- Brakes.” A review of the test specifications and task list indicates that air brake diagnosis and repair make up 56 percent of the ASE brake test. Section 2 of this test, “Mechanical/Foundation,” includes item 3, termed “Inspect, adjust, repair, or replace manual and automatic slack adjusters.” The sample test questions do not address the manual adjustment of ASAs. The ASE does not publish or endorse study guides for its tests, but several automotive repair guide companies do publish ASE study guides. One company’s ASE T4-Brake test study guide states, “Automatic slack adjusters may require periodic adjustment. The method varies by manufacturer.” Safety Board investigators reviewed all available ASA manufacturers’ service manuals; none suggest that ASAs may require periodic adjustment. American Trucking Associations Technology and Maintenance Council The American Trucking Associations, Inc., (ATA) Technology and Maintenance Council publishes recommended truck maintenance practices. Its Recommended Practice 609B (RP 609B) document, Manual and Automatic Slack Adjuster Removal, Installation and Maintenance, provides information regarding the removal, installation, operation, maintenance, and selection of heavy-duty vehicle manual slack adjusters and ASAs. The following statements appear in this document: {CAUTION} Self-adjusting brake adjusters do not eliminate or reduce the need for periodic inspection and maintenance of the adjuster components and attaching hardware. However, manual adjustment can be made temporarily to get a vehicle to a maintenance facility for inspections and repair, if necessary. A self-adjusting brake adjuster should not have to be manually adjusted except for installation and at brake reline. RP 609B also provides a preventative maintenance schedule for both manual slack adjusters and ASAs. Owner-Operator Independent Driver Association Survey In 2000, the Owner-Operator Independent Drivers Association (OOIDA) conducted a 13-question driver survey of its membership and found that 65 percent of owner-operator drivers and 59 percent of company drivers had ASAs on their equipment.60 When asked, “What brake maintenance do you personally perform?,” 75 percent of the owner-operators and 57 percent of the company drivers indicated that they adjust their brakes. Almost 20 percent of all responding drivers indicated that ASAs are the biggest problem with current brake systems. Drivers said ASAs are unreliable, excessively depended upon, maintained improperly, and more difficult to adjust than manual slack adjusters are. 60  Rick Craig, “The Driver Perspective,” Report of Proceedings of the North American Brake Safety Conference, September 15-16, 2000 (Toronto, Canada: CVSA, 2001) 57.

Factual Information 30 Highway Accident Report Operation Air Brake The CVSA and the Canadian Council of Motor Transport Administrators (CCMTA)61 sponsor the Operation Air Brake campaign, which consists of 2 days of brake inspections (1 day of announced and 1 day of unannounced inspections) conducted annually by CVSA member agencies. Since 1998, the CVSA has gathered statistics from Operation Air Brake that show that inspected brakes equipped with ASAs are placed out of service between 3.5 and 4.2 percent of the time, and inspected brakes equipped with manual slack adjusters are placed out of service between 8.3 and 9.1 percent of the time. The 2003 Operation Air Brake campaign included a driver survey on air brake adjustment knowledge. The survey, conducted during the brake check days and other enforcement activities, included 11 questions, and 4,055 professional drivers responded. According to preliminary results,62 “The responses reveal an overwhelming level of misunderstanding about the importance of brake adjustment and correct methods to inspect the adjustment on their vehicles.” About three-quarters of the drivers who responded indicated they were company drivers and the rest indicated they were owner-operators. The average experience level of both groups was 14.8 years of driving. The survey asked the drivers what source they rely on the most for providing reliable information about air brakes. The sources identified by the drivers were classroom training (28 percent); their company (30 percent); books, manuals, and videos (32 percent); and other drivers (10 percent). The Operation Air Brake Committee indicated that the drivers who identified books, manuals, and videos as their source of information regarding air brakes seemed to have a better understanding of the proper operation of air brakes than the other drivers and had fewer brake out-of-service violations. In addition, the survey asked drivers a question about their beliefs concerning ASAs. Figure 11 shows the results. In 2004, the CVSA, recognizing the importance of air brake education and proper brake adjustment, included a special education component in Operation Air Brake. On September 5, 2004, CVSA inspectors conducted demonstrations and provided educational materials to drivers and mechanics about achieving proper brake operation, recognizing potential brake problems, and understanding the need for properly maintained brakes. Some of the educational efforts took place at the 10 TravelCenters of America truck stops in Ohio; the Husky Truck Stop near Regina, Saskatchewan; and the TravelCenters of America truck stop near Baltimore, Maryland. 61  The CCMTA is the official organization in Canada for coordinating all matters dealing with the administration, regulation, and control of motor vehicle transportation and highway safety. The CCMTA includes members from all Canadian governments (Provincial, Territorial, and Federal), as well as associate members from transportation-related organizations. See http:www.ccmta.ca. 62  From Operation Air Brake campaign—Report of Driver Survey on Air Brake Adjustment Knowledge 2003, draft.

Factual Information 31 Highway Accident Report According to the CVSA,63 brake-related defects continue to be the most significant and frequent violations that safety inspectors discover during roadside inspections. Figure 11. Responses to 2003 Operation Air Brake driver survey question about automatic slack adjusters. (Source: Commercial Vehicle Safety Alliance) Beliefs About Automatic Brake Adjusters 140 2179 1373 362 n/a never go out of adjustment can be adjusted by drivers with the proper tools need adjustment on a regular basis The CVSA also developed a pamphlet on air brake adjustment for distribution during the 2004 Operation Air Brake campaign. (See appendix C for a photocopy of the pamphlet, entitled Air Brake Adjustment—Why is it so important?) The CVSA told Safety Board staff that it has printed 35,000 copies of the pamphlet, and demand for the pamphlet has been strong. The pamphlet includes the following language: READJUSTING AUTOMATIC BRAKE ADJUSTERS Automatic brake adjusters normally don’t require manual readjustment. If you have a brake that is over-stroking and it has an automatic brake adjuster, you have a problem with the brake or the adjuster. If you readjust it, you aren’t really fixing the problem. The same is true if someone else only readjusts it, the problem is still there. A manual readjust may bring the brake back into compliance and improve the way the brake operates, but it will only be temporary. Table 7 shows the results of the 2005 Operation Air Brake unannounced brake inspections, indicating the out-of-service rates in the United States and Canada and the percentage of manual and automatic slack adjuster-equipped brakes found out of adjustment. 63  See additional information at http://www.cvsa.org/programs/04operation_airbrake.html and http://www.cvsa.org/latestnews/cvsa_latestnews.html.

Factual Information 32 Highway Accident Report Table 7. Summary of May 5, 2005, CVSA Operation Air Brake results (unannounced inspections). The Operation Air Brake Committee determined that, based on the success of the 2004 Operation Air Brake education event, a major education and awareness campaign directed at drivers and mechanics would help address the chronic problems associated with air brake compliance, inspection, and maintenance. In 2005, the committee dedicated August 28 through September 3 as Brake Safety Awareness week. This event replaced the Operation Air Brake annual announced brake check day for 2005. The committee asked that each jurisdiction conduct one or more educational or awareness events during Brake Safety Awareness week. Commercial Vehicle Statistics Preliminary data from the FMCSA’s study on large truck crash causation64 indicate that in multivehicle crashes in which the truck was at fault, 38 percent involved vehicle equipment problems. Earlier data from Michigan65 suggest that truck brake conditions may have a role in crashes in which trucks strike other vehicles. In rear-end crashes in which the truck was the striking vehicle, the incidence of defective or poorly adjusted truck brakes was almost twice as high as in cases in which other vehicles struck trucks. A 2003 General Accounting Office analysis66 of NHTSA crash data for all vehicles during the period 1997 to 2001 found about 778,000 crashes in which police identified a Location Number of trucks checked Percent out of service for brake adjustment Percent out of service for brake components Percent out of service for brakes Percent of brakes out of adjustment Manual Auto Canadian jurisdictions (10 Provinces) 2,857 6.3 6.1 12.1 7.1 2.8 U.S. jurisdictions (27 States) 14,479 12.0 8.8 18.4 8.9 4.6 Total 17,336 11.1 8.4 17.4 8.7 4.2 64 Briefing by Ralph Craft of the FMCSA during Session 119 of the Transportation Research Board’s annual meeting, held on January 9, 2005, in Washington, D.C. 65 The Fatal Accident Complaint Team, Michigan State Police Motor Carrier Enforcement Division, project involved investigating fatal commercial vehicle crashes in Michigan from 1996 to 2001 to determine why the crashes occurred. Each truck was subjected to a North American Standard Inspection (CVSA level 1), evaluating its precrash compliance with motor vehicle and driver regulations. Ralph Craft, FMCSA Analysis Brief, Rear-End Crashes Involving Large Trucks, FMCSA-RI-03-019. 66 U.S. General Accounting Office, Highway Safety: Research Continues on a Variety of Factors that Contribute to Motor Vehicle Crashes, GAO-03-436 (Washington, DC: GAO, March 2003). (Note: The General Accounting Office has since changed its name to the Government Accountability Office.)

Factual Information 33 Highway Accident Report specific vehicle feature that might have contributed to the crash. Of those 778,000 crashes, brake systems were identified as a contributing factor 29 percent of the time. In addition, an examination67 of NHTSA’s 1998 National Automotive Sampling System/General Estimate System data shows that, in crashes involving a commercial vehicle, when vehicle defect was a likely factor, an estimated 36 percent of the crashes involved the braking system. These same data indicate that crashes involving the brake system as a contributing factor accounted for 49 percent of the injuries associated with commercial vehicle crashes. The Glen Rock accident involved a straight truck. UMTRI data68 for the year 2000 indicate that straight truck power configurations accounted for 33.3 percent of the 5,275 trucks involved in fatal accidents. In addition, 433 of these straight trucks (24.7 percent) were dump trucks. The drivers of 34.2 percent of the straight trucks and 32.9 percent of the straight trucks with trailers did not have CDLs. The Safety Board canvassed the heavy truck manufacturers through the Truck Manufacturers Association to determine how many trucks weighing less than 26,000 pounds are equipped with air brakes. Only International and Freightliner responded. International indicated that in 2004 it sold about 15,000 class 6 (19,501- to 26,000-pound) vehicles, about 40 percent of which were equipped with air brakes. Table 8 shows the information provided by Freightliner. Table 8. Domestic Freightliner vehicles built in the past 2 years. In the past 2 years, Freightliner has built 14,231 vehicles that weigh less than 26,000 pounds, and 84 percent of these vehicles had air brakes. The 1997 U.S. vehicle inventory and use survey69 indicated that 729,300 vehicles in the light-heavy or class 6 category (19,501 to 26,000 pounds) were in use. The recent Freightliner and International data show that many of these vehicles have air brakes. The latest U.S. vehicle inventory 67 U.S. Department of Transportation, Federal Motor Carrier Safety Administration, On-Board Sensors for Determining Brake System Performance, Task Order 3 of the Commercial Motor Vehicle Technology Diagnostics and Performance Enhancement Program, FMCSA-PSV-04-001 (Washington, DC: USDOT, December 2003). 68 Anne Matteson and Dan Blower, Trucks Involved in Fatal Accidents Factbook 2000, Center for National Truck Statistics, University of Michigan Transportation Research Institute, UMTRI 2003-20 (Ann Arbor, MI: July 2003). Class (weight in pounds) Air brakes Hydraulic brakes Total % air brakes Class 4 (14,001–16,000) 0 7 7 0 Class 5 (16,001–19,500) 32 696 728 4 Class 6 (19,501–26,000) 10,852 2,644 13,496 80 Class 7 (26,001–33,000) 16,685 356 17,041 98 Class 8 (33,001 and up) 97,360 0 97,360 100 69 This regularly conducted survey provides information on the physical and operational characteristics of the Nation’s truck population. See U.S. Department of Commerce, U.S. Census Bureau, 1997 Economic Census, Vehicle Inventory and Use Survey, EC97TV-US, issued October 1999.

Factual Information 34 Highway Accident Report and use survey, conducted in 2002,70 included a question about brakes. Evaluation of the survey’s raw data showed that 516,110 (30 percent) of the 1,709,574 vehicles in the 19,501- to 26,000-pound weight class were equipped with air brakes. El Cerrito, California, Accident Since the Glen Rock accident, the Safety Board has investigated another accident involving loss of braking capability on a steep incline, out-of-adjustment brakes, and ASAs. About 1:26 p.m., Pacific daylight time, on August 26, 2003, a 3-axle Kenworth dump truck, in combination with a 2-axle transfer-bin semitrailer,71 had been hauling hot asphalt to a construction site on top of a mountainous hillside in El Cerrito, California. The truck driver drove the truck to the top of Moeser Lane, unhooked the transfer-bin semitrailer, and started down Moeser Lane to a construction site 3 or 4 blocks from the top of the hill. The downgrade on the hill varied between 15 and 20 percent. According to the truck driver, he attempted to downshift to a lower gear and thought he had the truck in gear, but the sound of the engine indicated that the truck was stuck in neutral. The truck started to speed up, and the driver was unable to bring it under control using the service brakes. He recalled that he was getting some braking, but it did not slow the truck enough to bring it under control. The truck continued down the hill, while the driver sounded the truck’s horn. The truck struck six vehicles, injuring some of the occupants. About a mile down the hill, the truck ran off the right side of the roadway at the corner of Moeser Lane and Richmond Street and struck a utility pole, a gas line, and a house before coming to rest on its left side near the house. During the collisions and rollover, most of the hot asphalt from the bed of the truck was scattered, and some of it landed in the adjacent street and neighboring yards. The gas line the truck had struck ruptured and ignited. The fire destroyed the house that had been struck and the front of the accident truck; it also damaged gas and electric utility systems, resulting in a local power outage to about 20,000 homes. As a result of this accident, seven people were injured. Truck Information. The accident truck was a 1991 Kenworth model T-600A, 3- axle dump truck, with a sleeper cab. (The truck was originally manufactured as a 3-axle truck tractor, but it had been converted to a dump truck.) It was equipped with a Detroit Diesel Series 60 engine with a Jacobs Engine Brake, an Eaton-Fuller RTX14609BP 9- speed transmission, a Ross TAS65 power steering gearbox, and a rear axle with a 3.90 ratio. The factory-listed GVWR for the truck was 50,000 pounds. The truck was equipped with a standard air brake system with S-cam brakes. It did not have an ABS. Only the second axle (first drive axle) was equipped with spring parking/emergency brakes. The truck was equipped with Gunite ASAs. 70  The U.S. Census Bureau conducts a Vehicle Inventory and Use Survey every 5 years, during years ending in “2” and “7.” The Safety Board analyzed the raw data from the 2002 Economic Census, Vehicle Inventory and Use Survey, using the GVWR information from the Vehicle Identification Numbers. (See http://www.census.gov/suds/www/vius/2002.html.) 71  The transfer bin in this case was a 2-axle dump semitrailer that requires the load from the powered dump truck to be dumped first. Subsequently, by utilizing a ramp and cables, the bin body of the semitrailer is pulled onto the dump truck and dumped in the normal fashion, by raising the truck bed.

Factual Information 35 Highway Accident Report Brake Inspection and Testing. The California Highway Patrol obtained the brake pushrod measurements summarized in table 9 on scene. No further measurements were possible due to the slack adjusters being “backed off” so that the brake drums could be removed for inspection. Table 9. El Cerrito Kenworth truck brake test summary. All six wheels on the truck were equipped with Gunite ASAs. Safety Board investigators and Gunite representatives examined and tested the slack adjusters and found that the adjustment clutch was worn out for four of the six adjusters (left front, left rear, second left rear, and second right rear). Examination of the date codes and serial numbers revealed that five of the six adjusters were original equipment and had been on the truck since it was manufactured in 1991. The adjuster on the right rear, which was in adjustment, was the only one that had been replaced since the truck was new. Driver Information. The 24-year-old truck driver was the owner of the accident truck. He held a valid CDL with a March 26, 2006, expiration date, and a valid medical certificate with an April 25, 2005, expiration date. He had graduated from the A. B. Truck Driving School in San Jose, California, on August 23, 2001. The driver stated that on the morning of the accident, he had [manually] adjusted the brakes on the tractor and transfer-bin dump trailer. He said he had used a 9/16-inch wrench on the trailer72 and a smaller one for the dump truck brakes.73 In addition, the driver stated that his father was also a truck driver and had told him that bad brakes could Axle Air chamber size Slack arm lengthA Pushrod stroke Adjustment limitB Rated strokeC Left front T-16 5 1/2 in. Damaged 1 3/4 in. 2 1/4 in. Right front T-16 5 1/2 in. 1 1/2 in.D 1 3/4 in. 2 1/4 in. Left rear T-30 5 1/2 in. 2 1/2 in. 2 in. 2 1/2 in. Right rear T-30 5 1/2 in. 1 7/8 in. 2 in. 2 1/2 in. 2nd left rear T-30 5 1/2 in. 2 5/8 in.E 2 in. 2 1/2 in. 2nd right rear T-30 5 1/2 in. 2 3/8 in. 2 in. 2 1/2 in. AThe distance between the center of the splined camshaft and the center of the clevis pin, which secures the pushrod to the slack adjuster; also known as the “lever arm length.” BThe maximum pushrod stroke permitted. The values used for the “brake adjustment limit” are those in the CVSA North American Standard Out-of-Service Criteria. (Revised edition, April 2003.) CThe total length the pushrod can travel inside the air chamber. (When the “pushrod stroke” is equivalent to the “rated stroke,” generally no braking forces are obtained when the brakes are applied.) DDue to fire damage, this brake was measured using a steel bar to pry back the slack adjuster arm and, as measured in this manner, it was in legal adjustment. However, due to inherent variables, including the length and positioning of the bar and the amount of force exerted by the inspector, the measurement method lacked the consistency obtained when making a measurement pneumatically. A slightly higher pushrod stroke is usually obtained by using 80 to 100 psi of air. EThis brake was completely “bottomed out” during a static cool stroke, indicating that it was not providing any braking force, even without being heated or overheated. 72 The transfer bin semitrailer had manual slack adjusters and required the use of a 9/16-inch wrench to adjust them. A 9/16-inch wrench is the normal adjusting tool for manual slack adjusters. 73 According to Gunite’s Automatic Slack Adjuster Service Manual, ASA 100-1 (June 1994), a 7/16- inch wrench is used for the hex-adjusting nut.

Factual Information 36 Highway Accident Report mean his life. The driver said that he [manually] adjusted the brakes twice a week. The driver also said that he did not know he was not supposed to [manually] adjust an ASA. Other Investigations In four additional recent accident investigations, the Safety Board has encountered different brake maintenance problems involving ASAs found out of adjustment or not functioning. These accidents involved ASAs produced by several different manufacturers. Table 10 lists the investigations and the maintenance problems. Table 10. Recent investigations involving ASA maintenance problems. Accident investigation Automatic slack adjuster Date Location Manufacturer Maintenance problem May 31, 2001 Mountainburg, ArkansasA Rockwell A broken spring brake and incorrect installation of a brake chamber April 16, 2003 Hebron, KentuckyB Haldex and Bendix Worn clevis and clevis pins March 12, 2004 Gardens Corner, South CarolinaC Crewson Two adjusters on two different school buses lacked grease July 16, 2004 Chelsea, MichiganD Haldex Worn teeth on exterior control arm ANational Transportation Safety Board, Collision Between Truck-Tractor Semitrailer and School Bus Near Mountainburg, Arkansas, May 31, 2001, Highway Accident Report NTSB/HAR-02/03 (Washington, DC: NTSB, 2002). BPublic Docket HWY-03-M-H028. CPublic Docket HWY-04-M-H018. DPublic Docket HWY-04-M-H031.

37 Highway Accident Report Analysis The Glen Rock accident involved an untrained truck driver operating an overloaded, air brake-equipped vehicle with poorly maintained, out-of-adjustment brakes on a steep and weight-restricted hill, over which the truck was not permitted to travel. This analysis first discusses the factors and conditions the Safety Board was able to exclude as neither causing nor contributing to the accident. It then provides a brief overview of the accident events and a detailed discussion of the following major safety issues: (1) maintaining air brakes equipped with ASAs, (2) knowledge and skills needed to drive air brake-equipped vehicles, and (3) motor carrier oversight. Exclusions The accident occurred on a 3.4- to 13-percent grade on Church Street in the Borough of Glen Rock. Church Street had a load weight restriction, which was properly signed. The driver passed several load weight restriction signs before encountering the hill. First responders were on scene within 1 minute, and local fire departments and three ambulance services transported patients to area hospitals. Therefore, the Safety Board concludes that although the highway’s design included a steep grade, it was appropriately signed and, therefore, was not a factor in the accident; also, the emergency response was effective and appropriate. Accident Discussion The 1995 Ford dump truck was overloaded by 600 pounds (or about 2.3 percent of its GVWR of 26,000 pounds) and was proceeding southbound on Church Street, which has a steep downgrade. Safety Board-conducted computer simulations showed that the overloaded condition of the truck made a 5° F difference in brake temperature (final brake temperature of 456° F at 26,600 pounds and 451° F at 26,000 pounds) and did not noticeably affect the braking capability of the truck. The driver stated that he was traveling 25 to 35 mph, that he stopped the truck at the top of the hill, that he did not select a lower gear, and that, as he started down the hill, he pumped his brakes but the truck would not slow and instead began to speed up. He also said that about a quarter of the way down the hill, he lost his brakes, and the brake light began to flash.74 He knew the flashing light meant he had brake problems, because his 74  Postaccident testing showed that the red brake warning light would come on when the brake air pressure dropped below 70 psi, and the rear parking brakes would have been applied when the pressure dropped below 40 psi. However, because the rear brakes were so far out of adjustment, the parking brakes would have had little or no effect on slowing the truck.

Analysis 38 Highway Accident Report boss and a coworker had told him that if the brake light flashed, he did not have enough [air brake] pressure. Unfortunately, as he later told investigators, he did not know that pumping the brakes depleted the air pressure. Postaccident examination of the truck brakes showed that both rear brakes were significantly out of adjustment (they exceeded the adjustment limit by 1/2 inch), which would have resulted in little or no brake force for the rear wheels, even with enough air. The front brakes were well within adjustment limits. However, without sufficient air pressure, the front brakes would also have been ineffective. Computer simulations confirmed that the rear brakes provided little or no braking force but that the truck might have been stopped with the front brakes if the driver had not depleted the air pressure by pumping the brakes. Therefore, the Safety Board concludes that, based on the truck driver’s statements about pumping the brakes, postaccident examination of the brakes, and results from computer simulations, the accident truck did not have sufficient braking capability to stop before the initial impact with the stopped cars. In the course of its investigation, the Safety Board considered whether the truck driver’s condition might have affected the outcome of the accident. According to the SRPD, the Glen Rock accident truck driver admitted previous use of cocaine, heroin, rock cocaine, hydrocodone, and marijuana. Postaccident toxicological tests found morphine,75 metabolites of cocaine,76 and a metabolite of marijuana77 in the truck driver’s urine. Postaccident testing results for alcohol were negative. The toxicological findings indicated that, in all likelihood, the driver had consumed cocaine and heroin78 in the 2 days preceding the accident, despite his statement that he had last used cocaine about 2 weeks before the accident. However, testing limitations (blood and urine were drawn 3 and 3 1/4 hours, respectively, after the accident, and the sample sizes were insufficient to permit additional testing)79 preclude a determination as to whether the driver was under the influence of cocaine and morphine at the time of the accident. The effects of cocaine vary among individuals; the drug’s manifestations can include restlessness, increased risk- taking, and excitement and/or aggression. Cocaine also interferes with sleep. Morphine is noted for causing drowsiness, nausea, and respiratory depression, in addition to its 75  Morphine, a narcotic analgesic, is both a commonly used prescription pain reliever and the active ingredient in several common prescription medications and drugs of abuse. Morphine has a plasma half-life of about 2 to 3 hours. Following an oral dose, about 60 percent is excreted in the urine within 24 hours, and about 3 percent of the dose is excreted as free morphine within 48 hours. Morphine is initially eliminated from the blood fairly quickly. (Clarke’s Analysis of Drugs and Poisons, London: Pharmaceutical Press. Electronic version, 2004.) 76  Cocaine has a plasma half-life of 0.7 to 1.5 hours, depending on the dose. Elimination of cocaine and its metabolites from the urine is typically complete within 48 hours of ingestion. In plasma, it is usually eliminated within 18 to 24 hours. (See Clarke’s Analysis.) 77  Marijuana, a psychomimetic/mild hallucinogen, is a common drug of abuse. Its active ingredient, Δ9-THC, can be measured in plasma within seconds after inhalation. It has a plasma half-life of about 2 hours among frequent users, or about 1.5 hours otherwise. Its active metabolite, 11-hydroxy-Δ9-THC, has a half-life of about 120 to 144 hours, depending on frequency of use, with the longer half-life typical of infrequent users. Δ9-THC metabolites have been detected in urine for up to 12 days following a single oral dose. (See Clarke’s Analysis.) 78  Morphine is the primary active metabolite of heroin. 79  The driver’s blood was not tested for cocaine, cocaine metabolites, or morphine.

Analysis 39 Highway Accident Report analgesic properties. The presence of THC metabolites in the driver’s urine but not the plasma indicates the driver had consumed marijuana in the days (or weeks) preceding the accident but was not under the influence of the drug at the time of the collision. The Safety Board also considered the possibility that fatigue could have affected the truck driver’s performance. Because the driver operated within a 100-mile radius of the home terminal and returned to that location every day, he was not required to maintain status-of-duty records. When requested by the Safety Board, Blossom Valley was unable to provide the driver’s time records, despite being required by regulation to maintain such records. Consequently, the driver’s work schedule could not be established. In addition, the Safety Board could not adequately assess the impact of the driver’s drug use on his sleep patterns. The accident driver’s self-reported actions at the time of the accident suggest that he was alert and oriented toward the immediate situation. The driver stated that as he started down the hill, he pumped the brakes but could not stop the truck. In addition, he said that when he saw children at the bottom of the hill, he leaned out of the window and yelled, “No brakes, get out of the way.” Such actions do not indicate that his alertness was impaired or that drugs or fatigue affected his response to the emergency. The 35-mph impact speed, derived from the physical evidence, suggests that the truck driver attempted to brake the truck as it sped down the hill. Had he been so impaired by drugs or fatigue that he made no effort to brake the truck as it traveled down the hill, the speed of the truck would have been greater. Given the out-of-adjustment rear brakes and the truck driver’s lack of experience using air brakes, which resulted in his pumping the brakes, the truck did not have sufficient braking capability to stop. Therefore, the Safety Board concludes that although it cannot be determined if drugs or fatigue impaired the driver’s performance, he most likely could not have stopped the truck before the accident occurred. Air Brakes The rear air brakes of the accident truck were out of adjustment to the point that they had little or no braking capability. The Safety Board has found poorly maintained air brakes to be a causal factor in previous accident investigations80 and has been concerned about the 80 (a) National Transportation Safety Board, Francisco Flores Truck/Pickup Truck with Camper and Trailer Collision, U.S. Route 395, Bishop, California, June 29, 1974, Highway Accident Report NTSB/HAR-75/05 (Washington, DC: NTSB, 1975). (b) Texas Bus Lines, Inc., Charter Bus State Route 7, Near Jasper, Arkansas, June 5, 1980, Highway Accident Report NTSB/HAR-81/01 (Washington, DC: NTSB, 1981). (c) Direct Transit Lines, Inc., Tractor-Semitrailer/Multi-Vehicle Collision and Fire, U.S. Route 40, Frostburg, Maryland, February 18, 1981, Highway Accident Report NTSB/HAR-81/03 (Washington, DC: NTSB, 1981). (d) Eureka Springs, Arkansas, September 13, 1985, Highway Accident/Incident Summary Report NTSB/HAR-87/01/SUM (Washington, DC: NTSB, 1987). (e) Braking Deficiencies on Heavy Trucks in 32 Selected Accidents, Safety Study NTSB/SS-88/06 (Washington, DC: NTSB, 1988). (f) Collision Between Mission Consolidated Independent School District School Bus and Valley Coca-Cola Bottling Company, Inc., Tractor-Semitrailer, Intersection of Bryan Road and Texas Farm-To-Market Road 676, Alton, Texas, September 21, 1989, Highway Accident Report NTSB/HAR-90/02 (Washington, DC: NTSB, 1990). (g) Heavy Vehicle Airbrake Performance, Safety Study NTSB/SS-92/01

Analysis 40 Highway Accident Report proper operation of air-braked vehicles for more than 30 years. As a result of previous investigations, the Board has made recommendations about disseminating information regarding on-road brake adjustment,81 distributing appropriate brake maintenance materials,82 equipping air-braked vehicles with visible adjustment indicators,83 making pretrip brake inspections,84 and establishing brake inspector qualifications.85 (Appendix D provides a history of previous Safety Board brake adjustment recommendations.) Maintaining Air Brakes Equipped with Automatic Slack Adjusters The majority of heavy trucks on the road are equipped with ASAs. All air-braked vehicles manufactured after 1994 are required to have them and, in 1992, the Safety Board found that about 65 percent of the vehicles inspected during the Heavy Vehicle Airbrake Performance safety study86 were already equipped with ASAs. These safety devices were introduced without a concentrated education effort being employed. Problems Caused by Manually Adjusting ASAs. The postaccident inspection of the Glen Rock accident truck revealed that the two rear axle brakes were out of adjustment and produced little or no braking force. The front axle air chambers, which were slightly more than half the size of the rear chambers, were in proper adjustment. Yet, because the larger T-30 rear brakes produced little or no braking force, excessive strain was placed on the significantly smaller T-16 front brakes, which caused them to quickly overheat, resulting in severely diminished truck braking capability. The truck was equipped with Gunite ASAs on all four brakes. After the accident, when the two rear adjusters were tested at the Gunite facility with the worn “quick-connect” clevises and clevis pins from the accident truck, the pushrod stroke would not go below 2 1/2 inches, which is outside the adjustment limits, rendering the system incapable of producing braking force. However, when the ASAs were tested with new clevises and clevis pins, they functioned properly and the adjustment stayed well under 2 inches, which is within the

81 Safety Recommendation H-75-17. See appendix D for more information. 82  Safety Recommendations H-92-67, -72, and -74. See appendix D for more information. 83  Safety Recommendations H-92-50, -51, and -57. See appendix D for more information. 84  Safety Recommendation H-02-15. See appendix D for more information. 85  Safety Recommendations H-02-17 and -18. See appendix D for more information. 86  NTSB/SS-92/01. (Washington, DC: NTSB, 1992). (h) Mayflower Contract Services, Inc., Tour Bus Plunge from Tramway Road and Overturn Crash, Palm Springs, California, July 31, 1991, Highway Accident Report NTSB/HAR- 93/01 (Washington, DC: NTSB, 1993). (i) Truck Loss of Braking Control on Steep Downgrade and Collision With a Vehicle Near Plymouth Meeting, Pennsylvania, April 25, 1996, Highway Accident Report NTSB/HAR-97/02 (Washington, DC: NTSB, 1997). (j) Motorcoach Loss of Control and Overturn, New Mexico State Route 475, March 2, 1999, Highway Accident Brief NTSB/HAB-01/01 (Washington, DC: NTSB, 2001). (k) Collision Between Truck-Tractor Semitrailer and School Bus Near Mountainburg, Arkansas, May 31, 2001, Highway Accident Report NTSB/HAR-02/03 (Washington, DC: NTSB, 2002). (l) Highway Accident Investigation HWY-02-MH-003 concerning an October 2001 work zone collision accident in Monaca, Pennsylvania. The Safety Board is also investigating an accident involving braking issues that took place in Sulphur Springs, Texas, in 2004.

Analysis 41 Highway Accident Report adjustment limits and would provide adequate braking forces. Therefore, the Safety Board concludes that at the time of the accident, the ASAs for all four of the accident truck’s brakes were capable of working properly; however, the quick-connect clevises and clevis pins for both rear brakes were worn to the extent that they prevented the ASAs from properly adjusting the brakes, thereby reducing the capability of the rear brakes. The Safety Board reviewed the maintenance and inspection history of the accident truck, which had undergone four vehicle inspections between 2001 and the April 2003 accident—three Pennsylvania State annual inspections (August 2001, March 2002, and January 2003) and one roadside inspection (April 2002). During two of these inspections—the 2002 roadside inspection and the 2003 State annual inspection—the rear brakes were found to be out of adjustment. After the 2002 roadside inspection, when the accident truck was placed out of service for out-of-adjustment brakes, the driver of the vehicle, who was also a truck mechanic, manually adjusted the ASAs. The Safety Board could find no record of further examination of the brakes by the company or the mechanic to discover why the brakes had been out of adjustment. During the 2003 State annual inspection, a Ford dealership mechanic found the rear brakes to be out of adjustment, and he manually adjusted the ASAs. In an interview with Safety Board investigators, he said he had adjusted the brakes and thought he had fixed the problem. Had he performed a more in-depth examination of the brake system, he probably would have found and replaced the worn clevises and clevis pins, which would have enabled the ASAs to adjust the brakes properly and might have prevented the accident. The Gunite service manual gives specific instructions on how to conduct a torque test by turning the adjustment nut. If the Ford dealership mechanic had done a torque test, he might have realized that the adjuster itself was working properly. In addition, the Gunite service manual indicates that mechanics should “check the foundation brake for proper function; worn cam bushings, pins and rollers, broken springs, worn quick-connect clevis, worn clevis bushings and clevis pins. Repair as necessary and repeat the function test.”87 One reason that ASAs should not be manually adjusted is that every time the adjusting nut is turned in a counterclockwise direction, the internal components experience additional wear because the action abrades the internal adjusting mechanism. In the El Cerrito, California, accident, the driver stated that he manually adjusted the slack adjusters twice a week and had done so on the morning of the accident. Postaccident testing of the El Cerrito accident truck at the Gunite factory showed that three of the adjusting clutches were worn to the point that they could not hold an adjustment, probably due to their age and the deterioration caused by frequent manual adjustment. For the majority of ASAs, regular manual adjustment will cause premature wearing of the internal clutch, which is a necessary component for the automatic adjustment feature to work properly.88 87  Gunite Automatic Slack Adjuster Service Manual, ASA 100-1 (Gunite Corporation, June 1994) 7. 88  Manual adjustment will cause additional wear on the internal clutch on most ASAs, as the adjusting hex has to be rotated counterclockwise. Rockwell (now ArvinMeritor) has a special pawl that can be removed in older adjusters or pulled in new models, which will release the clutch so no damage will occur. Crewson Industries has recently introduced a new adjuster with a “push pin” release that also releases the clutch.

Analysis 42 Highway Accident Report Various brake component problems can cause a pushrod stroke to go beyond the limits for producing adequate braking capability, causing the brakes to be out of service. These problems include, but are not limited to, worn cam bushings, worn or broken pins and rollers, broken springs, worn clevises (both quick-connect and standard), and worn clevis bushings and pins. When a driver or mechanic finds a pushrod stroke to be long and manually adjusts an ASA to correct the long stroke, he or she is masking the true problem with the brake, not fixing it. In all likelihood, the adjustment will be temporary. ASA manufacturers Gunite, Haldex, and Bendix indicated to Safety Board investigators that they do not know how long (how many brake applications) a manually adjusted ASA will hold an adjustment. The drivers and mechanics who manually adjusted the ASAs on the trucks involved in the Glen Rock and El Cerrito accidents apparently did not understand that they were not fixing the underlying problem with the braking systems. They did not appreciate that when an ASA does not hold an adjustment, something is wrong with the adjuster itself or with some other foundation brake component. Therefore, the Safety Board concludes that the drivers and mechanics who manually adjusted the ASAs on the trucks involved in the Glen Rock and El Cerrito accidents did not look for underlying problems with the adjusters or related foundation brake components; consequently, they misdiagnosed the brake problems, probably because they were not properly educated on the function and care of ASAs and how they relate to foundation brake systems. Manually adjusting ASAs to fix an out-of-adjustment brake is a dangerous practice that can have serious consequences. If an ASA is manually adjusted, the operator may wrongly assume the adjustment has “fixed” the braking problem, which gives the operator a false sense of security about the effectiveness of the braking system. The operator may believe that the brakes are fully reliable, when in fact they can go out of adjustment at any time, particularly in the case of vehicles that operate in hilly or mountainous environments. As the Glen Rock and El Cerrito accidents demonstrate, manually adjusting ASAs can create a situation in which brakes will not be capable of responding properly when they are desperately needed. Insufficient Industry Awareness of the Risk Posed by Manually Adjusting ASAs. Although the CVSA’s Operation Air Brake data indicate that trucks with ASAs are placed out of service for out-of-adjustment brakes only half as frequently as those with brakes that have manual adjusters, ASA-equipped trucks are still being placed out of service for this deficiency, which suggests that ASAs have not solved the problem of out- of-adjustment brakes. Lack of knowledge about ASAs is one reason for the continuing problem. Since the Glen Rock and El Cerrito accidents, Safety Board investigators have questioned a number of randomly selected mechanics on the practice of manually adjusting ASAs. The majority indicated that they manually adjust ASAs when they are out of adjustment, a practice that ASA manufacturers neither suggest nor endorse. In addition, results of the driver survey conducted in 2000 by the OOIDA89 showed that a majority of drivers, particularly owner-operators, are performing brake adjustments 89  “The Driver Perspective,” Report of Proceedings of the North American Brake Safety Conference, September 15-16, 2000.

Analysis 43 Highway Accident Report on both manual slack adjusters and ASAs. The 2003 Operation Air Brake driver survey showed that about half of the drivers responding believed that ASAs never go out of adjustment and about one-third thought that a driver with proper tools could readjust ASAs. The Safety Board therefore concludes that the warnings in existing materials available to owners, drivers, mechanics, and inspectors of air-braked vehicles equipped with ASAs have not been successful in communicating the inherent dangers of manually adjusting ASAs to correct out-of-adjustment brakes. Operation Air Brake Committee members told Safety Board investigators that during the 2003 Operation Air Brake driver survey, drivers who obtained information about air brakes from manuals, rather than classroom training, their companies, or other truckers, knew more about the safe operation of air-braked vehicles and had fewer brake out-of-service violations. Educational and maintenance materials regarding vehicle components should be based on manufacturers’ recommendations because manufacturers are in the best position to understand how their products work. The service manuals of ASA manufacturers provide instructions on how to troubleshoot for a brake with excessive pushrod stroke. None of the manufacturers recommends manual ASA adjustment as a means to correct this problem. Most of the manufacturers explicitly state in their literature that an ASA should not have to be manually adjusted except at the time of brake installation. Nevertheless, only one manufacturer (Haldex) indicates in its literature that manual adjustment should not be undertaken to correct out-of-adjustment brakes and that this condition requires brake system troubleshooting. The other manufacturers do not definitively state that adjusting an ASA is the wrong way to remedy excessive pushrod stroke. The Safety Board believes that ASA manufacturers and marketers90 should revise their product literature to include conspicuously placed wording that clearly states that ASAs should not be manually adjusted in an effort to correct excessive pushrod stroke, because this condition indicates that a problem exists with the automatic adjuster, with the installation of the adjuster, or with related foundation brake components, which manual adjustment will not fix. Further, the literature should state that manual adjustment of ASAs is a dangerous practice that could have serious consequences, because it gives the operator a false sense of security about the effectiveness of the brakes, which are likely to go out of adjustment again soon. In August 2004, a coalition of five ASA manufacturers endorsed and submitted to the AAMVA language about ASAs to be included in the AAMVA’s new model Commercial Driver License Manual, which was distributed on January 3, 2006. The new manual includes language on manual adjustment of ASAs stating (in part) that ASAs should not have to be manually adjusted except during the installation of the ASAs and when performing brake maintenance. It also states that manual adjustment of an ASA to bring a brake pushrod stroke within legal limits is masking a mechanical problem, not fixing it, and that manual adjustment of most ASAs is likely to result in premature wear of the adjuster. Further, the new language states that manual adjustment of an ASA should be 90  Including Bendix Spicer, which markets ASAs manufactured by Haldex.

Analysis 44 Highway Accident Report used only in an emergency, as a temporary measure to correct the adjustment, because the brake will soon be back out of adjustment, given that manual adjustment will not fix the underlying braking problem. The Safety Board commends both the ASA manufacturers and the AAMVA for adding this language to the model manual. However, the new language concerning ASAs omits one vital element. It should also state that the manual adjustment of ASAs is actually dangerous because it gives the operator a false sense of security about the effectiveness of the braking system. The Safety Board understands that the AAMVA revises the model Commercial Driver License Manual about every 10 years and the 2005 version has already been distributed, so it is not possible to add this language to the current version. All 50 States use the information in the AAMVA model manual. Because the new model manual has only recently been distributed, the States probably have not yet been able to adopt it for their use. Therefore, to ensure that the State CDL manuals reflect the full range of risks posed by manual adjustment of ASAs, the Safety Board believes that when the 50 States and the District of Columbia incorporate the information on ASAs from the new AAMVA model Commercial Driver License Manual into their CDL manuals, they should include a statement that the manual adjustment of ASAs is dangerous because it gives the vehicle operator a false sense of security about the effectiveness of the braking system. In addition, the Safety Board will write a drop-in article for the AAMVA’s Move magazine. The article will explain that the States need to include material in their CDL manuals stating that manual adjustment of ASAs is a dangerous practice that can have serious consequences, because it gives the operator a false sense of security about the effectiveness of the brakes, which are likely to go out of adjustment again soon. The revision of the model CDL manual should help ensure that new CDL drivers are cautioned against manually adjusting ASAs, because drivers seeking CDLs usually use the manual to prepare for CDL qualification. However, the U.S. Department of Labor estimates that the total number of active CDL holders is about 2.9 million, and recent OOIDA and CVSA survey results suggest that a high proportion of experienced CDL drivers do not understand ASAs. In addition, about one-third of the brakes placed out of service for being out of adjustment have ASAs, which indicates that brake adjustment remains a serious maintenance and safety problem. As the Glen Rock, El Cerrito, and other accidents demonstrate, truck drivers, mechanics, and inspectors need to be better informed about the proper operation and maintenance of air brakes in general and ASAs in particular. The CVSA has recognized the importance of air brake education and proper brake adjustment. It developed and, during the 2004 and 2005 Operation Air Brake campaigns, distributed a pamphlet entitled Air Brake Adjustment—Why is it so important? The pamphlet includes clear language warning that manually adjusting an ASA is a temporary way to bring a brake into compliance (with out-of-service adjustment limits) but will not fix the underlying problem. The Safety Board commends this effort and encourages the CVSA to give additional emphasis to this critical safety issue. The Safety Board believes that the CVSA should revise its pamphlet, Air Brake Adjustment—Why is it so important?,

Analysis 45 Highway Accident Report to emphasize that the manual adjustment of ASAs is a dangerous practice that can have serious consequences, because it gives the operator a false sense of security about the effectiveness of the brakes, which are likely to go out of adjustment again soon. In addition, in a further effort to reach drivers, operators, mechanics, and others in the trucking industry, the Safety Board will write a drop-in article for Transport Topics, the magazine of the ATA, which has wide distribution in the general trucking industry. The article will include information about the risks associated with manually adjusting ASAs. Some drivers and owners of vehicles equipped with air brakes may not interact with the CVSA, the FMSCA, or the ATA. They include fire departments, construction workers and companies, nursery and landscaping companies, and recreational vehicle owners. To reach these drivers and owners, the Safety Board will contribute drop-in articles on the risks associated with manually adjusting ASAs to industry, trade, and other groups, including the International Association of Fire Chiefs, the American Nursery and Landscape Association, the National Private Truck Council, the National Recreational Vehicle Owners Club, and the Associated General Contractors of America, for their publications. In addition, the CVSA air brake adjustment pamphlet could be distributed at campgrounds and recreational vehicle parks. The ASE certifies brake repair and service professionals who maintain trucks, and its medium-heavy truck tests include test T4 for brakes. Given the widespread lack of awareness of the problems associated with manually adjusting ASAs in the trucking industry, the ASE should emphasize the risks associated with manually adjusting ASAs in its testing materials. As far as the Safety Board can determine, the T4 certification test does not currently address the manual adjustment of ASAs. Therefore, the Safety Board believes that the ASE should include the following information in its T4 brake certification testing materials: manually adjusting ASAs is dangerous and should not be done, except during installation or in an emergency to move the vehicle to a repair facility, because manual adjustment of this brake component (1) fails to address the true reason why the brakes are not maintaining adjustment, giving the operator a false sense of security about the effectiveness of the brakes, which are likely to go out of adjustment again soon, and (2) causes abnormal wear to the internal adjusting mechanism for most ASAs, which may lead to failure of this brake component. The ASE does not publish study guides or manuals on its certification tests, but several companies do publish such guides.91 The Safety Board’s examination of several private study guides for the ASE’s medium-heavy truck T4 brake test showed that they inadequately cover the maintenance of ASA-equipped brakes, and some contain incorrect information. One study guide wrongly states, “Automatic slack adjusters may require periodic adjustment.” Many mechanics use the study guides as a source of general maintenance information, as well as for test preparation, making it imperative that these guides contain thorough and accurate information about ASAs. Therefore, the Board believes that the publishers of ASE certification test study guides should include the following information in their guides: manually adjusting ASAs is dangerous and should 91  The leading publishers are Motor Age, Mitchell 1, and Thompson Delmar Learning.

Analysis 46 Highway Accident Report not be done, except during installation or in an emergency to move the vehicle to a repair facility, because manual adjustment of this brake component (1) fails to address the true reason why the brakes are not maintaining adjustment, giving the operator a false sense of security about the effectiveness of the brakes, which are likely to go out of adjustment again soon, and (2) causes abnormal wear to the internal adjusting mechanism for most ASAs, which may lead to failure of this brake component. Evidence from the Glen Rock accident suggests that some truck inspectors who carry out State annual inspections do not understand that if an ASA-equipped brake is out of adjustment, something is wrong with the adjuster or another foundation brake component and that manually adjusting the ASA merely masks the problem. Two different mechanics manually adjusted the ASAs on the Glen Rock accident truck several times. Both mechanics were Pennsylvania State-certified truck inspectors. Truck inspectors who perform annual inspections in the 23 other States (and the District of Columbia) that have State commercial vehicle inspection programs may be similarly unaware that manually adjusting ASAs is a dangerous and inappropriate response to an out-of-adjustment brake. Therefore, the Safety Board believes that the District of Columbia and the 24 States that have commercial vehicle inspection programs should include in their truck inspector training courses a module on ASAs that emphasizes that manually adjusting ASAs is dangerous and should not be done, except during installation or in an emergency to move the vehicle to a repair facility, because manual adjustment of this brake component (1) fails to address the true reason why the brakes are not maintaining adjustment, giving the operator a false sense of security about the effectiveness of the brakes, which are likely to go out of adjustment again soon, and (2) causes abnormal wear to the internal adjusting mechanism for most ASAs, which may lead to failure of this brake component. During a Maryland roadside inspection on April 10, 2002, the Glen Rock accident truck was placed out of service for out-of-adjustment brakes. The driver at the time manually adjusted the brakes before departing the inspection site, an action that is not uncommon. The Safety Board found no indication that the brakes were subsequently examined to determine why they had gone out of adjustment. The inspector who conducted the roadside inspection evidently did not indicate that troubleshooting should be conducted to determine the underlying problem that was causing the brakes to be out of adjustment. The CVSA has recognized the importance of air brake education and proper brake adjustment and has distributed materials informing drivers that manually adjusting an ASA will not remedy the underlying problem with an out-of-adjustment brake and is only a temporary fix; however, the CVSA North American Standard Inspection materials used to train roadside inspectors are silent on the subject. CVSA-trained roadside inspectors should be educated about the dangers of manually adjusting ASAs. The CVSA and the FMCSA National Training Center maintain the North American Standard Inspection training materials. Therefore, the Safety Board believes that the CVSA and the FMCSA should work together to develop and add to the North American Standard Inspection training materials a module that emphasizes that manually adjusting ASAs is dangerous and should not be done, except during installation or in an emergency to move the vehicle to a repair facility, because manual adjustment of this brake component (1) fails to address

Analysis 47 Highway Accident Report the true reason why the brakes are not maintaining adjustment, giving the operator a false sense of security about the effectiveness of the brakes, which are likely to go out of adjustment again soon, and (2) causes abnormal wear to the internal adjusting mechanism for most ASAs, which may lead to failure of this brake component. Truck manufacturers’ manuals afford yet another means of improving industry awareness of the risks associated with manually adjusting ASAs. The Ford owner’s manual for a model 2003 F650/750, which is similar to the Glen Rock accident truck, states that ASAs should be checked for adjustment every 4 months, or 20,000 miles, and more frequently if operated in hilly or mountainous regions or in mud. It does not inform drivers or mechanics about the dangers involved in adjusting ASAs. The Safety Board, through the Truck Manufacturers Association, queried medium-heavy truck manufacturers to determine what information, if any, they provide regarding the manual adjustment of ASAs. Freightliner, the only manufacturer to respond to the inquiry, indicated that its manuals are silent on the subject. Freightliner advised Safety Board investigators that it will revise its driver, maintenance, and service manuals to include cautions about manually adjusting ASAs when it next updates its manuals. To ensure that the manufacturers of vehicles equipped with air brakes provide appropriate guidance to vehicle operators, the Safety Board believes that the manufacturers should revise their product manuals to include conspicuously placed wording that clearly states that ASAs should not be manually adjusted in an effort to correct excessive pushrod stroke, because this condition indicates that a problem exists with the automatic adjuster, with the installation of the adjuster, or with related foundation brake components, which manual adjustment will not fix. Further, the product manuals should state that manual adjustment of ASAs is a dangerous practice that could have serious consequences, because it gives the operator a false sense of security about the effectiveness of the brakes, which are likely to go out of adjustment again soon. Knowledge and Skills Needed to Drive Air Brake-Equipped Vehicles Although the Glen Rock accident driver said that he slowed the truck before starting down the hill, he did not select a lower gear, which would have provided engine braking, an action recommended by the AAMVA model Commercial Driver License Manual and experienced truck drivers. Had he used a lower gear, the vehicle would have slowed due to normal engine compression. In addition, he pumped the brakes, reducing the capability of the front brakes and exacerbating the loss of braking capability in the out- of-adjustment rear brakes. Until recent widespread use of ABS brakes, drivers of hydraulically braked vehicles (passenger cars, sport utility vehicles, and pickups and other light-duty trucks) were taught to pump their brakes in emergencies.92 But in an air-braked vehicle, pumping the brakes depletes the air pressure, thereby drastically reducing the brakes’ capability. 92  Although ABS brakes were introduced in the 1970s, they were not widely used until the 1990s. ABS brakes are designed to help prevent a vehicle from skidding. The brakes are controlled by a computer that senses whether the tires are maintaining friction with the pavement or are sliding. For ABS brakes, steady brake pedal pressure is prescribed. Pumping the brake pedal defeats the purpose of ABS.

Analysis 48 Highway Accident Report The Glen Rock accident driver did not hold a CDL and he had not passed an air brake knowledge test; neither was required by regulation for him to drive the accident truck. The Glen Rock accident truck had a GVWR of 26,000 pounds and, for CDL licensing purposes, 49 CFR 383.5 defines a commercial vehicle as a motor vehicle that has a GVWR of 26,001 pounds or more. Consequently, the accident driver was not required to have a CDL to drive the accident truck. According to his statement, the driver had never received instruction on air brake operation. Also, although a road test is required by regulation, the motor carrier had not given the driver such a test in the accident truck. The accident driver said that he had been told that if the brake light came on, he had no [air] pressure, but it is not clear whether he understood what this meant. Therefore, the Safety Board concludes that the Glen Rock accident driver lacked the knowledge and skills required to safely drive an air brake-equipped vehicle; as a result, he did not select a lower gear before proceeding down the hill and he pumped the brakes, which depleted the available brake air pressure. Air brakes and hydraulic brakes operate differently. Because of these differences, drivers of air-braked vehicles need special instruction about how they function. In the United States, licensed drivers who do not hold CDLs are not typically given information about the operation of air brake systems, and they are not tested about air brakes before they are permitted to drive vehicles equipped with them. In contrast, the CDL licensing program recognizes that drivers need to be aware of the special characteristics of air brake systems and has established knowledge and skill requirements for operating them safely. The AAMVA model Commercial Driver License Manual contains a section that specifically addresses air brake knowledge. If a CDL applicant wants to be licensed to drive an air brake-equipped vehicle, the applicant is required93 to take a separate knowledge test and demonstrate proficiency in the inspection and operation of air brake systems. If a CDL applicant fails to pass the air brake knowledge and skills tests, the applicant is prohibited from driving vehicles with air brake systems. However, a non-CDL driver is not restricted from driving an air brake-equipped vehicle, whether in commercial or noncommercial use. Thus, no measures are in place to ensure that the drivers of air brake-equipped vehicles weighing less than 26,000 pounds have the knowledge and skills necessary for their safe operation. Canada has recognized the importance of air brake system proficiency in its licensing system. Since 2001, Transport Canada has required that all drivers who drive any vehicle equipped with air brakes obtain an air brake endorsement. Transport Canada reports that Canada has experienced a reduction in brake-related accidents since the adoption of this requirement. Also, between September 1999 and September 2004, Canada experienced a 25-percent reduction in brakes found to be out of adjustment to the point of being out of service.94 U.S. accident statistics show that about one-third of straight truck accidents involve drivers who do not have CDLs.95 Studies suggest that a significant portion of these 93  Title 49 CFR 383.95 and 383.113(c). 94  From Operation Air Brake data for 1999 through 2004. 95  Matteson and Blower, Trucks Involved in Fatal Accidents Factbook 2000.

Analysis 49 Highway Accident Report accidents involve braking problems.96 Data from the 2002 vehicle inventory and use survey97 indicate that at least 30 percent (516,110) of trucks in the 19,501- to 26,000- pound weight class are equipped with air brakes. In addition, Freightliner and International data for new vehicles indicate that about 80 percent and 40 percent, respectively, of these manufacturers’ new vehicles in this weight class are equipped with air brakes. These vehicles are in operation today (both in commercial and noncommercial use), and drivers without CDLs may legally operate them. Therefore, the Safety Board concludes that more than 500,000 vehicles equipped with air brakes may be operated by drivers who, like the Glen Rock truck driver, have no air brake training and thus may not be able to operate their vehicles safely. To summarize, under the CDL program, each State has an air brake testing requirement, information in its CDL manual concerning air brakes, and a test for air brake systems. However, non-CDL drivers are not required to fulfill any air brake knowledge or testing requirement before driving an air brake-equipped vehicle. Further, a CDL is not required to drive a commercial vehicle with a GWVR of 26,000 pounds or less. So two major categories of drivers—commercial drivers who are not required to hold CDLs and noncommercial drivers—may not receive any air brake training or testing before they drive air brake-equipped vehicles. As this accident demonstrates, all drivers should receive specialized training in using air brakes before driving a vehicle equipped with them. The FMCSA regulates commercial vehicle operations and commercial driver licensing. Therefore, the Safety Board believes that the FMCSA should require drivers of commercial vehicles that weigh less than 26,000 pounds and are equipped with air brakes to undergo training and testing to demonstrate proficiency in the inspection and operation of air-braked vehicles; the training should emphasize that manually adjusting ASAs is dangerous and should not be done, except during installation or in an emergency to move the vehicle to a repair facility. Further, to address the issue of untrained noncommercial drivers driving air brake- equipped vehicles, the Safety Board believes that the 50 States and the District of Columbia should adopt an air brake endorsement for drivers’ licenses that would require training and testing of drivers who drive air brake-equipped vehicles to ensure their proficiency in the operation of air-braked vehicles; the training should emphasize that manually adjusting ASAs is dangerous and should not be done, except during installation or in an emergency to move the vehicle to a repair facility. Currently, the States are equipped to provide air brake testing for CDL drivers who wish to remove the air brake restriction from their licenses. The States could extend such testing to commercial drivers of vehicles that weigh less than 26,000 pounds and are equipped with air brakes, as well as to noncommercial drivers who drive air-braked vehicles. In addition, 32 States have a classified license system, which should facilitate the implementation of air brake knowledge and skills testing for noncommercial drivers. 96  GAO-03-436, March 2003, and FMCSA-PSV-04-001, December 2003. 97  The Safety Board analyzed the raw data from the 2002 Economic Census, Vehicle Inventory and Use Survey, using the GVWR information from the Vehicle Identification Numbers.

Analysis 50 Highway Accident Report Motor Carrier Oversight Blossom Valley Blossom Valley employed a driver who had no experience driving air brake- equipped vehicles, did not train him in air brake use or pretrip inspection, and put him on the road in an air brake-equipped vehicle with out-of-adjustment rear brakes. In addition, the truck was loaded beyond its rated weight, and the driver was dispatched on a route that included a section of road the vehicle was not permitted to be on even when empty. (Apparently, the carrier ignored this routing prohibition after the accident as well. On March 10, 2004, another Blossom Valley truck was ticketed for traveling overweight down Church Street.) Moreover, the carrier did not have a scheduled maintenance program for its vehicles, did not have a drug and alcohol testing program, and did not maintain driver qualification files or keep time records on its drivers, all of which the FMCSA requires motor carriers to do. The Safety Board concludes that Blossom Valley did not exercise proper oversight of its drivers, vehicles, or operation, as evidenced by its sending an untrained truck driver in an overloaded vehicle with out-of-adjustment brakes on a route over a weight-restricted street; the carrier also failed to implement a scheduled vehicle maintenance program and to fulfill drug and alcohol testing and record-keeping requirements. In 2005, Blossom Valley Farms, Inc., in Pennsylvania was sold, and the new nursery does not make deliveries. Educating Motor Carriers The owner of Blossom Valley knew enough about motor carrier operational requirements to register with the USDOT. To obtain operating authority, the owner had to sign an FMCSA Form 150, Motor Carrier Identification Report (application for a USDOT number), which contains a statement indicating that the carrier understands the FMCSRs (and/or the Federal Hazardous Materials Regulations). However, Blossom Valley’s owner told investigators that, before the accident, he was unaware of the FMCSRs’ requirements as they applied to Blossom Valley operations. Consequently, the carrier did not adhere to the FMCSRs. The FMCSA has taken steps to educate carriers about their responsibilities under the FMCSRs. For instance, since January 1, 2003, all new motor carriers (private and for- hire) operating in interstate commerce must apply for registration (obtain a USDOT number) as a “new entrant.” According to the FMCSA,98 after the carrier receives its new entrant registration, it is subject to an 18-month-long safety-monitoring period, during which it will receive a safety audit and have its roadside crash and inspection information closely evaluated. The carrier will be required to demonstrate that it has the necessary systems in place to ensure basic safety management controls. Failure to do so may result in the carrier having its new entrant registration revoked. In FY 2003–2004, the FMCSA and the States, respectively, conducted 7,205 and 25,316 new entrant safety audits. Blossom Valley had registered with the USDOT in 1987, about 16 years before the FMCSA’s new entrant program was implemented and so was not subject to a safety-monitoring period. 98   See http://www.fmcsa.dot.gov/registration-licensing/registration/new-entrant.htm.

Analysis 51 Highway Accident Report The FMCSA’s compliance monitoring activities can also be helpful in instructing carriers about their responsibilities, because FMCSA inspectors generally treat a first compliance review as an educational visit. However, recent compliance monitoring activity indicates that the FMCSA and the States together conduct only about 11,300 compliance reviews each year. In FY 2004, active interstate truck and bus companies numbered 677,249, many of which were unrated carriers. Thus, FMCSA compliance activities affecting unrated carriers are limited and may not serve to educate many small, private motor carriers about the requirements they must meet. In fact, the FMCSA had not conducted a compliance review of Blossom Valley before the accident (nor assigned it a safety rating), so Blossom Valley was an unrated carrier, and this program did not enhance the carrier’s understanding of its responsibilities under Federal regulations. The FMCSA also has educational material on its Web site, including a link to A Motor Carrier’s Guide to Improving Highway Safety. This booklet provides information for commercial vehicle owners unfamiliar with the FMCSA and addresses the Federal regulations applicable to commercial vehicle operation. Despite the FMCSA’s educational efforts, Blossom Valley was evidently unaware of, and failed to fulfill, its responsibilities as a motor carrier under the FMCSRs. Given Blossom Valley’s deficient understanding of its responsibilities as a motor carrier, the Safety Board concludes that the FMCSA’s efforts to educate motor carriers about their responsibilities under Federal safety regulations have not reached all small, private, unrated carriers. The Safety Board recently issued a report on an accident in Tallulah, Louisiana,99 involving a motorcoach operated by a church group that did not realize it qualified as a motor carrier under Federal regulations. As a result of the October 13, 2003, accident, eight motorcoach passengers sustained fatal injuries, and the motorcoach driver and six passengers received serious injuries. On April 27, 2005, the Safety Board issued the following safety recommendation to the FMCSA: H-05-2 Develop and distribute educational materials for nontraditional commercial vehicle owners, such as church groups, on how to comply with the Federal Motor Carrier Safety Regulations; at a minimum, the materials should be posted on the Federal Motor Carrier Safety Administration Web site. The category “nontraditional commercial vehicle owners” includes small, private carriers such as Blossom Valley, and vigorous implementation of this recommendation may improve compliance with the FMCSRs on the part of such carriers. In a letter dated September 30, 2005, the FMCSA responded to Safety Recommendation H-05-2, indicating that it is “developing an educational brochure to increase the safety awareness and regulatory compliance of private motor carriers of passengers.” The Safety Board is reviewing the response. 99  National Transportation Safety Board, Motorcoach Run-Off-The-Road Accident, Tallulah, Louisiana, October 13, 2003, Highway Accident Report NTSB/HAR-05/01 (Washington, DC: NTSB, 2005).

Analysis 52 Highway Accident Report FMCSA Carrier Safety Rating Systems On April 10, 2002, about 1 year before this accident, the accident truck underwent a CVSA level 1 roadside inspection and was placed out of service. This roadside inspection was the only one conducted on a Blossom Valley vehicle in 2002, so the FMCSA’s SafeStat records showed the carrier with a 100-percent out-of-service rate for the year. However, the ISS-2 data for the carrier would not have included Blossom Valley’s out-of-service rate because the carrier had not undergone a FMCSA compliance review during its 16 years of operation; consequently, the system considered Blossom Valley “not rated.” Thus, Blossom Valley would have had an ISS-2 inspection value of 65 (inspection optional) a few weeks before the accident, based on “insufficient information,” because the carrier had not undergone a compliance review and was unrated at the time. A postaccident ISS-2 query for Blossom Valley conducted on September 19, 2003, indicated that the carrier’s inspection value was 82 (inspection warranted), as a result of the carrier’s postaccident compliance review safety rating of “Conditional,” which derived from an “Unsatisfactory” rating in the vehicle factor. Since the Glen Rock accident, two Blossom Valley vehicles have undergone roadside inspections that resulted in out-of- service vehicles, maintaining the carrier’s 100-percent out-of-service rate, and Blossom Valley’s safety rating remains “Conditional.” However, because the ISS-2 system automatically reduces an infraction score over time, a September 23, 2005, ISS-2 query indicated that the carrier’s inspection value was 73, placing it in the “inspection optional” category even though nothing about its safety posture had changed. The SafeStat system still showed the carrier with an out-of-service rate of 100 percent, and the compliance review rating was still “Conditional.” The ISS-2 system gives the carrier the benefit of the doubt and assumes it will improve its safety standing, regardless of whether it does so. The Safety Board therefore concludes that the FMCSA’s ISS-2 system does not always give an accurate and timely picture of a carrier’s safety posture, thereby reducing its effectiveness as a screening mechanism. The Safety Board understands that, in response to a recent USDOT, Office of the Inspector General, report,100 the FMCSA is making changes to the SafeStat and ISS-2 systems. The Safety Board’s report of the June 23, 2002, Victor, New York, motorcoach accident101 thoroughly discussed the inadequacies of SafeStat and the ISS-2 system, as well as the Inspector General’s recommendations. The facts about Blossom Valley’s FMCSA safety rating uncovered during the Glen Rock investigation underscore the Safety Board’s concerns, expressed in the Victor report, about the limitations of the FMCSA’s safety rating systems for motor carriers. The comparatively positive inspection value that Blossom Valley continues to maintain in the ISS-2 system, despite the carrier’s clear safety inadequacies, emphasizes the need for the FMCSA to improve its carrier safety rating systems. 100  U.S. Department of Transportation, Office of the Inspector General, Improvements Needed in the Motor Carrier Safety Status Measurement System, Audit Report MH-2004-034 (Washington, DC: USDOT, 2004). 101  National Transportation Safety Board, Motorcoach Run-off-the-Road and Rollover Off Interstate 90, Victor, New York, June 23, 2002, Highway Accident Report NTSB/HAR-04/03 (Washington, DC: NTSB, 2004).

53 Highway Accident Report Conclusions Findings 1. Although the highway’s design included a steep grade, it was appropriately signed and, therefore, was not a factor in the accident; also, the emergency response was effective and appropriate. 2. Based on the truck driver’s statements about pumping the brakes, postaccident examination of the brakes, and results from computer simulations, the accident truck did not have sufficient braking capability to stop before the initial impact with the stopped cars. 3. Although it cannot be determined if drugs or fatigue impaired the driver’s performance, he most likely could not have stopped the truck before the accident occurred. 4. At the time of the accident, the automatic slack adjusters for all four of the accident truck’s brakes were capable of working properly; however, the quick-connect clevises and clevis pins for both rear brakes were worn to the extent that they prevented the automatic slack adjusters from properly adjusting the brakes, thereby reducing the capability of the rear brakes. 5. The drivers and mechanics who manually adjusted the automatic slack adjusters on the trucks involved in the Glen Rock and El Cerrito accidents did not look for underlying problems with the adjusters or related foundation brake components; consequently, they misdiagnosed the brake problems, probably because they were not properly educated on the function and care of automatic slack adjusters and how they relate to foundation brake systems. 6. The warnings in existing materials available to owners, drivers, mechanics, and inspectors of air-braked vehicles equipped with automatic slack adjusters have not been successful in communicating the inherent dangers of manually adjusting automatic slack adjusters to correct out-of-adjustment brakes. 7. The Glen Rock accident driver lacked the knowledge and skills required to safely drive an air brake-equipped vehicle; as a result, he did not select a lower gear before proceeding down the hill and he pumped the brakes, which depleted the available brake air pressure. 8. More than 500,000 vehicles equipped with air brakes may be operated by drivers who, like the Glen Rock truck driver, have no air brake training and thus may not be able to operate their vehicles safely.

Conclusions 54 Highway Accident Report 9. Blossom Valley Farms, Inc., did not exercise proper oversight of its drivers, vehicles, or operation, as evidenced by its sending an untrained truck driver in an overloaded vehicle with out-of-adjustment brakes on a route over a weight-restricted street; the carrier also failed to implement a scheduled vehicle maintenance program and to fulfill drug and alcohol testing and record-keeping requirements.

1. The Federal Motor Carrier Safety Administration’s efforts to educate motor carriers

about their responsibilities under Federal safety regulations have not reached all small, private, unrated carriers.

1. The Federal Motor Carrier Safety Administration’s Inspection Selection System does

not always give an accurate and timely picture of a carrier’s safety posture, thereby reducing its effectiveness as a screening mechanism. Probable Cause The National Transportation Safety Board determines that the probable cause of this accident was the lack of oversight by Blossom Valley Farms, Inc., which resulted in an untrained driver improperly operating an overloaded, air brake-equipped vehicle with inadequately maintained brakes. Contributing to the accident was the misdiagnosis of the truck’s underlying brake problems by mechanics involved with the truck’s maintenance; also contributing was a lack of readily available and accurate information about automatic slack adjusters and inadequate warnings about the safety problems caused by manually adjusting them.

55 Highway Accident Report Recommendations As a result of its investigation, the National Transportation Safety Board makes the following safety recommendations: To the Federal Motor Carrier Safety Administration: Work with the Commercial Vehicle Safety Alliance to develop and add to the North American Standard Inspection training materials a module that emphasizes that manually adjusting automatic slack adjusters is dangerous and should not be done, except during installation or in an emergency to move the vehicle to a repair facility, because manual adjustment of this brake component (1) fails to address the true reason why the brakes are not maintaining adjustment, giving the operator a false sense of security about the effectiveness of the brakes, which are likely to go out of adjustment again soon, and (2) causes abnormal wear to the internal adjusting mechanism for most automatic slack adjusters, which may lead to failure of this brake component. (H-06-1) Require drivers of commercial vehicles that weigh less than 26,000 pounds and are equipped with air brakes to undergo training and testing to demonstrate proficiency in the inspection and operation of air-braked vehicles; the training should emphasize that manually adjusting automatic slack adjusters is dangerous and should not be done, except during installation or in an emergency to move the vehicle to a repair facility. (H-06-2) To the District of Columbia and the 50 States: When you incorporate the information on automatic slack adjusters from the new American Association of Motor Vehicle Administrators model Commercial Driver License Manual into your Commercial Driver’s License manual, include a statement that the manual adjustment of automatic slack adjusters is dangerous because it gives the vehicle operator a false sense of security about the effectiveness of the braking system. (H-06-3) Adopt an air brake endorsement for drivers’ licenses that would require training and testing of drivers who drive air brake-equipped vehicles to ensure their proficiency in the operation of air-braked vehicles; the training should emphasize that manually adjusting automatic slack adjusters is dangerous and should not be done, except during installation or in an emergency to move the vehicle to a repair facility. (H-06-4)

Recommendations 56 Highway Accident Report To the District of Columbia and the 24 States (Alabama, Arkansas, California, Connecticut, Hawaii, Illinois, Louisiana, Maine, Maryland, Michigan, Minnesota, New Hampshire, New Jersey, New York, Ohio, Oklahoma, Pennsylvania, Rhode Island, Texas, Utah, Vermont, Virginia, West Virginia, and Wisconsin) that have commercial vehicle inspection programs: Include in your truck inspector training courses a module on automatic slack adjusters that emphasizes that manually adjusting automatic slack adjusters is dangerous and should not be done, except during installation or in an emergency to move the vehicle to a repair facility, because manual adjustment of this brake component (1) fails to address the true reason why the brakes are not maintaining adjustment, giving the operator a false sense of security about the effectiveness of the brakes, which are likely to go out of adjustment again soon, and (2) causes abnormal wear to the internal adjusting mechanism for most automatic slack adjusters, which may lead to failure of this brake component. (H-06-5) To the Commercial Vehicle Safety Alliance: Revise your pamphlet, Air Brake Adjustment—Why is it so important?, to emphasize that the manual adjustment of automatic slack adjusters is a dangerous practice that can have serious consequences, because it gives the operator a false sense of security about the effectiveness of the brakes, which are likely to go out of adjustment again soon. (H-06-6) Work with the Federal Motor Carrier Safety Administration to develop and add to the North American Standard Inspection training materials a module that emphasizes that manually adjusting automatic slack adjusters is dangerous and should not be done, except during installation or in an emergency to move the vehicle to a repair facility, because manual adjustment of this brake component (1) fails to address the true reason why the brakes are not maintaining adjustment, giving the operator a false sense of security about the effectiveness of the brakes, which are likely to go out of adjustment again soon, and (2) causes abnormal wear to the internal adjusting mechanism for most automatic slack adjusters, which may lead to failure of this brake component. (H-06-7) To Haldex Brake Products Corporation, Bendix Commercial Vehicle Systems LLC, Bendix Spicer Foundation Brake LLC, Gunite Corporation, ArvinMeritor, Inc., and Crewson Industries, Inc. (manufacturers and marketers of automatic slack adjusters): Revise your product literature to include conspicuously placed wording that clearly states that automatic slack adjusters should not be manually adjusted in an effort to correct excessive pushrod stroke, because this condition indicates that a problem exists with the automatic adjuster, with the installation of the adjuster, or with related foundation brake components, which manual adjustment will not fix. Further, the literature

Recommendations 57 Highway Accident Report should state that manual adjustment of automatic slack adjusters is a dangerous practice that could have serious consequences, because it gives the operator a false sense of security about the effectiveness of the brakes, which are likely to go out of adjustment again soon. (H-06-8) To Freightliner LLC, Mack Trucks, Inc., International Truck and Engine Corporation, Kenworth Truck Company, Peterbilt Motors Company, Volvo Trucks North America, Inc., Ford Motor Company, General Motors Corporation, Hino Motor Sales U.S.A., Inc., and Nissan Diesel America Incorporated (manufacturers of vehicles equipped with air brakes): Revise your product manuals to include conspicuously placed wording that clearly states that automatic slack adjusters should not be manually adjusted in an effort to correct excessive pushrod stroke, because this condition indicates that a problem exists with the automatic adjuster, with the installation of the adjuster, or with related foundation brake components, which manual adjustment will not fix. Further, the product manuals should state that manual adjustment of automatic slack adjusters is a dangerous practice that could have serious consequences, because it gives the operator a false sense of security about the effectiveness of the brakes, which are likely to go out of adjustment again soon. (H-06-9) To the National Institute for Automotive Service Excellence: Include the following information in your T4 brake certification testing materials: manually adjusting automatic slack adjusters is dangerous and should not be done, except during installation or in an emergency to move the vehicle to a repair facility, because manual adjustment of this brake component (1) fails to address the true reason why the brakes are not maintaining adjustment, giving the operator a false sense of security about the effectiveness of the brakes, which are likely to go out of adjustment again soon, and (2) causes abnormal wear to the internal adjusting mechanism for most automatic slack adjusters, which may lead to failure of this brake component. (H-06-10) To Motor Age, Mitchell 1, and Thompson Delmar Learning (publishers of National Institute for Automotive Service Excellence certification test study guides): Include the following information in your National Institute for Automotive Service Excellence study guides: manually adjusting automatic slack adjusters is dangerous and should not be done, except during installation or in an emergency to move the vehicle to a repair facility, because manual adjustment of this brake component (1) fails to address the true reason why the brakes are not maintaining adjustment, giving the operator a false sense of security about the effectiveness of the brakes, which are likely to go out of adjustment again soon, and (2) causes

Recommendations 58 Highway Accident Report abnormal wear to the internal adjusting mechanism for most automatic slack adjusters, which may lead to failure of this brake component. (H-06-11) BY THE NATIONAL TRANSPORTATION SAFETY BOARD MARK V. ROSENKER Acting Chairman DEBORAH A. P. HERSMAN Member ELLEN ENGLEMAN CONNERS Member KATHRYN O’LEARY HIGGINS Member Adopted: February 7, 2006

59 Highway Accident Report Appendix A Investigation The National Transportation Safety Board was notified of the Glen Rock, Pennsylvania, accident on April 11, 2003. The Safety Board dispatched an investigative team on April 16, 2003, which included members from the Parsippany, New Jersey; Denver, Colorado; and Gardena, California, offices. Groups were established to investigate highway and vehicle factors, as well as motor carrier operations. Participating in the investigation were representatives of the Federal Motor Carrier Safety Administration, the Pennsylvania Department of Transportation, the Pennsylvania State Police, the Southern Regional Police Department, and the Gunite Corporation.

60 Highway Accident Report Appendix B Results of Safety Board Computer Simulations of Accident Events Sim. no. Initial speed (mph) In gear (Y/N) Brake forces (drag or pulse) Time 10 to 15 (psi) Time 30 (psi) Time 50 (psi) Highest speed (mph) Lowest speed (mph) Able to stop (speed end) Length sim. (sec.) Brake drum temp. (°F) Brake lining temp. (°F) 1 1 Y Drag 12 75.2 77.7 27 0 Y 92.7 737 485 2 1 Y Drag 12 65.2 67.7 26 0 Y 82.4 676 438 3 1 Y Drag 12 65.2 67.7 26 0 Y 81.7 669 430 4 1 Y Drag 22

85.2

26 1 N (30) 86.2 588 399 5 1 Y Drag 32

80.5

27 1 N (33) 81.8 546 358 6 1 Y Drag

32

-- 37 1 N (37) 73 540 323 7 1 Y Drag

32

72 37 1 N (36) 73 516 320 8 25 Y Drag 3 79.3 81.8 27 16 N (16) 87.7 761 500 9 25 Y Drag 3 69.3 71.8 26 0 Y 85.1 763 506 10 25 Y Drag 3 59.3 61.8 27 0 Y 75.2 707 458 11 25 Y Drag 3 50.5 53 27 0 Y 66.6 656 417 12 25 Y Drag 3 40.5 43 27 0 Y 56.6 595 370 13 25 Y Drag 21 55.3 57.8 37 21 N (21) 67.4 768 408 14 25 Y Drag 39.5 50.5 53 48 25 N (40) 58.2 550 259 15 25 Y Drag 38 49 51.5 47 25 N (35) 59.1 638 289 16 35 Y Drag 3 40.5 43 40 0 Y 54.7 918 552 17 35 Y Drag 3 30.5 33 38 0 Y 53.9 838 489 18 35 Y Drag 3 20.5 23 38 0 Y 42.9 733 415 19 35 Y Drag 3 50.5 53 39 27 N (27) 60.6 850 474 20 35 Y Drag 3 53.5 56 39 34 N (34) 59.8 746 446 21 45 Y Drag 3 38 40.5 53 45 N (47) 45.4 771 401 22 45 Y Drag 3 28 30.5 51 17 N (17) 53.2 1170 642 23 45 Y Drag 3 34.5 37 52 34 N (36) 46.7 1012 489 24 55 Y Drag 3 34.5 37 59 53 N (53) 39.2 817 402 25 55 Y Drag 3 25.5 28 58 34 N (34) 42.1 1177 549 26 55 Y Drag 3 26 28.5 58 35 N (35) 41.8 1158 536 27 25 N

None

--

70 25 N (70) 46.6 150 150 28 1 N

None

--

67 1 N (67) 63.9 150 150 29 1 Y/N None Neutral at 11.6 sec 67 1 N (67) 61.9 150 150 30 1 Y Pulse 12

32

28 0 Y 80.1 570 416 31 1 Y Pulse 12 32 (pump down) 31 1 N (31) 119.6 573 504 32 1 Y Pulse 12 32 (pump down) 30 1 N (30) 118 543 480 33 1 Y Pulse 12 32 (pump down) 36 1 N (36) 111.4 488 431 34 25 Y Pulse 3 Pumped down to 0 36 25 N (36) 75.6 466 356 35 25 Y Pulse 3 Pumped down to 0 35 25 N (35) 75.6 456 349

61 Highway Accident Report Appendix C CVSA Pamphlet Air Brake Adjustment—Why is it so important? Commercial Vehicle Safety Alliance www.cvsa.org 1101 17th Street, N.W., Suite 803 Washington, DC 20036 Phone: 202-775-1623 • Fax: 202-775-1624 • www.cvsa.org Safety Security Promoting Commercial Motor Vehicle Safety and Security Air Brake A D J U S T M E N T Why is it so important? CONTACTS For information about commercial motor vehicle safety & security or to inquire about inspection training needs for law enforcement and industry Commercial Vehicle Safety Alliance (CVSA) 1101 17th Street NW Suite 803 Washington, DC 20036 (202) 775-1623 www.cvsa.org For further information about commercial motor vehicle safety in the U.S. Federal Motor Carrier Safety Administration (FMCSA) Office of Bus and Truck Standards and Operations 400 Seventh Street SW Washington, DC 20590 (202) 366-1790 www.fmcsa.dot.gov For further information about commercial motor vehicle safety in Canada Canadian Council of Motor Transport Administrators (CCMTA) 2323 St. Laurent Boulevard Ottawa, Ontario, Canada K1G 4J8 (613) 736-1003 www.ccmta.ca For further information about commercial motor vehicle safety in Mexico Autotransporte Federal Secretaría de Comunicaciones y Transportes (SCT) Czda. de las Bombas, No. 411 Coyoacan, DF Ciudad de Mexico 04920 52-55-56841514 www.sct.gob.mx

Refer to the chart below to identify the adjustment limit of each brake. Any brake that is stroking over its adjustment limit is “out of adjustment.” Why It’s So Helpful To Have Stroke Indicators On Your Brakes There are devices to help you measure pushrod stroke. Visual “stroke indicators” can be installed onto each brake to provide a moving pointer that strokes with the brake. Some stroke indicators will help you identify exactly where the adjustment limit is and whether the stroke is under or over it. Others only provide a convenient way to measure the stroke. Checking brake adjustment generally means you have to get under the vehicle and take measurements. Using certain types of stroke indicators makes this job much easier.You can get accurate measurements without having to crawl under the vehicle. What To Do When Your Brakes Are Out Of Adjustment When your brakes are out of adjustment, what you do about it depends on whether your vehicle has manual or automatic brake adjusters. How To Tell When Your Brakes Are Out Of Adjustment Brake adjustment is all about pushrod stroke. There’s only one way to tell when you’ve got a brake adjustment problem. You’ve got to “measure the stroke.” The parts inside a brake chamber can only stroke so far before the brake chamber “bottoms out.” When that happens, the brake chamber doesn’t produce any more force on the brakes.To prevent chamber “bottom out,” a brake’s stroke must never be longer than its “adjustment limit.” You need to measure to be sure your brakes are properly adjusted and adjustment limits are different for each size and type of brake chamber. So, you need to know the size and type of brake chambers on each vehicle you’re operating as well as their adjustment limit. You can get information about the size and type of brake chambers on a vehicle from a technician, a dealer or your employer. What About “Free-Stroke” & “Slack” The distance you can pull the brake by hand using a bar or lever is called its “slack” or “free-stroke.” This distance is generally 3/8 to 3/4 inch. You may get some indication of adjustment levels, but you can’t really confirm proper brake adjustment this way. Measuring “free-stroke” or “slack” doesn’t provide an accurate indication of brake adjustment. How To “Measure The Stroke”Properly Before doing anything, block the wheels, release the spring brakes and have a good look at the brakes. Each brake must be in its normal released position. Make sure nothing is obviously wrong or out of place. If your vehicle doesn’t have stroke indicators, you’ll have to mark each pushrod. Now, to “measure the stroke” properly, you’ll need to keep the spring brakes released, make sure your air pressure gauges show that you have 90 to 100 psi in the air tanks, shut the engine off and then make a full service brake application.You must have some way to hold the brake pedal down for this step. You must measure how far each brake has stroked. Often an estimate will do, but any brake that is close to the adjustment limit must be carefully measured. Adjustment limits for clamp-type brake chambers Check stroke with 90-100 psi in tanks and brakes fully applied SIZE MARKING OUTSIDE DIAMETER ADJUSTMENT LIMIT 6 none 4 1/2” (115mm) 1 1/4” (32mm) 9 none 5 1/4” (133mm) 1 3/8” (35mm) 12 none 5 11/16” (144mm) 1 3/8” (35mm) 16 none 6 3/8” (162mm) 1 3/4” (45mm) 16LS Square Ports, Tag & 6 3/8” (162mm) 2” (51mm) Marking 20 none 6 25/32” (172mm) 1 3/4” (45mm) 20LS Square Ports, Tag & 6 25/32” (172mm) 2” (51mm) Marking 24 none 7 7/32” (183mm) 1 3/4” (45mm) 24L ‘L’ and Stroke Tag 7 7/32” (183mm) 2” (51mm) 24LS Square Ports, Tag & 7 7/32” (183mm) 2 1/2” (64mm) Marking 30 none 8 3/32” (205mm) 2” (51mm) 30 ‘DD3’ (Bus/Coach) 8 1/8” (206mm) 2 1/4” (57mm) 30LS Square Ports, Tag & 8 3/32” (205mm) 2 1/2” (64mm) Marking 36 none 9” (228mm) 2 1/4” (57mm) Appendix C 62 Highway Accident Report

READJUSTING MANUAL BRAKE ADJUSTERS Manual brake adjusters must be readjusted on a regular basis. If your vehicle has manual brake adjusters, you can readjust them if you’ve had the proper training. READJUSTING AUTOMATIC BRAKE ADJUSTERS Automatic brake adjusters normally don’t require manual readjustment. If you have a brake that is over-stroking and it has an automatic brake adjuster, you have a problem with the brake or the adjuster. If you readjust it, you aren’t really fixing the problem. The same is true if someone else only readjusts it, the problem is still there. A manual readjustment may bring the brake back into compliance and improve the way the brake operates, but it will only be temporary. When you have automatic brake adjusters that are over-stroking, there are some things you need to know before you even think about readjusting them. You may be legally prohibited from readjusting automatic brake adjusters in some jurisdictions. Your employer may prohibit you from readjusting automatic brake adjusters. You shouldn’t readjust an automatic brake adjuster unless you have been trained on exactly how to do it. Readjusting an automatic brake adjuster improperly can damage it. The brake will go out of adjustment again until the cause of the problem is repaired. It can go out of adjustment very quickly. If the brake is over-stroking, you need to check the free stroke or slack before you decide to readjust it. If this distance is also longer than normal, a readjustment may temporarily correct the problem. You have to re-check the pushrod stroke and free- stroke or slack after re-adjusting the brake. The pushrod stroke must now be less than the adjustment limit and the free stroke or slack must be in its normal range. If either of these is not the case, do not proceed. The brake is defective. If you readjust the brake, you will have to take responsibility for doing so. This means you must continue to monitor it and report the problem at the first opportunity. If you hire someone to correct an over-stroking problem on a brake with an automatic adjuster, be sure they know what they are doing. YOU MUST MEASURE THE STROKE TO CONFIRM THAT A BRAKE IS PROPERLY ADJUSTED. FIGURES: The difference between the released and applied position of the brake linkage must be less than the adjustment limit. Brake Released Measure stroke at “A” or “B” with 90 to 100 psi in tank and brakes fully applied Appendix C 63 Highway Accident Report

Why It’s So Important To Keep Your Brakes Properly Adjusted As a professional driver, you know there will be times when you really need your brakes. Having good brakes can get you out of a bad situation when another driver makes a serious driving error or some event requires extreme braking. To be able to rely on your brakes in every driving situation, they must be properly adjusted. When your brakes aren’t properly adjusted, they will let you down. Trucks that don’t stop the way they should can put people’s lives at risk, including your own. Trucks and trailers that operate with brakes out of adjustment are the most common reasons that drivers and vehicle operators are charged with violations. By taking the time to properly check brake adjustment, you’ll make sure your vehicle is safe and you’ll also avoid being charged with a violation. Whenever checking the brake adjustment, always be on the lookout for other defects like: damaged, broken or missing components, rusty drums and brakes that aren’t working. Appendix C 64 Highway Accident Report

65 Highway Accident Report Appendix D Previous Safety Board Recommendations on Brake Adjustment and Inspection Issues Brake Adjustment Guidelines. In 1975, the Safety Board investigated an accident involving a tractor-semitrailer that lost braking capability while descending a steep grade near Bishop, California.1 The vehicle began accelerating at a point 5 to 5 1/2 miles from a truck parking area, where the driver had stopped to adjust the brakes. While the driver was attempting to negotiate a curve, the trailer separated from the tractor, overturned in front of a pickup truck and attached camper-trailer traveling in the opposite direction, and struck the other vehicle, causing it to burst into flames. All seven occupants were killed. As a result, the Safety Board recommended that the Federal Highway Administration (FHWA): H-75-17 Develop and disseminate throughout the motor carrier industry, an “On Guard” bulletin alerting drivers of commercial vehicles equipped with externally adjustable braking systems of: a) the need to be familiar with company policies and practices with respect to on-road adjustment of brakes; b) methods and techniques for detecting potential or existing problems in adjustment; c) the scope of the problem in insuring proper brake adjustment; d) methods or techniques for the proper on-road adjustment of braking systems currently and generally in use. In response, the FHWA developed a bulletin entitled Danger-Driver Adjusted Brakes, which was circulated to all carriers for display on bulletin boards and distribution to drivers and safety supervisors. The Safety Board classified this recommendation “Closed—Acceptable Action” on October 20, 1977. A similar recommendation resulted from the Safety Board’s 1992 safety study on heavy vehicle air brake performance.2 The Safety Board recommended that the National Private Truck Council, the Owner-Operator Independent Driver Association, and the American Trucking Associations, Inc., (ATA) work with one another 1  National Transportation Safety Board, Francisco Flores Truck/Pickup Truck with Camper and Trailer Collision, U.S. Route 395, Bishop, California, June 29, 1974, Highway Accident Report NTSB/HAR-75/05 (Washington, DC: NTSB, 1975). 2  National Transportation Safety Board, Heavy Vehicle Airbrake Performance, Safety Study NTSB/SS-92/01 (Washington, DC: NTSB, 1992).

Appendix D 66 Highway Accident Report H-92-67, -72, and -74 To complete and distribute to member carriers appropriate brake maintenance materials that clearly establish standard inspection techniques (including adjustment indicators), inspection and adjustment interval guidelines, and an adjustment method (covering both manual and automatic slack adjusters) for S-cam brakes on heavy vehicles. Encourage members to provide a copy of the information to each driver of a heavy vehicle and to each mechanic who services heavy vehicles. On July 29, 2002, the Safety Board classified Safety Recommendation H-92-67 to the National Private Truck Council “Closed—Unacceptable Action/No Response Received.” In 1993, the Owner-Operator Independent Driver Association produced and distributed more than 15,000 copies of a brake videotape and accompanying booklet, entitled What’s Stopping You?, which stressed the importance of regular preventive brake maintenance, provided an overview of roadside inspection procedures, and warned of the potentially serious consequences of mismatching brake components. Also included in the pamphlet was information from the FHWA and the University of Michigan Transportation Research Institute on downhill braking techniques. The Safety Board classified Safety Recommendation H-92-72 to the Owner-Operator Independent Driver Association “Closed—Acceptable Action” on January 30, 2001. Through its maintenance council, the ATA developed a training video on how to conduct truck brake inspection and maintenance. In 1992, the ATA informed the Safety Board that efforts were under way with the FHWA’s Office of Motor Carriers to develop a method carriers could use to establish an appropriate brake adjustment interval for their own operations. The Federal Motor Carrier Safety Administration (FMCSA) Web site now contains a comprehensive list of brake maintenance materials and guidelines. The Safety Board classified Safety Recommendation H-92-74 to the ATA “Closed— Acceptable Action” on July 16, 2002. Automatic Slack Adjusters and Out-of-Adjustment Indicators. Beginning in 1978, the Safety Board made several safety recommendations to require that vehicles be equipped with automatic slack adjusters and out-of-adjustment indicators.3 In 1977 and 1978, the Safety Board investigated five accidents in which commercial vehicle drivers were unable to maintain speed control on downgrades. The major causal factor in four of these accidents was improper adjustment of the vehicles’ service brakes; in the fifth accident, the trailer brakes were totally inoperative. In two instances, the owners and operators had failed to ensure that the vehicles were safe for operation before they were dispatched. In its 1992 study of heavy vehicle air brake performance,4 the Safety Board issued safety recommendations that superseded those resulting from the investigations conducted 3  Safety Recommendations H-78-48 and H-88-30 were superseded by Safety Recommendation H-92-

1. Safety Recommendations H-81-1 and H-88-32 were superseded by Safety Recommendation H-92-51.

4  NTSB/SS-92/01.

Appendix D 67 Highway Accident Report in the 1970s and 1980s. The Board cited numerous brake deficiencies, including serious instances of out-of-adjustment brakes, as causal or contributing factors in the accidents investigated to support the 1992 safety study. The Safety Board urged the National Highway Traffic Safety Administration (NHTSA) to H-92-50 Require that air-braked vehicles be equipped with visible adjustment indicators that will allow one person to check the level of adjustment. H-92-51 Expedite the proposed rulemaking to require automatic adjusters on vehicles equipped with air brake systems. NHTSA issued a final rule on October 20, 1992, amending Federal Motor Vehicle Safety Standard 121, “Air Brake Systems,” and Federal Motor Vehicle Safety Standard 105, “Hydraulic Brake Systems,” to require automatic brake adjusters on all air-braked and hydraulic-braked vehicles manufactured after October 20, 1994. Consequently, the Safety Board classified both recommendations “Closed—Acceptable Action” on December 21, 1992. The Safety Board also recommended that the FHWA H-92-57 Encourage the installation of vehicle brake adjustment indicators on all vehicles equipped with air brake systems for easy detection of adjustment levels. In 1995, the FHWA published a report entitled Evaluation of Brake Adjustment Criteria for Heavy Trucks, which presented analyses, findings, and recommendations concerning the brake adjustment criteria of the North American Uniform Driver-Vehicle Inspection Criteria for Heavy Trucks. The FHWA also issued a final rule requiring motor carriers that have vehicles manufactured on or after October 20, 1994, to retain automatic brake adjustment indicators. The Safety Board classified this recommendation “Closed— Acceptable Action” on February 5, 1996. Brake Inspection. In 2002, the Safety Board issued an accident report on a May 31, 2001, accident that took place near Mountainburg, Arkansas, when a Gayle Stuart Trucking, Inc., truck-tractor semitrailer collided with a 65-passenger school bus operated by the Mountainburg, Arkansas, public schools. Three school bus passengers were fatally injured; two other passengers received serious injuries. Four passengers, the school bus driver, and the truck driver sustained minor injuries.5 5  National Transportation Safety Board, Collision Between Truck-Tractor Semitrailer and School Bus Near Mountainburg, Arkansas, May 31, 2001, Highway Accident Report NTSB/HAR-02/03 (Washington, DC: NTSB, 2002).

Appendix D 68 Highway Accident Report One of the major safety issues discussed in the report was the poor condition of the tractor-semitrailer’s brakes. In the report, the Safety Board noted that the tractor- semitrailer was equipped with manual slack adjusters on the tractor brakes and automatic slack adjusters on the trailer brakes. Postaccident, 8 of the 10 brakes were found to have been either out of adjustment or nonfunctional at the time of the accident; at least 4 brakes could not have provided any braking force. The Safety Board concluded that six brakes on the tractor were out of adjustment either because the owner had not properly adjusted them, or because the brakes went out of adjustment due to a disproportional workload, or both. The Mountainburg driver said he visually inspected the brakes on the day of the accident and did not find them to be out of adjustment. However, during the pretrip inspection, the driver did not follow the recommended practice of pulling on the pushrod and measuring the stroke to determine whether the brakes were out of adjustment. The Safety Board concluded that the driver did not conduct a sufficiently thorough pretrip inspection on either the tractor or the trailer to discover brake deficiencies. The regulation covering pretrip driver inspections, 49 Code of Federal Regulations (CFR) 396.13(a), stipulates only that the driver be satisfied that the motor vehicle is in safe operating condition before beginning driving; the regulation does not specify what must be done during a pretrip inspection or which procedures must be performed daily on the vehicle. The Safety Board issued the following safety recommendation to the FMCSA: H-02-15 Revise 49 Code of Federal Regulations 396.13, Driver Inspection, to require minimum pretrip inspection procedures for determining brake adjustment. In its initial response to this recommendation, dated January 3, 2003, the FMCSA stated that it considered that Federal regulations already adequately covered the intent of this recommendation, because (under 49 CFR 396.13(a)) the driver must be satisfied that the vehicle is in safe operating condition, including (under 49 CFR 392.71) that specified parts, such as the service brakes and the hand brake, are in good working order. Following this FMCSA response, the Safety Board classified the recommendation “Open— Unacceptable Response” on July 1, 2003. The FMCSA sent another response, dated August 9, 2004, requesting reconsideration of this classification. On January 25, 2005, the Safety Board stated its classification of Safety Recommendation H-02-15 would remain “Open—Unacceptable Response.” The Mountainburg accident investigation also raised issues concerning the qualifications of brake inspectors. Title 49 CFR 396.25, “Qualification of Brake Inspectors,” requires that each brake inspector successfully complete an apprenticeship or training program or have a certificate of experience totaling at least 1 year. The person responsible for maintaining the brakes on the trailer of the Mountainburg accident vehicle could prove the required experience; however, he failed to notice problems that a qualified

Appendix D 69 Highway Accident Report mechanic should have noticed during routine maintenance and inspections. The Safety Board concluded that the carrier’s mechanic lacked proper training in brake maintenance and inspections, did not detect the poorly adjusted or inoperative brakes on the trailer, and did not perform recommended maintenance. Under the FMCSA’s motor carrier compliance review process, a violation of 49 CFR 396.25 is not considered “Critical.” Thus, if a carrier does not have a qualified brake inspector, its rating is not affected. Consequently, the Safety Board issued the following safety recommendation to the FMCSA: H-02-17 During compliance reviews, rate companies as unsatisfactory in the vehicle factor category if the mechanics and drivers responsible for maintaining brake systems are not qualified brake inspectors. In its initial response to Safety Recommendation H-02-17, dated January 3, 2003, the FMCSA stated that it would review its process of assessing motor carriers’ safety management control activities that influence the vehicle factor of a carrier’s safety rating. The Safety Board classified the recommendation “Open—Acceptable Response” on July 1, 2003. In a May 28, 2004, letter to the Safety Board concerning this recommendation, the FMCSA stated Because our safety fitness rating methodology is based on the overall performance (e.g., vehicle, driver, accident) of a motor carrier during a compliance review, we do not take the specific approach recommended by NTSB. We are concerned that basing the rating on only one single component of the carrier’s operation—the vehicle portion—would not yield a fair determination of the carrier’s overall safety fitness, and hence, would not result in increased effectiveness. FMCSA’s investigators do review carrier profiles prior to each and every compliance review. As a matter of standard practice, if the profile indicates evidence of brake problems, the investigator focuses his or her investigation on the inspection and maintenance of the vehicles, including the qualifications of brake inspectors. In its December 15, 2004, response to the FMCSA, the Safety Board indicated that the Board continues to believe that implementation of Safety Recommendation H-02-17 is necessary, given that brake failures have dire consequences for traffic safety. The Board noted that it was aware the FMCSA had published an advance notice of proposed rulemaking in 1998 that was intended to lead to a more performance-based rating system. The Board also stated that it understood from previous correspondence that the FMCSA would factor the recommendation into its plans as it proceeds to issuing a notice of proposed rulemaking (NPRM). The Board noted that it would consider the FMCSA’s response acceptable if the NPRM and final rule address brake mechanic qualifications. Pending such action, the Safety Board classified Safety Recommendation H-02-17 “Open—Unacceptable Response.”

Appendix D 70 Highway Accident Report Also in the Mountainburg report, to ensure that mechanics working on truck brake systems for carriers have the knowledge necessary to maintain such systems, the Safety Board issued the following safety recommendation to the FMCSA: H-02-18 Revise 49 Code of Federal Regulations 396.25, Qualifications of Brake Inspectors, to require certification after testing as a prerequisite for qualification and specify, at a minimum, formal training in brake maintenance and inspection. In its initial (January 3, 2003) response to Safety Recommendation H-02-18, the FMSCA stated that it would research the training, examination, and certification requirements of organizations that certify automotive mechanics and then evaluate the results of the research and determine the appropriate next steps. On July 1, 2003, the Safety Board classified this recommendation “Open—Acceptable Response.” Subsequently, in a letter dated August 9, 2004, the FMCSA indicated that implementing Safety Recommendation H-02-18 would impose a significantly increased burden on motor carriers and suggested alternative approaches to fulfilling the intent of the recommendation. The Safety Board did not find the alternatives satisfactory and reclassified the recommendation “Open—Unacceptable Response” on January 25, 2005.

FD07318 ｜ 2006_美国_HAR0602.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2006 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

Passenger Vehicle Median Crossover and Head-On Collision With Another Passenger Vehicle Linden, New Jersey May 1, 2003 Highway Accident Report NTSB/HAR-06/02 PB2006-916202 Notation 7754 National Transportation Safety Board Washington, D.C.

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Highway Accident Report Passenger Vehicle Median Crossover and Head-On Collision With Another Passenger Vehicle Linden, New Jersey May 1, 2003 NTSB/HAR-06/02 PB2006-916202 National Transportation Safety Board Notation 7754 490 L’Enfant Plaza, S.W. Adopted February 7, 2006 Washington, D.C. 20594

National Transportation Safety Board. 2006. Passenger Vehicle Median Crossover and Head-On Collision With Another Passenger Vehicle, Linden, New Jersey, May 1, 2003. Highway Accident Report NTSB/HAR-06/02. Washington, DC. Abstract: On May 1, 2003, about 2:11 a.m., eastern daylight time, a 1998 Mercedes Benz CLK320, driven by a 34-year-old off-duty police officer, was traveling southbound on U.S. Route 1 through the city of Linden in Union County, New Jersey. The vehicle was traveling in the right lane of a six-lane divided highway. The weather was clear, and the roadway was dry, except for a puddle of water adjacent to a service station on the west side of the roadway. Near milepost 41.4, the Mercedes, traveling 48 to 62 mph, hit the curb on the west side of the road and swerved to the left. The Mercedes crossed the other two southbound lanes; mounted and crossed an 11.5-foot-wide, 6-inch-high raised concrete curb median; and entered the northbound lanes, where it collided head on with a 1986 Ford Taurus traveling in the left northbound lane. The Mercedes rolled up and over the Ford and landed on its roof. The Mercedes slid approximately 80 feet across the northbound lanes and struck a wooden utility pole next to the east side of the roadway, where it came to rest straddling the right northbound lane and the grassy area to the east of the roadway. Following the collision, the Ford remained upright, rotated about 163 degrees counterclockwise, and slid about 50 feet, where it came to rest in the right northbound lane. The Ford was occupied by a 33-year-old driver and four passengers ranging in age from 18 to 31. The drivers of both vehicles and three of the four Ford Taurus passengers died at the scene. The fourth Ford passenger died several hours later in a hospital. Major safety issues identified in this report are alcohol impairment, speed enforcement, and evaluative criteria for median barrier installation. As a result of its investigation, the Safety Board makes safety recommendations to the Federal Highway Administration, the city of Linden, and the American Association of State Highway and Transportation Officials. The Safety Board also reiterates a previously issued recommendation to the State of New Jersey. The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Web at http://www.ntsb.gov. Other information about available publications also may be obtained from the Web site or by contacting: National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (800) 877-6799 or (202) 314-6551 Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2006-916202 from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605-6000

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

iii Highway Accident Report Contents Acronyms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Accident Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Preaccident Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Emergency Response and Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Toxicological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Physical Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Driver Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Awake/Asleep Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Vehicle and Wreckage Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Mercedes Benz CLK320 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Ford Taurus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Highway Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Roadway Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Construction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Speed Limit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Lighting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Average Daily Traffic Count on U.S. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Accident History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Meteorology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Other Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Pavement Friction Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Video Surveillance Tape and Logs From Gas Station . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Alcohol Impairment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Speed Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Median Barrier Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Mercedes Speed Calculation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Mercedes Driver Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Response to Another Vehicle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Alcohol Consumption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Operator Fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Roadway Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Vehicle Speed and Speed Enforcement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Median Barriers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Contents iv Highway Accident Report Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 New Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Reiterated Recommendation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Appendix A Investigation and Public Hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

v Highway Accident Report Acronyms and Abbreviations AASHTO American Association of State Highway and Transportation Officials ADT average daily traffic AERF Alcohol Education and Rehabilitation Fund ASOS Automated Surface Observing System ATTF Auto Theft Task Force BAC blood alcohol concentration CAMI Civil Aeromedical Institute DOT U.S. Department of Transportation DWI driving while impaired/intoxicated FARS Fatality Analysis Reporting System FHWA Federal Highway Administration Green Book A Policy on Geometric Design of Highways and Streets IDRC Intoxicated Driver Resource Center I-278 Interstate 278 LPD Linden Police Department MP milepost NHS National Highway System NHTSA National Highway Traffic Safety Administration NIAAA National Institute on Alcohol Abuse and Alcoholism NJDOT New Jersey Department of Transportation U.S. 1 U.S. Route 1

vi Highway Accident Report Executive Summary On May 1, 2003, about 2:11 a.m., eastern daylight time, a 1998 Mercedes Benz CLK320, driven by a 34-year-old off-duty police officer, was traveling southbound on U.S. Route 1 through the city of Linden in Union County, New Jersey. The vehicle was traveling in the right lane of a six-lane divided highway. The weather was clear, and the roadway was dry, except for a puddle of water adjacent to a service station on the west side of the roadway. Near milepost 41.4, the Mercedes, traveling 48 to 62 mph, hit the curb on the west side of the road and swerved to the left. The Mercedes crossed the other two southbound lanes; mounted and crossed an 11.5-foot-wide, 6-inch-high raised concrete curb median; and entered the northbound lanes, where it collided head on with a 1986 Ford Taurus traveling in the left northbound lane. The Mercedes rolled up and over the Ford and landed on its roof. The Mercedes slid approximately 80 feet across the northbound lanes and struck a wooden utility pole next to the east side of the roadway, where it came to rest straddling the right northbound lane and the grassy area to the east of the roadway. Following the collision, the Ford remained upright, rotated about 163 degrees counterclockwise, and slid about 50 feet, where it came to rest in the right northbound lane. The Ford was occupied by a 33-year-old driver and four passengers ranging in age from 18 to 31. The drivers of both vehicles and three of the four Ford Taurus passengers died at the scene. The fourth Ford passenger died several hours later in a hospital. The National Transportation Safety Board determines that the probable cause of this accident was the Mercedes driver’s loss of control of the vehicle due to alcohol impairment. Contributing to the severity of the accident were the lack of barriers separating traffic in the northbound and southbound traffic lanes and the failure of the Mercedes driver to wear his seat belt. Major safety issues identified in this accident are alcohol impairment, speed enforcement, and evaluative criteria for median barrier installation. As a result of this accident, the Safety Board makes safety recommendations to the Federal Highway Administration, the city of Linden, and the American Association of State Highway and Transportation Officials. The Safety Board also reiterates a recommendation to the State of New Jersey.

1 Highway Accident Report Factual Information Accident Narrative On May 1, 2003, about 2:11 a.m., eastern daylight time, a 1998 Mercedes Benz CLK320 (Mercedes), driven by a 34-year-old off-duty police officer, was traveling southbound on U.S. Route 1 (U.S. 1) through the city of Linden in Union County, New Jersey. The vehicle was in the right lane of a six-lane divided highway. The weather was clear, and the roadway was dry, except for a puddle of water adjacent to a service station on the west side of the roadway. Near milepost (MP) 41.4, the Mercedes, traveling 48 to 62 mph,1 hit the curb on the west side of the road and swerved to the left. The Mercedes crossed the other two southbound lanes; mounted and crossed an 11.5-foot-wide, 6-inch-high raised concrete curb median; and entered the northbound lanes, where it collided head on with a 1986 Ford Taurus (Ford) traveling in the left northbound lane. The Mercedes rolled up and over the Ford and landed on its roof. The Mercedes slid approximately 80 feet across the northbound lanes and struck a wooden utility pole next to the east side of the roadway, where it came to rest straddling the right northbound lane and the grassy area to the east of the roadway. Following the collision, the Ford remained upright, rotated about 163 degrees counterclockwise, and slid about 50 feet, where it came to rest in the right northbound lane. (See figure 1.) The Ford was occupied by a 33-year-old driver and four passengers ranging in age from 20 to 31, who were returning home from work at a local restaurant. The drivers of both vehicles and three of the four Ford passengers died at the scene. The fourth Ford passenger died several hours later in a hospital. Preaccident Events On Monday evening, April 28, the driver of the Mercedes played in a softball game that ended at about 9:00 p.m.2 According to the driver’s brother, he remained at the softball field for about an hour following the game and then went to his girlfriend’s house. The driver’s girlfriend said the driver left her residence at 2:00 a.m. and then called her at 2:15 a.m. on Tuesday, April 29, from his residence. 1 The vehicle’s speed was calculated based on the roadway pavement surface, pavement age, and roadway usage. Additional information on speed calculation is contained in the “Analysis” section of this report. 2 Information detailing the activities of the Mercedes driver before the accident was obtained from interviews conducted with family members, the driver’s supervisor, softball teammates, and a friend.

Factual Information 2 Highway Accident Report Figure 1. Linden, New Jersey, accident scene. Beginning of tire mark Utility pole Light pole Driveway Mercedes at final rest Ford at final rest 0 N Driveway Driveway 30 60 90 Area of impact Driveway to gas station Driveway to gas station FEET Area of standing water Mercedes engine and transmission Mercedes exhaust

Factual Information 3 Highway Accident Report According to his family, the Mercedes driver had originally been scheduled to work his assigned shift from 8:00 p.m. to 6:00 a.m. at the Union/Essex Auto Theft Task Force (ATTF)3 on Tuesday, April 29, and Wednesday, April 30, but took the days off from work to replace or repair a damaged contact lens. The driver’s girlfriend said he visited her at her workplace during the day on Tuesday and left about 5:30 p.m. to run some errands. His family said he stayed overnight Tuesday night at a friend’s house. On Wednesday, April 30, the Mercedes driver’s sister-in-law said she saw the driver at home sometime in the morning, as she was leaving to run errands, and again at 3:00 p.m., when she returned home. At 6:30 p.m., the driver and his brother left in separate cars for a softball game. Before arriving at the game, the Mercedes driver stopped at a local bar and bought a round of drinks for the bar; the bartender/manager stated that the driver did not drink at this time. The Mercedes driver played in a softball game that began about 7:30 p.m. and ended about 9:30 p.m. Following the game, he stayed at the field with several teammates. Although some team members said that they drank beer after the game, none said that they remembered seeing the driver consuming alcohol. The bartender/manager said the driver returned to the local bar between 11:00 p.m. and midnight but was not sure whether the driver had any alcohol during this visit. About 2:00 a.m. Thursday morning, May 1, the Mercedes driver left the bar and was driving toward U.S. 1, when he met a friend. The Mercedes driver and his friend stopped to talk; they were about 850 feet from the bar. The friend said the driver did not appear intoxicated and that the driver told him he was heading home. The driver traveled about 3.35 miles before the accident occurred at 2:11 a.m. Figure 2 shows the location of the accident site, the driver’s home, the softball field, and the local bar visited by the Mercedes driver; table 1 provides approximate distances between locations. 3 Essex and Union County police officers rotate into the task force for 30 to 60 days and then return to normal duty.

Figure 2. Locations of interest. LOCAL BAR SOFTBALL FIELD ACCIDENT SITE DRIVER’S HOME 95 95 278 278 Garden State Parkway 1 1 1 Linden Rahway Factual Information 4 Highway Accident Report Table 1. Approximate distances between locations of interest. From To Distance Driver’s home Softball field 7.44 miles Softball field Local bar 1.44 miles Local bar Accident site 3.35 miles Accident site Driver’s home 2.79 miles Local bar Driver’s home 6.14 miles Injuries According to the Union County Medical Examiner, the 34-year-old driver of the Mercedes died from multiple blunt-force injuries. The driver sustained blunt-force trauma to the head, chest, abdomen, and lower-left extremity. He was partially ejected from the vehicle. All four occupants of the Ford were fatally injured. The 33-year-old male driver of the Ford died of multiple blunt-force injuries to his head, blunt-force trauma to his chest and abdomen, and fractures to his left arm and leg. The 20-year-old female front-seat

Factual Information 5 Highway Accident Report passenger sustained injuries to her head, chest, and abdomen. The left-rear passenger was a 31-year-old male, who sustained blunt-force trauma to his head, neck, and abdomen and fractures to his ribs, arms, and legs. The 20-year-old male seated in the center-rear seat sustained blunt-force trauma to the neck and face. The 22-year-old male right-rear passenger was transported to the hospital, where he was pronounced dead approximately 3.5 hours after the accident. He sustained multiple blunt-force trauma injuries to the head, chest, abdomen, and lower extremities. Table 2 is based on the International Civil Aviation Organization’s injury criteria, which the National Transportation Safety Board uses in accident investigation reports. Table 2. Injuries.* Injury type Drivers Passengers Others Total Fatal 2 4 0 6 Serious 0 0 0 0 Minor 0 0 0 0 None 0 0 0 0 Total 2 4 0 6 *Title 49 Code of Federal Regulations Part 830.2 defines a fatal injury as any injury that results in death within 30 days of the accident. It defines a serious injury as an injury that requires hospitalization for more than 48 hours, commencing within 7 days from the date the injury was received; results in a fracture of any bone (except simple fractures of the fingers, toes, or nose); causes severe hemorrhages, nerve, muscle, or tendon damage; involves any internal organ; or involves second- or third-degree burns, or any burns affecting more than 5 percent of the body surface. Emergency Response and Survival Aspects The Linden Fire Department arrived at the accident scene at 2:15 a.m. At 2:19 a.m., the Rahway Volunteer Ambulance responded to the scene and transported a Ford passenger to the University of Medicine and Dentistry of New Jersey, Newark campus. The Mercedes sustained extensive contact damage to the right front and left rear of the vehicle. The driver’s seat was equipped with a three-point restraint system, which was found in the retracted position. When extended, the belt webbing was clean and without visible evidence of loading. Dirt was found within the driver’s seat belt latchplate and latchplate receiver. Dirt was also found within the occupant compartment, which investigating law enforcement personnel believed to have entered the vehicle during the rollover. The driver-side air bag deployed. Restraint usage for the driver and the four passengers of the Ford is unknown; lap/shoulder belts were available at four seating locations, and a lap belt was available at the rear-center seat. The Ford did not have air bags. Toxicological Information The New Jersey State Toxicology Laboratory and, at the request of the National Transportation Safety Board, the Federal Aviation Administration’s Civil Aeromedical

Factual Information 6 Highway Accident Report Institute (CAMI), conducted toxicological testing on the driver of the Mercedes. Two samples were collected from the driver postmortem by the Union County Medical Examiner and transferred to the New Jersey State Toxicology Laboratory and CAMI, which reported, respectively, blood alcohol concentrations (BACs) of 0.351 and 0.326.4 (See table 3 for test results.) In New Jersey, drivers with a BAC of 0.08 or greater are considered impaired. Table 3. Toxicological information for the Mercedes driver. New Jersey State Toxicology Laboratory CAMI Blood Ethanol (alcohol), 0.351 percent; pseudoephedrine, 0.27 mg/L. Ethanol (alcohol), 326 mg/dlL, mg/hg (0.326 percent); pseudoephedrine detected. Urine None of tested drugs detected.a Ethanol (alcohol),379 mg/dL, mg/hg (0.379 percent); acetaldehyde, 8 mg/dL, mg/hg. Vitreous humor Ethanol (alcohol), 0.268 percent. Ethanol (alcohol), 210 mg/dL, mg/hg (0.210 percent); acetaldehyde,1 mg/dL, mg/hg. Brain Ethanol (alcohol), 0.287 percent. Not tested. Liver Pseudoephedrine, 11.0 mg/kg. Not tested. Stomach contentb Ethanol (alcohol), 0.680 percent; pseudoephedrine, 110 mg/kg; pill containing phenmetrazine. Fexofenandine, in a brown tablet marked “Allegra D”; pseudoephedrine, in a brown tablet marked “Allegra D.” Nasal swab None of tested drugsc detected. Not tested. aTested for barbiturates, benzodiazepines, cannabinoids, cocaine metabolites, methadone, opiates, phencyclidine (PCP), phenytoin, propoxyphene, and TCAntidepressants. bThe Union County Medical Examiner found two tablets marked “Allegra” in the driver’s stomach. cTested for cocaine metabolites and opiates. Toxicological tests for the driver of the Ford, conducted by the New Jersey State Toxicology Laboratory, were negative for alcohol and illicit drugs. Physical Evidence Safety Board investigators observed multiple tire scuff marks and scrapes along both the vertical and horizontal faces of the concrete curb on the southbound side of the median.5 An additional tire scuff mark and scrape were noted on the top of the concrete curb adjacent to the northbound side of the roadway. The diagonal distance between the 4 Differences in testing equipment, specimens, or procedures could account for the discrepant results. This report uses the more conservative BAC of 0.326 reported by CAMI. 5 The Linden Police Department (LPD) documented two tire marks in the southbound lanes of the roadway, which were not visible when Safety Board investigators arrived at the accident location because, before the roadway reopened, a motorized street sweeper had cleaned the area. The Safety Board incorporated the evidence previously mapped by the LPD on May 1 into its documents. Assisted by the LPD, Safety Board investigators electronically mapped additional points at the accident location on May 4.

Factual Information 7 Highway Accident Report last tire scuff mark on the southbound side of the median and the tire scuff mark adjacent to the northbound side of the median was about 23 feet. During its investigation, the LPD observed a puddle of water adjacent to the north driveway of the gas station that was not present when Safety Board investigators arrived at the accident location. Using LPD postaccident photographs,6 Safety Board investigators estimated that the area of water extended from a point about 1 foot north of the curb of the gas station’s driveway to an area about 34 feet south of the curb. (See figure 1.) A drop inlet7 was located north of the puddle. The water was primarily contained along the west curb of the driveway. At the driveway, the water extended about 2 to 3 feet into the right southbound lane and tapered off toward the curb as it transitioned to the south. The water’s depth was not measured. The puddle may have resulted from a hosing down of the gas station driveway by an attendant before the accident. The puddle that appeared in postaccident photographs may have been larger than the one encountered by the Mercedes driver due to rainfall or water applied by fire and rescue equipment. In addition, Safety Board investigators noted one scar at the nose of the driveway curb and another that started about 3 feet south of the first one. Both scars were adjacent to the tire mark produced by the Mercedes as it struck the curb and veered across the two southbound lanes. Driver Information General The driver of the Mercedes was a 34-year-old male. At the time of the accident, the driver held a valid class “D” New Jersey driver’s license with no endorsements and a corrective lenses restriction. The National Driver Register showed no current or pending suspensions for the Mercedes driver. The driver’s motor vehicle history showed three accident reports (July 9, 1988; July 25, 1993; and July 31, 1993), a report of consuming alcoholic beverages as a passenger in a motor vehicle (November 26, 1993), and failure to appear for unpaid parking tickets (April 16, 1995). The Mercedes driver was a Union County police officer. About 3 weeks before the accident, the Mercedes driver had been assigned to the ATTF. He had been driving for about 1 week with the ATTF since completing his training. The driver’s supervisor described the driver as being “very sharp” and characterized his attitude as “positive” and “upbeat.” The supervisor did not know whether the driver was experiencing personal problems. The driver’s family said that the driver was in “good health.” The family further noted that the driver suffered from allergies but did not know whether he was taking medication. The family indicated that the driver did not regularly take prescription or over-the-counter 6 Since the original photographs did not allow for sufficient examination of the scene details, the brightness and contrast of the photographs were digitally enhanced. 7 A drop inlet is a heavy steel grid or grate flush with the roadway’s surface. Located at a low point along the road, it is intended to collect and drain storm water from the roadway surface.

Factual Information 8 Highway Accident Report drugs, did not smoke, and only drank “socially” (with his brother, on weekends, or when not working). The family said the driver was “upbeat” and described him as “strictly business on duty, focused on friends when off duty.” According to medical records, the driver had a left knee injury in 2000 and a right knee injury in 2002. His 1998 preemployment physical showed that he had 20/20 vision in his right eye and 20/30 vision in his left eye when wearing contacts. The preemployment physical also indicated he had no hearing problems. Awake/Asleep Schedule Information on the Mercedes driver’s sleep schedule for the 72 hours before the accident, developed from interviews conducted with members of his family, his supervisor, softball teammates, and friends, is shown in figure 3. During this period, the Mercedes driver slept for at least 17 hours; the driver’s sleep activities the day before the accident are unknown. Vehicle and Wreckage Information Mercedes Benz CLK320 The 1998 Mercedes Benz CLK320 coupe, 2-door model, was 180 inches long, 68 inches wide, and 54 inches tall, and had a curb weight8 of 3,240 pounds. The Mercedes had a manual 5-speed transmission. It did not have event-recording capabilities. The vehicle sustained extensive contact damage, which was concentrated in the right front and left rear of the vehicle (see figures 4 and 5). The right-front body panels and hood had been crushed diagonally in the direction of the vehicle’s left rear. An indentation matching the shape and dimension of the Ford’s A-pillar9 was located on the side of the right-front fender, about 1 foot forward from the Mercedes’ firewall. The hood had fully opened and had been Figure 3. Mercedes driver’s awake/asleep schedule. 8 Refers to the weight of a vehicle without passengers or cargo but including all fluids (oil, gas, and coolant) and equipment specified as standard. 9 A slender vertical structure supporting an automobile’s roof. The A-pillar is located on both sides of the windshield; the B-pillar is located between the front and rear windows; and the C-pillar is located on both sides of the trunk.

12 a.m. 1 2 3 4 5 6 7 8 9 10 11 12 p.m. 1 2 3 4 5 6 7 8 9 10 11 4/28

4/29

4/30

5/1

Accident occurs at 2:11 a.m. Awake Legend Asleep Unknown

Factual Information 9 Highway Accident Report Figure 4. 1998 Mercedes Benz CLK320. Figure 5. Crash profile of 1998 Mercedes Benz CLK320. 0 20 40 60 80 100 INCHES Area of impact with utility pole Left-rear tire B-pillar Left-front tire Right-rear tire B-pillar Opening in sunroof Hood panel in final position Sunroof interior panel Contact damage to windshield from hood panel Engine compartment

Factual Information 10 Highway Accident Report driven into the windshield. The impact to the left rear of the vehicle resulted from the subsequent collision with a wooden utility pole. The contact damage was semicircular in shape and extended about 2 feet into the trunk. In addition to the heavy contact damage, the roof of the Mercedes sustained some deformation, scrapes, and multiple scratches. During the accident sequence, the right-front wheel and related suspension components became detached from the vehicle. The vehicle’s engine and transmission became detached, as well, and were found in the southbound lanes approximately 77 feet from the Mercedes’ final resting place. The exhaust system also became detached and was found approximately 92 feet from the Mercedes in the northbound lanes. Postaccident examination of the Mercedes detected no mechanical deficiencies. Ford Taurus The 1986 Ford Taurus, 4-door model, with automatic transmission, was 189 inches long, 71 inches wide, and 54 inches high, and had a curb weight of 2,865 pounds. Postaccident examination of the Ford detected no mechanical deficiencies. Contact damage to the Ford was observed along the left side of the vehicle beginning on the left side of the front grill assembly (see figures 6 and 7). Additionally, the radiator core support was pushed in, and components on the top and left side of the engine also received contact damage. The most substantial impact to the left front was in the area of the wheel assembly. The entire left-front tire had been displaced rearward about 2 feet, and the wheel assembly had a circumferential indentation resulting from contact. The contact damage along the left side extended across both doors and terminated just forward of the left-rear wheel. Deformation to the A-pillar was semicircular and directed inward toward the passenger compartment of the vehicle. The leading edge of the roof panel was pushed rearward and crushed down into the passenger compartment. The steering wheel received substantial deformation damage, and the steering column was Figure 6. 1986 Ford Taurus.

Factual Information 11 Highway Accident Report fractured. In addition to the contact damage from the accident, the vehicle had extensive damage and other contact damage resulting from extrication efforts. Highway Information Design The accident occurred on U.S. 1 near MP 41.4 in the city of Linden, Union County, New Jersey. This section of U.S. 1 is a divided, two-way, six-lane asphalt-paved roadway (three lanes designated for northbound traffic and three lanes designated for southbound traffic), extending in a northeast/southwest direction. Slightly north of the accident site, the southbound lanes transitioned from four lanes to three. White retroreflective lane lines mark the individual travel lanes. The left edges of the northbound and southbound travel lanes are marked with solid, yellow, retroreflective Figure 7. Crash profile of Ford Taurus. 0 20 40 60 80 100 INCHES A-pillar B-pillar C-pillar Right-front tire Right-rear tire B-pillar C-pillar Left-front tire Left-rear tire Lower control arm assembly Right-side upper strut mounting point Left-side upper strut mounting point

Factual Information 12 Highway Accident Report edge lines delineating the median boundaries. The width between the yellow line in the northbound travel lane to the yellow line in the southbound travel lane is 13.5 feet. Roadway dimensions are provided in table 4. Table 4. U.S. 1 lane width (measured near MP 41.4). Left lane Center lane Right lane Northbound 10.23 feet 10.45 feet 12.35 feet Southbound 14.48 feet 11.77 feet 12.50 feet The northbound and southbound lanes are divided by an 11.5-foot-wide raised median with 6-inch-high Portland cement concrete curbing. (See figure 8.) The median is backfilled with asphaltic concrete. The distance from the face of the vertical curb wall to the yellow edge lines is 1 foot. The cross section consists of a curb and gutter. There was no median barrier at the accident site. A New Jersey-type median barrier10 begins about 200 feet north of the accident site and continues north toward the Interstate 278 (I-278) interchange. This barrier was installed during the construction of the I-278 interchange in the late 1960s. Another median barrier was installed south of the accident location beginning at MP 39.4 in the town of Rahway. Black tire rubber smears and metallic scrapes were found on both median barriers during the Safety Board’s Figure 8. Raised curbed median near accident location. 10 Refers to a barrier wall cross section developed by the State of New Jersey for use on its facilities. Widely used in the United States and other countries for median and roadside barriers, it is commonly referred to as a New Jersey barrier.

Factual Information 13 Highway Accident Report investigation. The segment of U.S. 1 that passes through the city of Linden is the only segment of U.S. 1 without a median barrier from Newark Airport to the Garden State Parkway, a distance of about 11 miles. The New Jersey Department of Transportation (NJDOT) offered a number of possible reasons for the lack of a median barrier at the accident site: the segment’s straightness, the difficulty in safely terminating the segment’s barrier ends, and the lack of recent reconstruction projects in the area. Roadway Classification The NJDOT describes the accident segment of U.S. 1 as a “land service highway.”11 It is also a part of the Federal Highway Administration’s (FHWA’s) National Highway System (NHS).12 Construction The NJDOT built the accident segment of U.S. 1 in 1960. NJDOT records indicate a gradual upgrading of the original roadway through a sequence of reconstruction projects; the last project completed was one for pavement rehabilitation in September

1. Several reconstruction projects involved changes to the median islands.

Speed Limit According to the construction plans, the design speed for the accident segment of U.S. 1 was 45 mph. The posted speed limit is 40 mph; 40-mph signs13 were placed on both the northbound (near MP 41.2) and southbound (near MP 41.6) approaches to the accident area. Other than a 1965 NJDOT memorandum authorizing the 40-mph speed limit, the NJDOT had no records regarding speed limits on U.S. 1 in the city of Linden or any record indicating that a speed survey had ever been conducted in that area. The month after the accident, Safety Board investigators recorded the speeds of 102 vehicles on U.S 1, MP 41.4, from 9:45 p.m. to 12:15 a.m. The 85th percentile speed was 72 mph, and the median speed was 62 mph. Of the 102 vehicles measured, only 2 were traveling at or below the posted speed limit and 6 were measured to be traveling at speeds of 80 mph or greater, more than twice the speed limit. Seventy percent of the vehicles were traveling between 50 and 70 mph. At the request of the Safety Board, the NJDOT conducted two spot-speed studies near the accident location. Those studies, conducted during daytime hours for northbound vehicles only, yielded 85th percentile speeds of 58 mph and 52 mph. Traffic signals along the entire accident segment of U.S. 1 are coordinated with a progression speed of 40 mph. In areas where traffic signal frequency is high, running 11 An arterial or collector highway on which access to abutting property is permitted. On arterial highways and major collector roads, such access is usually regulated to protect the public safety and maintain the efficiency of the highways. 12 The NHS comprises approximately 160,000 miles of roadway important to the Nation’s economy, defense, and mobility. 13 U.S. Department of Transportation (DOT), Federal Highway Administration, Manual on Uniform Traffic Control Devices, Section 2B-10, Speed Limit Sign (R2-1) (Washington, DC: FHWA, 2003).

Factual Information 14 Highway Accident Report speeds are consistent with the posted and signal progression speeds. Vehicles traveling southbound on U.S. 1 encounter a traffic signal 1/2 mile north of the accident location. The next signal is a “stop and go” signal slightly less than a 1/2 mile south of the accident location. Thus, vehicles can travel approximately 1 mile without encountering a traffic signal. Additionally, traffic from I-278 exits onto U.S. 1 just before the signal north of the accident location. The speed limit on I-278 is 50 mph. LPD officials noted that they were aware of the high frequency of speeding on U.S. 1 in the vicinity of the accident but had not conducted directed speed limit enforcement there because of limited resources.14 The LPD was unable to provide the number of traffic citations issued on U.S. 1 because the department’s database could not accommodate such a query. Lighting During nighttime hours, artificial lighting illuminated the roadway. Thirteen overhead streetlights were located in the vicinity of the accident: seven on the eastern right-of-way and six on the western right-of-way. During the on-scene investigation, none of the lights on the west (southbound side) of the roadway were working, and three of the seven lights on the east (northbound side) of the roadway were working. The gas station located on the western right-of-way provided additional lighting. According to NJDOT officials, on State routes, the local power company maintains street lighting mounted on timber poles. Average Daily Traffic Count on U.S. 1 Over the course of a year, the NJDOT conducts traffic counts at 1,000 selected sample sites on all types of public roads for a 48-hour period. In 2003, the average daily traffic (ADT) count at MP 41.85 of U.S. 1 was 69,635. Table 5 shows ADT counts for 1998 through 2003. Table 5. Average daily traffic counts for U.S. 1 between MPs 41 and 42. Year Count Distance from accident location 2003 69,635 0.45 mile north 2002 66,238 0.05 mile south 2001 50,531 0.66 mile south 2000 Not available — 1999 82,014 0.45 mile north 1998 48,836 0.25 mile south Accident History Table 6 presents the accident history for U.S. 1 between MPs 41 and 42.15 In 2001, one nonfatal median crossover accident occurred on U.S. 1 near the accident location. A review of LPD reports revealed that of the fatal accidents that occurred on U.S. 1 in Linden from 2000 through 2003, only the accident discussed in this report involved a median 14 As of August 18, 2005, the LPD consisted of some 136 officers. The patrol division is responsible for traffic law enforcement. 15 NJDOT Crash Records and Statistics .

Factual Information 15 Highway Accident Report crossover. The 2003 accident rate for the accident segment of U.S. 1 was 2.25 per 1 million vehicle miles driven, as compared to the Statewide accident rate for that period of 3.73 per 1 million vehicle miles driven on urban arterials with four or more lanes and raised medians. Table 6. Accident Information for U.S. 1 between MPs 41 and 42. Year Total accidents Fatal Injury Property damage 2003 154 2 53 99 2002 144 2 44 98 2001 147 1 56 90 2000 192 1 62 129 Inspection of the Linden segment of U.S. 1 revealed little or no evidence of vehicle incursions on the barrier curb faces or on the asphaltic concrete backfill forming the median.16 There was evidence of run-off-the-road events. Meteorology The Newark Automated Surface Observing System (ASOS) is located approximately 6 miles northeast of Linden, and the Somerville ASOS is about 22 miles west of Linden. Neither station reported the presence of rain, mist, or fog during the 24 hours before the accident. Other Information Pavement Friction Tests Skid resistance tests were conducted at the accident location to determine the pavement friction on the northbound and southbound travel lanes of U.S. 1 between MPs 41.3 and 41.9.17 A trailer-mounted friction-testing device was towed behind a vehicle in each of the three northbound and southbound dry traffic lanes.18 Southbound lanes had an average skid number of 78, and northbound lanes had an average skid number of 80.19 16 Such evidence would include tire rubber scrub marks on the vertical faces of median curbs and tire marks on the median’s top surface. 17 Skid resistance tests were conducted on May 4, 2003, by NJDOT personnel from the Pavement Management Division in Trenton. 18 American Society for Testing and Materials standard E274-97 utilizes a measurement representing the steady-state friction force on a locked test wheel as it is dragged over a wetted pavement surface under constant load and at a constant speed while its major plane is parallel to its direction of motion and perpendicular to the pavement. Because it was known the accident occurred on a dry roadway, a dry surface was tested. 19 A skid number represents the frictional properties of the pavement. These numbers are used to evaluate the skid resistance of the pavement relative to other pavements and/or to evaluate the change in skid resistance of the pavement with time. Skid numbers of 78 and 80 are considered high, indicative of new pavement in good condition.

Factual Information 16 Highway Accident Report Video Surveillance Tape and Logs From Gas Station The gas station located on the western right-of-way operated 24 hours per day. The gas station had a surveillance system consisting of four cameras, a multiplexer, and a recorder. One of the cameras was positioned so as to capture a partial view of U.S. 1. No imagery of the accident sequence or potential witness vehicles could be identified. The gas station logs record all sales and significant events, such as safe drops, vendor payouts, and driveaways. The logs show no activity between 1:33 a.m. and 5:28 a.m. on May 1, 2003. Alcohol Impairment After alcohol is consumed, it passes from the stomach and the intestines into the blood.20 The alcohol is then metabolized.21 Most of the alcohol consumed is metabolized in the liver; however, a small amount of alcohol escapes metabolism and is excreted in the breath and urine. Until all of the alcohol is metabolized, it is distributed throughout the body, affecting the brain and other tissues. The liver can metabolize only a certain amount of alcohol per hour, regardless of the amount that has been consumed. Alcohol is metabolized more slowly than it is absorbed;22 therefore, consumption must be controlled to prevent accumulation in the body and intoxication. In general, after the consumption of one standard drink,23 the amount of alcohol in the drinker’s blood (BAC) peaks within 30 to 45 minutes.24 Reductions in attention, judgment, and control can be observed at a BAC as low as 0.02, and many individuals with a BAC of 0.25 or greater experience confusion, vomiting, loss of consciousness, and even death.25,26 Driving performance is substantially impaired in almost everyone at BACs of 0.08 or greater, but impaired driving behaviors can be seen at lower BACs.27,28 Fatality Analysis Reporting System (FARS) data show that, in 2004, 58,156 drivers were involved in fatal accidents on U.S. roadways. About 25 percent (14,259) of those drivers had a BAC greater than 0.01. Specifically, 2,264 drivers involved in fatal accidents (3.9 percent) had a BAC between 0.01 and 0.07; 4,062 drivers (7.0 percent) 20 This process is referred to as absorption. 21 Metabolism occurs when the body converts ingested substances to other compounds. Metabolism involves a number of processes, one of which is oxidation. Through oxidation, alcohol is detoxified and removed from the blood, preventing the alcohol from accumulating and destroying cells and organs. 22 Several factors influence alcohol absorption, including gender and the presence of food in the stomach. 23 A standard drink is defined as 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof distilled spirits, all of which contain 1 ounce of alcohol. 24 National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism (NIAAA), Alcohol Metabolism, Alcohol Alert No. 35, PH 371 (Washington, DC: NIAAA, 1997). 25 K.M. Dubowski, Acute Alcohol Influence, National Commission Against Drunk Driving (Washington, DC: NHTSA, 1997). 26 National Highway Traffic Safety Administration, The ABCs of BAC, A Guide to Understanding Blood Alcohol Concentration and Alcohol Impairment, DOT HS 809 844 (Washington, DC: NHTSA, 2005). 27 H. Moskowitz and D. Fiorentino, A Review of the Literature on the Effects of Low Doses of Alcohol on Driving-Related Skills (Washington, DC: NHTSA, 2000). 28 DOT HS 809 844.

Factual Information 17 Highway Accident Report had a BAC between 0.08 and 0.14; 7,195 drivers (12.4 percent) had a BAC between 0.15 and 0.29; and 737 drivers (1.3 percent) had a BAC greater than 0.30 (see figure 9).29 Drivers With High BACs. In 2000, the Safety Board released a report on the hard core drinking driver.30 In its report, the Safety Board defined a hard core drinking driver as a repeat offender (that is, an offender with more than one conviction or arrest for driving while impaired/intoxicated [DWI] within the past 10 years) or a high BAC offender (BAC of 0.15 or greater). Although impairment from alcohol is pronounced in most individuals at a BAC of 0.15 or greater, some can function and even drive a vehicle at higher BAC levels.31 In a study32 of 81 drinking drivers in Sweden with high BACs (BAC greater than or equal to 0.400), it was concluded that attempting to drive a motor vehicle with a high BAC indicates “an exceptionally high cellular tolerance to the impairment caused by this drug. The alcohol burn-off rate was relatively high in these heavy drinkers (0.023 percent per hour),[33] which probably reflects the development of metabolic tolerance as well.” Figure 9. BACs of drivers involved in fatal accidents (FARS 2004). 29 Numbers and percentages were calculated using imputed data. 30 National Transportation Safety Board, Actions to Reduce Fatalities, Injuries, and Crashes Involving the Hard Core Drinking Driver, Safety Report NTSB/SR-00/01 (Washington, DC: NTSB, 2000). 31 DOT HS 809 844. 32 A.W. Jones, “The Drunkest Drinking Driver in Sweden: Blood Alcohol Concentration 0.545 Percent w/v.,” Journal of Studies on Alcohol, Vol. 60, No. 3 (1999): 400-06. (Abstract only.) 33 According to the National Highway Traffic Safety Administration (NHTSA), the average metabolism rate for moderate drinkers produces a 0.017 per hour decline in BAC level. For further information, see National Highway Traffic Safety Administration, Computing a BAC Estimate (Washington, DC: NHTSA, 1994) . 0 100 200 300 400 500 600 700 800 0.01 0.05 0.09 0.13 0.17 0.21 0.25 0.29 0.33 0.37 0.41 0.45 0.49 Blood alcohol concentration (BAC) Number of drivers involved in fatal accidents

Factual Information 18 Highway Accident Report Individuals who are able to function at high BAC levels, which in others would be incapacitating or even fatal, have very likely developed a tolerance to alcohol. Tolerance to alcohol can be displayed in two ways: the effect of a given dose of alcohol decreases as tolerance develops, and a greater dose of alcohol is required to produce a given effect. Consuming alcohol in the same environment or under the same cues can develop or accelerate alcohol tolerance.34 Learned tolerance, where the repeated practice of a task in association with alcohol consumption leads to the development of tolerance, can reduce the alcohol-induced impairment that would ordinarily accompany the performance of that task.35 However, the tolerance acquired in a certain environment or for a specific task is not readily transferred to new or different situations. A driver who has developed behavioral tolerance to driving a familiar car over a particular route under routine circumstances may drive without being involved in an accident despite the consumption of substantial amounts of alcohol. However, a driver who encounters a novel environment would be at the same elevated risk for an accident as a new driver with the same BAC because of the lack of prior learning opportunities for the new situation.36 Several studies show that the drivers with high BACs are at a greater risk of being involved in a fatal accident than zero-BAC drivers.37 The 2000 Safety Board report cited research by the Insurance Institute for Highway Safety that estimated the relative fatality risk for drivers in single-vehicle accidents with high BACs to be 385 times that of a zero- BAC driver. The Traffic Injury Research Foundation estimated that high-BAC drivers were more than 200 times more likely to be involved in a fatal accident than a nondrinking driver. NHTSA research shows that some impaired drivers may not be arrested or involved in an accident. NHTSA reports that “on average, a driver can drive [impaired] 5,000 miles before being arrested for a DUI [driving under the influence] offense.”38 Other research found that, on average, 1 arrest occurs per 88 episodes of driving over the legal limit and per 6 stops for suspicion of driving under the influence.39 More recent research has shown that drivers with very high BACs were far more likely to be described as having histories suggestive of problem drinking than other fatally injured drivers; nonetheless, a substantial proportion were not described as having drinking histories.40 34 National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, Alcohol and Tolerance, Alcohol Alert No. 28, PH 356 (Washington, DC: NIAAA, 1995). 35 National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, Drinking and Driving, Alcohol Alert No. 31, PH 362 (Washington, DC: NIAAA, 1996). 36 Alcohol Alert No. 31. 37 NTSB/SR-00/01. 38 National Highway Traffic Safety Administration, Alcohol and Highway Safety 1984: A Review of the State of the Knowledge (Washington, DC: NHTSA, n.d.) 56. 39 P. Zador, S. Krawchuck, and B. Moore, Drinking and Driving Trips, Stops by Police, and Arrests: Analyses of the 1995 National Survey of Drinking and Driving Attitudes and Behavior, DOT HS 809 184 (Washington, DC: NHTSA, 2001). 40 S.P. Baker, E.R. Braver, L.H. Chen, G. Li, and A.F. Williams, “Drinking Histories of Fatally Injured Drivers,” Injury Prevention, Vol. 8 (September 2002): 221-26.

Factual Information 19 Highway Accident Report The Safety Board concluded in its 2000 report41 that the elevated accident risk and potential for recidivism of high-BAC (0.15 or greater) drivers constitute a safety problem that warrants State legislation to create a high-BAC “aggravated” alcohol offense. The Safety Board outlined a model program (see figure 10) to reduce hard core drinking driving that incorporates several elements, including vehicle sanctions to restrict or separate hard core drinking drivers from their vehicles, and frequent, well-publicized sobriety checkpoints. The Safety Board model program also recommends that the States pass legislation that defines a high BAC (0.15 or greater) as an “aggravated” DWI offense requiring strong intervention similar to that ordinarily prescribed for repeat DWI offenders. State Laws. In all 50 States and the District of Columbia, a driver with a BAC level of 0.08 or greater is considered to be impaired. A majority of States have also established laws that reflect the need for additional penalties or countermeasures when drivers have BACs of 0.15 or greater.42 In New Jersey, effective January 20, 2004, a person with a BAC of 0.08 or greater who operates a vehicle is considered to be driving under the influence.43 New Jersey’s law pertaining to drivers with a 0.10 BAC, which was the legal limit before 2004, also remains in effect. Penalties for driving while impaired in New Jersey are shown in table 7. 41 NTSB/SR-00/01. 42 For higher BACs, the following States mandate education, assessment, and/or increased penalties or consider the BAC an aggravating factor: Arizona, Arkansas, California, Georgia, Indiana, Iowa, Louisiana, Maine, Missouri, Oklahoma, Rhode Island, South Carolina, Texas, Virginia, and Washington, for a BAC of 0.15; Alaska, Connecticut, Delaware, Illinois, Montana, Nebraska, New Hampshire, New Mexico, North Carolina, Pennsylvania, and Utah, for a BAC of 0.16; Ohio, South Dakota, and Wisconsin, for a BAC of 0.17; Kentucky, Nevada, and North Dakota, for a BAC of 0.18; and Colorado, District of Columbia, Florida, Idaho, Massachusetts, Minnesota, and Tennessee, for a BAC of 0.20. For further information, see the Mothers Against Drunk Drivers (MADD) Web site: . 43 The Department of Transportation Appropriation Act for fiscal year 2001 (H.R. 4475) included a provision that the States must enact 0.08 BAC per se laws by 2004 or begin losing Federal highway construction funds.

Factual Information 20 Highway Accident Report Figure 10. National Transportation Safety Board model program to reduce hard core drinking driving. Model Program Elements 1. Frequent and well-publicized statewide sobriety checkpoints that include checking for valid driver’s licenses. Checkpoints should not be limited to holiday periods. [P] 2. Vehicle sanctions to restrict or separate hard core drinking drivers from their vehicles, including license plate actions (impoundments, confiscation, or other actions); vehicle immobilization, impoundment, and forfeiture; and ignition interlocks for high-BAC first offenders and repeat offenders. [P] 3. State and community cooperative programs involving driver licensing agencies, law enforcement officers, judges, and probation officers to enforce DWI suspension and revocation. [P] 4. Legislation to require that DWI offenders who have been convicted or administratively adjudicated maintain a zero BAC while operating a motor vehicle. [P] 5. Legislation that defines a high BAC (0.15 or greater) as an “aggravated” DWI offense that requires strong intervention similar to that ordinarily prescribed for repeat DWI offenders. [P] 6. As alternatives to confinement, programs to reduce hard core drinking driver recidivism that include home detention with electronic monitoring and/or intensive probation supervision programs. [S] 7. Legislation that restricts the plea bargaining of a DWI offense to a lesser, non-alcohol-related offense and that requires the reasons for DWI charge reductions be entered into the public record. [S] 8. Elimination of the use of diversion programs that permit erasing, deferring, or otherwise purging the DWI offense record or that allow the offender to avoid license suspension. [P] 9. Administrative license revocation for BAC test failure and refusal. [P]

1. A DWI record retention and DWI offense enhancement look-back period of at least

10 years. S

1. Individualized sanction programs for hard core DWI offenders that rely on effective

countermeasures for use by courts that hear DWI cases. [S] To determine a State’s progress in addressing hard core drinking drivers through the hard core model program, staff has prioritized the above elements as follows: Primary elements [P]. Elements that research indicates will directly reduce fatalities such as sobriety checkpoints (1), vehicle sanctions (2), “hot sheet” programs (3), zero BAC restrictions (4), increased penalties for high-BAC offenders (5), diversion elimination (8), and administrative license revocation (9). Secondary elements [S]. Elements that staff concludes will help the DWI countermeasure system function more efficiently such as alternatives to jail incarceration (6), plea bargaining restrictions (7), 10-year look-back and records retention period (10), and individualized sanction programs (11).

Factual Information 21 Highway Accident Report Table 7. New Jersey penalties for impaired driving (alcohol or drug related). BAC greater than or equal to 0.08 but less than 0.10 BAC greater than or equal to 0.10 Second offense within 10 years of first offense Third offense within 10 years of second offense License loss 3 months 7 months–1 year 2 years 10 years Fines, fees, and surcharges -$250–$400 fine -$75 per day IDRC fee -$100 drunk driving fund -$100 Alcohol Education and Rehabilitation Fund (AERF) -$1,000 a year for 3 years surcharge -$75 Safe Neighborhood Services Fund -$300–$500 fine -$75 per day IDRC fee -$100 drunk driving fund -$100 AERF -$1,000 a year for 3 years surcharge -$75 Safe Neighborhood Services Fund -$500–$1000 fine -$100 per day IDRC fee -$100 drunk driving fund -$100 AERF -$1,000 a year for 3 years surcharge -$75 Safe Neighborhood Services Fund -$1,000 fine -$100 per day IDRC fee -$100 drunk driving fund -$100 AERF -$1,500 a year for 3 years surcharge -$75 Safe Neighborhood Services Fund Prison term Up to 30 days Up to 30 days 48 hours to 90 days 180 days Community service, Intoxicated Driver Resource Center (IDRC), or detainment 12–48 hours IDRC 12–48 hours IDRC -30 days community service -12–48 hours IDRC -Up to 90 days community service, which can reduce period of imprisonment -12–48 hours IDRC Operator Fatigue and Alcohol. Operator fatigue factors, including sleep loss, the time of day at which the accident occurred, and shiftwork have been implicated as causal or contributing factors in several Safety Board investigations.44,45 Reduced sleep can magnify the effects of low doses of alcohol.46 Alcohol use also can impact sleep and

44 (a) National Transportation Safety Board, Motorcoach Run-off-the-Road and Overturn, Victor, New York, June 23, 2002, Highway Accident Report NTSB/HAR-04/03 (Washington, DC: NTSB, 2004). (b) National Transportation Safety Board, 15-Passenger Child Care Van Run-off-Road Accident, Memphis, Tennessee, April 4, 2002, Highway Accident Report NTSB/HAR-04/02 (Washington, DC: NTSB, 2004). (c) National Transportation Safety Board, Single Vehicle Run-off-Road Rollover, U.S. Route 101, San Miguel, California, January 2, 2001, Highway Accident Brief NTSB/HAB-02/01 (Washington, DC: NTSB, 2002). (d) National Transportation Safety Board, Greyhound Motorcoach Run-off-the-Road Accident, Burnt Cabins, Pennsylvania, June 20, 1998, Highway Accident Report NTSB/HAR-00/01 (Washington, DC: NTSB, 2000). 45 (a) National Transportation Safety Board, Motorcoach Run-off-the-Road Accident, Tallulah, Louisiana, October 13, 2003, Highway Accident Report NTSB/HAR-05/01 (Washington, DC: NTSB, 2005). (b) NTSB/HAR-04/03. (c) National Transportation Safety Board, Single-Vehicle Motorcoach Rollover Near Interstate Highway 24, Pleasant View, Tennessee, April 19, 2001, Highway Accident Brief NTSB/HAB-02/18 (Washington, DC: NTSB, 2002). (d) National Transportation Safety Board, Collision With School Bus, Chappell Hill, Texas, April 7, 1998, Highway Accident Brief NTSB/HAB-02/16 (Washington, DC: NTSB, 2002). 46 T. Roehrs, D. Beare, F. Zorick, and T. Roth “Sleepiness and Ethanol Effects on Simulated Driving,” Alcoholism: Clinical and Experimental Research, Vol. 18, No. 1 (January/February 1994):154-58.

Factual Information 22 Highway Accident Report sleep quality, leading to daytime fatigue and sleepiness.47,48 Alcohol consumption by nonalcoholics can induce sleep problems by disrupting the sequences and duration of sleep states and by decreasing total sleep time. It also has a sedating effect in that it decreases the time required to fall asleep. A 2000 poll conducted by the National Sleep Foundation shows that about 19 percent of individuals have taken alcohol to induce sleep, acknowledging the sedating effect of alcohol. Over time, with continued consumption of alcohol just before bedtime, alcohol’s sleep-inducing effect decreases. Alcoholics experience problems falling asleep, frequent awakenings, and a decreased total sleep time, and are more likely to suffer from certain sleep disorders, including sleep apnea.49 Alcohol Use and Seat Belt Use. Since 1999, restraint usage increased from 67 percent to 82 percent nationwide and from 63 percent to 86 percent in New Jersey. Seat belt use among drivers involved in fatal accidents is substantially lower for drivers impaired by alcohol.50 Safety belts were used by only 28 percent of fatally injured drivers with BACs of 0.08 or greater, as compared to 41 percent of fatally injured drivers with BACs between 0.01 and 0.07, and 57 percent of fatally injured drivers with 0.00 BACs.51 Lap/shoulder belts, when used, reduce the risk of fatal injury to front-seat passenger car occupants by 45 percent and the risk of moderate-to-critical injury by 50 percent.52 Additional occupant protection is provided by air bags.53 NHTSA analyses indicate that air bags reduced fatalities by 14 percent when no safety belt was used and by an additional 11 percent when a safety belt was used with air bags.54 47 T. Roehrs and T. Roth, Sleep, Sleepiness, and Alcohol Use, National Institute on Alcohol Abuse and Alcoholism . 48 National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, Alcohol and Sleep, Alcohol Alert No. 41 (Washington, DC: NIAAA, 1998). 49 (a) K. Brower, Alcohol’s Effects on Sleep in Alcoholics, National Institute on Alcohol Abuse and Alcoholism. . (b) NIAAA Alcohol Alert No. 41. 50 (a) National Highway Traffic Safety Administration, Traffic Safety Facts 2004 Data: Occupant Protection, DOT HS 809 909 (Washington, DC: NHTSA, 2005). (b) National Highway Traffic Safety Administration, Seat Belt Use in 2005—Use Rates in the States and Territories, DOT HS 809 970 (Washington, DC: NHTSA, 2005). 51 National Highway Traffic Safety Administration, Traffic Safety Facts 2004 Data: Alcohol, DOT HS 809 905 (Washington, DC: NHTSA, 2005). 52 National Highway Traffic Safety Administration, Sixth Report to Congress, Fourth Report to the President, The National Initiative for Increasing Safety Belt Use, DOT HS 809 823 (Washington, DC: NHTSA, June 2004). 53 National Highway Traffic Safety Administration, Third Report to Congress, Effectiveness of Occupant Protection Systems and Their Use (Washington, DC: NHTSA, December 1996) . 54 National Highway Traffic Safety Administration, Traffic Safety Facts 2003 Data: Occupant Protection, DOT HS 809 765 (Washington, DC: NHTSA, 2004).

Factual Information 23 Highway Accident Report Alcohol Use and Speeding. In 2004, 40 percent of drivers with a 0.08 or greater BAC who were involved in fatal accidents were speeding, as compared to 15 percent of drivers with a 0.00 BAC.55 Speed Management Speeding56 contributed to 30 percent of fatal accidents in 2004,57 resulting in nearly 13,192 lives lost. Slightly less than 12 percent of all fatalities in New Jersey are speeding related.58 Speeding reduces a driver’s ability to steer safely around curves or objects in the roadway, extends vehicle stopping distance, and increases the distance a vehicle travels while the driver reacts to a dangerous situation.59 Speed limits are set to improve safety by reducing the risks imposed by drivers’ speed choices. Generally, a balance between safety and travel efficiency (that is, minimizing travel time) is sought. Speed limits establish an upper bound on speeds, reducing the probability and severity of accidents. They also reduce speed disparities among vehicles. Established speed limits determine an enforcement standard, and effective enforcement deters unwanted driving behaviors.60 Typically, speed limits are enforced using traditional methods such as patrol cars with radar or other vehicle-speed measuring devices. The increasing number of vehicles, drivers, and vehicle miles driven, combined with competing demands for law enforcement personnel, have made traditional patrol car enforcement less practical and efficient; therefore, other methods of speed management and enforcement, such as speed cameras or photo radar, variable message signs, and roadway design, are being implemented. 61 Speed cameras use radar to trigger a camera that photographs a vehicle and its license plate when the vehicle’s speed exceeds a preset limit. Violation notices are usually sent to the vehicle owner.62 Speed cameras have been successfully used in a 55 National Highway Traffic Safety Administration, Traffic Safety Facts 2004 Data: Speeding, DOT HS 809 915 (Washington, DC: NHTSA, 2005). 56 NHTSA considers an accident to be speeding related if the driver was charged with a speeding- related offense or if the officer indicated that racing, driving too fast for conditions, or exceeding the posted speed limit contributed to the accident. 57 DOT HS 809 915. 58 C. Liu, C. Chen, R. Subramanian,, and D. Utter, Analysis of Speeding-Related Fatal Motor Vehicle Traffic Crashes, DOT HS 809 839 (Washington, DC: NHTSA, 2005). 59 DOT HS 809 915. 60 (a) National Research Council, Transportation Research Board, Managing Speed Review: Current Practices for Setting and Enforcing Speed Limits, Special Report 254 (Washington, DC: National Academy Press, 1998). (b) U.S. Department of Transportation, Speed Management Strategic Initiative (Washington, DC: DOT, June 2005). 61 Insurance Institute for Highway Safety, Q&A: Speed—Law Enforcement . 62 The National Committee on Uniform Traffic Laws and Ordinances has developed a model law for automated traffic law enforcement that includes a civil fine for violations.

Factual Information 24 Highway Accident Report few States63 and in the District of Columbia, where, for example, average speeds declined 14 percent and the proportion of vehicles exceeding the speed limit by more than 10 mph declined by 82 percent.64 Speed cameras are more widely used in countries outside of the United States as a means of speed enforcement.65 New Jersey statute prohibits the use of speed cameras.66 In 2004, legislation67 was proposed to authorize the use of photo- radar devices for enforcement purposes on certain local streets. The legislature did not act on this bill. Variable message signs that show the speed of a traveling vehicle or alert a driver to an upcoming safety situation (such as a work zone or fog) have had limited effectiveness. For example, the variable message signs or speed feedback indicators that are intended to increase awareness of excessive speeds and encourage drivers to slow down showed a 7- to 10-percent decrease in speeds in the presence of the indicator. After the indicator was removed, the speed reduction disappeared. Traffic enforcement activity prolonged the effectiveness of the indicator. 68 Roadway design measures such as speed humps, traffic circles, and roadway markings have reduced the incidence and severity of accidents.69 The FHWA also notes that such traffic calming projects result in reduced traffic volume, diverting potential accidents to other locations. Median Barrier Guidelines National Guidelines. The American Association of State Highway and Transportation Officials’ (AASHTO’s) Roadside Design Guide70 defines median barriers as “longitudinal barriers that are most commonly used to separate opposing traffic on a divided highway.” According to the Roadside Design Guide, median barriers should be installed only if the consequences of striking a barrier are expected to be less severe than if no barrier existed. Guidance contained in AASHTO’s Roadside Design Guide for the installation 63 According to the Insurance Institute for Highway Safety, speed cameras are used in Arizona, California, Colorado, North Carolina, Ohio, Oregon, and the District of Columbia . 64 (a) Insurance Institute for Highway Safety . (b) Insurance Institute for Highway Safety, “Cameras Reduce Speeding on D.C. Streets,” Status Reports, Vol. 37, No. 5 (May 2002). 65 M. Peden, R. Scurfield, D. Sleet, D. Mohan, A. Hyder, E. Jarawan, and C. Mathers, eds., World Report on Road Traffic Injury Prevention (Geneva: World Health Organization, 2004). 66 New Jersey Statute 39:4-103.1. 67 Assembly Bill No. 2369, February 23, 2004. 68 S.M. Casey and A.K. Lund, “The Effects of Mobile Roadside Speedometers on Traffic Speeds,” Accident Analysis and Prevention, Vol. 25, No. 5 (1993): 627-34. 69 Federal Highway Safety Administration, Synthesis of Safety Research Related to Speed and Speed Management, FHWA-RD-98-154 (Washington, DC: FHWA, 1998). 70 American Association of State Highway and Transportation Officials, Roadside Design Guide (Washington, DC: AASHTO, 2002).

Factual Information 25 Highway Accident Report of barriers on high-speed,71 controlled-access roadways that have relatively flat, traversable medians is based on a combination of ADT and center median widths. The Roadside Design Guide suggests that the need for median barriers be evaluated on roadways where the ADT is at least 20,000 vehicles and the median width is less than 10 meters (32.8 feet). Barriers are optional for roadways where the median width is less than 10 meters and the ADT is 30,000 or fewer vehicles. Barriers are also considered optional for median widths between 10 and 15 meters (41.2 feet), regardless of the ADT. Barriers are not normally considered for medians 15 or more meters wide. The Roadside Design Guide states that median barriers are sometimes used on high-volume, non-access-controlled roadways. It also notes that terminating such barriers can be difficult, and sight distance may be a significant problem at intersections. AASHTO’s A Policy on Geometric Design of Highways and Streets (Green Book) further explains, Careful consideration should be given to the installation of median barriers on multilane expressways or other highways with partial control of access. Even medians that are narrow permit inadvertent encroachments with a chance of recovery and can also include geometric features to accommodate crossing or left- turn traffic. With the addition of barriers, barrier ends at median openings present formidable obstacles. Crash cushions, although needing maintenance and imposing a high initial cost, may be needed to shield an errant motorist from the barrier ends. Consequently, an evaluation of the number of median openings, crash history, alignment, sight distance, design speed, traffic volumes, and median width should be conducted prior to installation of median barriers on non-freeway facilities. 72 AASHTO’s Green Book states that on low-speed urban arterial streets, a raised curb median may be used. The Roadside Design Guide defines a vertical curb as a curb having a vertical or nearly vertical face of 6 inches or higher. These types of curbs are intended to discourage motorists from deliberately leaving the roadway. The Green Book73 notes that raised curb medians are desirable for preventing midblock left turns and can also provide a refuge for pedestrians and space for signs and other appurtenances. However, the same guidance warns that raised curb medians do not prevent pedestrian or cross-median accidents unless a median barrier is present, noting the raised curb may cause drivers to lose control of their vehicles if struck. The Roadside Design Guide states that raised curb medians are generally not desirable for high-speed roadways because, if an errant vehicle became airborne, the change in the bumper height 71 Both AASHTO’s A Policy on Geometric Design of Highways and Streets and the FHWA’s Manual on Uniform Traffic Control Devices use the terms “low speed” and “high speed” but do not define them. Interviews with veteran traffic engineers indicate that 45 mph is widely considered to be the boundary between low- and high-speed facilities. For further information, see American Association of State Highway and Transportation Officials, A Policy on Geometric Design of Highways and Streets (Washington, DC: AASHTO, 2004) and U.S. Department of Transportation, Federal Highway Administration, Manual on Uniform Traffic Control Devices (Washington, DC: FHWA, 2003). 72  A Policy on Geometric Design of Highways and Streets, 2004, chapter 4. 73 A Policy on Geometric Design of Highways and Streets, 2004, chapter 7.

Factual Information 26 Highway Accident Report could become crucial if a secondary accident occurs. The Green Book further notes that these types of medians can be difficult to see at night without appropriate lighting or delineation.74 New Jersey Median Barrier Guidelines. The NJDOT has adopted AASHTO median barrier warrants as part of the State’s Roadway Design Manual. However, AASHTO guidelines do not always accommodate New Jersey requirements; where discrepancies exist, the NJDOT guidelines are followed for all roadways except interstate highways. NJDOT guidelines state that the number of crossovers, accident history, alignment, sight distance, design speed, traffic volume, and median width should be evaluated before median barriers are installed on noninterstate highways.75 As a practice, the NJDOT does not place median barriers on nonfreeway roadways that permit left turns. The NJDOT’s Roadway Design Manual also suggests that a number of factors be considered before installing median barriers on highways with partial control of access, in part, because of potential problems at each intersection or median crossover where the median barrier must be terminated. Safety Board staff observed numerous median barrier wall terminations on U.S. 1, which varied from elaborate crash cushions to no end treatment. In October 2002, the NJDOT developed the “Cross Median Crash Reduction Program,” which evaluates the accident history of roadway segments to help determine where to install median barriers. The program identified an initial list of freeway segments for further consideration. Because the program did not evaluate nonfreeway segments, U.S. 1 was not considered as a possible location to place a barrier. The NJDOT expects the program to be expanded, pending future funding, to include the entire State roadway network. 74 A Policy on Geometric Design of Highways and Streets, 2004, chapter 7. 75 New Jersey Department of Transportation, Roadway Design Manual, Section 8, “Guidelines for Guide Rail Design and Median Barriers.”

27 Highway Accident Report Analysis This analysis first discusses the factors and conditions the Safety Board was able to exclude as neither causing nor contributing to the accident. It then provides a brief overview of the accident events and discusses the safety issues relevant to this accident: alcohol impairment, speed enforcement, and evaluative criteria for median barrier installation. Exclusions At the time of the accident, no rain or fog was reported and the roadway was dry, except for the puddle of water in the right southbound lane of U.S. 1 observed by the LPD. Mechanical inspection of both vehicles failed to detect any mechanical defects that would have affected the drivers’ ability to control their respective vehicles. The damage to the vehicles was consistent with impact. The Linden Fire Department arrived at the accident site in about 4 minutes, and an ambulance arrived approximately 8 minutes after the accident. The roadway was appropriately marked with maximum speed signs (40 mph), and the travel lanes of the roadway were well marked with solid, yellow, retroflective lines designating the edges of the travel lanes and dashed, white, retroflective lines indicating individual travel lanes. Although the roadway lighting was in poor condition, it was supplemented by lighting from the gas station. The Union County Medical Examiner’s report on the Mercedes driver noted two intact tablets in the driver’s stomach marked “Allegra.” Testing conducted by the CAMI indicated the tablet was composed of pseudoephedrine (a nasal decongestant) and fexofenadine (an antihistamine), a combination commonly known as “Allegra-D.”76,77 Pseudoephedrine is a mild stimulant that is not typically expected to result in impairment. 76 Allegra-D is a prescription drug used to relieve the symptoms of seasonal allergic rhinitis in adults and children over 12. 77 Toxicological testing performed by the New Jersey State Toxicology Laboratory reported phenmetrazine in a pill in the Mercedes driver’s stomach, but the autopsy report noted that tablets removed from the driver’s stomach were marked “Allegra.” The toxicological report notes only pseudoephedrine, alcohol, and acetaldehyde (a metabolite of alcohol) in the driver’s blood and tissues. Phenmetrazine was marketed in the United States under the brand name Preludin as a weight control pill, which the manufacturer ceased making in 1991. Chemically, phenmetrazine and pseudoephedrine are similar substances. The tablets in the driver’s stomach were most likely Allegra-D (pseudoephedrine and fexofenadine), not phenmetrazine.

Analysis 28 Highway Accident Report Fexofenadine has been demonstrated to be free of performance impairment during psychomotor tests and actual driving performance, when taken at typical doses, alone or with alcohol.78 The Safety Board therefore concludes that the weather, the mechanical condition of the vehicles, the roadway markings, the roadway lighting, and the driver’s use of prescription drugs neither caused nor contributed to the accident. The Safety Board further concludes that the emergency response was timely and adequate. LPD officers noted that, upon arriving at the accident scene, they observed a puddle of standing water, 2 to 3 feet at the widest part, which extended about 35 feet in the right southbound traffic lane adjacent to the north driveway of the gas station. (See figure 1, top-right corner of diagram.) A drop inlet located north of the puddle and intended to drain that area did not function as designed because it was no longer at the lowest point in the gutter, allowing a pool of water to collect. Variances in the thickness of the asphaltic concrete surface quite likely occurred the last time the roadway was resurfaced. The LPD accident report indicated that the puddle could have caused the vehicle to hydroplane.79 However, the Safety Board’s analysis of the physical evidence shows that hydroplaning was not a factor in the accident sequence. The origin of the tire marks produced by the Mercedes indicates that the vehicle was already traveling toward the west curb of the roadway as it approached the area of standing water. The scars and scuff mark observed on the nose of the curb were most likely produced by the right-front tire and wheel rim of the Mercedes. Given the diameter of the tire, as the leading edge made contact with the curb, the portion of the tire in contact with the pavement would have been trailing behind and would not yet have entered the water adjacent to the curb’s nose. In other words, the front of the tire would have struck the curb before any other portion could have encountered the puddle. The impact of the tire and wheel rim with the curb would have contributed to the vehicle’s loss of control. As the vehicle’s right-side tires departed the curb, the limited amount of water on the roadway would have precluded more than one tire at a time from rolling through the water. With one tire in the puddle and three tires on dry pavement, the vehicle would have 78 (a) F. Ridout, Z. Shamsi, R. Meadows, S. Johnson, and I. Hindmarch, “A Single-Center, Randomized, Double-Blind, Placebo-Controlled, Crossover Investigation of the Effects of Fexofenadine Hydrochloride 180 mg Alone and With Alcohol, With Hydroxyzine Hydrochloride 50 mg as a Positive Internal Control, on Aspects of Cognitive and Psychomotor Function Related to Driving a Car,” Clinical Therapeutics, Vol. 25, No. 5 (May 2003): 1518-38. (b) P.C. Potter, J.M. Schepers, and C.H. Van Niekerk, “The Effects of Fexofenadine on Reaction Time, Decision-Making, and Driver Behavior,” Annals of Allergy, Asthma, and Immunology, Vol. 91, No. 2 (August 2003): 177-81. (c) J.M. Weiler, J.R. Bloomfield, G.G. Woodworth, A.R. Grant, T.A. Layton, T.L. Brown, D.R. McKenzie, T.W. Baker, G.S. Watson, “Effects of Fexofenadine, Diphenhydramine, and Alcohol on Driving Performance, A Randomized, Placebo-Controlled Trial in the Iowa Driving Simulator,” Annals of Internal Medicine, Vol. 132, No. 5 (March 2000): 354-63. (d) A. Vermeeren and J.F. O’Hanlon, “Fexofenadine’s Effects, Alone and With Alcohol, on Actual Driving and Psychomotor Performance,” The Journal of Allergy and Clinical Immunology, Vol. 101, No. 3 (March 1998): 306-11. 79 Hydroplaning refers to the separation of a tire from the road surface by a layer of water, which reduces available friction, causing the tire to slide.

Analysis 29 Highway Accident Report maintained its frictional adhesion to the roadway, and the small amount of water would have had no significant effect on vehicle control. Moreover, given the size of the puddle and the vehicle’s speed, the tire would have been in contact with the water for less than one wheel revolution and for only a fraction of a second—approximately 0.005 second— further supporting an insignificant impact on vehicle control. Therefore, the Safety Board concludes that the Mercedes’ contact with the puddle in the southbound lanes of U.S. 1 was of insufficient extent and duration to have caused the vehicle to hydroplane and did not contribute to the accident. Accident On April 30, 2003, the driver of the 1998 Mercedes left his house about 6:30 p.m. for a softball game. On the way to the game, the driver stopped by a local bar and bought a round of drinks for the patrons. He played in a softball game, which began about 7:30 p.m. and ended at 9:30 p.m. The driver and several teammates remained at the field after the game, and some of the players consumed alcohol. About 11:30 p.m., the driver returned to the local bar, which he left about 2:00 a.m. As he left the bar, he met a friend and stopped to talk for a few minutes. The Mercedes driver drove about 3.35 miles in the southbound lanes of U.S. 1 in Linden before the accident. Near MP 41.4, as indicated by the tire marks, the vehicle was traveling between 48 and 62 mph,80 hit the curb on the west side of the road, swerved to the left, crossed the other two southbound lanes, mounted and crossed the 11.5-foot-wide, 6-inch-high raised curb median, and entered the northbound lanes, where it collided head on with a 1986 Ford. As the Mercedes crossed over the raised center median, the vehicle had rotated about 71 degrees counterclockwise from its original orientation in the right southbound traffic lane. (See figure 1 for a diagram of the accident scene.) As evidenced by the vehicle damage, the initial contact between the two vehicles occurred between the right front of the Mercedes and the left front of the Ford. The Mercedes most likely began to rotate clockwise about its longitudinal axis, rolled up and over the Ford, landed on its roof, and slid about 80 feet into a wooden utility pole on the east side of the roadway. The Ford remained upright and rotated counterclockwise about 163 degrees, and then slid about 50 feet to its point of final rest in the northbound lanes of U.S. 1. Mercedes Speed Calculation LPD investigators documented two tire marks observed in the southbound lanes of the roadway and classified them as critical curve speed scuff marks. The properties of these marks were used to calculate the speed of the vehicle as it traversed the southbound 80 See speed calculation section that follows.

Analysis 30 Highway Accident Report lanes of the highway. Using 78, the skid number obtained by the NJDOT for the southbound lanes, calculations showed that the vehicle’s speed would have been 62 mph as it traversed the southbound lanes. However, this skid number was probably too high, given that the NJDOT conducted its testing on a dry road surface, whereas the testing standards are for wet surfaces. Based on the physical examination of the pavement surface, as well as consideration of the roadway’s usage (ADT between 48,000 and 82,000 vehicles) and the pavement age (most recent paving project was in 1991), the traffic lanes were determined to be traffic polished. In this condition, typical skid numbers would be in the range of 45 to 65,81 not the friction value of 78 reported by the NJDOT. Using these typical values, the Mercedes’ speed was calculated to range from 48 to 57 mph. Mercedes Driver Actions The Safety Board’s accident investigation indicated that the Mercedes was already traveling toward the curb before it approached the water puddle. The roadway and median scuff marks also showed that, after hitting the west curb, the vehicle swerved to the left across the other two southbound lanes on U.S. 1. The scuff marks at the scene suggest that the Mercedes driver initiated a significant steering maneuver to swerve the vehicle to the left across the two southbound lanes on U.S. 1. The Safety Board considered several possible explanations for the steering maneuver. Response to Another Vehicle Although the video surveillance tape from the gas station was not usable, gas station logs showed no activity at the pumps for approximately 30 minutes before the accident, reducing the likelihood that the Mercedes driver’s maneuver was in response to a vehicle leaving the gas station. Alcohol Consumption CAMI testing82 showed alcohol in the Mercedes driver’s blood (0.326 percent) and other bodily fluids.83 In the hours before the accident, the driver was at two places where alcohol was being consumed. Although no one reported seeing the driver drinking alcoholic beverages at the softball field or local bar, the driver’s BAC level indicates that he had consumed significant amounts of alcohol before the accident. Several possible scenarios could explain the driver’s high BAC level. In one such scenario, the driver, after having consumed alcohol most of the day, would have had a drink at the bar, followed by a couple of beers at the softball game, and then returned to the bar and continued to drink 81 L.B. Fricke, Traffic Accident Reconstruction, Volume 2 of the Traffic Investigation Manual (Evanston, IL: Northwestern Traffic Institute, 1990). 82 Testing was also performed by the New Jersey State Toxicological Laboratory, which found a 0.351 BAC. The more conservative CAMI results are used here. 83 According to CAMI, 0.379 percent in urine and 0.210 percent in vitreous humor.

Analysis 31 Highway Accident Report until leaving, thus consuming enough alcohol to increase his BAC before the accident. However, because the driver’s specific drinking behavior—that is, what he was drinking or the time at which he started drinking—is not known, the Board calculated84 the amount of alcohol that a sober, 230-pound male would have had to drink to reach a 0.326 BAC under various conditions.85 Based on those calculations, a prototypical male who began drinking about 7.5 hours before reaching a 0.326 BAC (about the time the driver made his first trip to the bar) would have had to consume approximately twenty-seven 12-ounce beers.86 The same person who began drinking about 5 hours before reaching a 0.326 BAC (about the time the driver’s softball game ended) would have had to consume twenty-five 12-ounce beers or, if he began drinking about 3 hours before reaching a 0.326 BAC, twenty-three 12-ounce beers. At a BAC of 0.326, most individuals would experience dizziness; impaired muscular coordination, including an inability to stand or walk; reduced perception and visual functions; vomiting; and, possibly, loss of consciousness. However, the driver of the Mercedes was able to talk with friends and drive for approximately 3.35 miles before becoming involved in an accident. Individuals who are able to function with high BACs have very likely developed a tolerance to alcohol and therefore need to drink more alcohol than others to produce the same effect. Practicing the same task while under the influence of low doses of alcohol can lead to successful performance of the task by such individuals, unless they encounter something unusual. The Safety Board concludes that the Mercedes driver’s ability to function (that is, to talk with friends and drive his vehicle for 3.35 miles) after consuming amounts of alcohol that would have incapacitated a nontolerant individual indicates that he had probably developed a tolerance to alcohol. In most individuals, driving impairment can appear at a BAC of 0.02. Driving performance is impaired in almost everyone at a BAC of 0.08 or greater. At a BAC of 0.08, most drivers experience increased distractibility, steering difficulties, reduced visual acuity, and affected coordination. An alcohol-tolerant driver who might otherwise be able to drive successfully at these BAC levels still has degraded driving skills and can exhibit impaired performance if something beyond his practiced behavior occurs. An unanticipated situation can place the alcohol-tolerant driver at the same risk for an accident, due to lack of prior learning opportunities for the unexpected event, as a novice driver who has the same BAC.87 Although the Mercedes driver had very likely acquired a tolerance to alcohol, the unexpected occurrence of drifting over and hitting the curb exceeded his ability to compensate for his high BAC level. His performance would then have been comparable to that of a non-alcohol-tolerant driver in that his level of distractibility, ability to steer the vehicle, visual acuity, coordination, and reaction time, among other abilities, would have been affected. The Safety Board concludes that despite 84 Safety Board calculations followed the guidelines contained in: Computing a BAC Estimate . 85 According to the autopsy report, the driver weighed between 220 and 230 pounds. 86 The Safety Board stresses that these are estimates based on drinks containing 1 ounce of alcohol. Calculations also show the driver would have had to consume twenty 5-ounce glasses of wine or nineteen 1.5-ounce liquor drinks to achieve a 0.326 BAC. 87 (a) NIAAA, Alcohol Alert No. 28. (b) NIAAA, Alcohol Alert No. 31.

Analysis 32 Highway Accident Report the Mercedes driver’s apparent alcohol tolerance, he exhibited alcohol-impaired performance in allowing his vehicle to drift over and strike the curb, steering abruptly after hitting the curb, and crossing the three lanes of traffic and the median. The Mercedes driver’s driving record did not indicate any previous violations of DWI laws. However, NHTSA research has shown that drivers can drive impaired for thousands of miles and on several occasions before being arrested for a DWI offense.88 The Safety Board concludes that although the Mercedes driver had no record of impaired driving penalties or violations, it is very likely that a driver with such a high BAC had previously driven impaired. The Mercedes driver’s BAC indicates the driver consumed significant amounts of alcohol before the accident. It is also very likely that the driver had a problem with alcohol for a substantial period of time because his behaviors indicate he had developed a tolerance to alcohol. However, few people appeared to be aware of the driver’s problem with alcohol. The driver’s family and friends said that he was a social drinker, yet no one indicated that the driver was a problem drinker. Additionally, the driver of the Mercedes was a police officer and associated with other law enforcement personnel socially (for example, softball games) and through work. Drivers’ histories are not always indicative of problem drinking, and people are not always aware of or do not want to acknowledge a drinking problem.89 However, unlike the general public, police officers are responsible for enforcing impaired driving laws and frequently receive training in detecting impaired driving behaviors and signs of alcohol or drug use.90 Some States, such as New York, provide impaired driving detection training for all of their officers; others, such as New Jersey, conduct training on this topic as requested (about a half-dozen courses each year). The Safety Board concludes that as a police officer, the driver of the Mercedes associated with and worked with other police officers who should have been able to recognize signs of excessive alcohol use and impairment. The Safety Board will inform the International Association of Chiefs of Police, the National Sheriffs’ Association, and the Fraternal Order of Police of the circumstances of this accident and encourage law enforcement organizations to conduct refresher training on recognizing signs of excessive alcohol use and impairment. The Safety Board’s model program to counter the hard core drinking driver, which targets drivers with a high BAC as well as repeat offenders, has several elements, including frequent and well-publicized sobriety checkpoints, vehicle sanctions to restrict or separate hard core drinking drivers from their vehicles, State and community programs to enforce DWI suspensions, legislation that defines a high BAC (0.15 or greater) as an “aggravated” DWI offense, administrative license revocation for BAC test failure and refusal, and individualized sanction programs for repeat DWI offenders. 88 (a) Alcohol and Highway Safety 1984: A Review of the State of the Knowledge, 56. (b) DOT HS 809 184. 89 Injury Prevention, Vol. 8 (September 2002): 221-26. 90 NHTSA has developed standards for training on detecting impaired driving: DWI Detection and Standardization Field Sobriety Testing Basic Course, DWI Detection and Standardized Field Sobriety Instructor Training, DWI Detection and Standardized Field Sobriety Testing Refresher Training, and Drug Recognition Expert Training.

Analysis 33 Highway Accident Report In 2000, the Safety Board recommended that the States and the District of Columbia establish their own DWI programs: H-00-26 Establish a comprehensive program that is designed to reduce the incidence of alcohol-related crashes, injuries, and fatalities caused by hard core drinking drivers and that includes elements such as those suggested in the National Transportation Safety Board’s Model Program. On July 5, 2005, the State of New Jersey responded to Safety Recommendation H-00-26, indicating that it had passed legislation in 1999 giving the courts discretion to order that an interlock device91 be installed on the motor vehicle of a first-time DWI offender and requiring that an interlock device be installed for second or subsequent offenders. New Jersey law also authorizes the arresting law enforcement agency to impound a vehicle operated by a person arrested for DWI for up to 12 hours following the arrest, if the agency determines that releasing the vehicle to the person arrested represents a threat to public safety. New Jersey permits sobriety checkpoints and, according to the New Jersey Division of Highway Traffic Safety, Linden received $10,000 in drunk driving prevention funds in 2004 (of which, $4,600 was spent on checkpoints) and $14,000 in drunk driving prevention funds in 2005. New Jersey also has alternatives to confinement, restricts plea-bargaining, and has a look-back period of at least 10 years. However, New Jersey has not initiated many of the other elements of the model program: laws addressing administrative license revocation, zero BAC restriction for DWI offenders, elimination of diversion programs (such as education, counseling, or community service), or specialized DWI courts. Finally, New Jersey does not have legislation defining a high BAC (0.15 or greater) as an “aggravated” DWI offense requiring strong intervention similar to that ordinarily prescribed for repeat DWI offenders.92 Because New Jersey has implemented only one of seven of the model program’s primary elements, Safety Recommendation H-00-26 was classified “Open— Unacceptable Response” on September 20, 2005. The Safety Board concludes that New Jersey lacks a comprehensive approach to preventing hard core drinking driving, including legislation that defines a high BAC (0.15 or greater) as an aggravated DWI offense; therefore, the Safety Board reiterates Safety Recommendation H-00-26 to the State of New Jersey. Operator Fatigue The Safety Board also explored the role operator fatigue may have played in the accident. Alcohol consumption can disrupt sleep and lead to decreased total sleep time, 91 Device attached to a vehicle’s ignition system that prevents the vehicle from being started if a driver’s breath alcohol concentration (as measured by blowing into the device) is above an established level. 92 In May 2005, the New Jersey Senate proposed legislation to increase penalties for drunk drivers with BACs of 0.15 or higher (Senate Bill No. 2469, May 5, 2005), but no action has been taken on the bill.

Analysis 34 Highway Accident Report thereby contributing to impaired performance.93 Alcohol consumption and sleepiness can also combine to impair driving performance.94 In the 72 hours before the accident, the Mercedes driver slept at least 17 hours; however, the driver’s sleep activities the day before the accident are unknown. The Mercedes driver had been working a nontraditional schedule (8:00 p.m. to 6:00 a.m.) for approximately 1 month and, according to his family, attempted to maintain that sleep schedule on his days off. However, the driver’s sleep schedule showed that on Monday, April 28, he slept from 1:00 a.m. to about 11:00 a.m. and on Tuesday, April 29, he slept from 4:00 a.m. to 11:00 a.m., times covering periods that he would normally have been awake and on duty. Furthermore, the accident occurred at 2:11 a.m., a time at which the body is predisposed for sleep. Although information on the amount of sleep the Mercedes driver received in the 24 hours before the accident is limited, sufficient information exists to suggest the combined effects of alcohol consumption and reduced, low-quality sleep may have impaired the driver’s performance. The driver’s sleep schedule, the time that the accident occurred, and the consumption of alcohol all could have contributed to the driver’s impaired performance. The Safety Board, therefore, concludes that although it cannot be determined conclusively whether the driver of the Mercedes was fatigued at the time of the accident or whether he fell asleep, sufficient evidence exists to suggest that impaired performance due to the combined effects of alcohol consumption and operator fatigue possibly contributed to the accident. Survival Aspects The drivers of both vehicles and three of the four passengers in the Ford died at the accident site. The fourth passenger died about 3.5 hours later at the hospital. Contact damage to the Ford was along the left side of the vehicle. It began at the front grill assembly, continued across both the driver and left-rear passenger doors, and ended just before the rear left wheel. The left side of the vehicle and the roof panel were pushed into the passenger compartment. The Safety Board concludes that the intrusion into the occupant compartments of the Ford rendered the vehicle occupant space unsurvivable. The Mercedes sustained extensive contact damage, which was concentrated in the right front and left rear of the vehicle, providing survivable space in the Mercedes. Further, the driver’s air bag deployed during the accident. However, the seat belt was found in the retracted position, and the belt webbing did not show signs of stress. The driver did not sustain any injuries over the abdomen or pelvis that would have been consistent with seat belt wear at the time of the accident. Further, the driver of the 93 (a) Sleep, Sleepiness, and Alcohol Use . (b) Alcohol Alert No. 41. (c) Alcohol’s Effects on Sleep in Alcoholics . 94 Alcoholism: Clinical and Experimental Research, Vol. 18, No. 1 (January/February 1994): 154-58.

Analysis 35 Highway Accident Report Mercedes was partially ejected from the vehicle. The Safety Board concludes that had the driver of the Mercedes been restrained, the seat belt, in conjunction with the air bag and the survivable space in the Mercedes, would have reduced his risk of ejection and fatal injury. Lap/shoulder belts reduce the risk of injury, and air bags provide supplemental protection to lap/shoulder belts.95 Restraint use is lower for those impaired by alcohol and at night.96 NHTSA is initiating a demonstration project of seat belt enforcement at night that will include a component of restraint use and alcohol impairment.97 The project was awarded in September 2005 and is currently under development. The Safety Board looks forward to reviewing the results of this demonstration project. Roadway Issues Vehicle Speed and Speed Enforcement U.S. 1 in the vicinity of the accident is considered a low-speed urban arterial roadway. It was designed for a travel speed of 45 mph and has a posted speed limit of 40 mph. The Safety Board calculated the travel speed of the Mercedes to have been between 48 and 62 mph. The driver of the Mercedes was thus speeding, which is more prevalent among alcohol-impaired drivers, and a Safety Board speed survey also showed that few other drivers were complying with the posted speed limit. According to this survey, the 85th percentile speed was 72 mph, and the median speed was 62 mph. Further, survey results showed only two vehicles were traveling at or below 40 mph, and six were traveling at 80 mph or greater. Two additional spot-speed studies conducted by the NJDOT yielded 85th percentile speeds of 58 mph and 52 mph. The widespread disregard for the speed limit suggests a low level of speed enforcement on this stretch of U.S. 1. LPD officials stated that the department was aware of the high frequency of speeding on U.S. 1 in the vicinity of the accident but had not conducted directed speed limit enforcement there because of limited resources. The Safety Board concludes that drivers are not complying with the posted speed limit of 40 mph on U.S. 1 in the vicinity of the accident and that the apparent lack of traffic law enforcement in this area may contribute to the higher travel speeds. As noted earlier, speeding contributed to 30 percent of fatal accidents in 2004,98 resulting in nearly 13,192 lives lost. Further, speeding reduces a driver’s ability to steer safely around curves or objects in the roadway, extends vehicle stopping distance, and increases the distance a vehicle travels while the driver reacts to a 95 Third Report to Congress, Effectiveness of Occupant Protection Systems and Their Use . 96 (a) National Highway Traffic Safety Administration, Restraint Use Among Fatally Injured Passenger Vehicle Occupants by Time of Day, DOT HS 809 817 (Washington, DC: NHTSA, 2004). (b) National Highway Traffic Safety Administration, Traffic Safety Facts 2002: Alcohol, DOT HS 809 606 (Washington, DC: NHTSA, 2003). 97 NHTSA contract number DTNHT22-05-Z-05094, “Develop and Evaluate Nighttime Belt Enforcement.” 98 DOT HS 809 915.

Analysis 36 Highway Accident Report dangerous situation.99 Consequently, the Safety Board believes that the city of Linden should develop and implement a speed enforcement plan for U.S. 1. Median Barriers The Mercedes was traveling between 48 and 62 mph in the southbound lanes of U.S. 1 just before the accident occurred. When the Mercedes lost control, it swerved to the left, mounted a 6-inch curb, crossed an 11.5-foot-wide median, and entered the northbound lanes, where it collided head on with the Ford, killing the driver of the Mercedes and the five occupants of the Ford. During the accident sequence, the Mercedes’ contact with the raised median caused the vehicle to rotate about its longitudinal axis. A postaccident examination of the vehicles revealed that the right-front fender of the rotating Mercedes made contact with the Taurus’ driver-side A-pillar. As a result, the crash forces were primarily directed into the passenger compartment of the Taurus, dramatically increasing the severity of the accident. The accident segment of U.S. 1 had only a 6-inch-high raised concrete curb median to separate northbound and southbound traffic, for reasons that the NJDOT was unable to document. Consequently, no barrier was in place that could have prevented vehicles traveling in the southbound lanes from veering into the northbound lanes (or vice versa). However, median barriers were located north and south of the accident site. Physical evidence found on these median barriers, such as the black tire rubber smears and metallic scrapes, suggests vehicle contact with these taller structures. AASHTO guidelines, which the NJDOT has adopted, suggest that raised curb medians, such as the one present at the accident site, are best used on low-speed urban arterial roadways to prevent midblock left turns and provide a place for pedestrians and signs.100 The AASHTO guidelines also note that on high-speed roadways, striking a raised median curb can cause a driver to lose control, with the vehicle contacting the curb tripping, overturning, or becoming airborne, as was the case in this accident. Although the portion of U.S. 1 where the accident occurred had a posted 40-mph speed limit, traffic surveys showed that vehicles routinely traveled at substantially greater speeds. The Safety Board concludes that a raised curb median, such as the one on U.S. 1 in the vicinity of the accident, is not sufficient to prevent crossover median accidents and can cause a vehicle to become out of control or airborne at the speeds at which vehicles travel on that segment of roadway. The Safety Board further concludes that had a median barrier been present at the accident site, the Mercedes probably would not have crossed from the southbound lanes into the northbound lanes and collided with the Ford. Following the accident, the NJDOT evaluated the accident site for the installation of a median barrier. For several reasons, including the low occurrence of median crossover accidents and the straight alignment of the roadway segment, the NJDOT determined that a median barrier was not needed for this segment of U.S. 1. 99 DOT HS 809 915. 100 A Policy on Geometric Design of Highways and Streets (2004) and Roadside Design Guide (2002).

Analysis 37 Highway Accident Report Determining whether a median barrier should be installed on roadways that have relatively flat, traversable medians, such as the accident roadway, is difficult because AASHTO guidelines for median barrier installation do not provide clear guidance. AASHTO’s Roadside Design Guide provides guidance for the installation of median barriers on high-speed, controlled-access roadways based on a combination of ADT and center median widths. Because the section of U.S. 1 where the accident occurred had an estimated ADT exceeding 66,000 vehicles and a median width of 11.5 feet, the Roadside Design Guide would suggest that the roadway be evaluated as to the need for a median barrier. However, these guidelines do not state how to conduct such an evaluation or suggest specific information to consider. Additional guidance in the Roadside Design Guide states that median barriers are sometimes used on high-volume, non-access- controlled roadways but provides no specific guidance about median barrier installation other than information pertaining to the potential hazards in terminating barrier ends and sight distance. For such roadways, AASHTO’s A Policy on Geometric Design of Highways and Streets (as adopted by New Jersey) suggests several factors to consider in installing a median barrier on multilane expressways or other highways with partial control of access: the number of median openings, accident history, alignment, sight distance, design speed, traffic volumes, and median width. However, specific guidance is lacking concerning the conditions warranting the installation of median barriers, such as the level of traffic volume, number or rate of accidents, sight distance, or median width measurements. The Safety Board has previously asked the FHWA and AASHTO to revise the median barrier guidelines to reflect changes in the factors affecting the probability of cross-median accidents.101 Specifically, the Safety Board recommended that the FHWA, in conjunction with AASHTO (Safety Recommendation H-98-24): H-98-12 Review, with the American Association of State Highway and Transportation Officials, the median barrier warrants and revise them as necessary to reflect changes in the factors affecting the probability of cross- median accidents, including changes in the vehicle fleet and the percentage of heavy trucks using the roadway. AASHTO has informed the Safety Board that it is revising the guidance for median barriers. When completed, it is expected that the guidance will be released as an updated chapter in the Roadside Design Guide.102 The Safety Board looks forward to the opportunity to review this additional guidance; until then, Safety Recommendations H-98-12 and -24 remain classified “Open—Acceptable Response.” 101  (a) National Transportation Safety Board, Ford Explorer Sport Collision With Ford Windstar Minivan and Jeep Grand Cherokee on Interstate 95/495 Near Largo, Maryland, February 1, 2002, Highway Accident Report NTSB/HAR-03/02 (Washington, DC: NTSB, 2003). (b) National Transportation Safety Board, Multiple Vehicle Crossover Accident, Slinger, Wisconsin, February 12, 1997, Highway Accident Report NTSB/HAR-98/01 (Washington, DC: NTSB, 1998). 102 AASHTO plans full review of the Roadside Design Guide, culminating in a fully updated guide, possibly in 2008 (March 16, 2005, e-mail from the Associate Program Director, Engineering, AASHTO).

Analysis 38 Highway Accident Report As traffic, congestion, and vehicle speeds increase on roadways similar to the accident roadway, the probability of a median crossover accident also increases. The Safety Board recognizes that the installation of median barriers on roadways entails a complex decision-making process involving a number of roadway characteristics, a process made more difficult by the fact that the current median barrier installation guidelines are inadequate for determining when to install a median barrier. The Safety Board concludes that the AASHTO guidelines for the installation of a median barrier are inadequate because they do not include specific guidance on how to evaluate highway factors, such as accident history, sight distance, and vehicle type or speed, to determine whether a median barrier is necessary. The Safety Board believes that AASHTO and the FHWA should work together to establish evaluative criteria for determining when to install median barriers on high-volume, high-speed roadways, regardless of access type.

39 Highway Accident Report Conclusions Findings 1. The following elements neither caused nor contributed to the accident: the weather, the mechanical condition of the vehicles, the roadway markings, the roadway lighting, and the driver’s use of prescription drugs. 2. The emergency response was timely and adequate. 3. The Mercedes’ contact with the puddle in the southbound lanes of U.S. Route 1 was of insufficient extent and duration to have caused the vehicle to hydroplane and did not contribute to the accident. 4. The Mercedes driver’s ability to function (that is, to talk with friends and drive his vehicle for 3.35 miles) after consuming amounts of alcohol that would have incapacitated a nontolerant individual indicates that he had probably developed a tolerance to alcohol. 5. Despite the Mercedes driver’s apparent alcohol tolerance, he exhibited alcohol-impaired performance in allowing his vehicle to drift over and strike the curb, steering abruptly after hitting the curb, and crossing the three lanes of traffic and the median. 6. Although the Mercedes driver had no record of impaired driving penalties or violations, it is very likely that a driver with such a high blood alcohol concentration had previously driven impaired. 7. The driver of the Mercedes associated with and worked with other police officers who should have been able to recognize signs of excessive alcohol use and impairment. 8. New Jersey lacks a comprehensive approach to preventing hard core drinking driving, including legislation that defines a high blood alcohol concentration (0.15 or greater) as an aggravated DWI offense. 9. Although it cannot be determined conclusively whether the driver of the Mercedes was fatigued at the time of the accident or whether he fell asleep, sufficient evidence exists to suggest that impaired performance due to the combined effects of alcohol consumption and operator fatigue possibly contributed to the accident.

1. The intrusion into the occupant compartments of the Ford rendered the vehicle

occupant space unsurvivable.

Conclusions 40 Highway Accident Report

1. Had the driver of the Mercedes been restrained, the seat belt, in conjunction with the

air bag and the survivable space in the Mercedes, would have reduced his risk of ejection and fatal injury.

1. Drivers are not complying with the posted speed limit of 40 mph on U.S. Route 1 in

the vicinity of the accident, and the apparent lack of traffic law enforcement in this area may contribute to the higher travel speeds.

1. A raised curb median, such as the one on U.S. Route 1 in the vicinity of the accident,

is not sufficient to prevent crossover median accidents and can cause a vehicle to become out of control or airborne at the speeds at which vehicles travel on that segment of roadway.

1. Had a median barrier been present at the accident site, the Mercedes probably would

not have crossed from the southbound lanes into the northbound lanes and collided with the Ford.

1. American Association of State Highway and Transportation Officials guidelines for

the installation of a median barrier are inadequate because they do not include specific guidance on how to evaluate highway factors, such as accident history, sight distance, and vehicle type or speed, to determine whether a median barrier is necessary. Probable Cause The National Transportation Safety Board determines that the probable cause of this accident was the Mercedes driver’s loss of control of the vehicle due to alcohol impairment. Contributing to the severity of the accident were the lack of barriers separating traffic in the northbound and southbound traffic lanes and the failure of the Mercedes driver to wear his seat belt.

41 Highway Accident Report Recommendations As a result of its investigation, the National Transportation Safety Board makes the following safety recommendations: New Recommendations To the Federal Highway Administration: Work with the American Association of State Highway and Transportation Officials to establish evaluative criteria for determining when to install median barriers on high-volume, high-speed roadways, regardless of access type. (H-06-12) To the American Association of State Highway and Transportation Officials: Work with the Federal Highway Administration to establish evaluative criteria for determining when to install median barriers on high-volume, high-speed roadways, regardless of access type. (H-06-13) To the city of Linden: Develop and implement a speed enforcement plan for U.S. Route 1. (H-06-14) Reiterated Recommendation The National Transportation Safety Board reiterates the following previously issued recommendation: To the State of New Jersey: Establish a comprehensive program that is designed to reduce the incidence of alcohol-related crashes, injuries, and fatalities caused by hard core drinking drivers and that includes elements such as those suggested in the National Transportation Safety Board’s Model Program. (H-00-26)

Recommendations 42 Highway Accident Report BY THE NATIONAL TRANSPORTATION SAFETY BOARD MARK V. ROSENKER Acting Chairman DEBORAH A. P. HERSMAN Member ELLEN ENGLEMAN CONNERS Member KATHRYN O’LEARY HIGGINS Member Adopted: February 7, 2006

43 Highway Accident Report Appendix A Investigation and Public Hearing The National Transportation Safety Board was notified of the Linden, New Jersey, accident on May 1, 2003. Investigative team members were dispatched from the Washington, D.C., and Atlanta, Georgia, offices. Groups were established to investigate human performance, highway, and vehicle factors. Participating in the investigation were representatives of the Federal Highway Administration, the New Jersey Department of Transportation, and the Linden, New Jersey, Police Department. No public hearing was held; no depositions were taken.

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FD07319 ｜ 2006_美国_HAR0603.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2006 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

Multivehicle Collision on Interstate 90 Hampshire–Marengo Toll Plaza Near Hampshire, Illinois October 1, 2003 Highway Accident Report NTSB/HAR-06/03 PB2006-916203 Notation 7776A National Transportation Safety Board Washington, D.C.

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Highway Accident Report Multivehicle Collision on Interstate 90 Hampshire–Marengo Toll Plaza Near Hampshire, Illinois October 1, 2003 NTSB/HAR-06/03 PB2006-916203 National Transportation Safety Board Notation 7776A 490 L’Enfant Plaza, S.W. Adopted April 18, 2006 Washington, D.C. 20594

National Transportation Safety Board. 2006. Multivehicle Collision on Interstate 90, Hampshire– Marengo Toll Plaza, Near Hampshire, Illinois, October 1, 2003. Highway Accident Report NTSB/HAR-06/03. Washington, DC. Abstract: On October 1, 2003, a multivehicle accident occurred on the approach to an Interstate 90 toll plaza near Hampshire, Illinois. About 2:57 p.m., a 1995 Freightliner tractor-trailer chassis and cargo container combination unit was traveling eastbound on the interstate, approaching the Hampshire– Marengo toll plaza at milepost 41.6, when it struck the rear of a 1999 Goshen GC2 25-passenger specialty bus. As both vehicles moved forward, the specialty bus struck the rear of a 2000 Chevrolet Silverado 1500 pickup truck, which was pushed into the rear of a 1998 Ford conventional tractor-box trailer. As its cargo container and chassis began to overturn, the Freightliner also struck the upper portion of the pickup truck’s in-bed camper and the rear left side of the Ford trailer. The Freightliner and the specialty bus continued forward and came to rest in the median. The pickup truck was then struck by another eastbound vehicle, a 2000 Kenworth tractor with Polar tank trailer. Eight specialty bus passengers were fatally injured, and 12 passengers sustained minor-to-serious injuries. The bus driver, the pickup truck driver, and the Freightliner driver received minor injuries. The Ford driver and codriver and the Kenworth driver were not injured. Major safety issues identified in this investigation include toll plaza design and the lack of national standards for toll plaza design, Federal Motor Carrier Safety Administration oversight of passenger motor carriers operating on revoked authority, collision warning system performance standards and requirements for new commercial vehicles, and vehicle incompatibility and heavy truck aggressivity. As a result of this accident investigation, the Safety Board makes recommendations to the U.S. Department of Energy, the U.S. Department of Transportation, the Federal Motor Carrier Safety Administration, the Federal Highway Administration, the American Association of State Highway and Transportation Officials, and the International Bridge, Tunnel and Turnpike Association. The Safety Board reiterates two recommendations to the National Highway Traffic Safety Administration. The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Web at http://www.ntsb.gov. Other information about available publications also may be obtained from the Web site or by contacting: National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (800) 877-6799 or (202) 314-6551 Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2006-916203 from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605-6000 The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

iii Highway Accident Report Contents Acronyms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Accident Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Synopsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Freightliner Tractor-Trailer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Goshen Specialty Bus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Chevrolet Pickup, Ford Tractor-Box Trailer, and Kenworth Tractor-Tank Trailer . . . 7 Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Vehicle 1: Freightliner Tractor-Trailer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Vehicle 2: Goshen Specialty Bus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Vehicle 3: Chevrolet Pickup Truck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Vehicle 4: Ford Tractor-Box Trailer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Vehicle 5: Kenworth Tractor-Tank Trailer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Driver Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Freightliner Driver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Bus Driver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Other Drivers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Vehicle Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Freightliner Tractor-Trailer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Goshen Specialty Bus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Chevrolet Pickup Truck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Ford Tractor-Box Trailer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Kenworth Tractor-Tank Trailer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Operations Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Frontline Transportation Company . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Leisure Pursuit Charters, Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Federal Motor Carrier Safety Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Highway Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Traffic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Illinois State Toll Highway Authority System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Hampshire–Marengo Tollbooth Configuration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Rumble Strips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Toxicological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Specialty Bus Tail Lights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Freightliner Gear Speed Calculations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Forensic Evidence Documentation and Accident Simulation . . . . . . . . . . . . . . . . . . . . 33 Other Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Contents iv Highway Accident Report Toll Roads . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 American Association of State Highway and Transportation Officials . . . . . . . . . . . . 43 Federal Highway Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 International Toll Roads . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Safe, Accountable, Flexible, Efficient Transportation Equity Act . . . . . . . . . . . . . . . . 45 State Vehicle Codes for Intermodal Trailer, Chassis, and Safety . . . . . . . . . . . . . . . . . 46 Vehicle Incompatibility and Heavy Truck Aggressivity . . . . . . . . . . . . . . . . . . . . . . . . 46 Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Accident Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Freightliner Driver Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Collision Warning Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Highway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Federal Motor Carrier Safety Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Intermodal Chassis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Oversight of Passenger Carriers Operating on Revoked Authority . . . . . . . . . . . . . . . 58 Vehicle Incompatibility and Heavy Truck Aggressivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 New Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Reiterated Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Appendixes A: Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 B: Freightliner Combination Vehicle Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 C: SDM Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 D: State Toll Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 E: SAFETEA-LU 2005 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 F: Illinois Vehicle Code, Intermodal Equipment Exchange . . . . . . . . . . . . . . . . . . . 84

v Highway Accident Report Acronyms and Abbreviations AASHTO American Association of State Highway and Transportation Officials ACC adaptive cruise control AE algorithm enable CDL commercial driver’s license CFR Code of Federal Regulations COSCO China Ocean Shipping Company CSA Comprehensive Safety Analysis 2010 Initiative CVSA Commercial Vehicle Safety Alliance CWS collision warning system DMV Department of Motor Vehicles DOE U.S. Department of Energy DOT U.S. Department of Transportation ECE Economic Commission for Europe ECM electronic control module EDGEN Engineering Dynamics Corporation General Analysis Tool EDSMAC4 Engineering Dynamics Corporation Simulation of Automobile Collisions EEPROM electronically erasable programmable read-only memory ETC electronic toll collection FHWA Federal Highway Administration Florida DOT Florida Department of Transportation FMCSA Federal Motor Carrier Safety Administration FMCSRs Federal Motor Carrier Safety Regulations FY fiscal year GCWR gross combination weight rating GVWR gross vehicle weight rating HM hazardous materials HVE Human Vehicle Environment I-90 Interstate 90 IBTTA International Bridge, Tunnel and Turnpike Association ICC Interstate Commerce Commission ITS intelligent transportation systems

Acronyms and Abbreviations vi Highway Accident Report ISP Illinois State Police ISTHA Illinois State Toll Highway Authority IVI Intelligent Vehicle Initiative (NHTSA) LTV light trucks and vans MCMIS Motor Carrier Management Information System MCSAP Motor Carrier Safety Assistance Program MP milepost MUTCD Manual on Uniform Traffic Control Devices NCHRP National Cooperative Highway Research Program NHS National Highway System NHTSA National Highway Traffic Safety Administration OOS out of service ORT open road tolling PRISM Performance Registration Information Systems Management psi pound per square inch SafeStat Safety Status Measurement System SAFETEA-LU Safe, Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for Users SDM sensing diagnostic module SIMON Simulation Model Nonlinear TEA-21 Transportation Equity Act for the 21st Century U.S.C. United States Code VMT vehicle miles traveled

vii Highway Accident Report Executive Summary On October 1, 2003, a multivehicle accident occurred on the approach to an Interstate 90 (I-90) toll plaza near Hampshire, Illinois. About 2:57 p.m., a 1995 Freightliner tractor-trailer chassis and cargo container combination unit was traveling eastbound on I-90, approaching the Hampshire–Marengo toll plaza at milepost 41.6, when it struck the rear of a 1999 Goshen GC2 25-passenger specialty bus. As both vehicles moved forward, the specialty bus struck the rear of a 2000 Chevrolet Silverado 1500 pickup truck, which was pushed into the rear of a 1998 Ford conventional tractor-box trailer. As its cargo container and chassis began to overturn, the Freightliner also struck the upper portion of the pickup truck’s in-bed camper and the rear left side of the Ford trailer. The Freightliner and the specialty bus continued forward and came to rest in the median. The pickup truck was then struck by another eastbound vehicle, a 2000 Kenworth tractor with Polar tank trailer. Eight specialty bus passengers were fatally injured, and 12 passengers sustained minor-to-serious injuries. The bus driver, the pickup truck driver, and the Freightliner driver received minor injuries. The Ford driver and codriver and the Kenworth driver were not injured. The National Transportation Safety Board determines that the probable cause of the accident was the failure of the Freightliner truck driver, who was operating his vehicle too fast for traffic conditions, to slow for traffic. Contributing to the accident was the traffic backup in a 45-mph zone, created by vehicles stopping for the Hampshire–Marengo toll plaza. The structural incompatibility between the Freightliner tractor-trailer and the specialty bus contributed to the severity of the accident. The following safety issues were identified in this investigation: • Toll plaza design and the lack of national standards for toll plaza design, • Federal Motor Carrier Safety Administration (FMCSA) oversight of passenger motor carriers operating on revoked authority, • Collision warning system performance standards and requirements for new commercial vehicles, and • Vehicle incompatibility and heavy truck aggressivity. As a result of this accident investigation, the Safety Board makes recommendations to the U.S. Department of Energy, the U.S. Department of Transportation, the FMCSA, the Federal Highway Administration, the American Association of State Highway and Transportation Officials, and the International Bridge, Tunnel and Turnpike Association. The Safety Board reiterates two recommendations to the National Highway Traffic Safety Administration.

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1 Highway Accident Report Factual Information Accident Narrative Synopsis About 2:57 p.m.1 on October 1, 2003, a 1995 Freightliner tractor-trailer chassis and cargo container combination unit, operated by Frontline Transportation Company of Elk Grove Village, Illinois, was traveling eastbound on Interstate 90 (I-90) approaching the Hampshire–Marengo toll plaza (plaza 7) at milepost (MP) 41.6 near Hampshire, Illinois (see figures 1 and 2), when it struck the rear of a 1999 Goshen GC2 25-passenger specialty bus operated by Leisure Pursuit Charters, Inc. (Leisure), of Lake Bluff, Illinois. (See figures 3 and 4.) As both vehicles moved forward, the specialty bus struck the rear of a 2000 Chevrolet Silverado 1500 extended cab pickup truck, which was pushed into the rear of a 1998 Ford conventional tractor-box trailer. (See figures 5 and 6.) The Freightliner also struck the upper portion of the pickup truck’s in-bed camper and the rear left side of the Ford trailer as the Freightliner’s cargo container and chassis began to overturn. The Freightliner and the specialty bus continued forward and came to rest in the median; the Freightliner’s trailer overturned completely. The pickup truck was then struck by another eastbound vehicle, a 2000 Kenworth tractor with Polar tank trailer. (See figures 7 and 8.) Eight bus passengers were fatally injured, and 12 passengers sustained minor-to-serious injuries. The bus driver, the pickup truck driver, and the Freightliner driver received minor injuries. The Ford driver and codriver and the Kenworth driver were not injured. .

1 Unless otherwise indicated, all times in this report are central daylight time.

Factual Information 2 Highway Accident Report Figure 1. Regional map of accident location. Figure 2. View of accident location, I-90 eastbound. KANE COUNTY 90 Lake Michigan DE KALB COUNTY McHENRY COUNTY Chicago Accident location (see inset) N 90 Accident location PLAZA 7 Hampshire-Marengo Hampshire 20

Factual Information 3 Highway Accident Report Figure 3. Damaged Freightliner tractor-trailer. (Courtesy of Illinois State Police) Figure 4. Damaged Goshen specialty bus.

Factual Information 4 Highway Accident Report Figure 5. Damaged pickup truck. (Courtesy of Illinois State Police) Figure 6. Damaged Ford tractor-box trailer.

Factual Information 5 Highway Accident Report Figure 7. Damaged Kenworth tractor-tank trailer. Figure 8. Accident scene diagram. Goshen specialty bus Freightliner tractor-trailer position Furrow and plow marks Gouge and scrape marks I-90 Westbound Center median I-90 Eastbound Utility pole Tire marks Gouge and scrape marks Curved tire marks Kenworth tractor-tank trailer position Chevrolet pickup truck Ford tractor-box trailer position Milepost 41.5 Scale in feet 0 50 100 150 200 NORTH

Factual Information 6 Highway Accident Report Freightliner Tractor-Trailer The Freightliner driver reported that on the morning of the accident, about 6:00 a.m., he picked up his tractor at a rental space in Chicago, Illinois, and completed a 10- to 15-minute pretrip inspection, verifying that the lights, tires, brakes, and other equipment were in safe operating condition. Before picking up the accident chassis, he picked up another chassis trailer and cargo container and delivered both to a rail yard. He then drove to the Hamilton rail yard, where he picked up the accident chassis and empty cargo container. He reported conducting a 14-minute inspection of the chassis trailer and container—including the brakes,2 tires, and lights—and also said that he inspected the cargo container for cleanliness and damage. From the Hamilton yard, he drove to Midwest Recycling in Rockford, Illinois, where the cargo container was loaded with bundled recycling paper. He then departed for the return trip to Chicago. The Freightliner driver reported that he was traveling at a speed of 40 to 45 mph in the right lane of I-90 east, following a specialty bus by about two car lengths.3 He stated that he routinely maintained this vehicle separation distance to prevent other vehicles from changing lanes into his path.4 He reported that he remained in the right lane from the time he departed Rockford until he reached the accident location and that he experienced difficulty pulling the loaded container because of the small engine in his truck. The driver said that traffic was moving normally into the toll plaza and that the sun was high and to his rear, without glare or reflection. He stated that he maintained a constant view ahead and was startled when he saw the specialty bus stopped just in front of his vehicle. According to the Freightliner driver, the bus was not displaying brake lights. The driver stated that he braked hard and turned the steering wheel to the left in an unsuccessful attempt to avoid a collision. He said that he felt the truck brakes “grab,” but the braking action was insufficient to stop the truck, and the trailer shifted to his left5 and went out of control; the trailer overturned and the truck came to a stop in the median. The driver remained in his truck until the police arrived and asked him to exit the vehicle. Goshen Specialty Bus On October 1, 2003, about 9:25 a.m., the accident specialty bus left Chicago with 20 passengers on board for a roundtrip sightseeing charter to Rockford. About 2:15 p.m., the bus departed Rockford for the return trip to Chicago. The bus driver stated that he was in the left lane while on I-90 east and switched to the right lane 1 to 1.5 miles prior to the accident location. He reported that he was traveling at a speed of approximately 45 mph 2 To ensure that the brakes were operational, the driver said that he visually inspected them, then pulled the trailer forward and applied the brakes to bring the trailer to a stop. 3 A car length is typically 15 to 20 feet. 4 Illinois Department of Motor Vehicles, Illinois Commercial Driver’s License Study Guide (Springfield, Illinois: Illinois DMV, 2003) 11, 43–44. “Following the vehicle ahead too closely is the failure of a truck to leave sufficient distance for being overtaken by another vehicle.” One example given for proper following speed is: “Over 40 mph, you would need 7 seconds for a 60-foot vehicle. Remember to add 1 second for speeds above 40 mph.” At 40 mph, a driver would need a headway of 410 feet—and at 45 mph, 462 feet. Both of these distances are more than 10 times the 2 car lengths (40 feet) described by the driver as his typical following distance. 5 The trailer actually shifted and rolled to the right.

Factual Information 7 Highway Accident Report about 1 mile west of the Hampshire–Marengo toll plaza when he observed a line of vehicles approaching the plaza and gradually began to reduce speed to ensure passenger comfort. The driver stated that the line of traffic was a little longer than usual and that only one manual toll booth appeared to be in operation. According to the driver, this toll plaza does not operate an automatic toll lane for commercial vehicles. The bus driver reported that the sun was above and behind him at the time of the accident and that he did not experience adverse sun glare or reflection. He said that he was driving 10 mph about 0.5 mile from the toll plaza, when he observed in his left side mirror a red tractor-trailer approaching in his lane at a high rate of speed. The driver reported feeling the impact of the tractor-trailer and feeling his vehicle hit a vehicle ahead of him in the right lane. The driver’s air bag deployed, the bus was pushed into the median, and the driver reported steering to the right to avoid entering the westbound traffic lanes. The driver said that he unbuckled his seat belt and stepped out of the bus to call for emergency assistance. Chevrolet Pickup, Ford Tractor-Box Trailer, and Kenworth Tractor-Tank Trailer When the specialty bus was struck by the Freightliner, it was pushed forward and struck a 2000 Chevrolet Silverado pickup truck equipped with a bed-mounted camper. The pickup truck driver stated that he had been traveling in the right lane at a constant speed of 50 mph when he suddenly heard a loud crash and was simultaneously forced back into his seat by the impact of something striking his vehicle from behind. The driver reported that he had been looking forward and did not observe the traffic behind him and had no recollection of the vehicles ahead of him. He stated that he heard no other sounds prior to the collision and had not braked, changed lanes, or made any other maneuver before the accident. He remembered that his vehicle came to rest beneath a large truck and that he was trapped in the driver’s seat. He had been wearing his three-point seat belt, and his air bag deployed. When the pickup truck was struck from behind by the specialty bus, the truck was pushed forward into the rear of a 1998 Ford tractor pulling a box trailer. The driver of the Ford combination unit stated to Safety Board investigators that he had been traveling in the right lane at a speed of 30 to 35 mph while approaching the toll plaza. He recalled following another tractor-semitrailer that was about two truck lengths ahead of him and said that he had not noticed the traffic to his rear. He reported hearing a loud “explosion” and feeling a simultaneous impact involving the rear of his vehicle, followed by two other impacts, and immediately brought his truck to a stop. After departing his vehicle, he said that he talked to the driver trapped in the cab of the pickup truck until emergency personnel arrived. The fifth vehicle involved in this accident was a 2000 Kenworth tractor-tank trailer. The driver reported that he drove the same route weekly and, on the day of the accident, was traveling in the right lane after reducing his speed from 62 mph in the posted 45-mph work area speed zone, anticipating slower traffic on the approach to the toll plaza. He stated that he was following a pickup truck, which was 50 to 100 feet ahead of his

Factual Information 8 Highway Accident Report vehicle, and the pickup truck was closely following a Ford tractor-box trailer, when the specialty bus and the Freightliner tractor-trailer passed him in the left lane and then merged back into the right lane in front of him. He reported that, as he approached the toll plaza, he did not notice whether a line of vehicles was waiting to go through the manual toll booth. The Kenworth driver said that he observed the Freightliner in the left lane, braking hard with brake lights illuminated, and then watched it collide with the Ford tractor-box trailer and overturn. According to the Kenworth driver, he saw the pickup truck collide with the Ford and then lost sight of it as his vehicle skidded forward. During this sequence, he reported that he braked hard in an attempt to avoid becoming involved in the accident and later realized that the front of his vehicle had collided with the pickup truck. Injuries Eight specialty bus passengers were killed, four passengers received serious injuries, and eight received minor injuries. (See figure 9.) The bus driver, the pickup truck driver, and the Freightliner driver sustained minor injuries.6 The Ford driver and codriver and the Kenworth driver were not injured. (See table 1.) Table 1. Injuries. 6 Safety Board postaccident inspection of the specialty bus, pickup truck, and Freightliner drivers’ three-point seat belts revealed abrasions or “load marks” indicative of use at the time of the accident. InjuryA Specialty bus driver Specialty bus passengers Pickup truck and tractor-trailer driversB Total Fatal 0 8 0 8 Serious 0 4 0 4 Minor 1 8 2 11 None 0 0 3 3 Total 1 20 5 26 A Title 49 Code of Federal Regulations (CFR) 830.2 defines a fatal injury as any injury that results in death within 30 days of the accident. It defines a serious injury as any injury that requires hospitalization for more than 48 hours, commencing within 7 days of the date of injury; results in a fracture of any bone (except simple fractures of fingers, toes, or nose); causes severe hemorrhages or nerve, muscle, or tendon damage; involves any internal organ; or involves second- or third-degree burns, or any burn affecting more than 5 percent of the body surface. B Chevrolet pickup truck, Freightliner tractor-trailer, Ford tractor-box trailer (including codriver), and Kenworth tractor-tank trailer.

Factual Information 9 Highway Accident Report Figure 9. Specialty bus seating diagram. INTERNATIONAL CIVIL AVIATION ORGANIZATION INJURY LEGEND F = FEMALE M = MALE # = AGE Source: NTSB M S

F

= None Minor Serious Fatal

N=

(E) (R) (NR) (PE) RESTRAINED NOT RESTRAINED PARTIALLY EJECTED EJECTED SAMPLE F - 14 : M INJURY LEVEL AGE GENDER 3 1 2 4 5 6 F - 76 : F (NR-PE) F - 66 : M (NR) F - 52 : M (R) F - 66 : S (NR-E) F - 40 : S (R) F - 70 : S (NR) F - 64 : F (NR-E) F - 66 : F (R) F - 75 : F (NR-PE) M - 57 : M (R) F - 73 : M (R) F - 56 : M (R) F - 53 : F F - 67 : M (R-PE) F - 74 : F (R) F - 54 : F (R) M - 74 : S (NR) F - 73 : M (NR) F - 66 : F (NR-PE) F - 78 : M (NR) F - 58 : M (NR) A B C D A B C D E

Factual Information 10 Highway Accident Report Safety Board investigators interviewed 11 of the 12 surviving specialty bus passengers, and most stated that they were sleeping when the accident occurred. Those passengers who reported that they were restrained7 recalled their seats being thrown forward and becoming entangled in the interior vehicle wreckage. Some passengers exited the bus onto the roadside, and rescue personnel extricated the entrapped passengers. Two passengers seated in the first row on the right were ejected from the bus, and one was fatally injured. One passenger seated in the fourth row on the left, though restrained with a lap belt, was partially ejected and sustained minor injuries. Three other fatally injured passengers, seated in the fifth and sixth rows, were partially ejected. Emergency Response At 2:56 p.m., Kane County Sheriff’s dispatchers and the Illinois State Police (ISP) were notified of the accident through 911 communications, and they immediately initiated an emergency response. The first emergency medical personnel and police and fire responders arrived on scene at 3:05 p.m. The ISP and 27 local fire and rescue departments and other emergency service agencies responded to the accident, as did 13 ambulances and 4 medical flight helicopters. A lieutenant from the Hampshire Fire Department served as incident commander for the medical and fire response. Damage Vehicle 1: Freightliner Tractor-Trailer The Safety Board’s postaccident inspection of the 1995 Freightliner FLD tractor and Theurer trailer cargo container combination unit revealed tire damage to the steer axle left and right tires and to the outside tires on the second and third axles; the fourth and fifth axle outside tires received superficial cuts. The steering and suspension systems were not damaged. The brake system accessory line had a small air leak due to accident damage. The trailer frame, which had overturned on the roadway and traveled through the median before coming to rest, was deformed; the tractor remained upright and attached to the trailer by the kingpin. The trailer chassis remained engaged to the cargo container at the rear lock pins (the front left and right lock pins were disengaged, and mud was embedded in the lock pin opening). In the tractor cab interior, the floorboard—as well as the firewall and steering wheel—were displaced aft approximately 11 inches. The dashboard and accessory panel were deformed rearward within a few inches of the driver’s seat. The driver’s three-point restraint showed abrasions to the webbing. 7 Although the Federal Motor Vehicle Safety Standards do not require restraints, the passenger seats were equipped with lap belts.

Factual Information 11 Highway Accident Report Vehicle 2: Goshen Specialty Bus Postaccident inspection of the 1999 Goshen GC2 25-passenger specialty bus showed accident damage both to the front and rear of the vehicle. The right front corner of the bus, which struck the bumper of the pickup truck, sustained damage that continued down the right side of the bus, crushing the boarding door area and sidewall rearward, and intruded approximately 4 feet into the front of the passenger compartment. Impact damage from the Freightliner displaced the rear of the passenger compartment interior forward approximately 5 feet. The right front and right rear tires sustained abrasion damage. (See figure 10.) Longitudinal deformation of the frame rails was less than 5 inches when measured from the inside edge on an exemplar vehicle’s bumper. (See figure 11.) Figure 10. Specialty bus rear-impact damage.

Factual Information 12 Highway Accident Report Damage to the bus interior was also documented. The 3/4-inch plywood flooring, which had been bolted through a rubber grommet to anchorage points on the vehicle chassis frame rails, was buckled in the rear at the floor seam and pushed forward. Emergency response personnel had removed four seats—the right side pair of seats in rows four and five—for passenger extrication. In the sixth row, the rear impact tore the passenger seats (all but the right side window seat) from the floor mountings; the floor- mounted rails connecting the seats were cut to gain access to passengers during the emergency response. Several seatback tray tables were broken, and several seat footrests and both the left and right modesty panels at the front of the bus were deformed. The driver’s air bag deployed. Seat belt webbing abrasions were observed at the driver’s location and at passenger seats 2C, 3A, 3B, 3D, 4A, 4B, and 5A. The restraint webbing at passenger seat 4B was cut during the emergency response. Vehicle 3: Chevrolet Pickup Truck The front-loading door area of the specialty bus struck the rear bumper of the 2000 Chevrolet 1500 extended cab pickup truck, and the overturning Freightliner trailer struck the camper shell in the truck bed. After impact with the rear of the Ford tractor-box trailer, the pickup truck was struck in the rear by the Kenworth tractor-tank trailer. The roof and left side rail of the cab were crushed downward, touching the headrest atop the driver’s bucket seat. Intrusion of the back panel of the extended cab into the driver’s seatback was significant. The left portion of the dashboard was deformed rearward toward the driver’s seat. Inspection of the driver’s three-point restraint showed evidence of abrasion to the webbing near the D-ring on the B-pillar; the driver’s air bag deployed. In addition, the master cylinder and brake booster were damaged, the left rear wheel assembly was detached, and the electronic and hydraulic lines were severed. Figure 11. Overlay of exemplar specialty bus to accident vehicle.

Factual Information 13 Highway Accident Report Vehicle 4: Ford Tractor-Box Trailer The 1998 Ford conventional tractor was not damaged. The Trailmobile box trailer—approximately 53 feet long and 8.5 feet wide—was damaged at the left rear corner, where approximately 11.5 feet had been scraped and crushed downward and inward by the Freightliner trailer as it overturned. Of the two loading doors at the rear of the trailer, the left door and left corner framing were broken and crushed into the cargo area, and the center latch area of the right door was damaged. At the left rear corner, the roof of the trailer had bent upward. Vehicle 5: Kenworth Tractor-Tank Trailer The 2000 Kenworth T803 tractor sustained damage to the quick-connect valve on the brake’s air system and to the right front of the grill and bumper when it struck the rear of the pickup truck. The Polar tank trailer of this combination unit was not damaged. Driver Information Freightliner Driver Certification and Experience. The 49-year-old Freightliner driver held a valid Illinois class A8 commercial driver’s license (CDL), with a corrective lenses restriction and an expiration date of January 5, 2006. He possessed a valid medical certificate issued August 6, 2003, approximately 2 months prior to the accident, with an expiration date of August 6, 2005. The driver had 13 years of truck driving experience and had been employed full time by Frontline Transportation Company for 6 weeks at the time of the accident. Medical. According to the Freightliner driver, he did not take any prescription medications, was wearing his prescription eyeglasses at the time of the accident, and was not fatigued. Duty Status. The Freightliner driver reported that he picked up his tractor about 6:00 a.m.; picked up and delivered a chassis trailer and cargo container; and then picked up the accident chassis and cargo container and traveled to Midwest Recycling in Rockford, Illinois, where the container was loaded. He said that he had driven the Chicago–Rockford route on four or five previous occasions. Table 2 summarizes his 72- hour history based on the Safety Board’s interview of the driver. 8 Class A license classification includes any combination of vehicles with a gross combination weight rating (GCWR) of 26,001 pounds or more, provided that the gross vehicle weight rating (GVWR) of the vehicle(s) being towed exceeds 10,000 pounds. (Holders of a class A license may, with appropriate endorsements, operate all vehicles within classes B, C, and D.)

Factual Information 14 Highway Accident Report Table 2. Freightliner driver’s 72-hour history. Bus Driver Certification and Experience. At the time of the accident, the 57-year-old bus driver held an Illinois class B9 CDL, with a passenger endorsement and an expiration date of September 27, 2007. The bus driver did not possess a valid medical certificate in accordance with 49 CFR 391.41. His medical certificate had been issued in 1999 and had expired in 2001. While working for Leisure, the bus driver had accumulated 6.5 years of experience driving buses similar to the accident bus. He said that he was very familiar with the I-90 route, having traveled it many times. He had previously worked as a professional firefighter with the Great Lakes Naval Training Center, where he operated heavy fire department vehicles and served as a driving instructor. Medical. During an interview with Safety Board investigators, the bus driver stated that he was a Type II diabetic and used prescribed medications to control the condition. The driver reported that he was taking the prescription medications Lotensin, Actose, Amoryl, and Metformin daily; monitored his blood sugar and diet; and had undergone cataract surgery on his right eye during the year prior to the accident. On October 10, 2003, following the accident, the bus driver passed a complete physical examination for commercial driver fitness and was issued a valid medical certificate. The medical examination report indicated that the driver’s Type II diabetes was well controlled through the use of prescribed oral medication. Duty Status. The bus driver reported for duty at 7:00 a.m. on October 1, 2003. He then drove the accident bus 35 miles from the company headquarters in Lake Bluff, Illinois, to downtown Chicago, where he arrived at 9:15 a.m. He loaded his passengers and departed on a round-trip route from Chicago to Rockford at 9:25 a.m. At 2:15 p.m., he departed Rockford for the return trip to Chicago. Table 3 presents his 72-hour history based on the Safety Board’s interview of the driver. The bus driver was not required to keep driver logs due to the local nature of his operations.10 9 Class B license classification includes any single vehicle with a GVWR of 26,001 pounds or more, or any such vehicle towing a vehicle not exceeding 10,000 pounds GVWR. (Holders of a class B license may, with appropriate endorsements, operate all vehicles within class C, which includes any vehicle weighing 26,000 pounds [GVWR] or less designed to transport 16 or more people.) 10 The bus driver’s operations fell within the 100-air-mile exemption. See , January 31, 2006. DAY TIME (DAYLIGHT) 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00 24:00 9/28/2003 9/29/2003 9/30/2003 10/1/2003 Off Duty On Duty Sleeping NIGHT TIME (DARKNESS) NIGHT TIME (DARKNESS)

Factual Information 15 Highway Accident Report Table 3. Bus driver’s 72-hour history. Other Drivers Chevrolet Pickup Truck. The 67-year-old pickup truck driver was traveling eastbound on I-90 from Beaver Dam, Wisconsin, to Bartlett, Illinois. The evening prior to the accident day he had been camping in Horicon, Wisconsin, and reported that he slept from 11:00 p.m. until 8:00 a.m. in his camper, which was mounted in the bed of his truck. Ford Tractor-Box Trailer. The 56-year-old Ford driver had 27 years of truck driving experience as an employee of Penner International, Inc. At the time of the accident, he was driving eastbound on I-90 en route to Durham, North Carolina, from Steinbach, Manitoba, Canada, transporting a box trailer containing 25 pallets of prescription medication. His codriver was asleep in the sleeper berth. Kenworth Tractor-Tank Trailer. The 59-year-old Kenworth driver was an employee of Carl Klemm, Inc., and had 36 years of truck driving experience. At the time of the accident, he was transporting a tanker load of ink dye capsule liquid and was traveling eastbound on I-90, en route to West Carrollton, Ohio, from Portage, Wisconsin. The driver said that he had been on vacation for several days before returning to work on the day of the accident. Vehicle Information Freightliner Tractor-Trailer The 1995 Freightliner model FLD tractor was equipped with a Cummins Inc. M11-330E electronic diesel fuel injection engine and nine-speed manual Eaton Fuller Corporation RTX transmission. The tractor was owned and operated by the accident driver, who was working for Frontline Transportation Company11 of Elk Grove Village, Illinois. The wheel base was 235 inches, and the tractor’s GVWR was 46,000 pounds.12 The 1984 Theurer Inc. model 220-CC-40GN trailer chassis was owned by TRAC Lease Incorporated of New York, New York,13 and leased to China Ocean Shipping Company (COSCO). The accident trailer had a DOT Federal Highway Administration (FHWA) inspection sticker dated June 2003. 11 U.S. Department of Transportation (DOT) No. 880860. 12 For tractor, chassis trailer, and cargo container details, see appendix B. 13 At the time of the accident, TRAC Lease owned approximately 205,000 chassis trailers nationwide. DAY TIME (DAYLIGHT) 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00 24:00 9/28/2003 9/29/2003 9/30/2003 10/1/2003 Off Duty On Duty Sleeping NIGHT TIME (DARKNESS) NIGHT TIME (DARKNESS)

Factual Information 16 Highway Accident Report The trailer was about 41 feet long and 8 feet wide and had a GVWR of 72,715 pounds. The tractor-trailer chassis combination unit was equipped with Rockwell automatic slack adjusters on the first, second, and third axles.14 The fourth and fifth trailer axles15 were equipped with 6-inch manual slack adjusters. The tractor container trailer combination unit was equipped with a pneumatic air brake system. COSCO had a contract with Hamilton Container Service of Chicago, Illinois, to inspect, maintain, and store its chassis trailers. Hamilton had last inspected the accident trailer on June 5, 2003, and the last brake adjustment on the trailer had been completed in November 2002. The 40-foot- long, 9.5-foot-high cargo container on the chassis was filled with bundled magazines and newspapers. The gross maximum weight of the chassis, cargo container, and cargo was 67,200 pounds. The Theurer chassis front lock pins (left and right) could be set in an unlocked or a slide-in locked position in a metal bracket. During Safety Board inspection of the trailer, the front two lock pins appeared to be in the unlocked position. Small-gauge wire was wrapped around the area of the left front lock pin. The rear lock pins were twist locks that secured the cargo container to the chassis. During postaccident inspection, Safety Board investigators took pushrod stroke measurements and compared them to adjustment limits to determine whether they were within the limit (2 inches) for nondefective brakes. The fourth axle right-side brake exceeded the 2-inch adjustment limit by 1/16 inch. The left and right brakes on the fifth axle exceeded the 2-inch limit by 1/2 inch. As clamp-type pneumatic brakes, the fourth axle right brake and the left and right brakes on the fifth axle would be considered out of adjustment.16 Postaccident, the ISP weighed the Freightliner and chassis cargo container combination unit at 76,480 pounds. The heights of the bumper and underlying structural members were also documented. On a Freightliner exemplar tractor, the front bumper,17 which was 16.8 to 28.8 inches above ground, was about 12 inches high. The structural member of the truck-tractor front bumper was a 9.25- by 74.3- by 0.179-inch seven-gauge steel channel. The bottom of the channel on the loaded truck-tractor was approximately 22.1 inches above ground,18 and the top of the channel was approximately 31.4 inches above ground. (See figure 12.) 14 The steer axle was equipped with 15-inch brake drums; the second and third axles had 16.5-inch brake drums. 15 The trailer chassis was equipped with 16.5-inch brake drums on the fourth and fifth axles. 16 Commercial Vehicle Safety Alliance, North American Standard Out-of-Service Criteria (Washington, DC: CVSA, 2002) 15. 17 The front bumper is constructed of flexible, aerodynamic molded plastic. 18 Freightliner LLC told investigators that the structural component behind the bumper is about 1.75 inches higher in the unloaded condition.

Factual Information 17 Highway Accident Report Goshen Specialty Bus The 1999 Ford E-450 Super-Duty chassis was equipped with a 6.8-liter V-10 engine, a four-speed automatic Ford 4R100 transmission, and a 1999 Goshen GC2 body unit. When inspected postaccident, the odometer indicated 165,457 miles. The chassis was equipped with four-wheel hydraulic disc brakes with two piston calipers. During postaccident inspection, the ISP and Safety Board investigators noted no brake system defects. The GVWR of the specialty bus was 14,050 pounds, and the wheel base was 158 inches. The ISP weighed the specialty bus at 9,860 pounds. On an exemplar bus, the rear bumper, which was 20.4 to 28.8 inches above ground, was about 8.4 inches high. The bumper mounts directly to the end of the frame rails on the chassis. (See figure 13.) The 25-passenger bus body was equipped with a driver’s bucket seat and five rows of four bench seats, two on each side of the bus. The sixth row, which spanned the width of the bus, was a bench seat with five passenger positions. Each passenger seat was equipped with a two-point (lap belt only) restraint system. The driver’s seat was equipped with a three-point restraint and frontal air bag. Figure 12. Freightliner bumper heights.

Factual Information 18 Highway Accident Report Chevrolet Pickup Truck The 2000 Chevrolet Silverado 1500 extended cab pickup truck was equipped with a 5.3-liter V8 engine, automatic transmission, and Shadow Cruiser camper mounted in the pickup bed. The camper was approximately 7 feet wide, 8 feet long, and 62 inches high when closed. The pickup had a four-wheel antilock braking system, four-wheel hydraulic disc brakes, and single-piston calipers. This vehicle was also equipped with a driver’s frontal air bag, which deployed during the accident sequence. The air bag system was electronically controlled by a sensing diagnostic module (SDM) located under the driver’s seat. In addition to its primary function of sensing a crash event and deploying the vehicle’s air bag, the SDM was also capable of recording a limited amount of crash data related to the air bag deployment. Safety Board investigators and the ISP conducted a download of the SDM data on October 4, 2003, using the ISP’s Vetronix Corporation Crash Data Retrieval Tool. (See appendix C for details.) Ford Tractor-Box Trailer The 1998 Ford tractor was equipped with a Cummins N14-370F diesel engine and Fuller transmission. When inspected postaccident, the vehicle odometer indicated 395,896 miles. The Ford did not have a dedicated event data recorder, and the engine’s electronic control module (ECM) was not designed to capture or monitor operational or accident- Figure 13. Specialty bus bumper heights.

Factual Information 19 Highway Accident Report related data. The tractor was not damaged in the accident. The 2003 Trailmobile Canada Limited trailer, which sustained some damage, was 53 feet long and 8.5 feet wide. During postaccident inspection, Safety Board investigators found no anomalies in the vehicle’s operating systems. Kenworth Tractor-Tank Trailer The 2000 Kenworth T803 tractor was equipped with a Cummins model C12-380 diesel engine and 10-speed Fuller manual transmission. When inspected postaccident, the vehicle odometer indicated 506,934 miles. The 1981 Polar tank trailer was owned by Klemm Tank Lines and had a postaccident hub meter reading of 96,509 miles. Operations Information Frontline Transportation Company The Freightliner driver, an owner/operator of his tractor, had leased the tractor to Frontline and was an employee of Frontline. According to the Federal Motor Carrier Safety Administration (FMCSA) registration, Frontline Transportation Company19 was an authorized interstate for-hire carrier20 of general freight and intermodal containers, headquartered in Elk Grove Village, Illinois. The company began business in 1999. In October 2003, Frontline reported 14 full-time drivers, 2 company tractors, 12 leased tractors, and 20 leased trailers. Other employees included the company president, one manager/supervisor, and two dispatchers. Frontline operated under contract to COSCO, which operated a fleet of vessels and leased the intermodal chassis equipment.21,22 Because COSCO was not an interstate for- hire carrier, it was not registered with the FMCSA. Ocean carriers such as COSCO use trailer chassis to move their international shipping cargo containers from ports to rail yards, from rail yards to customers, or directly from ports to customers. Like COSCO, which was leasing the accident trailer from TRAC Lease, many ocean carriers contract with other companies to provide chassis on demand at the port where the cargo is unloaded.23 19 DOT No. 880860. 20 A “for-hire” carrier is a person or company that transports cargo or passengers for compensation. 21 Most international ocean carrier regulation falls under the Federal Maritime Commission, which is outside DOT oversight. 22 When COSCO freight arrived at the ports in containers, it was loaded onto chassis trailers for transport to customers or delivered to rail yards for transport to other rail yards. Once the freight arrived at the port or final rail yard, Frontline transported the chassis-contained freight to COSCO customers. 23 Peter F. Swan, A Study of the Economic Impacts and the Need for Proposed Changes to Intermodal Container Chassis Inspection Rules (Alexandria, VA: American Trucking Associations, 2004) 6. See , January 31, 2006.

Factual Information 20 Highway Accident Report According to the FMCSA, Frontline received a compliance review on August 23, 2002, that resulted in a conditional rating. Frontline was cited for driver logbook violations and vehicle and maintenance record violations, as defined in Federal Motor Carrier Safety Regulations (FMCSRs), 49 CFR 396.11(a) and 395.8(a). The FMCSA did not conduct another compliance review until October 7, 2003. This postaccident review resulted in an unsatisfactory rating. Frontline was cited for multiple violations, some of which included: • Failing to conduct preemployment drug testing (49 CFR 382.301(a)), • Failing to maintain an accident register (49 CFR 390.15(b)), • Failing to conduct inquiries with previous employers (49 CFR 40.25(b) and 382.105), • Failing to maintain vehicle maintenance records (49 CFR 396.3(b)), and • Failing to require drivers to make a record-of-duty status (49 CFR 395.8(a)). After receiving the unsatisfactory rating, Frontline had 60 days to correct its deficiencies or the FMCSA could prohibit it from operating in interstate commerce. On November 26, 2003, the FMCSA conducted a followup compliance review of Frontline and found several noncritical violations;24 the FMCSA concluded that Frontline had improved and gave the company an overall conditional rating.25 In April 2004, Frontline ceased operations after the FMCSA made an out-of-service (OOS) determination; Frontline had failed to pay fines assessed during the postaccident compliance review. Leisure Pursuit Charters, Inc. Leisure Pursuit Charters owned the specialty bus involved in the accident. The FMCSA listed Leisure Pursuit Incorporated, doing business as Leisure Pursuit Charters, as an interstate for-hire passenger carrier26 operating out of headquarters in Lake Bluff, Illinois. At the time of the accident, Leisure had a fleet of six buses and employed four full-time and nine part-time drivers. According to the company, which incorporated in 1989, its business slowed after September 11, 2001, and it dropped its Interstate Commerce Commission (ICC)27 permit and reduced insurance coverage from the required 24 These violations included failing to require a driver to furnish a list of motor vehicle traffic violations every 12 months, using a driver who had not completed and furnished an employment application, requiring or permitting a driver to drive more than 10 hours, failing to require a driver to make a record-of-duty status, and failing to require a driver to prepare a driver vehicle inspection report. 25 The conditional rating was the result of an “unsatisfactory” in the accident category; the other categories were rated “satisfactory.” Frontline had 5.714 recordable crashes per million miles (4 recordable crashes multiplied by 1 million miles, divided by 700,000 total actual operated miles). A rate of 0.00 to 1.50 is considered “satisfactory,” while a rate greater than 1.50 is considered “unsatisfactory.” 26 DOT No. 679636. 27 Effective January 1, 1996, the ICC was abolished, and a number of its functions were eliminated. The remaining motor carrier (trucking) functions were transferred to the DOT (and are now under the authority of the FMCSA).

Factual Information 21 Highway Accident Report $5 million to $1.5 million in December 2001.28 The insurance company notified the FMCSA of the lowered coverage, and the FMCSA subsequently sent Leisure a letter saying that its operating authority would be revoked if it failed to comply with the insurance requirements. According to the FMCSA, Leisure failed to respond to the notification letter and did not increase its insurance minimum. The FMCSA revoked Leisure’s interstate operating authority on January 29, 2002. The company president told Safety Board investigators that he did not receive the FMCSA revocation letter (because of an office move), and Leisure continued to operate with the reduced insurance. During the postaccident compliance review,29 the FMCSA documented at least eight interstate charters taken by Leisure after the date of its revocation of operating authority.30,31 During one of these interstate trips, on March 5, 2002, a driver was pulled over in Wisconsin, subjected to a level 332 roadside inspection, and cited for speeding. The inspection was for the driver only, and information related to the interstate operating status of the carrier (which had been revoked) was not gathered. The driver had been pulled over by a patrol officer who was certified to conduct driver-only inspections and did not have laptop computer access to the FMCSA enforcement database, which would have indicated that Leisure was inactive. At the time, only ISP Commercial Motor Vehicle Division officers were certified to conduct vehicle-level inspections and had access to the FMCSA safety databases.33 When the accident occurred, Leisure owned six vehicles, most of which were operating either daily or weekly and were similar to the accident vehicle, with a seating capacity of 16 passengers or more. Because of the number of passengers permitted on board these vehicles, the operator or carrier was required to maintain $5 million in insurance because it was still conducting interstate business. 28 Title 49 CFR 387.33 requires that any for-hire motor carrier with a seating capacity of 16 passengers or more operating in interstate or foreign commerce have a minimum $5 million insurance coverage. 29 During the postaccident compliance review, Leisure was cited and fined by the FMCSA for using a driver prior to receiving preemployment drug screening results ($1,760), inadequate or lack of financial responsibility ($2,330), and having no medical certificate in the accident driver’s qualification file ($390). According to the Illinois Secretary of State, the Leisure Pursuit Corporation was dissolved on July 1, 2004. 30 The compliance review did not result in inspection of every charter trip taken by Leisure after its revocation date; these eight interstate trips were found during a review of driver records. 31 In addition, the FMCSA compliance review listed the following violations: failing to randomly test drivers for controlled substances and alcohol; failing to investigate a driver’s background; failing to maintain a list or certificate relating to violations of motor vehicle laws and ordinances; failing to maintain medical examiners’ certificates in drivers’ qualification files; operating a motor vehicle providing transportation without the required registration or beyond the scope of the registration; requiring or permitting a driver to drive after having been on duty for more than 70 hours in 8 consecutive days; failing to keep a record of tests on push-out windows, emergency doors, and emergency door marking lights on buses; and using a commercial vehicle that was not periodically inspected. 32 Level 3 is a driver-only inspection in which the inspector examines the driver’s license, medical certificate, record-of-duty status, hours of service, and seat belt use. 33 An ISP senior enforcement officer reported that driver-only inspections account for about 25 percent of roadside inspections, while vehicle walk-around inspections account for the remaining 75 percent. Since this accident, ISP patrol officers have been certified to conduct both driver-only and walk-around vehicle inspections and have laptop computer access to the FMCSA databases.

Factual Information 22 Highway Accident Report Federal Motor Carrier Safety Administration The FMCSA was established as a separate administration within DOT on January 1, 2000, pursuant to the Motor Carrier Safety Improvement Act of 1999. Its primary mission is to reduce accidents, injuries, and fatalities involving large trucks and buses. According to the FMCSA, the agency develops and enforces data-driven regulations and uses safety information systems to focus on higher risk carriers. The FMCSA requires a motor carrier to have adequate management controls that comply with applicable safety requirements and uses a rating formula to determine a motor carrier’s safety fitness. The FMCSA mission is primarily accomplished through on-site compliance reviews and roadside inspections of a carrier’s vehicles and drivers. Compliance Reviews. In accordance with 49 CFR Part 385, appendix A, the first step in the safety fitness rating methodology is an FMCSA-conducted compliance review. Applying six factors (see table 4), the FMCSA rates a carrier’s compliance with the FMCSRs, which establish safe operating requirements for commercial vehicle drivers, carriers, vehicles, and vehicle equipment. A carrier may be selected for a compliance review if identified as a high risk because of: • A Safety Status Measurement System (SafeStat) score,34 • A complaint against the company, • An enforcement followup to ensure that an enforcement action was effective, • Involvement in a fatal accident, • Involvement in a major hazardous materials (HM) accident, 35 • A DOT Office of Inspector General request, • A congressional inquiry, or • A carrier’s request. In fiscal year (FY) 2003, 9,068 Federal compliance reviews were conducted; in FY 2004, 7,637; and in FY 2005, 7,998.36 In Illinois, the FMCSA has revoked the operating authority of 270 carriers since 2002. 34 SafeStat is an automated, data-driven analysis system that is designed to incorporate on-road safety performance information and enforcement history with on-site compliance review information to measure the relative safety fitness of interstate motor carriers. 35 According to the FMCSA, compliance reviews occurring outside the Motor Carrier Safety Assistance Program (MCSAP) are based on focus areas (HM or passenger carriers) identified in each State’s safety plan and congressional mandates, such as public complaints and revisiting “conditional”-rated carriers. 36 See (a) , January 4, 2006. (b) , February 24, 2006. These statistics are current as of the dates shown.

Factual Information 23 Highway Accident Report Table 4. Motor carrier safety rating factors. The six factors listed in table 4 provide the basis for determining a carrier’s safety rating, that is, the degree to which the carrier is in compliance with the FMCSRs and meets the Federal safety fitness standard. As defined below, each factor is rated “satisfactory,” “conditional,” or “unsatisfactory,” except the accident factor, which is rated either “satisfactory” or “unsatisfactory”: • A satisfactory rating indicates that the carrier has not violated any acute regulations37 or shown a pattern of noncompliance with critical regulations.38 • A conditional rating indicates that the carrier has violated one acute regulation or has a pattern of noncompliance with critical regulations. • An unsatisfactory rating indicates that the carrier has violated two or more acute regulations or has a pattern of noncompliance with two or more critical regulations. The rating for factor 6, the accident factor, is based on the number of recordable accidents39 in relation to the carrier’s annual mileage. According to the FMCSA, an accident rate below 1.5 per million miles is considered “satisfactory”; anything higher is rated “unsatisfactory.” The ratings for the first five factors and the accident factor (number of recordable accidents per million miles traveled in the 12 months prior to the compliance review) are entered into a rating table, which is used to establish the motor carrier’s overall safety rating (see table 5). Each of the six factors receives equal weight. Factor Applicable FMCSRs or other criteria 1–General Parts 387 and 390 2–Driver Parts 382, 383, and 391 3–Operational Parts 392 and 395 4–Vehicle Parts 393 and 396 5–Hazardous materials Parts 171, 177, 180, and 397 6–Accident Recordable preventable rate 37 Acute violations of the FMCSRs or HM regulations—for example, requiring or permitting the operation of an OOS vehicle before repairs are made—demand immediate corrective action regardless of the motor carrier’s overall safety posture (49 CFR Part 385, appendix B II(b)). 38 Critical violations indicate deficiencies in the motor carrier’s management controls, such as requiring or permitting a driver to drive after having been on duty for 15 hours (49 CFR Part 385, appendix B II(b)). 39 The FMCSA defines a recordable accident as an occurrence involving a commercial motor vehicle operating on a public road in interstate or intrastate commerce that results in a fatality, a bodily injury, or a vehicle incurring disabling damage that requires it to be towed from the scene (49 CFR 390.5).

Factual Information 24 Highway Accident Report Table 5. Motor carrier safety rating table. In September 2005, Safety Board staff met with the FMCSA and learned that it is currently evaluating the compliance review process as part of the Comprehensive Safety Analysis (CSA) 2010 Initiative. According to the FMCSA, the CSA 2010 Initiative is an effort to evaluate the effectiveness of the FMCSA’s current safety compliance and enforcement programs, such as compliance reviews and roadside inspections, and to identify better methods of achieving a crash-free environment. The FMCSA indicated that the evaluation is still in its early stages, no conclusions have been reached, and it is too soon to speculate on what specific changes may be made in the safety rating process. Full implementation of any changes proposed by the initiative is not expected until 2010. Roadside Inspections. Most State roadside inspections are conducted under the FMCSA-administered MCSAP, a Federal grant program that provides States with financial assistance to hire staff and implement strategies to enforce the FMCSRs. MCSAP provides funds to promote the detection and correction of commercial motor vehicle safety defects, commercial vehicle driver deficiencies, and unsafe motor carrier practices before they become contributing factors to accidents or HM incidents. Under the FMCSA roadside inspection program, qualified safety inspectors carry out commercial vehicle roadside inspections in compliance with the North American Standard Inspection Program guidelines, which were developed by the CVSA and the FMCSA. During roadside inspections, an inspector examines vehicles or their drivers or both to determine whether they meet the FMCSRs. The five levels of inspection are: • Level I: Examination of the driver’s license, medical examiner’s certificate and waiver (if applicable), alcohol and drugs, driver’s record-of-duty status (as required), hours of service, seat belt, vehicle inspection report, brake system, coupling devices, exhaust system, frame, fuel system, turn signals, brake lamps, tail lamps, head lamps, lamps on projecting loads, safe loading, steering mechanism, suspension, tires, van and open-top trailer bodies, wheels and rims, windshield wipers, emergency exits on buses, and HM requirements. • Level II: A walk-around driver/vehicle inspection that includes each of the items specified under the North American Standard Inspection Program guidelines. At a minimum, level II inspections must include level I items; it is assumed that the walk-around driver/vehicle inspection includes only those items that can be inspected without physically getting under the vehicle. Number of factors with unsatisfactory ratings Number of factors with conditional ratings Resultant overall safety rating 0 2 or less Satisfactory 0 More than 2 Conditional 1 2 or less Conditional 1 More than 2 Unsatisfactory 2 or more 0 Unsatisfactory

Factual Information 25 Highway Accident Report • Level III: A driver/credential examination that includes, at a minimum, as required or applicable, examination of the driver’s license, medical certification, skill performance evaluation certificate, driver’s record-of-duty status, hours of service, seat belt, and HM requirements. Those items not indicated in the North American Standard level III driver/credential inspection procedure are not included in a level III inspection. • Level IV: A “special inspection,” normally in support of a study or to verify or refute a suspected trend, that typically includes a one-time examination of a particular item—for example, a postaccident examination of commercial vehicles involved in an accident. • Level V: A vehicle-only inspection that includes each of the vehicle inspection items specified under level I, without a driver present, conducted at any location. Once an inspection is completed, the finding of serious safety violations can result in the issuance of driver or vehicle OOS orders. Any such violations must be corrected before the affected driver or vehicle can return to service. (See table 6 for roadside inspection data.) Table 6. Registered vehicles, roadside inspections, and OOS data. According to 49 CFR 350.213(b)(4), to obtain MCSAP funding, a State must conduct activities to enforce registration requirements under 49 United States Code (U.S.C.) 13902 and 49 CFR Part 365 and financial responsibility requirements under 49 U.S.C. 31138 and 31139 and 49 CFR Part 387.40 In addition, to qualify for MCSAP basic program funds under 49 CFR 350.201, a State must enforce financial responsibility requirements under 49 U.S.C. 13906, 31138, and 31139 and 49 CFR Part 387. In FY 2004, the State of Illinois received $5.6 million in MCSAP funding.41 Type of vehicle 2003 Registered vehiclesA FY 2003 Roadside inspections FY 2004 Roadside inspectionsB FY 2004 Driver inspections (OOS rate) FY 2004 Vehicle inspections (OOS rate) FY 2005 Roadside inspections Large trucks 7,912,018 2,991,788 (37.8%) 2,949,487 (37.3%) 2,859,219 (6.7%) 2,159,368 (23.9%) 2,950,640 (37.3%) Buses 776,550 42,377 (5.5%) 42,864 (5.5%) 23,568 (5.1%) 36,731 (9.5%) 48,625 (6.3%) SOURCE: See and Motor Carrier Safety Progress report, June 30, 2004. ARegistered vehicles are those that have been registered through a State motor vehicle department; as of December 23, 2005, the most recent year for which data are available is 2003. BRoadside inspections may include driver and vehicle within the same inspection count. 40 See , January 31, 2006. 41 Information obtained from Safety Programs Office, FMCSA.

Factual Information 26 Highway Accident Report Insurance Compliance and Operating Authority Revocation. According to FMCSA safety regulations at 49 CFR 387.33, any for-hire motor carrier of passengers operating in interstate or foreign commerce with a seating capacity of 16 persons or more must have minimum insurance coverage of $5 million. When a passenger carrier no longer carries the minimum insurance, or a policy is set to expire, the insurance company notifies the FMCSA, which then sends a letter to the carrier, giving it 90 days to either renew or change insurance. If the carrier fails to comply, the FMCSA revokes the carrier’s operating authority and changes its operating status to “inactive” within FMCSA databases.42 According to the FMCSA,43 a carrier that continues to operate while inactive is “rarely prosecuted through compliance reviews or roadside inspections.”44 The FMCSA has indicated that, in January 2004, as part of its insurance compliance initiatives, it implemented a policy change for revocation of operating status that reduced the notice period from 90 days to 30 days. If a carrier fails to renew its policy by the 30th day, the FMCSA immediately revokes its authority to operate, which places the carrier in OOS status. In addition, the FMCSA stated to Safety Board staff that a carrier’s OOS status appears in bold red in the Motor Carrier Management Information System (MCMIS) if its safety data are checked by an MCSAP inspector during a roadside inspection. The FMCSA also said that it maintains a list of cancellations in the MCMIS licensing and information report, which shows all carriers currently operating with canceled insurance—in effect, operating without authority. On February 8, 2004, the FMCSA Administrator made a speech to the United Motorcoach Association in Atlanta, Georgia, in which she pledged to work with association members to get uninsured and “other illegal motorcoach operators” off the highways. The Administrator further stated: FMCSA will start to cross-match insurance revocations with inspection and crash databases, and generate automated claim letters for prompt field enforcement action. Where a carrier shows inspection or crash activity during the time that its insurance is suspended, FMCSA will know the company is operating without authority and enforcement action will be swift. These matches will be done electronically, supplementing field observations of motor carrier operations. These changes underscore FMCSA’s commitment to increased safety. 42 The active or inactive designation refers to the status of the motor carrier number assigned to a company that has applied for operating authority. “Inactive” applies when a carrier either has had its operating authority involuntarily revoked by the FMCSA or has requested a revocation. 43 E-mail correspondence from Office of Policy and Program Development, FMCSA, September 22, 2005. 44 According to FMCSA regulation 49 CFR 387.41, the penalty for violation of the insurance minimum is that any person (except an employee who acts without knowledge) who knowingly violates the rules of this subpart is liable to the United States for civil penalty of no more than $11,000 for each violation, and if any such violation is a continuing one, each day of violation constitutes a separate offense. In determining the amount of such penalty, the Administrator or his/her designee takes into account the nature, circumstances, extent, and gravity of the violation committed and, with respect to the person found to have committed such violation, the degree of culpability, history of prior offenses, ability to pay, effect on ability to continue to do business, and such other matters as justice may require.

Factual Information 27 Highway Accident Report Performance and Registration Information Systems Management. The Performance and Registration Information Systems Management (PRISM) program is a voluntary Federal–State partnership that makes safe performance a requirement for obtaining and keeping commercial vehicle registration. PRISM links Federal motor carrier safety records with a State’s vehicle registration system.45 The DOT number of the carrier responsible for safety is identified at the vehicle level, allowing the State to determine a carrier’s safety fitness before issuing license plates. Safety performance is continuously monitored, and carriers prohibited by the FMCSA from operating in interstate commerce may have their ability to register vehicles denied. According to the FMCSA, PRISM plays a key role in its effort to remove high-risk carriers from highways. As of December 31, 2005, 42 States—including Illinois—were participating in the PRISM program.46 The PRISM commercial vehicle registration process establishes a system of accountability to verify that no vehicle is license-plated without identifying the carrier responsible for its safety.47 The use of registration sanctions serves as an incentive for unsafe carriers to improve their safety performance, according to the FMCSA.48 In addition, through monitoring, carriers that do not improve their safety performance face progressively more stringent penalties, which may result in unfit or imminent hazard determinations and the possible suspension of vehicle registrations by the State. Highway Information General The accident occurred on I-90 east at MP 41.6, approximately 2,600 feet west of the Hampshire–Marengo toll plaza. I-90—a divided, straight, and level four-lane asphalt roadway—is classified as an urban principal arterial road.49 As part of the Illinois State Toll Highway, this section of roadway is referred to as the “Northwest Tollway,” 76.5 miles stretching from I-294 in Chicago northwest to the Wisconsin State line. At the accident location, the 41-foot-wide paved portion of roadway comprised two main travel lanes (25 feet total width), an 11-foot-wide right shoulder, and a 5-foot-wide left shoulder. A 50-foot-wide depressed grassy median separated the eastbound and westbound lanes. Because of a construction work zone that extended from MPs 25.5 to 62.5, the posted 45 In some States, legislation must be passed to provide the legal authority to impose vehicle registration sanctions against motor carriers that have been prohibited from operation by the FMCSA. 46 States not participating in PRISM as of December 2005 are Maryland, Michigan, Mississippi, Montana, Nevada, North Dakota, and Wisconsin. The State of New York had signed a letter of intent. 47 See , January 31, 2006. 48 E-mail correspondence from Office of Policy and Program Development, FMCSA, September 22, 2005. 49 The urban principal arterial road system serves the major centers of activity of urbanized areas, the highest traffic volume corridors, and the longest trip desires, and carries a high proportion of the total urban travel even though it constitutes a relatively small percentage of the total roadway network. American Association of State Highway and Transportation Officials, A Policy on Geometric Design of Highways and Streets (Washington, DC: AASHTO, 2004) 11.

Factual Information 28 Highway Accident Report speed limit for I-90 at the accident site was 45 mph. The signage for the reduced speed limit began 5.3 miles prior to the accident site, and toll information signage began 0.5 mile prior to the accident site (at MP 42.1). Traffic The ISP accident report stated that traffic at the time of the accident was moderate to heavy and “normal for this road at this time” of day. According to the Illinois State Toll Highway Authority (ISTHA), in 2002 the average daily traffic in the vicinity of the accident site was 43,710 vehicles. (See table 7.) Table 7. Number of passenger and commercial vehicles traveling through Hampshire– Marengo toll plaza and average daily traffic count, 1999–2002. In August 2003, ISTHA vehicle classification data showed that 1,391,327 vehicles passed through the Hampshire–Marengo toll plaza, 224,767 (16.2 percent) of which were commercial vehicles. Illinois State Toll Highway Authority System ISTHA, established in 1953 as the Illinois State Toll Highway Commission, was created by a special act of the Illinois State Legislature. It is a user-financed administrative agency of the State of Illinois, the purpose of which is to operate, maintain, and service a system of toll roads located in northern Illinois. The tollway system encompasses 274 miles of mainline roadway and 20 mainline plazas. Hampshire–Marengo Tollbooth Configuration Figures 14 and 15 show the Hampshire–Marengo approach view and toll booth and toll lane configuration at the time of the accident. Lanes 1–3 (from right to left) were manual cash lanes with toll collectors for all vehicles, and lanes 4–6 (from right to left) were automatic coin lanes for cars only. At the time of the accident, the only manual lane available for commercial traffic was lane 3. Lane 1 was open weekdays during peak commercial hours, from 6:00 a.m. to 2:00 p.m., and closed the rest of the day. At the time of the accident, the toll collector for lane 2 was on break, and this lane was closed.50 The Year Passenger vehicles Commercial vehicles Average daily traffic count 2002 12,807,763 3,146,263 43,710 2001 12,137,871 3,194,329 42,000 2000 10,993,903 3,033,146 39,900 1999 11,430,000 3,133,781 38,470 50 The toll collector was in the toll plaza building’s restroom.

Factual Information 29 Highway Accident Report lane 3 toll collector stated that he observed no unusual queuing of traffic in lane 3 before the accident; he said that four or five tractor-semitrailers were in line to pass through the toll plaza. Figure 14. Approach view of accident toll plaza. Figure 15. Accident scene toll plaza lanes.

Factual Information 30 Highway Accident Report At the time of the accident, the Hampshire–Marengo toll plaza was under construction for conversion of an existing manual lane (lane 3) to an I-PASS51-only lane for use by both passenger and commercial vehicles. (See figure 15.) The Hampshire– Marengo toll plaza I-PASS-only lane, completed in November 2003, was designed to allow I-PASS participants to drive through at a posted speed of 5 mph without stopping. I-PASS was in use on all lanes at the time of the accident; both passenger and commercial vehicles were required to stop. When the transponder was detected, a gate was activated in the automatic lanes or activated by the toll collector in the manual lanes, and the vehicle could proceed. Eight mainline toll plazas were converted to open road tolling (ORT) in 2005, and the remaining 12 plazas are expected to be completed by September 2006.52 As a rule, after conversion each plaza will have as many ORT lanes as it has mainline lanes leading into or exiting the plaza. Vehicles without an I-PASS will exit the new mainline to pay tolls at express plazas located on the sides of the roadway. These plazas are located so as not to affect the free flow of traffic on the mainline. The Hampshire–Marengo toll plaza was scheduled to receive an estimated $42.7 million in 2005–2006 for reconstruction and consolidation with the Belvidere toll plaza (plaza 5). According to ISTHA, this reconstruction was part of its ORT conversion; the 10-year $5.3-billion plan is intended to provide customers with faster, safer, and more reliable travel. ISTHA stated that the conversion from traditional toll plazas to a barrier-free system, as a first in the United States, “will allow I-PASS users to travel at highway speeds on the mainline while their tolls are collected electronically by a gantry overhead, reducing traffic congestion and travel times.”53 As of December 2005, construction work had started on the reconstruction and consolidation of the two plazas. When the mainline toll plazas are removed, I-PASS customers will have unimpeded travel over the entire 274-mile tollway. (See figure 16.) Rumble Strips The accident occurred at MP 41.6, approximately 2,600 feet west of the Hampshire– Marengo toll plaza. Rumble strips54 had been installed approximately 1,200 feet prior to the toll plaza in both the eastbound and westbound directions. According to ISTHA, the rumble strips were removed because they were not included in the construction plans for the roadway resurfacing project that began in June 2003, which extended from MPs 36 to 53.55 51 I-PASS is an electronic toll collection (ETC) program developed by ISTHA. Motorists enrolled in I-PASS obtain a transponder device, which allows them to pay tolls electronically from a prepaid account. In 2001, I-PASS ETC accounted for more than 36 percent of all toll revenue; more than 700,000 transponders were in use. The I-PASS lane was expected to process 2,000 vehicles per hour; the manual lanes at the Hampshire–Marengo toll booths processed an average of 300 vehicles per hour. (See appendix D for a table of States with and without toll facilities.) 52 Telephone communication with ISTHA manager of maintenance and traffic, December 8, 2005. 53 Illinois State Toll Highway Authority, Open Roads for a Faster Future (Springfield, IL: ISTHA, 2005) 4. 54 Rumble strips—intermittent narrow, transverse areas of rough-textured or slightly raised or depressed road surface—are used to alert drivers to unusual vehicular traffic conditions. By means of noise and vibration, they attract the driver’s attention to such features as unexpected changes in alignment and to conditions requiring a stop. U.S. Department of Transportation, Federal Highway Administration, Manual on Uniform Traffic Control Devices (MUTCD), (Washington, DC: FHWA, 2003) 6F–44F. 55 Illinois State Toll Highway Authority Contract RR-02-5062, Roadway Resurfacing, Northwest Tollway (I-90).

Factual Information 31 Highway Accident Report Rumble strips were originally in place at every mainline toll plaza on I-90; ISTHA started removing the strips in 1987 and 1988 because of pavement and resurfacing projects and noise complaints from residential neighborhoods adjacent to the toll highway.56 As a result of the accident, ISTHA began reinstalling rumble strips at several mainline plazas on I-90, including those at Belvidere, Hampshire–Marengo, and Elgin. Currently, seven mainline plazas on the ISTHA system have rumble strips. (See table 8.) Table 8. Current rumble strip locations on ISTHA tollway system. Figure 16. Graphic depiction of open road toll system. (Courtesy of Illinois State Toll Highway Authority) 56 Telephone communication with ISTHA manager of maintenance and traffic, December 30, 2005. Tollway section Mainline tollbooth plaza Traffic direction Northwest South Beloit (plaza 1) Both Northwest Belvidere (plaza 5) Both Northwest Hampshire–Marengo (plaza 7) Both Northwest Elgin (plaza 9) Eastbound only East-west DeKalb (plaza 66) Both East-west Dixon (plaza 69) Both Tristate Waukegan (plaza 21) Both

Factual Information 32 Highway Accident Report Meteorological Information The National Weather Service at DeKalb-Taylor Municipal Airport, 21 miles south of the accident site, reported the weather at 3:00 p.m. on October 1, 2003, as mostly sunny and clear, with a temperature of 50 degrees Fahrenheit, 23 percent humidity, and winds northwest at 15 mph. Toxicological Information Toxicological specimens were collected from the Freightliner driver at a local hospital following the accident. The ISP laboratory tested the specimens and found the driver’s blood and urine to be negative for alcohol and other drugs of abuse. The Safety Board also had the specimens tested 57 and determined that no carbon monoxide, cyanide, ethanol, or other drugs were present. Toxicological specimens were collected from the bus driver 2 days after the accident, on October 3, 2003. The specimens were evaluated locally and were found to be negative for drugs of abuse. No alcohol testing was conducted. According to 49 CFR 382.303, the employer of a driver of a commercial motor vehicle operating on a public road in commerce is required to conduct alcohol and controlled substance testing on that driver if the vehicle is involved in a fatal accident. Safety Board investigators found no evidence that Leisure completed any postaccident alcohol testing on the bus driver, as required. Tests and Research Specialty Bus Tail Lights The left and right tail light assemblies from the specialty bus were sent to the Safety Board’s materials laboratory for examination, which revealed the identification “CEC 1157” on the base of the right tail light bulb. According to a representative of General Electric, a manufacturer of type 1157 bulbs, only one filament is used when the tail lights are on, and both filaments are used when the brakes are applied. Examination of the filaments within the right tail light bulb revealed that both were severely stretched and deformed, consistent with their being hot at the moment of impact. Stretched and deformed filaments indicate that the brakes were applied at impact. 57 The specimens were tested at the Federal Aviation Administration Civil Aeromedical Institute toxicology laboratory for a wide range of licit and illicit substances, including amphetamines, opiates, marijuana, antihistamines, meprobamate, methaqualone, and nicotine.

Factual Information 33 Highway Accident Report Examination of the filaments within the left tail light bulb revealed that one filament was stretched and deformed, though not as severely as the filaments within the right tail light bulb.58 The second filament in the left tail light bulb did not display significant stretching or deformation. Freightliner Gear Speed Calculations The maximum rpm setting on the Freightliner tractor engine was read out through the engine’s ECM as 2,030. The gear ratio of the Dana Spicer DS402 drive axle was 4.11. The rpm of the tires on both the tractor and trailer (size 295/75R22.5) was 518. Using this information, the Safety Board calculated various speeds for each transmission gear of the Freightliner tractor. (See table 9.) According to the ISP report, the Freightliner driver stated that his tractor was in eighth gear at the time of the accident. The driver also stated that he was following the specialty bus in the right lane at a speed of 40 to 45 mph. The posted speed limit in the work zone where the accident occurred was 45 mph. Table 9. Freightliner gear speed calculations. Forensic Evidence Documentation and Accident Simulation Physical evidence found on the roadway included scrapes and gouges consistent with similar evidence found on the undercarriage of the specialty bus. Curved tire marks that varied in radius from 227 to 491 feet and had striations running perpendicular to the direction of travel were also found on the roadway. The tire marks traveled from the right lane to the left lane and terminated at the center median, where 113-foot-long tire furrows ran to the final rest position of the Freightliner tractor-trailer. Subsequent to the on-scene 58 The lens on the left tail light was of a different style than the right tail light. GearA Transmission gear ratio Gear speed range (mph)B 1 12.57 0–4.55 2 7.47 4.56–7.66 3 5.28 7.67–10.84 4 3.83 10.85–14.94 5 2.79 14.95–20.51 6 1.95 20.52–29.34 7 1.38 29.35–41.46 8 1.00 41.47–57.21 9 0.73 57.22–78.37 A For each gear, the maximum engine rpm was 2,030, the tire rpm was 518, and the drive axle gear ratio was 4.11. B Calculation: 60 times the maximum engine rpm (2,030), divided by the sum of the drive axle gear ratio (4.11), multiplied by the transmission gear ratio, multiplied by the tire rpm (518).

Factual Information 34 Highway Accident Report investigation, faint straight tire marks, 38 feet long, were observed in ISP photographs; these straight tire marks preceded the curved tire marks. One set of additional tire marks, 197 feet long, was located in the right lane, terminating at the final rest position of the Kenworth tractor-tank trailer; and two sets of tire marks—one 20 feet long, the other 113 feet long—were also located in the right lane, terminating in the vicinity of the Kenworth tractor-tank trailer. The Safety Board staff conducted simulations59 of the accident to determine the speeds of the specialty bus, pickup truck, and Ford tractor-box trailer as they were approaching the Hampshire–Marengo toll plaza relative to the speeds of the approaching Freightliner and Kenworth tractor-trailers. (See table 10.) The simulations used physical evidence and data collected on scene, including tire marks, points of impact between the vehicles, final rest positions, and data from the pickup’s SDM. After the accident, Safety Board investigators interviewed the drivers of the accident vehicles and obtained their estimated speeds prior to the collision. Table 10. Driver-estimated preaccident speeds and simulation preaccident speed comparison. Based on the SDM data and other physical evidence, several scenarios were identified and evaluated. The results of the simulations that most closely matched the physical evidence indicate that the vehicles at the front of the accident queue—the specialty bus, the pickup truck, and the Ford tractor-box trailer—were traveling at substantially lower speeds (0 to 10 mph) than the Freightliner tractor-trailer (50 mph) and the Kenworth tractor-tank trailer (55 to 62 mph), which were approaching from the rear. (See figure 17.) 59 Software used for the simulations included the Human Vehicle Environment (HVE) system, Simulation Model Nonlinear (SIMON), ReadDataFile by Collision Engineering Associates, Inc., Engineering Dynamics Corporation General Analysis Tool (EDGEN), Engineering Dynamics Corporation Simulation of Automobile Collisions (EDSMAC4), and Autocad and Viewpoint models by Digimation, Inc. Vehicle Driver’s stated speed prior to collision (mph) Preaccident speed simulation results Freightliner tractor-trailer (vehicle 1) 40–45 50 Specialty bus (vehicle 2) 10 10 Pickup truck (vehicle 3) 50 3 Ford tractor-box trailer (vehicle 4) 30–35 0–3 Kenworth tractor-tank trailer (vehicle 5) 62 (had begun braking) 55–62

Factual Information 35 Highway Accident Report The simulations indicated that the Freightliner tractor-trailer was traveling about 50 mph, slightly above the driver’s estimated speed of 40 to 45 mph, prior to striking the rear of the specialty bus. The simulations showed that the specialty bus was traveling about 10 mph, the bus driver’s estimated speed, as it approached the toll plaza behind a pickup truck that was traveling about 3 mph60 (the pickup truck driver recalled that he had been traveling 50 mph before the accident). The simulations showed the Ford tractor-box trailer traveling 0 to 3 mph in front of the pickup truck, with a maximum potential speed of 20 mph (the driver had reported traveling 30 to 35 mph before the accident). The simulations also indicated that the driver of the final striking vehicle—the Kenworth tractor-tank trailer—was traveling about 62 mph before applying his brakes and subsequently striking the pickup truck and the Ford tractor-box trailer. As the “bullet” vehicle, the Freightliner tractor-trailer (vehicle 1) was the first striking vehicle into the rear of the secondary target vehicle, the specialty bus (vehicle 2). As shown in table 10, the simulation results indicate a significant difference in speed between the vehicles at the front of the accident (vehicles 2, 3, and 4), which were traveling from 0 to 10 mph, and vehicles 1 and 5, which were approaching from the rear at Figure 17. Accident scene diagram indicating physical evidence. 60 The pickup truck’s SDM indicated that the vehicle was traveling 3 mph for 3 seconds and then less than 1 second later underwent a negative (rearward) change in velocity (delta-v) of at least 13.77 mph. Vehicle speed data were sampled at 1-second intervals beginning 5 seconds prior to the collisions that resulted in the rearward delta-v. See appendix C for further explanation of SDM data. I-90 Westbound I-90 Eastbound Gouge and scrape marks Furrow and plow marks Gouge and scrape marks Location of tire marks identified in ISP photograph Curved tire marks Tire marks Center median Milepost 41.5 0 50 100 150 200 Scale in feet

Factual Information 36 Highway Accident Report speeds of 50 to 62 mph. The simulations also indicate that vehicles 2, 3, and 4 were traveling at speeds well below the posted 45-mph speed limit as they approached the toll plaza and manual cash lane queue. In addition, the physical evidence and the simulation results showed the following: • Traveling approximately 50 mph, the Freightliner tractor-trailer struck the specialty bus, which was traveling about 10 mph. (See figure 18.) • Following the collision, as the specialty bus was moving about 40 mph, its right front door area contacted the left rear corner of the pickup truck, which was traveling about 3 mph. (See figure 19.) • The collision with the pickup truck pushed it forward; and within less than 1 second, the front of the pickup truck struck the rear of the Ford tractor-box trailer, which was traveling 0 to 3 mph.61 (See figure 20.) • As the Freightliner and the specialty bus veered toward the center median, the Freightliner’s trailer rolled onto the bed-mounted camper of the pickup truck and then onto the rear upper left corner of the Ford box trailer. (See figure 21.) • The Freightliner and the specialty bus continued toward the median; the Freightliner trailer overturned in the left lane, while the tractor remained upright. Both vehicles then entered the median and came to rest. • Meanwhile, a trailing vehicle—the Kenworth tractor-tank trailer—struck the pickup truck, which had already been in contact with the rear of the Ford tractor-box trailer from its initial impact and partial rotation, and pushed the pickup truck and the Ford combination unit to their final rest positions. (See figures 22 and 23.) 61 As indicated by the simulation results, the speed of the Ford tractor-box trailer was substantially slower than the 30 to 35 mph reported by the driver. The simulations showed that if this vehicle had been traveling any faster than 10 mph, the pickup truck would not have been able to “speed up” during the collision in time to make contact with the rear of the trailer; the trailer’s speed, if 30 to 35 mph, would have moved it forward, away from the slower vehicles colliding behind it.

Factual Information 37 Highway Accident Report Figure 18. Freightliner tractor-trailer strikes specialty bus. Figure 19. Specialty bus contacts left rear corner of pickup truck.

Factual Information 38 Highway Accident Report Figure 20. Pickup truck, pushed forward, strikes Ford tractor- box trailer. Figure 21. Freightliner trailer rolls onto pickup truck camper and box trailer.

Factual Information 39 Highway Accident Report Figure 22. Freightliner and specialty bus come to rest in median and Kenworth tractor-tank trailer strikes pickup truck, already in contact with box trailer. Figure 23. Final rest positions of all five vehicles.

Factual Information 40 Highway Accident Report Other Information Toll Roads Accident Statistics. According to FHWA estimates, the United States has 4,927 miles of toll roads, compared to 46,334 miles of interstate highway and 9,213 miles of urban freeways and expressways. Toll roads constitute approximately 9 percent of the motorway-standard mileage. Mileage and accident data by vehicle type are routinely collected on ticket-controlled segments of many toll roads; these tickets distinguish between commercial and passenger motor vehicles and document miles traveled. A 2002 study reported that, on most toll roads, tractor-trailers and other commercial vehicles were involved in more multivehicle accidents than passenger cars.62 In Illinois, commercial vehicles were 57 percent more likely to be in a multivehicle accident than a passenger car. The study concluded that the difference in accident rates between large commercial motor vehicles and passenger vehicles appeared to depend on type of collision, specific toll road, and traffic density.63 Rear-end accidents and sideswipes were the two most common types of collisions among commercial motor vehicles. Rear-end accidents accounted for about 30 percent of all collisions, regardless of vehicle type. From 1998–2002, the rear-end accident rate within a 5-mile radius of the Hampshire–Marengo toll plaza averaged approximately 40 percent, exceeding any other type of collision, including sideswipes (at approximately 20 percent). In 2002, the rear- end accident rate on the entire ISTHA toll system was 49.6 percent.64 Also in 2002, the Pennsylvania Turnpike and the New Jersey Turnpike recorded rear-end accident rates within a 1-mile radius of mainline plazas at 30.2 percent and 37.8 percent, respectively.65,66 Electronic Toll Collection and Open Road Tolling. ETC uses electronic equipment instead of manual cash collection or automatic coin machine collection. By means of automatic vehicle identification technology, customers subscribe to a program that allows their vehicle to be automatically identified in a toll lane by an electronic transponder. If the customer does not have an electronic transponder, a camera digitally photographs the license plate, and the registered owner is subsequently billed for the trip—or, if a cash lane was available, the customer is ticketed or fined for failure to pay the toll. Benefits of ETC include reduced staffing levels (compared to manually collecting tolls), increased throughput of vehicles, and reduced operating costs.67 The number of toll 62 Elisa R. Braver, Mark G. Solomon, and David S. Preusser, “Toll Road Crashes of Commercial and Passenger Motor Vehicles,” Accident Analysis and Prevention, Vol. 34 (2002): 293–303. 63 Insurance Institute for Highway Safety, “Commercial and Passenger Motor Vehicle Crashes on Toll Roads,” IIHS Status Report, Vol. 34, No. 7 (1999): 4–5. 64 Wilbur Smith Associates, 2000–2002 Traffic Crash Data Report for the Illinois State Toll Highway Authority (Chicago, IL: 2003), 2–8. 65 E-mail correspondence from traffic engineering manager, Pennsylvania Turnpike Commission, January 16, 2004. 66 E-mail correspondence from director of operations, New Jersey Turnpike Authority, January 20, 2004. 67 University of South Florida–Florida Department of Transportation, Center for Urban Transportation Research, Feasibility of Open Road Tolling in Florida (Tampa, FL: USF–Florida DOT, 2001) 10–11.

Factual Information 41 Highway Accident Report facilities with electronic technology has increased from 49 in 1995 to about 160 in 2003.68 From 1989 until 2004, the proportion of tolls collected by ETC had increased from 0 to 50 percent or more at almost all U.S. toll facilities. A 1996 study determined that a manual lane processes 300 to 500 vehicles per hour, and an automated coin lane processes 600 to 900 vehicles per hour.69 A dedicated automated vehicle identification lane can average 1,000 to 1,500 vehicles per hour. The definition of ORT varies among toll authorities. For example, the Florida Turnpike Enterprise defines ORT as a method and system of collecting tolls on expressways and other facilities that essentially involves no toll collectors in traditional toll booths,70 and ISTHA defines ORT as a method of collecting tolls electronically while driving nonstop at posted highway speeds.71 Generally, ORT refers to a toll collection scenario in which vehicles are identified electronically instead of having to stop for manual payment of a toll. Proponents of ETC and ORT cite reduced congestion, reduced accident rates, improved fuel economy, and reduced pollution as benefits.72 Cash-paying toll traffic now constitutes the minority traffic segment.73 Some toll roads provide nonstop travel in lanes adjacent to the median for ETC or ORT customers, while requiring cash-paying customers to exit the mainline toll highway to the right and pay tolls at express plazas located along the sides of the highway. Some States with ORT currently in use, or planned, are Florida (Florida Turnpike, Orlando–Orange County Expressway, Miami–Dade County Expressway), New Jersey (Garden State Parkway, New Jersey Turnpike), Colorado (E-470 Beltway, Northwest Parkway), Texas (Dallas North Tollway), Illinois (Illinois Toll Highway System), Virginia (Pocahontas Parkway), Pennsylvania (Pennsylvania Turnpike), and California (Transportation Corridor Agency).74 In July 2003, the Florida DOT completed a case study of a conventional mainline barrier toll plaza renovation on the Orlando–Orange County Expressway that included ORT.75 Prior to renovation, the plaza was operated during normal conditions (nonpeak traffic hours) with four lanes in each direction—two manual cash lanes, one automatic coin machine lane, and one dedicated ETC lane. The ETC lane was located to the left of 68 U.S. Department of Transportation, Federal Highway Administration, Toll Facilities in the United States: Bridges–Roads–Tunnels–Ferries, FHWA-PL-03-017 (Washington, DC: FHWA, 2003) 4–7. 69 Intelligent Transportation Systems Society of Canada, Electronic Toll Collection (Toronto, Ontario: SRI Consulting, 1996). See , January 31, 2006. 70 Feasibility of Open Road Tolling in Florida, 10–11. 71 Open Roads for a Faster Future, 5. 72 Electronic Toll Collection. 73 U.S. Department of Transportation, Federal Highway Administration, Developing Traffic Control Strategies: Geometric and Safety Design, Plaza Operations and Toll Lane Configurations (Washington, DC: FHWA, 2005) 4. 74 Data obtained from deputy program director, Post, Buckley, Schuh & Jernigan, consultants to the Florida Turnpike Enterprise, Florida DOT, September 14, 2005. 75 Data obtained from Post, Buckley, Schuh & Jernigan, consultants to the Orlando–Orange County Expressway Authority, Florida DOT, September 19, 2005.

Factual Information 42 Highway Accident Report the other three lanes and had a speed limit of 35 mph. Renovation included demolishing the middle lanes of the barrier plaza to incorporate four lanes of express ETC. The lanes were elevated to permit a 70-mph speed limit and were separated from the coin machine lanes by a barrier. Postconstruction, the plaza configuration consisted of six toll lanes per direction—two manual cash lanes and two coin machine lanes to the right and two express ETC lanes to the left. The rear-end accident rate at this location declined from 27 accidents prerenovation (1 year before construction)76 to 12 accidents postrenovation (1 year after construction).77 In 1999, ISTHA converted two mainline barrier toll plazas on the I-355 North/South Tollway in Chicago to ORT plazas. The Boughton Road plaza renovation was completed in February of that year, and the Army Trail Road plaza was completed in December. Prior to construction of the ORT lanes, both plazas operated with six toll lanes in each direction—three manual cash lanes and three automatic coin machine lanes. The renovation involved widening the plaza to accommodate four express ETC lanes in the median. A barrier separated these lanes from the automatic coin machine lanes. The final plaza configurations consist of eight toll lanes in each direction—three manual cash lanes on the right, three automatic coin lanes in the middle, and two express ETC lanes on the left. Prior to renovation of the Army Trail Road plaza, the average daily traffic was 7,150 vehicles per hour in both directions; after renovation, the traffic volume increased to 10,600 vehicles per hour. Prior to renovation of the Boughton Road plaza, the average daily traffic was 6,500 vehicles per hour in both directions; after renovation, the traffic volume increased to 9,800 vehicles per hour. The rear-end accident rate at each plaza declined following renovation.78 (See table 11.) Table 11. Rear-end accidents at two I-355 North/South Tollway plazas, pre- and post- ORT renovation. Toll Plaza Design. Several factors are considered in toll plaza design, such as proposed location on the roadway, right-of-way, traffic demand, method of toll collection, infrastructure, and approach and departure geometrics. Other factors taken into account 76 February 1, 2001, through January 31, 2002. 77 August 1, 2003, through July 31, 2004. 78 Data obtained from Wilbur Smith and Associates, consultant to the ISTHA, September 22, 2005. Year Number of accidents (Army Trail Road) Number of accidents (Boughton Road) Time frame 1996 34 31 2 yr prerenovation 1997 56 34 1 yr prerenovation 2000 15 20 1 yr postrenovation 2001 12 14 2 yr postrenovation

Factual Information 43 Highway Accident Report include violation enforcement, environmental issues (water, air, noise, and lighting), budget, staffing, safety, and capacity options; these factors can vary considerably across toll plazas.79 American Association of State Highway and Transportation Officials AASHTO is a nonprofit, nonpartisan association founded in 1914 as the American Association of State Highway Officials. It represents highway and transportation departments in the 50 States, the District of Columbia, and Puerto Rico. The association’s mission is to advocate transportation-related policies and to provide technical services to support States in efficiently and safely moving people and goods.80 AASHTO also publishes the guidance for highway geometric design in its book, A Policy on Geometric Design of Highways and Streets,81 commonly known as the “Green Book.” An FHWA office memorandum dated February 23, 2005, established that the fifth edition (2004) of the AASHTO Green Book “should be applied as the design standard for all projects on the National Highway System (NHS).”82,83 The Green Book is the basis for the geometric design standards of most transportation agencies.84 The fifth edition of the Green Book contains no guidance on the design of toll plazas or dedicated lanes. According to FHWA staff,85 the Green Book will be updated in 2007 or 2008, a process that entails extensive research and data analysis. One approach to provide the research and analysis required for an update is the development of written AASHTO guidelines on particular research subjects. Federal Highway Administration As established in 23 CFR Part 655, Subpart F, the FHWA administrator approves the MUTCD as the national standard for all traffic control devices installed on any street, highway, or bicycle trail open to public travel in accordance with 23 U.S.C. 109(d) and 402(a). The MUTCD contains the design, application, and placement standards for all traffic control devices and is the standard used by State and local transportation professionals in selecting, installing, and maintaining such devices.86 The current edition of the MUTCD (2003, with Revision No. 1) contains no guidance on the design of toll plazas or the use of dedicated lanes. 79 Developing Traffic Control Strategies: Geometric and Safety Design, Plaza Operations and Toll Lane Configuration, 1. 80 See , February 24, 2006. 81 American Association of State Highway and Transportation Officials, A Policy on Geometric Design of Highways and Streets, 5th ed. (Washington, DC: AASHTO, 2004). 82 See , January 9, 2006. 83 AASHTO established the National Highway Task Force in December 1988 to look beyond interstate completion; the board of directors recommended the creation of a National Highway System. The NHS Designation Act was enacted in November 1995. 84 Transportation Research Board of the National Academies, National Cooperative Highway Research Program, Leveraging Resources for Better Transportation (Washington, DC: TRB, 2005) 11. 85 Information obtained from Office of Program Administration, FHWA, November 2, 2005. 86 Traffic control devices include signs, signals, and pavement markings used to guide or warn road users.

Factual Information 44 Highway Accident Report In January 2003, the FHWA met with representatives of the International Bridge, Tunnel and Turnpike Association (IBTTA)87 to begin discussing how to achieve uniformity, efficient traffic flow, and improved safety at toll plazas. The FHWA and IBTTA agreed to pursue the goal of developing a compendium of best practices and control strategies for handling traffic within these complex roadway environments. In January 2004, the FHWA initiated a contract study to identify and define current practices, to develop guidelines based on multiple sources of information, to achieve consensus among toll agencies, and to determine possible MUTCD language for traffic control devices at toll plazas. The study is expected to result in a consistent national traffic control strategy for toll plazas, enhanced plaza safety and operations, and improved driver comprehension and reaction at toll plazas. The study results are to be published in a report entitled State of the Practice and Recommendations on Traffic Control Strategies at Tollbooth Plazas, which is planned for completion and distribution by summer 2006.88 The FHWA does not expect operating agencies to immediately adopt all recommendations and convert existing plazas. Rather, it advises that the recommendations be seriously considered for future facility retrofits or reconstructions, as well as any new construction. The FHWA anticipates including information from the traffic control strategies report, such as language about express ETC lanes, in the next edition of the MUTCD.89 No date has been set for publication of a revised MUTCD. Once funding has been obligated, the rulemaking activities associated with publishing a new edition can begin; this process generally takes about 3 years. International Toll Roads Several fully automated toll roads, with no toll booths or plazas, are already in operation around the world. Toronto’s highway 407, which runs 65 miles east–west just north of the city, is one of the world’s first open-access, all-electronic toll highways. It opened in October 1997. Transponders are required for all commercial vehicles. The entrances and exits of nontransponder-equipped, noncommercial vehicles are recorded via license plate optical character recognition high-speed cameras; customers’ addresses are obtained through the Canadian motor vehicle department, and the users are billed directly.90 In Norway, drivers entering the city of Oslo have been paying tolls via an ETC system since 1990. In France, Italy, and Portugal—which have established freeway tolling infrastructures—the decision to implement ETC is made by toll authorities, primarily as an aid to reducing operating costs, increasing toll revenue, and providing improved 87 According to IBTTA, the association is a worldwide alliance of toll operators and associated industries that provides a forum for sharing knowledge and ideas to promote and enhance toll-financed transportation services. IBTTA has 280 members in 24 countries. See , March 7, 2006. 88 E-mail correspondence from Office of Transportation Operations, FHWA, October 12, 2005. 89 E-mail correspondence from Office of Transportation Operations, FHWA, October 12, 2005. 90 See , January 31, 2006.

Factual Information 45 Highway Accident Report customer service.91 In Mexico, in addition to limited ETC installations on selected portions of the roadway system running between Tijuana and Guatemala, interest is growing in the installation of electronic systems at border crossings between Mexico and the States of California and Texas.92 In Australia, toll roads can be found in the cities of Brisbane, Sydney, and Melbourne. CityLink is a tolled freeway system in Melbourne on which tolls are collected electronically by e-TAG, and there are no toll booths along the entire length of the system. In the Philippines, on the main island of Luzon, the 84- kilometer North Luzon expressway uses ETC.93 Safe, Accountable, Flexible, Efficient Transportation Equity Act The Safe, Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for Users (SAFETEA-LU) was signed by the President on August 10, 2005, and provides over $201 billion in funding for highway and safety programs and nearly $46 billion for public transportation from FYs 2005–2009. These programs include toll road safety research and motor carrier oversight. Passenger Carrier Roadside Inspections. The motor carrier safety grants provisions under SAFETEA-LU amend the State Plan Contents section of 49 U.S.C. Section 31102(b)(1) to include language that (except in the event of imminent danger or obvious safety hazards) prohibits the inspection of a vehicle transporting passengers for a motor carrier of passengers unless the inspection is conducted at a station, terminal, border crossing, maintenance facility, destination, or other location where a motor carrier may make a planned stop. Toll Road Safety. The toll provisions under SAFETEA-LU require the Secretary of Transportation to conduct a study of the safety of highway toll collection facilities, including toll booths. The act requires consideration of (1) the effect of design or construction of facilities on the likelihood of vehicle collisions with the facilities; (2) the safety of crosswalks used by toll collectors in transit to and from toll booths; (3) the extent of the enforcement of speed limits in the vicinity of facilities; (4) the use of warning devices, such as vibration and rumble strips, to alert approaching drivers; (5) the law enforcement practices and jurisdictional issues that affect safety in the vicinity of facilities; and (6) the incidence of accidents and injuries in the vicinity of toll booths. (See appendix E.) Intermodal Equipment Oversight. The roadability94 provisions under SAFETEA-LU that relate to the inspection, repair, and maintenance of intermodal equipment require the Secretary of Transportation, within 1 year, to issue regulations 91 See , January 31, 2006. 92 See , January 31, 2006. 93 See , January 31, 2006. 94 Typically, the term “roadability” is defined as the ability of a motor vehicle to maintain a steady, balanced, and comfortable ride, especially under a variety of road conditions. For motor carrier safety, it is viewed as the roadworthiness of the vehicle—that is, whether the vehicle meets certain systems requirements to safely operate on the Nation’s highways.

Factual Information 46 Highway Accident Report establishing a program to ensure that equipment used to transport intermodal containers is safe and systemically maintained. In the United States, intermodal chassis are used to transport cargo valued at more than $450 billion annually.95 Cargo containers hauled by rail and shipping companies are regularly transferred to trucks before final delivery. Most chassis are not owned by trucking companies and are not included as part of the existing compliance review process for truck operators. Data collected by the FMCSA suggest that trucks hauling intermodal equipment receive OOS notices more frequently than heavy trucks in general. Intermodal equipment providers own 750,000 chassis nationwide, which handled more than 20 million container movements in 2002.96 (See appendix E.) State Vehicle Codes for Intermodal Trailer, Chassis, and Safety Four States—California, South Carolina, Louisiana, and Illinois—have State laws under which an intrastate intermodal chassis, trailer, or container owner is responsible for the maintenance and condition of equipment. In Illinois, the law became effective in July 2000 and prohibits the interchange of intermodal equipment in violation of FMCSRs. (See appendix F for the full text.) The Illinois law gives the owner of the equipment responsibility for its upkeep and requires the owner to reimburse truckers for any fines, penalties, or repair costs incurred because of defects specified by the law. Violations may result in fines of up to $500. The law, codified in 625 Illinois Compiled Statutes 5/18b– 112(b), states, in part: It is the responsibility of the equipment provider to inspect and, if a vehicle at the time of inspection does not comply with all federal motor carrier safety regulation requirements, perform the necessary repairs on all vehicles prior to interchange or offering for interchange. Vehicle Incompatibility and Heavy Truck Aggressivity Vehicle incompatibility is defined as design differences among vehicle types that result in disproportionate damage patterns following a collision. These differences include weight, stiffness, and geometry aspects.97 If any of these factors vary significantly between two impacting vehicles, the vehicles will not be compatible in a collision. One vehicle will probably absorb more of the impact energy, either through crush or large accelerations, while the other vehicle is considered to have high aggressivity. “Crashworthiness” refers to how well a vehicle protects its occupants in an accident. This protection involves aspects such as the crash behavior of structures and materials and impact biomechanics. Crashworthiness is a function of the compatibility of the impacting vehicles and the methods of energy management for occupant protection, among other factors. 95 National Highway Traffic Safety Administration, January 26, 2004, press release (Washington, DC: NHTSA, 2004). 96 Alan M. Robinson, Intermodal Truck Equipment Safety: Legislation in the 108th Congress, Congressional Research Service (Washington, DC: CRS, May 6, 2004) 1–3. 97 S. Acierno and others, “Vehicle Mismatch: Injury Patterns and Severity,” Accident Analysis and Prevention, Vol. 36 (2004): 761.

Factual Information 47 Highway Accident Report In April 2000, the 21st Century Truck Program was announced at a gathering of U.S. truck and supporting industries, environmentalists, and Federal agency representatives, including the U.S. Department of Energy (DOE) and the DOT. This multiagency and industry partnership released a “roadmap” for developing a viable technology for the improvement of safety in the Nation’s trucking industry.98 One of the program’s many goals and research objectives is to improve truck and bus safety by fostering advancements in vehicle design and performance, such as reducing truck frontal aggressivity in multivehicle collisions.99 According to the roadmap, the milestone for improving crashworthiness—including the completion of laboratory tests and field trials of systems to reduce the destructive effects of accidents—is mid-2009.100 98 See , January 31, 2006. 99 See , January 31, 2006. 100 See , January 31, 2006.

48 Highway Accident Report Analysis The Safety Board considered several factors that may have caused or contributed to the severity of the multivehicle collision, including the Freightliner driver’s performance, Federal oversight of intermodal chassis operations and passenger carriers, lack of collision warning systems on commercial vehicles, and vehicle incompatibility and heavy truck aggressivity. In addition, this accident raised concerns about toll road design and operation. The Safety Board is responsible for investigating transportation safety issues of national significance. Thirty-one States have at least one State or local toll facility. Of the remaining 19 States, many are planning to create toll authorities. Toll plazas can be prone to sudden stops and lane changes and to unsafe approach and departure speeds, particularly in an environment of merging and queuing vehicles, which effectively increases the probability of a collision.101 Following a brief discussion of factors that were determined not to be causal to the accident, this analysis discusses toll plazas and other causal issues. Exclusions The weather was clear and dry at the time of the accident. Postaccident inspection of the specialty bus, pickup truck, Ford tractor-box trailer, and Kenworth tractor-tank trailer indicated no mechanical problems with the vehicles. No defects in highway road design were found. The Safety Board concludes that the weather; the mechanical condition of the specialty bus, pickup truck, Ford tractor-box trailer, and Kenworth tractor-tank trailer; and the design and condition of the roadway did not cause or contribute to the accident. Following the accident, the ISP required a blood sample to be taken from the Freightliner driver and the specialty bus driver; both samples tested negative for controlled substances. In addition, the Freightliner driver’s sample tested negative for alcohol. The bus driver was not tested for alcohol because the ISP investigating officers detected no evidence of alcohol use. Although 49 CFR Part 382 required Leisure to conduct postaccident testing for alcohol, the company failed to do so, and the Safety Board therefore could not determine whether the bus driver was under the influence of alcohol at the time of the accident. Because the specialty bus was rear-ended, the driver— whether impaired or unimpaired—probably could not have taken any action that might have prevented or mitigated the accident. According to the FMCSA, Leisure Pursuit Charters is no longer in operation; nevertheless, the Safety Board is concerned that the company failed to fulfill its responsibility to ensure that its driver was tested for alcohol following the accident. 101 U.S. Department of Transportation, Federal Highway Administration, Developing Traffic Control Strategies at Toll Plazas: Signing and Markings (Washington, DC: FHWA, 2005) 1.

Analysis 49 Highway Accident Report When interviewed by the Safety Board, the Freightliner driver reported that he was not taking any prescription medications at the time of the accident. In addition, he possessed a valid medical certificate and a CDL. The 72-hour history for both the Freightliner driver and the specialty bus driver indicated no fatigue-inducing events or activities, and neither driver reported sleeping problems. The specialty bus driver did not have a valid medical certificate at the time of the accident, but he did pass a medical examination and receive a certificate 9 days later. Although the Safety Board is concerned that Leisure did not identify that one of its drivers had been operating a passenger carrier for 2 years on an expired medical certificate, the evidence does not indicate that the bus driver’s health contributed to the accident. Emergency responders and medical personnel were expeditiously dispatched to the accident scene. The injured received medical care on scene and were transported to local hospitals in a timely manner. The Safety Board therefore concludes that neither the Freightliner driver nor the specialty bus driver was adversely affected by medications, medical conditions, or fatigue and that the emergency response was timely and effective. Accident Discussion The physical evidence at the accident scene, vehicle damage, and simulation results indicate that the vehicles at the front of the accident—the specialty bus, the pickup truck, and the Ford tractor-box-trailer (vehicles 2, 3, and 4)—were traveling at substantially lower speeds (0 to 10 mph) than vehicle 1, the Freightliner tractor-trailer (50 mph), and vehicle 5, the Kenworth tractor-tank trailer (55 to 62 mph), which were approaching from the rear. The simulations also indicate that the three vehicles at the front of the accident were traveling at speeds well below the posted 45-mph speed limit, probably because they were approaching the toll plaza and manual cash lane queue. Based on the pickup truck’s SDM and physical evidence, the simulations showed that the Freightliner was traveling about 50 mph, slightly above the driver’s estimated speed of 40 to 45 mph, prior to striking the rear of the specialty bus. This impact caused the right front door area of the specialty bus (now accelerated to approximately 40 mph) to contact the left rear corner of the pickup truck, which was traveling about 3 mph. As the pickup truck was pushed forward, it struck the rear of the Ford tractor-box trailer, which had been traveling 0 to 3 mph. As the Freightliner and the specialty bus veered toward the center median, the Freightliner trailer rolled onto the bed-mounted camper of the pickup truck and then onto the rear left upper corner of the Ford tractor unit’s box trailer. As the Freightliner and the specialty bus continued toward the median, the Freightliner trailer overturned in the left lane, while the tractor remained upright. Both vehicles then entered the median and came to rest. The simulation also indicated that the final striking vehicle—the Kenworth tractor- tank trailer—had been traveling about 62 mph before braking and subsequently hitting the pickup truck (which had already made contact with the rear of the Ford box trailer from its

Analysis 50 Highway Accident Report initial impact and partial rotation) and pushing it and the Ford combination unit to their final rest positions. The Safety Board identified factors, including physical evidence from the scene and the driver’s own statements, that indicate the Freightliner driver was traveling at a rate of speed too fast for traffic conditions. Because the driver stated that he did not observe brake lights on the specialty bus, the Safety Board examined whether the sun may have impaired his ability to detect the brake lights and whether it may have contributed to his inability to recognize the slowed vehicles in front of him. The Safety Board also examined whether the three out-of-adjustment brakes on the intermodal chassis trailer may have prevented the driver from being able to stop his vehicle to avoid a collision with the specialty bus. Freightliner Driver Performance When interviewed after the accident, the Freightliner driver stated that he was following the specialty bus by approximately two car lengths, had maintained a constant view ahead, and was startled by the appearance of the bus stopped ahead of him and not displaying brake lights. Safety Board investigators determined that the position of the sun was above and behind the truck and the driver—opposite to that which would have interfered with the driver’s vision. Further, the rear-view mirrors on the Freightliner were set normally to facilitate a horizontal view of traffic to the driver’s rear, at an angle that probably would not have produced a reflection of the sun into the eyes of the driver. Although the Freightliner driver reported that he had not observed brake lights on the specialty bus while approaching the toll plaza, laboratory examination of the brake light bulbs established that the right tail and brake lights and the left tail and brake lights of the bus were illuminated at the time of rear-end impact. The angle, altitude, and intensity of the sun are unlikely to have degraded the effective brightness or contrast of the bus’s brake lights in a manner that would have contributed to the cause of the accident. The Freightliner driver stated to Safety Board investigators that he braked “hard and steered to the left” to avoid a collision with the specialty bus. However, postaccident examination of the roadway showed no evidence of preimpact tire marks. Physical evidence at the scene did include 38-foot-long tire marks in the right traffic lane eastbound that were straight and preceded the curved tire marks, which had striations running perpendicular to the direction of travel. These tire marks were located on the roadway west of the location where the Freightliner tractor struck the rear of the bus. Although the postimpact brake marks are indicative of the driver using his brakes, their location and the impact in the center of the right lane are evidence that the driver’s steering to the left and the vehicle’s braking occurred after the collision between the front of the Freightliner tractor and the rear of the bus. For commercial vehicle air brake systems, such as the Freightliner’s pneumatic brake system, a delay occurs between the driver applying the brake pedal and the delivery

Analysis 51 Highway Accident Report of full air pressure to apply the brakes at the wheels. This delay, known as “air brake lag time,” typically ranges from 0.6 to 0.8 second for a tractor to 1.0 second for a trailer. Three of the 10 brakes on the Freightliner combination unit (all located on the trailer) were found to be not properly maintained within adjustment limits. Brake force calculations showed that, even with the three defective brakes, had the driver been applying the brakes for longer than 1 second prior to impact, in-adjustment brakes would have locked up and left preimpact tire marks. The left side of the vehicle’s fourth axle on the trailer did in fact leave tire marks on the roadway surface; however, these marks were made after the front bumper of the tractor had already struck the rear of the specialty bus. Given the absence of preimpact tire marks, the Freightliner driver must have been braking for less than 1 second prior to impact. During this time, air pressure in the braking system would have been building from 0 pound per square inch (psi) to about 90 to 100 psi for a hard (emergency) brake application. At 90 psi, it was calculated that the Freightliner could have decelerated at a rate of 0.435 g; however, only about two-thirds of this value would have been available through the first second of braking because of the nonlinear rise in air pressure, bringing the preimpact deceleration rate to 0.290 g. If all of the Freightliner vehicle’s brakes had been in proper adjustment, the calculated preimpact deceleration rate would have been 0.591 g, two-thirds of which is 0.394 g. When the preimpact deceleration rate is combined with the approximate 50-mph Freightliner impact speed, the preimpact speed with the defective brakes is about 56 mph. Using 56 mph as an initial speed, in 1 second at a deceleration rate of 0.394 g, had all the brakes been in proper adjustment, the impact speed would have been approximately 47 mph—a difference of only about 3 mph from the 50-mph impact speed with defective brakes. The Freightliner driver most likely applied his brakes either at or just before impact. Because of the short amount of time the driver was braking, the braking system did not have an opportunity to significantly reduce the speed of the Freightliner at impact, regardless of its mechanical condition. Therefore, the Safety Board concludes that brake force calculations, together with the physical evidence on scene, indicate that the Freightliner’s out-of-adjustment brakes did not contribute to the accident. The Freightliner driver admitted that he usually maintained a distance of only two car lengths from vehicles he was following to prevent other vehicles from crossing into his path. Two car lengths is normally about 40 feet, and even at a conservative speed of 40 mph (for a tractor-trailer transporting a load in excess of 76,000 pounds), the driver should have been maintaining a distance of at least 10 times 40 feet. According to the Illinois DMV, at 40 mph, a driver would need a headway of 410 feet and, at 45 mph, 462 feet to stop.102 Thus, to have adequate stopping distance, the Freightliner driver should have been following the vehicle ahead of him by well over 400 feet. Moreover, numerous traffic controls in the area warned of the toll plaza, traffic was moderate to heavy at the time of the accident, and the vehicles ahead of him were traveling at a rate much slower than the posted 45-mph speed limit because of the toll plaza queue. The Freightliner driver, who had driven this route on four or five previous occasions, was aware that he would be 102 Illinois Commercial Driver’s License Study Guide, 43–44.

Analysis 52 Highway Accident Report required to stop at the Hampshire–Marengo toll plaza on his return trip. Therefore, the Safety Board concludes that the Freightliner driver had ample cues indicating that he needed to allow more space between his heavy vehicle and those ahead, and his failure to maintain adequate following distance and to reduce the speed of his vehicle relative to the slowing traffic ahead contributed to this accident. Collision Warning Systems According to the DOT, preliminary analyses have shown that 1,836,000 police- reported crashes, or about 48 percent of accidents, could be prevented by rear-end103 or run-off-the-road and lane change collision warning systems (CWSs).104 Although the 1995 Freightliner truck was an older model year vehicle, this accident and resultant loss of life might have been avoidable if the vehicle had been equipped with a CWS. The Freightliner driver did not perceive the slowing and stopped vehicles ahead and, as a result, did not apply the brakes in time to slow his vehicle to avoid an accident. If the accident tractor had been equipped with a warning system based on rear-end CWS design, the system should have detected the slower moving traffic directly ahead and warned the driver of the impending collision, providing more time for him to decelerate and avoid a rear-end accident. The Safety Board concludes that the Freightliner driver did not detect the slowing traffic ahead of his vehicle, and had the Freightliner truck been equipped with a CWS designed to detect this type of situation and alert drivers, that technology might have prevented this accident. In May 2001, the Safety Board adopted the report Vehicle- and Infrastructure- Based Technology for the Prevention of Rear-End Collisions.105 In 1999 and 2000, the Safety Board investigated nine rear-end collisions in which 20 people died and 181 were injured. Common to all nine accidents was the following driver’s degraded perception of traffic conditions ahead. As the Safety Board had already reported in 1995106 and further discussed in its 1999 public hearing,107 existing technology in the form of intelligent transportation systems (ITS) can help prevent rear-end collisions. In the nine such accidents investigated by the Board, one (and sometimes more) of the available technologies would have helped alert the drivers to the vehicles ahead and would have prevented or mitigated the circumstances of the collisions. 103 Rear-end CWS devices use electronic sensors to detect the motion of a lead vehicle, compute whether a collision is likely, and trigger an alarm to alert the driver to an impending collision. Auditory warnings are helpful in improving reaction times during deceleration events. 104 See , February 24, 2006. 105 National Transportation Safety Board, Vehicle- and Infrastructure-Based Technology for the Prevention of Rear-End Collisions, Special Investigation Report NTSB/SIR-01/01 (Washington, DC: NTSB, 2001). 106 National Transportation Safety Board, Multiple Vehicle Collision With Fire During Fog Near Milepost 118 on Interstate 40, Menifee, Arkansas, January 9, 1995, Special Investigation of Collision Warning Technology, Highway Accident Report NTSB/HAR-95/03 (Washington, DC: NTSB, 1995). 107 National Transportation Safety Board, Docket No. DCA-99-SH-002.

Analysis 53 Highway Accident Report As a result of its investigations, the Safety Board issued two recommendations to NHTSA in May 2001: H-01-6 Complete rulemaking on adaptive cruise control and collision warning system performance standards for new commercial vehicles. At a minimum, these standards should address obstacle detection distance, timing of alerts, and human factors guidelines, such as the mode and type of warning. H-01-7 After promulgating performance standards for collision warning systems for commercial vehicles, require that all new commercial vehicles be equipped with a collision warning system. On July 6, 2005, NHTSA responded to the Safety Board that the DOT had established an intelligent vehicle initiative (IVI) as a major component of the ITS program and was evaluating the performance of adaptive cruise control (ACC) and CWS. The goal of the IVI is to improve the safety and efficiency of motor vehicle operations by reducing accidents through the use of advanced driver assistance systems, such as ACC and CWS. To achieve this objective, NHTSA—along with the FHWA and the FMCSA—completed field operational tests to evaluate the performance of advanced safety systems under normal fleet conditions and released the results report in August 2005. According to NHTSA, it is evaluating the results data to determine how to improve commercial vehicle safety, which will allow it to further address the Safety Board’s recommendations; a final report was expected to be published in fall 2005. The Safety Board replied to NHTSA on October 31, 2005, informing it that the status of the recommendations will remain “Open—Acceptable Response” pending publication of the final report on the field operational tests, application of test results to improve commercial and passenger vehicle safety through the use of ACC and CWS, and development of IVI performance standards. As of April 1, 2006, the Safety Board is still awaiting the final report from NHTSA. To date, though NHTSA has finished field operational tests and awarded grant funds for further research, it has been 5 years since the Safety Board issued the recommendations pertaining to collision warning technology. According to NHTSA’s program milestones, full evaluation of the safety benefits of vehicles equipped with safety systems to address multiple crash types will not be completed until 2009—10 years after the Safety Board held its public hearing on existing ITS technology that could help prevent rear-end accidents. Accidents such as the Hampshire rear-end collision, with high loss of life, underscore the need for NHTSA to move forward more expeditiously. Therefore, the Safety Board is reiterating Safety Recommendations H-01-6 and -7, urging NHTSA to complete rulemaking on ACC and CWS performance standards for new commercial vehicles, addressing obstacle detection distance, timing of alerts, and human factors guidelines, such as the mode and type of

Analysis 54 Highway Accident Report warning; and, after promulgating performance standards, to require that all new commercial vehicles be equipped with CWS. Highway The Hampshire–Marengo toll plaza created a situation in which traffic backed up in the right lane 0.5 mile from the toll plaza itself; this queue caused vehicles that had been traveling in a 45-mph zone to come to almost a complete stop. Backups at toll plazas present a safety hazard; in particular, they tend to increase the incidence of rear-end collisions. For example, in 2002, rear-end collisions represented 49.6 percent of all collisions on the ISTHA system, the highest rate for all types of collisions, exceeding the next highest category, sideswipes, which accounted for 21.4 percent of all collisions. Further, from 1998–2002, rear-end accidents within a 5-mile radius of the Hampshire–Marengo toll plaza ranged from 34.0 to 41.4 percent of total collisions.108 Toll authorities nationwide experience rear-end collision rates that exceed other types of collisions, in part because toll plazas interrupt the flow of high-speed traffic to intermittently collect tolls. In 2002, rear-end accidents within a 1-mile radius of mainline plazas on the Pennsylvania Turnpike and the New Jersey Turnpike accounted for 30.2 percent and 37.8 percent, respectively, of all accidents.109,110 One advantage of ETC is the elimination of queuing, and ORT systems improve safety for the motoring public by eliminating the traffic queue at toll collection locations and significantly reducing the likelihood of rear-end accidents. According to the DOT, it takes “39 percent longer, on average, to make a peak period trip in urban areas compared with the time it would take if traffic were flowing freely.”111 The demand for expansion of the current highway system—both to relieve congestion in densely populated areas and to meet transportation needs in rapidly growing areas—continues to increase at a significant rate and shows no signs of slowing.112 The acceptance of electronic tolling as a strategy to meet and manage demand is growing in popularity among the general public.113 108 Wilbur Smith Associates, 2000–2002 Traffic Crash Data Report for the Illinois State Toll Highway Authority (Chicago, IL: 2003) 2–8. 109 Data obtained from traffic engineering manager, Pennsylvania Turnpike Commission, January 16, 2004. 110 Data obtained from director of operations, New Jersey Turnpike Authority, January 20, 2004. 111 Emilio Suarez and Kevin Hoeflich, “The End of the Tollbooth?” Public Roads, Vol. 68, No. 6 (May– June 2005): 3–4. 112 Peter A. Kopac, “Dispelling Highway Construction Myths,” Public Roads, Vol. 68, No. 6 (May–June 2005): 3–4. 113 National Cooperative Highway Research Program, Tolling Practices for Highway Facilities, A Synthesis of Highway Practice, Synthesis Report 262 (Washington, DC: Transportation Research Board of the National Academies, 1998) 3.

Analysis 55 Highway Accident Report Current toll industry practices and policies can be a useful frame of reference for government entities or organizations that are contemplating or implementing tolls on transportation facilities or retrofitting tolling facilities to increase efficiency and reduce congestion.114 In the United States, toll plazas have been designed and constructed for more than 50 years without national design standards.115 An extensive literature search revealed that no general standards exist for the design of toll plazas.116 The standards developed by individual toll operators have been based on years of experience in improving or expanding their facilities.117 Consequently, the design practices and safety of toll plazas vary considerably nationwide. Toll authorities are becoming more prevalent across the country, and the Federal Government supports them through policies118 contained in the Transportation Equity Act for the 21st Century (TEA-21) and SAFETEA-LU. The new SAFETEA-LU legislation charges the Secretary of Transportation to address toll plaza safety, focusing on toll worker safety. Although the Safety Board is confident that the FHWA will appropriately incorporate information and data derived from its study of toll plaza safety for workers into the MUTCD, the Board remains concerned about the safety of the traveling public. Historically concentrated in the eastern States, toll roads operate across the country today. As more toll roads are built and many toll plazas are retrofitted for ETC, the need for standards and guidelines to ensure uniformity and safety becomes paramount. AASHTO is a preeminent source of technical information on highways and other transportation facilities.119 According to AASHTO staff, the next update of the Green Book will be in 2007 or 2008. The development of an AASHTO guide document is one approach used by AASHTO to fulfill the research and analysis requirements for updating the Green Book. The FHWA’s MUTCD sets national standards for traffic control devices placed on streets and highways by authority of a public body or official having jurisdiction to regulate, warn, or guide traffic. The FHWA expects to release State of the Practice and Recommendations on Traffic Control Strategies at Tollbooth Plazas in 2006. The purpose of this report is to provide recommended safety and operations guidelines for agencies that operate or are planning to operate toll facilities. Although the FHWA plans to incorporate information from this report into the next edition of the MUTCD, as appropriate, the MUTCD revision process can take 3 or more years. Currently, neither AASHTO’s Green Book nor FHWA’s MUTCD contains any guidance or discussion of toll plaza design techniques or ETC systems. 114 NCHRP Synthesis Report 262, 4. 115 Developing Traffic Control Strategies at Toll Plazas: Signing and Markings, 2. 116 National Cooperative Highway Research Program, Toll Plaza Design, A Synthesis of Highway Practice, Synthesis Report 240 (Washington, DC: Transportation Research Board of the National Academies, 1997) 1. 117 NCHRP Synthesis Report 240, 1. 118 See , April 19, 2006. 119 Leveraging Resources for Better Transportation, 5.

Analysis 56 Highway Accident Report Much has changed in the tolling industry since 1997–1998, when the most recent NCHRP synthesis reports were published. Information and guidance on current practices should be a priority, given the increasing demand for highway expansion and the removal of toll plazas or incorporation of ETC on existing toll roads. Toll plazas with manual and coin-operated collection booths create sudden stops in traffic flow. The resultant traffic queues on high-speed interstates increase the likelihood of accidents and present a safety hazard to the traveling public that ETC systems largely eliminate. Other benefits of ETC include reduced congestion, improved fuel economy, and reduced pollution. Some toll roads even provide ETC customers with nonstop travel lanes adjacent to the median. The Safety Board concludes that traditional toll plazas, such as the Hampshire–Marengo toll plaza (as configured on the day of the accident), create traffic backups that present a safety hazard; the conversion of traditional plazas to ETC systems should greatly reduce such hazards and improve safety on toll roads. When either building or redesigning a toll plaza, the responsible authority needs up-to-date guidelines and standards to help ensure the safety of the traveling public. NCHRP Synthesis Report 240 identifies problems associated with electronic tolling, many of which, such as the following, have been resolved since its publication in 1997: • Differences in systems and protocols between adjacent toll facilities (in Texas, for example, customers can now buy a TollTag for interoperable use on toll roads in Dallas, in Houston, at Dallas–Fort Worth International Airport, and at Dallas Love Field Airport), and • Incentives to encourage ETC program participation (on the ISTHA system in Illinois, automobile customers are given a 50-percent discount for using I-PASS lanes ($0.40) rather than cash lanes ($0.80), and commercial vehicles receive a discount for traveling during nonpeak hours). Technology has thus evolved since 1997. To present the current practice in toll plaza design, a cooperative research and analysis effort among the FHWA, AASHTO, and the IBTTA (representing the toll industry) is needed to establish new AASHTO guidelines that will eventually be used in updating the next edition of the Green Book. The Safety Board believes that the FHWA, AASHTO, and the IBTTA should cooperate to develop written guidelines on toll plaza design that provide information on current tolling practices, ETC strategies, and other equipment designed to eliminate queuing at toll plazas and to improve toll road safety. The Safety Board further believes that AASHTO should include the information from the written guidelines on toll plaza design in the next update of the Green Book.

Analysis 57 Highway Accident Report Federal Motor Carrier Safety Administration During the investigation of this accident, the Safety Board examined the FMCSA’s oversight of intermodal chassis operations and passenger carriers operating on revoked authority, such as Leisure Pursuit Charters. Intermodal Chassis Although the Freightliner driver reported to Safety Board investigators that he conducted a 14-minute inspection of the accident trailer prior to operating the equipment, postaccident inspection revealed three out-of-adjustment brakes on the intermodal chassis. When a tractor driver picks up an intermodal chassis, as was the case in this accident, he or she has the federally mandated responsibility to be satisfied that the vehicle is in safe operating condition. Although the accident driver visually inspected the trailer brakes, this pretrip inspection did not identify the out-of-adjustment brakes, which are a safety hazard because they reduce a vehicle’s braking efficiency. Had the accident trailer been pulled over by law enforcement for a roadside vehicle inspection, the out-of-adjustment brakes would have placed the entire vehicle out of service until they were properly adjusted. The Freightliner driver worked for Frontline Transportation Company, which was under contract to COSCO, a company that operates a fleet of vessels engaged in international shipping to U.S. ports. The freight arrives at the ports in cargo containers and is loaded onto chassis trailers for transport to customers or to rail yards. Once the freight arrives at the final rail yard, the motor carrier—Frontline in this accident—transports it in cargo containers on chassis trailers (also known as intermodal equipment) owned or leased by COSCO, to COSCO customers. The owners or lessees of the intermodal equipment are usually shipping companies that are not considered motor carriers; therefore, they are not required to register with the FMCSA, obtain a DOT number, adhere to the FMCSRs, or undergo compliance reviews, including on-site safety inspections. Trucking companies and drivers that offer contract transport service to intermodal equipment owners use the chassis trailers or cargo containers provided, and this equipment may not comply with the FMCSRs. In this accident, though the Freightliner driver did visually inspect the trailer provided by COSCO, a quick pretrip inspection was inadequate to determine whether the brakes were roadworthy. Although motor carriers and drivers transport such equipment in interstate commerce, they are not the owners of the equipment and do not have control or authority over its routine inspection, systemic maintenance, or repair to ensure compliance with Federal safety regulations. However, if these carriers and drivers are subjected to a roadside inspection, they are cited and fined for the intermodal equipment safety violations and their safety record is negatively affected for failure of the equipment owner to provide safe equipment. The owner of the accident trailer—TRAC Lease—owns more than 200,000 intermodal chassis trailers, and an average of 54,000 such trailers are being transported daily over our Nation’s highways. Recent Federal legislation will help close this safety loophole. Under SAFETEA- LU, intermodal equipment owners will be required to obtain a DOT number and adhere to

Analysis 58 Highway Accident Report the FMCSRs. The SAFETEA legislation mandates that the FMCSA enact rulemaking120 to require that equipment providers meet all safety regulations prior to providing the equipment for transport and certify and document that inspections and repairs have been performed. In addition, the FMCSA will be given authority to enter the port facility that provides the equipment to review the inspection process and ensure compliance with Federal safety regulations. Further, if a tractor-trailer combination unit is pulled over for a roadside inspection, and the trailer chassis and container are owned by an intermodal equipment company, any violations or defects found during the inspection will be assessed to the owner of the equipment, thus affecting the intermodal carrier’s safety record. The Safety Board concludes that, by requiring intermodal equipment owners to obtain a DOT number and adhere to the FMCSRs, the new rulemaking required by SAFETEA-LU will help close the gap in the FMCSA’s oversight of intermodal equipment, such as that involved in this accident, and improve freight transportation safety. Oversight of Passenger Carriers Operating on Revoked Authority The Leisure-owned specialty bus was rear-ended and thus did not initiate the accident. Nonetheless, the Safety Board reviewed the motor carrier’s operations as part of the accident investigation. In addition, the FMCSA conducted a postaccident compliance review of Leisure and issued the company a safety rating of “conditional” because of its violation of safety regulations for both drivers and their vehicles. These violations included: • Failing to randomly test drivers for controlled substances and alcohol, • Failing to investigate a driver’s background, • Failing to maintain a list or certificate relating to violations of motor vehicle laws and ordinances, • Failing to maintain medical examiners’ certificates in drivers’ qualification files, • Operating a motor vehicle providing transportation without the required registration or beyond the scope of the registration, • Requiring or permitting a driver to drive after having been on duty for more than 70 hours in 8 consecutive days, • Failing to keep a record of tests on push-out windows, emergency doors, and emergency door marking lights on buses, and • Using a commercial vehicle not periodically inspected. By the very nature of these violations—all of which are safety-related—Leisure placed its passengers at risk, along with the general public who shared the road with Leisure’s vehicles and drivers. 120 According to the FMCSA, a Notice of Proposed Rulemaking is expected to be published in the Federal Register on June 1, 2006.

Analysis 59 Highway Accident Report During its investigation, the Safety Board determined that Leisure had been operating on a revoked interstate authority at least eight times before the accident. On January 29, 2002, the FMCSA had revoked Leisure’s operating authority because of inadequate insurance; however, according to Leisure’s president, he had not received the revocation letter due to an office move. During the FMCSA postaccident compliance review, inspectors discovered that Leisure had conducted at least eight interstate charters after having its operating authority revoked. On one of these trips, a driver for Leisure had been pulled over for an MCSAP roadside inspection (driver only); because of the limited nature of the inspection, the company’s revoked operating status was not identified, and the FMCSA was not notified that the company was operating on revoked authority. Because of the safety violations found during Leisure’s postaccident compliance review, and the fact that the company had been operating without authority during these violations, the Safety Board reviewed the process by which the FMCSA monitors passenger carriers that have lost operating authority to verify that they are no longer providing for-hire interstate charter services to the public. According to the FMCSA, once a company receives a final notification of operating status revocation, it is listed in the FMCSA databases as “inactive.” Although Leisure’s operating status was revoked and its assigned motor carrier number was inactive, the company continued to provide charters to the public. Leisure was knowingly operating without proper authority and in violation of safety requirements, while being paid by customers to whom it was providing uninspected vehicles and drivers who lacked medical examination certificates or background checks, as documented in the FMCSA compliance review. Had the accident not occurred, these violations probably would have continued because Leisure was not listed as active in FMCSA databases, and the databases provided no link between roadside inspection and the inactive operating status of the carrier. The FMCSA believed that the company had stopped operating as a result of the notice of revocation; however, it had no measures in place to verify that the company had indeed ceased operations. This situation represents a breakdown in the FMCSA process of operating authority revocation meant to protect the public from illegally operating and potentially unsafe companies. Further, once a carrier becomes inactive—even though it is not removed from the FMCSA databases that are used to determine the need for a compliance review or safety audit—it is no longer targeted for a compliance review because it is not registered as active. Given the inactive designation and in the absence of roadside inspection statistics, the FMCSA is unlikely to identify an illegally operating carrier as a high-risk carrier for a compliance review. The FMCSA programs to protect passengers and the traveling public are directed to carriers with an active operating status. In a 2004 address to the United Motorcoach Association, the FMCSA administrator stated that the agency recognizes the reality of passenger carriers operating without proper authority and promised to work with association members to get uninsured and other illegal motorcoach operators off the highways. The method discussed to prompt field action was cross checking insurance revocations with roadside inspection and accident databases. The Safety Board has received no indication from the FMCSA that it

Analysis 60 Highway Accident Report has initiated this process. In January 2004, the FMCSA informed the Safety Board that inactive passenger carriers would be discovered and subsequently placed in OOS status by means of roadside inspections. However, in 2004, of the approximately 776,550 registered buses, only 5.5 percent underwent roadside inspections. Further, as a result of new SAFETEA-LU legislation, the FMCSA cannot conduct roadside inspections of passenger carriers. In light of such numbers and the new legislation, the likelihood of inspectors detecting a passenger carrier operating on a revoked authority is extremely low. The Safety Board is very concerned that the FMCSA does not have a method to guarantee that passenger carriers whose authority has been revoked will be expeditiously identified and prevented from further unsafe operations or that they will cease operations. PRISM is a voluntary Federal–State partnership that makes safe performance a requirement for obtaining and keeping commercial vehicle registration. PRISM links FMCSA records on motor carrier safety with a State’s vehicle registration system. The DOT or motor carrier number of the carrier responsible for the vehicle’s safety is identified at the vehicle level, allowing the State to determine a carrier’s safety fitness before issuing license plates. The program monitors safety performance, and carriers prohibited by the FMCSA from operating in interstate commerce may not be allowed to register their vehicles. PRISM plays a key role in the FMCSA’s effort to remove high-risk carriers from highways; however, not all States participate in PRISM. The use of registration sanctions serves as an incentive for unsafe carriers to improve their safety performance. However, at the time of the accident, Illinois was not part of the PRISM program. Even if Illinois had participated in PRISM then, Leisure still would have been able to continue operating until the vehicle’s registration expired. In addition, under PRISM, if Leisure was not stopped for a roadside inspection and did not become a priority for an FMCSA compliance review, the FMCSA would not have identified it as an unsafe carrier. Without a process to verify that the operations of revoked passenger carriers have ceased, undetected inactive carriers can continue to provide unsafe service to the public and operate on the Nation’s highways without oversight. Other motor carriers can similarly circumvent the system, operating on revoked authority without the required amount of insurance and violating key safety regulations. Such motor carriers would not be identified unless one of their vehicles was either inspected at a “planned stop,” as dictated in the new SAFETEA-LU legislation, or involved in a fatal accident, a situation that allows commercial passenger buses to essentially travel unchecked. An agency whose mission is to ensure safe transportation must close this loophole, which undermines the effectiveness of Federal safety regulations. The FMCSA process of notifying the operator in violation of its revocation is only a first step in preventing unsafe carriers from continuing operation. Relying on the possibility of an inspection or involvement in a fatal accident to catch those carriers operating without authority is not sufficient as a safety net.

Analysis 61 Highway Accident Report The Safety Board concludes that the FMCSA’s process for revocation of operating authority is inadequate because, as this accident demonstrates, it fails to follow up and verify that the OOS carrier has ceased operations. The Safety Board believes that the FMCSA should establish a program to verify that motor carriers have ceased operations after the effective date of revocation of operating authority. The FMCSA indicates that it has begun a project to develop a more effective operational model for its enforcement and compliance activities, referred to as the CSA 2010 Initiative. However, full implementation of any changes in the safety rating process is not expected until 2010. The Safety Board is concerned that this long time frame jeopardizes the safety of the traveling public through unnecessary exposure to possibly unsafe commercial motor vehicles. Moreover, though FMCSA staff have indicated that the CSA 2010 Initiative is a top-to-bottom evaluation of the compliance review system, Safety Board staff have identified the separate issue of passenger carriers operating on revoked licenses as another problem area within the FMCSA’s oversight of commercial motor carriers. The Safety Board understands that all changes resulting from the FMCSA’s compliance review evaluation would be implemented by 2010, with proposed rulemaking notices issued in the time leading up to the effective date. However, the CSA 2010 Initiative was first announced almost 2 years ago, and the Board has received no information regarding the FMCSA’s plans to implement the initiative, nor is the Board aware of any public document outlining the specific steps the agency plans to take to accomplish the review and to implement changes. The Safety Board believes that waiting 4 more years for significant action to be taken to amend the troubled motor carrier compliance review system is unacceptable. Failing to expeditiously implement a program to verify that revoked passenger carriers do not continue to operate will continue to negatively affect the safety of the traveling public. Given the lengthy implementation process for the CSA 2010 Initiative and the uncertainty of results, the Safety Board fully expects that the FMCSA will not wait to develop a program based on the outcome of the CSA 2010 project, but will instead take action now to implement the Board’s recommendation for a followup program. Vehicle Incompatibility and Heavy Truck Aggressivity During the Hampshire–Marengo accident sequence, the Freightliner driver stated that he did not see the brake lights on the specialty bus, that the bus suddenly stopped in front of him, and that—though he braked—he was unable to avoid a collision with the rear of the bus. When the Freightliner tractor struck the rear of the specialty bus, it overrode the bus bumper and entered the passenger compartment because of differences in vehicle

Analysis 62 Highway Accident Report weights121 and structural stiffness and because of geometric mismatch. (See figure 24.) The differences in weight and stiffness and the geometric mismatch are often referred to as vehicle “aggressivity.” NHTSA’s Web page, “Heavy Vehicle Aggressivity Program,”122 last updated in June 2000, states that the common belief is that not much can be done to diminish the consequences of crashes between smaller vehicles and large trucks because of the significant differences in vehicle mass. However, research has shown that geometric height differences and a lack of forgiving front truck structures can be modified to help reduce heavy truck aggressivity and to mitigate the severity of these types of accidents.123,124,125 Examples of these modifications, often referred to as “front underride protection systems”—which can result in reduced intrusion or occupant injury—include energy-absorbing front structures to offset the weight differences between two impacting vehicles, as well as bumpers designed to deflect the impacted vehicle away from the front of the truck, thereby reducing the total change in velocity of the smaller vehicle. 121 Of the 10 passengers interviewed who provided estimates of their weight, the average weight was 144 pounds. The driver weighed about 200 pounds. The total weight of an exemplar bus (including driver) was 10,420 pounds. Combined with an average weight of 150 pounds for 20 passengers, the difference between the specialty bus weight of 13,420 pounds and the combination unit at 76,480 pounds was 63,060 pounds, or a ratio of about 6 to 1. 122 See , March 23, 2006. Figure 24. Freightliner and specialty bus bumper height comparison. 123 A. Berg, M. Krehl, L. Riebeck, and U. Breitling, “Passive Safety of Trucks in Frontal and Rear-End Collisions With Cars,” Proceedings, 18th International Technical Conference on Enhanced Safety of Vehicles, Nagoya, Japan (Washington, DC: NHTSA, 2003). 124 A. K. Prasad, R. M. Clarke, D. Willke, and M. Monk, Reducing Heavy Truck Aggressivity in Collisions With Passenger Cars, DOT HS 808 476 (Washington, DC: NHTSA, 1995). 125 K. Mendis, A. Mani, A. K. Prasad, D. Willke, M. Mond, and R. M. Clarke, “Concepts to Reduce Heavy Truck Aggressivity in Truck-to-Car Collisions, Proceedings, 15th International Technical Conference on Enhanced Safety of Vehicles, Melbourne, Australia (Washington, DC: NHTSA, 1996).

Analysis 63 Highway Accident Report In this accident, as a result of the heavy truck’s aggressivity, an almost 5-foot intrusion into the bus’s passenger compartment led to loss of survivable space for many passengers seated in the rear; seven of the eight passengers seated in the last three rows of the bus were fatally injured. Except for the ejected passenger seated in row 1, the passengers seated forward in the bus (in rows 1–3) sustained minor-to-serious injuries. In other words, the crash forces experienced by the passengers seated away from the intrusion area were mitigated by the crushing of the rear of the bus. The Safety Board concludes that the combination of the large weight difference (almost 6 to 1) between the Freightliner tractor-trailer and the specialty bus, the impact speed of the tractor-trailer into the specialty bus, the difference in stiffness between the tractor front end and the bus body, and the geometric mismatch during the dynamic collision led to the truck overriding the bus’s rear structure and resulted in extensive intrusion damage into the rear passenger compartment, a loss of survivable space in that area, and the deaths of seven passengers. Occupant protection requires that survivable space be maintained for all passengers, and that the interior structure provide sufficient support and energy absorption so that crash forces are survivable. Vehicles with high aggressivity, such as heavy trucks, often compromise the survivable space in the vehicles they hit. Currently, the United States does not have a requirement for front underride protection126 on heavy trucks. Europe began studying and testing such devices in 1994 and subsequently established regulations requiring these protection devices on heavy vehicles. Regulations of the Economic Commission for Europe (ECE) are in place for both front underride and rear underride protection (ECE-R 93 and ECE-R 58, respectively); the regulations provide standard specifications for the mount, dimensions, and static stability performance of these devices. In the United States, a 2004 study conducted by the NCHRP, entitled A Guide for Reducing Collisions Involving Heavy Trucks, noted that combination-unit trucks (usually tractor-semitrailers) were found to have a markedly different crash involvement profile than vehicles in general. According to the study, these vehicles have relatively low crash rates per mile traveled, but with much greater crash costs per year, and over their operational lives, more than four times higher than most other vehicle types. This means that from a cost-benefit standpoint, safety investments in tractor-trailers are likely to have much greater per-vehicle benefits than similar investments in other vehicle types.127 A 1998 NHTSA overview report on vehicle compatibility and light truck (light trucks and vans [LTV]128) issues stated that the number of LTVs has grown dramatically since the early 1980s. A 2003 study of vehicle mismatch and injury indicated that motor 126 A front underride protection system is an energy-absorbing structure on the front of a truck that reduces injuries to occupants in a vehicle struck by the front of the truck. 127 Transportation Research Board of the National Academies, National Cooperative Highway Research Program, Guidance for Implementation of the AASHTO Strategic Safety Plan, Volume 13: A Guide for Reducing Collisions Involving Heavy Trucks, NCHRP Report 500 (Washington, DC: TRB, 2004) III-3. 128 According to NHTSA, the LTV category consists of trucks of 10,000 pounds GVWR or less and includes pickups, vans, minivans, truck-based station wagons, and sport utility vehicles.

Analysis 64 Highway Accident Report vehicle registrations for the year 2000 showed 77.8 million light trucks in the United States, a 63.8 percent increase since 1990; LTVs now account for 40 percent of all registered motor vehicles. During the same 10-year period, the number of registered passenger vehicles increased by 1 percent.129 In addition to the increase in LTVs, the number of registered large trucks increased by 30 percent between 1993 and 2003, and miles traveled by large trucks increased 35 percent.130 If these trends continue, LTVs and large trucks will soon constitute the majority of vehicles on the road, resulting in even greater occurrences of vehicle incompatibility in accidents. In 2003, approximately 457,000 large trucks (GVWR exceeding 10,000 pounds) were involved in traffic accidents and accounted for 8 percent of vehicles involved in fatal accidents. These traffic accidents resulted in 4,669 fatalities and 122,000 injuries; 85 percent of those killed and 78 percent of those injured were the occupants of other vehicles (passenger cars and LTVs), pedestrians, or bicyclists.131 The initial point of impact for 62.8 percent of the fatal accidents involved the front of the truck.132 In accidents involving a large truck during 2004, some 4,006 occupants of passenger cars and LTVs were killed, and 85,000 such occupants were injured.133 According to the DOT, its goal is to reduce highway fatality rates from 1.46 persons per 100 million vehicle miles traveled (VMT) in 2004 to 1 person per 100 million VMT by 2008. The FMCSA’s goal is to reduce commercial motor vehicle-related fatalities from 2.3 per 100 million commercial motor VMT in 2004 to 1.65 per 100 million commercial motor VMT by 2008.134 Achieving these ambitious goals will clearly require a large reduction in fatalities resulting from accidents between large trucks and passenger vehicles. NHTSA has made some progress in testing and evaluating measures to reduce heavy truck aggressivity; however, the agency has published little recently to indicate continued testing or the intent to implement changes in the industry. The Safety Board recognizes that NHTSA has discussed the need to reduce fatalities resulting from large truck accidents and has stated that research and implementation of ITS technologies for accident avoidance is a priority. But the agency has not included large truck incompatibility among its priorities for rulemaking or research support for calendar years 2005–2009. The 21st Century Truck Program, of which the DOT is a partner, announced in its “roadmap” in December 2000 the goal to improve truck safety by fostering advancements in vehicle design and performance, such as reducing truck frontal aggressivity in multivehicle collisions. However, the milestone set for completing laboratory tests and 129 Acierno, “Vehicle Mismatch: Injury Patterns and Severity,” 761. 130 See , March 28, 2006. 131 See , March 23, 2006. 132 See , March 28, 2006. 133 A total of 761 truck occupants were killed, and about 27,000 were injured. See , March 28, 2006. 134 See (a) , March 23, 2006. (b) , March 23, 2006.

Analysis 65 Highway Accident Report field trials of systems designed to reduce the destructive effects of truck accidents is not until midyear 2009. The incompatibility of large trucks with passenger cars is not a new issue, and the Europeans have been doing work in this area since at least 1994. In keeping with the DOT’s own goals to reduce fatalities resulting from large truck accidents and the 21st Century Truck Program’s goal to foster advancements in vehicle design and reduction of truck frontal aggressivity, both the department and the truck program need to increase their investments in truck design initiatives that could ameliorate the severity of collisions with large trucks. The Safety Board therefore concludes that although NHTSA has acknowledged the seriousness of the vehicle incompatibility problem in contributing to the severity of traffic accidents, it has not allocated adequate resources to that issue as it affects heavy trucks, a major cause of death for occupants in both passenger cars and LTVs. Therefore, the Safety Board believes that the DOT should include heavy vehicles in its research, testing, and eventual rulemaking on highway vehicle incompatibility, especially as that incompatibility affects the severity of accidents. In addition, the Safety Board believes that the DOE should report to the Safety Board the 21st Century Truck Program’s plans and timetable for prioritizing research, testing, and design enhancements that address heavy truck aggressivity.

66 Highway Accident Report Conclusions Findings 1. The weather; the mechanical condition of the specialty bus, pickup truck, Ford tractor-box trailer, and Kenworth tractor-tank trailer; and the design and condition of the roadway did not cause or contribute to the accident. 2. Neither the Freightliner driver nor the specialty bus driver was adversely affected by medications, medical conditions, or fatigue; and the emergency response was timely and effective. 3. Brake force calculations, together with the physical evidence on scene, indicate that the Freightliner’s out-of-adjustment brakes did not contribute to the accident. 4. The Freightliner driver had ample cues indicating that he needed to allow more space between his heavy vehicle and those ahead, and his failure to maintain adequate following distance and to reduce the speed of his vehicle relative to the slowing traffic ahead contributed to this accident. 5. The Freightliner driver did not detect the slowing traffic ahead of his vehicle, and had the Freightliner truck been equipped with a collision warning system designed to detect this type of situation and alert drivers, that technology might have prevented this accident. 6. Traditional toll plazas, such as the Hampshire–Marengo toll plaza (as configured on the day of the accident), create traffic backups that present a safety hazard; the conversion of traditional plazas to electronic toll collection systems should greatly reduce such hazards and improve safety on toll roads. 7. By requiring intermodal equipment owners to obtain a U.S. Department of Transportation number and adhere to the Federal Motor Carrier Safety Regulations, the new rulemaking required by the Safe, Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for Users will help close the gap in the Federal Motor Carrier Safety Administration’s oversight of intermodal equipment, such as that involved in this accident, and improve freight transportation safety. 8. The Federal Motor Carrier Safety Administration’s process for revocation of operating authority is inadequate because, as this accident demonstrates, it fails to follow up and verify that the out-of-service carrier has ceased operations.

Conclusions 67 Highway Accident Report 9. The combination of the large weight difference (almost 6 to 1) between the Freightliner tractor-trailer and the specialty bus, the impact speed of the tractor-trailer into the specialty bus, the difference in stiffness between the tractor front end and the bus body, and the geometric mismatch during the dynamic collision led to the truck overriding the bus’s rear structure and resulted in extensive intrusion damage into the rear passenger compartment, a loss of survivable space in that area, and the deaths of seven passengers.

1. Although the National Highway Traffic Safety Administration has acknowledged the

seriousness of the vehicle incompatibility problem in contributing to the severity of traffic accidents, it has not allocated adequate resources to that issue as it affects heavy trucks, a major cause of death for occupants in both passenger cars and light trucks and vans. Probable Cause The National Transportation Safety Board determines that the probable cause of the accident was the failure of the Freightliner truck driver, who was operating his vehicle too fast for traffic conditions, to slow for traffic. Contributing to the accident was the traffic backup in a 45-mph zone, created by vehicles stopping for the Hampshire–Marengo toll plaza. The structural incompatibility between the Freightliner tractor-trailer and the specialty bus contributed to the severity of the accident.

68 Highway Accident Report Recommendations As a result of its investigation, the National Transportation Safety Board makes the following safety recommendations: New Recommendations To the U.S. Department of Energy: Report to the National Transportation Safety Board the 21st Century Truck Program’s plans and timetable for prioritizing research, testing, and design enhancements that address heavy truck aggressivity. (H-06-15) To the U.S. Department of Transportation: Include heavy vehicles in your research, testing, and eventual rulemaking on highway vehicle incompatibility, especially as that incompatibility affects the severity of accidents. (H-06-16) To the Federal Motor Carrier Safety Administration: Establish a program to verify that motor carriers have ceased operations after the effective date of revocation of operating authority. (H-06-17) To the Federal Highway Administration: Cooperate with the American Association of State Highway and Transportation Officials and the International Bridge, Tunnel and Turnpike Association to develop written guidelines on toll plaza design that provide information on current tolling practices, electronic toll collection strategies, and other equipment designed to eliminate queuing at toll plazas and to improve toll road safety. (H-06-18) To the American Association of State Highway and Transportation Officials: Cooperate with the Federal Highway Administration and the International Bridge, Tunnel and Turnpike Association to develop written guidelines on toll plaza design that provide information on current tolling practices, electronic toll collection strategies, and other equipment designed to eliminate queuing at toll plazas and to improve toll road safety. (H-06-19)

Recommendations 69 Highway Accident Report Include the information from the written guidelines on toll plaza design in the next update of A Policy on Geometric Design of Highways and Streets (Green Book). (H-06-20) To the International Bridge, Tunnel and Turnpike Association: Cooperate with the Federal Highway Administration and the American Association of State Highway and Transportation Officials to develop written guidelines on toll plaza design that provide information on current tolling practices, electronic toll collection strategies, and other equipment designed to eliminate queuing at toll plazas and to improve toll road safety. (H-06-21) Reiterated Recommendations The National Transportation Safety Board also reiterates the following recommendations: To the National Highway Traffic Safety Administration: Complete rulemaking on adaptive cruise control and collision warning system performance standards for new commercial vehicles. At a minimum, these standards should address obstacle detection distance, timing of alerts, and human factors guidelines, such as the mode and type of warning. (H-01-6) After promulgating performance standards for collision warning systems for commercial vehicles, require that all new commercial vehicles be equipped with a collision warning system. (H-01-7) BY THE NATIONAL TRANSPORTATION SAFETY BOARD MARK V. ROSENKER ELLEN ENGLEMAN CONNERS Acting Chairman Member DEBORAH A. P. HERSMAN Member KATHRYN O’LEARY HIGGINS Member Adopted: April 18, 2006

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71 Highway Accident Report Appendix A Investigation The National Transportation Safety Board was notified of the Hampshire, Illinois, accident on October 1, 2003. An investigative team was dispatched with members from the Washington, D.C.; Atlanta, Georgia; and Arlington, Texas, offices. Groups were established to investigate human performance; motor carrier operations; and highway, vehicle, and survival factors. Participating in the investigation were representatives of the Federal Motor Carrier Safety Administration; the Federal Highway Administration; the Illinois State Police; the Illinois State Toll Highway Authority; the International Bridge, Tunnel and Turnpike Association; Leisure Pursuit Charters, Inc.; Frontline Transportation Company; Ford Motor Company; Goshen Coach Division of McCoy Miller, Inc.; and the Hampshire Fire Department. No public hearing was held; no depositions were taken.

72 Highway Accident Report Appendix B Freightliner Combination Vehicle Information Freightliner FLD tractor Manufacturer: Freightliner Corporation Model: FLD 120064S T Date of manufacture: August 1994 Gross vehicle weight rating: 46,000 pounds (lbs) Gross axle weight rating: 12,000 lbs (steer axle) Gross axle weight rating: 16,000 lbs (rear axles, each) Curb weight: 16,160 lbs (8,609 lbs front, 7,551 lbs rear) Unsprung tractor weight: 5,000 lbs (total, approximate) Theurer trailer chassis Manufacturer: Theurer Inc. (Subsidiary Kiddie, Inc.) Model: 220-CC-40GN Date of manufacture: September 1984 Gross vehicle weight rating: 72,715 lbs Gross axle weight rating: 19,040 lbs (tandem axles, each) Tare weight: 16,500 lbs Curb eight: 16,160 lbs (8,609 lbs front, 7,551 lbs rear) Overall length, width 40.7 feet (ft), 8.0 ft Overall height driver side: 48.0 inches (in) (from ground) Overall height right side: 44.5 in (from ground) Cargo container Manufacturer: Yangzhou Tangyun Container Co., LTD. Type: TYC-112B Date of manufacture: October 2002 Maximum gross weight: 67,200 lbs Tare weight: 8,780 lbs

Appendix B 73 Highway Accident Report Payload: 58,420 lbs Allowable stack weight: 476,200 lbs Exterior length, height, width 40.0 ft, 9.5 ft, 8.0 ft On October 1, 2003, the Illinois State Police weighed the Freightliner tractor- trailer using in-ground scales at Arrowhead Shell in Hampshire, Illinois. The steer axle weighed 9,280 pounds, the second and third axles weighed 38,780 pounds, and the fourth and fifth axles weighed 28,420 pounds—for a total vehicle weight of 76,480 pounds.

74 Highway Accident Report Appendix C SDM Data Sensing Diagnostic Module The 2000 Chevrolet Silverado 1500 extended cab pickup truck was equipped with an advanced frontal occupant protection system, which incorporated manual three-point safety belts, along with a driver and passenger supplemental restraint system, which consisted of frontal air bags at both the driver and passenger positions. Under such a system, crash detection, as well as air bag deployment, is managed by an electronic control module identified as a sensing diagnostic module (SDM) by the General Motors Corporation. The primary purpose of the SDM is to “sense” an impending crash event and to determine when and if air bag deployment is warranted. The SDM does not sense a rear-end collision as a crash event. Rather, a crash event is sensed when the vehicle rapidly decreases speed, experiencing a rearward (negative) change in velocity (delta-v). In addition to its primary function, the accident SDM was equipped with nonvolatile electronically erasable programmable read-only memory (EEPROM) used to preserve critical operating data, including precrash data, crash severity data, and air bag deployment, as well as diagnostic trouble codes. According to the SDM, the pickup truck was traveling 3 mph for at least 3 seconds. It was then most likely struck from behind by the specialty bus, which had accelerated to about 40 mph from the first rear-end crash. This rear impact into the pickup truck caused it to increase speed. The pickup truck was then forced into the rear of the Ford tractor-box trailer. The SDM quite likely sensed the crash event from this rear impact, activated the driver’s air bag, and recorded a maximum rearward (negative) delta-v of 13.77 mph. The actual delta-v may have been higher than this value because the SDM may not have recorded the entire crash pulse. The information retrieved from the accident vehicle’s SDM revealed 5 seconds of precrash data. The SDM receives various data, including precrash parameters, from the vehicle’s class II communications bus1 asynchronously2 at 1-second intervals. Because the data are asynchronous, the actual time interval has been determined to vary +/–0.02 second, providing an interval closer to about every 0.8 to 1.2 seconds. Vehicle speeds that fall within these precrash data intervals are not recorded and therefore are unavailable. By design, the precrash data obtained from the accident represent the time before the algorithm enable (AE) occurs. Table C-1 summarizes precrash data from the accident SDM for vehicle speed and engine speed. 1 A communications bus is a network arrangement in which all devices are directly attached, and all data pass through each of the devices; each device has a unique identity and can recognize those signals intended for it. 2 “Asynchronous” pertains to a transmission technique that does not require a common clock between the communicating devices; timing signals are derived from special characters in the data stream itself.

Appendix C 75 Highway Accident Report As shown in the table, the data retrieved from the SDM indicated that at 5, 4, 3, and 2 seconds before AE, the pickup truck’s operational information showed the vehicle traveling 3 mph.3 The data further indicate that, about 1 second prior to AE, the vehicle slowed to 1 mph and the engine speed was reported as 0 rpm.4 Other SDM data showed a recorded crash pulse indicating that the pickup truck experienced a maximum recorded rearward (negative) deceleration delta-v of at least 13.77 mph within the recorded data. Table C-1. Partial list of SDM-derived precrash data from Chevrolet pickup truck. According to information obtained by the Safety Board during the investigation, the type of SDM on the pickup truck records only a rearward (negative) delta-v. It would not have recorded an impact to the rear of the vehicle that resulted in a vehicle forward (positive) delta-v. Because the SDM does not record forward delta-v, the pickup truck was most likely struck from behind prior to experiencing AE without the SDM detecting the collision. For example, the specialty bus could have struck the pickup truck between 0.0 and 1.0 second prior to AE. Because the SDM records only whole-second increments before AE, it would not have detected the speed change as a result of such a collision. As shown in table C-1, the SDM data indicate that the vehicle’s speed dropped to 1 mph and the engine rpm dropped to 0 approximately 1.0 second prior to AE. At this point in the precrash data, the time prior to AE is very possibly between 0.001 and 0.999 second—not 1.0 second. AE is generally located at a value less than 1.0 second and more than 0.999 second. Safety Board investigators examined the SDM data, along with other evidence. They applied the reported SDM data to the known accident circumstances and found that, most likely, just prior to being struck from behind by the specialty bus, the pickup truck was in the process of slowing to a stop and was traveling 3 mph for a least 3.0 seconds. This time frame is represented within the SDM precrash data as –5 through –2 seconds. 3 These data are intended to represent the forward, or longitudinal, speed of the vehicle. 4 The SDM receives speed data from the vehicle’s power train control module, which calculates road speed. Seconds before AEA Vehicle speed (mph) Engine speed (rpm) –5 3 640 –4 3 512 –3 3 512 –2 3 512 –1 1 0 A Algorithm enable (AE), or “wake-up,” refers to negative acceleration (about –1 to –2 g’s over two consecutive samples) observed by the air bag’s control module microcomputer. A negative acceleration results in a decrease in the vehicle’s speed. The module then begins running the “algorithm,” leading to the deployment decision.

Appendix C 76 Highway Accident Report (See table C-1.) At this point (somewhere between –2 and –1 seconds), the pickup truck was struck from behind, pushing it into the rear of the vehicle in front of it, resulting in a rearward (negative) change in velocity (negative acceleration). If this occurred, the pickup truck would have traveled at 3 mph for approximately 3.0 seconds and then, approximately 0.999 to 0.001 second later, undergone a rearward acceleration that resulted in a recorded delta-v of at least 13.77 mph. Because of data rebuffering,5 the SDM “precrash” data reported at –1 second to AE is believed to have occurred “after” AE and, therefore, the reported data would have occurred after initial impact and during vehicle engagement. In the simulations described in this report, the pickup truck is traveling 3 mph prior to AE; however, even if the SDM reported vehicle speed at –1 second, of the 1 mph that occurred prior to AE, this reduction in speed would not significantly affect the simulation results. Safety Board investigators obtained no physical evidence to indicate that the reported SDM data were erroneous or invalid. Air Bag Deployment According to the SDM data, the pickup truck underwent a rearward delta-v as a result of the collision that caused the air bag to deploy. Based on the physical evidence documented from the accident scene and the Safety Board’s simulations, only two of the collisions that occurred during this multivehicle accident would have resulted in a rearward delta-v and decelerations:

1. When the specialty bus pushed the pickup truck forward into the rear of the

Ford tractor-box trailer, and

1. When the Kenworth tractor-tank trailer subsequently struck the pickup truck,

causing it to move forward again and strike the Ford tractor-box trailer in a secondary collision. The other collision occurred when the pickup truck was struck from behind by the specialty bus, following the Freightliner’s collision with the bus. This collision caused the pickup truck to accelerate forward, increasing its speed, and did not cause the rearward deceleration and change in velocity needed to deploy the air bag. 5 The accident SDM was identified as belonging to a family of modules in which some precrash data may actually be recorded after, rather than before, AE. This potential for anomalous precrash data is caused by a phenomenon known as “data rebuffering,” which may result in some precrash data being recorded after AE.

77 Highway Accident Report Appendix D State Toll Facilities Table 12. States with and without toll facilities.A With 1 toll facility More than 1 toll facility No toll facilities Alaska California Alabama Arkansas Colorado Arizona Kansas Delaware Connecticut Kentucky Florida Hawaii Maine Georgia Idaho Missouri Illinois Iowa Nevada Indiana Minnesota New Hampshire Louisiana Mississippi Ohio Maryland Montana Oklahoma Massachusetts New Mexico Rhode Island Michigan North Carolina South Carolina Nebraska North Dakota New Jersey South Dakota New York Tennessee Oregon Utah Pennsylvania Vermont Texas Washington Virginia Wisconsin West Virginia Wyoming SOURCE: U.S. Department of Transportation, Federal Highway Administration, Highway Statistics, 2003 (Washington, DC: FHWA, 2004). A “Toll facilities” exclude ferry facilities. Table D-1.

78 Highway Accident Report Appendix E SAFETEA-LU 2005 The following language is a verbatim excerpt from the Safe, Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for Users, signed into law on August 10, 2005: SEC. 4106 MOTOR CARRIER SAFETY GRANTS (a) State Plan Contents. Section 31102(b)(1) of title 49, United States Code, is amended– (7) By adding at the end the following: “(X) except in the case of an imminent or obvious safety hazard, ensures that an inspection of a vehicle transporting passengers for a motor carrier of passengers is conducted at a station, terminal, border crossing, maintenance facility, destination, or other location where a motor carrier may make a planned stop.” SEC. 4118 ROADABILITY (a) In General. Subchapter III of chapter 311 of title 49, United States Code (as amended by sections 4116 and 4117 of this Act) is amended by adding at the end of the following: § 31151. Roadability (b) Inspection, Repair, and Maintenance of Intermodal Equipment. (1) In General. Not later than 1 year after the date of enactment of this section, the Secretary of Transportation, after providing notice and opportunity for comment, shall issue regulations establishing a program to ensure that intermodal equipment used to transport intermodal containers is safe and systemically maintained. (2) Intermodal Equipment Safety Regulations. The Secretary shall issue the regulations under this section as a subpart of the Federal motor carrier safety regulations. (3) Contents. The regulations issued under this section shall include, at a minimum– (A) a requirement to identify intermodal equipment providers responsible for the inspection and maintenance of intermodal equipment

Appendix E 79 Highway Accident Report that is interchanged or intended for interchange to motor carriers in intermodal transportation; (B) a requirement to match intermodal equipment readily to an intermodal equipment provider through a unique identifying number; (C) a requirement that an intermodal equipment provider identified under subparagraph (A) systemically inspect, repair, and maintain, or cause to be systemically inspected, repaired, and maintained, intermodal equipment described in subparagraph (A) that is intended for interchange with a motor carrier; (D) a requirement to ensure that each intermodal equipment provider identified under subparagraph (A) maintains a system of maintenance and repair records for such equipment; (E) requirements that– (i) a specific list of intermodal equipment components or items be identified for the visual or audible inspection of which a driver is responsible before operating the equipment over the road; and (ii) the inspection under clause (i) be conducted as part of the Federal requirement in effect on the date of enactment of this Act that a driver be satisfied that the intermodal equipment components are in good working order before the equipment is operated over the road; (F) a requirement that a facility at which an intermodal equipment provider regularly makes intermodal equipment available for interchange have an operational process and space readily available for a motor carrier to have an equipment defect identified pursuant to subparagraph (E) repaired or the equipment replaced prior to departure; (G) a program for the evaluation and audit of compliance by intermodal equipment providers with applicable Federal motor carrier safety regulations; (H) a civil penalty structure consistent with section 521(b) of title 49, United States Code, for intermodal equipment providers that fail to attain satisfactory compliance with applicable Federal motor carrier safety regulations; and (I) a prohibition on intermodal equipment providers from placing intermodal equipment in service on the public highways to the extent such providers or their equipment are found to pose an imminent hazard;

Appendix E 80 Highway Accident Report (J) a process by which motor carriers and agents of motor carriers shall be able to request the Federal Motor Carrier Safety Administration to undertake an investigation of an intermodal equipment provider identified under subparagraph (A) that is alleged to be not in compliance with the regulations under this section; (K) a process by which equipment providers and agents of equipment providers shall be able to request the Administration to undertake an investigation of a motor carrier that is alleged to be not in compliance with the regulations issued under this section (L) a process by which a driver or motor carrier transporting intermodal equipment is required to report to the intermodal equipment provider or the provider’s designated agent any actual damage or defect in the intermodal equipment of which the driver or motor carrier is aware at the time the intermodal equipment is returned to the intermodal equipment provider or the provider’s designated agent; (M) a requirement that any actual damage or defect identified in the process established under subparagraph (L) be repaired before the equipment is made available for interchange to a motor carrier and that repairs of this equipment made pursuant to the requirements of this subparagraph and reports made pursuant to this subparagraph (L) process be documented in the maintenance records for such equipment; and (N) a procedure under which motor carriers, drivers and intermodal equipment providers may seek correction of their motor carrier safety records through the deletion from those records of violations of safety regulations attributable to deficiencies in the intermodal chassis or trailer for which they should not have been held responsible. (4) Deadline for Rulemaking Proceeding. Not later than 120 days after the date of enactment of this section, the Secretary shall initiate a rulemaking proceeding for issuance of the regulations under this section. (c) Inspection, Repair, and Maintenance of Intermodal Equipment. The Secretary or an employee of the Department of Transportation designated by the Secretary may inspect intermodal equipment, and copy related maintenance and repair records for such equipment, on demand and display of proper credentials. (d) Out-Of-Service Until Repair. Any intermodal equipment that is determined under this section to fail to comply with applicable Federal safety regulations may be placed out of service by the Secretary or a Federal, State, or government official designated by the Secretary and may not be used on a public highway until the repairs necessary to bring such equipment into compliance have been completed. Repairs of equipment taken out of service shall be documented in the maintenance records for such equipment.

Appendix E 81 Highway Accident Report (e) Preemption Generally. Except as provided in subsection (e), a law, regulation, order, or other requirement of a State, a political subdivision of a State, or a tribal organization relating to commercial motor vehicle safety is preempted if such law, regulation, order, or other requirement exceeds or is inconsistent with a requirement imposed under or pursuant to this section. (f) Pre-Existing State Requirements. (1) In General. Except as provided in paragraph (2), a State requirement for the periodic inspection of intermodal chassis by intermodal equipment providers that was in effect on January 1, 2005, shall remain in effect only until the date which requirements prescribed under this section take effect. (2) Nonpreemption Determinations. (A) In General. Notwithstanding subsection (d), a State requirement described in paragraph (1) is not preempted by a Federal requirement prescribed under this section if the Secretary determines that the State requirement is as effective as the Federal requirement and does not unduly burden interstate commerce. (B) Application Required. Subparagraph (A) applies to a State requirement only if the State applies to the Secretary for a determination under this paragraph with respect to the requirement before the date on which the regulations issued under this section take effect. The Secretary shall make a determination with respect to any such application within 6 months after the date on which the Secretary receives the application. (C) Amended State Requirements. Any amendment to a State requirement not preempted under this subsection because of a determination by the Secretary under subparagraph (A) may not take effect unless– (i) it is submitted to the Secretary before the effective date of the amendment; and (ii) the Secretary determines that the amendment would not cause the State requirement to be less effective than the Federal requirement and would not unduly burden interstate commerce. (g) Definitions. In this section the following definitions apply: (1) Intermodal Equipment. The term “intermodal equipment” means trailing equipment that is used on the intermodal transportation of containers over public highways in interstate commerce, including trailers and chassis.

Appendix E 82 Highway Accident Report (2) Intermodal Equipment Interchange Agreement. The term “intermodal equipment interchange agreement” means the Uniform Intermodal Interchange and Facilities Access Agreement or any other written document executed by an intermodal equipment provider or its agency and a motor carrier or its agent, the primary purpose of which is to establish the responsibilities and liabilities of both parties with respect to the interchange of the intermodal equipment. (3) Intermodal Equipment Provider. The term “intermodal equipment provider” means any person that interchanges intermodal equipment with a motor carrier pursuant to a written interchange agreement or has a contractual responsibility for the maintenance of the intermodal equipment. (4) Interchange. The term “interchange” (A) means the act of providing intermodal equipment to a motor carrier pursuant to an intermodal equipment interchange agreement for the purpose of transporting the equipment for loading or unloading by any person or repositioning the equipment for the benefit of the equipment provider; but (B) does not include the leasing of equipment to a motor carrier for primary use in the motor carrier’s freight hauling operations. (b) Clerical Amendment. The analysis for such subchapter (as amended by sections 4116 and 4117 of this Act) is amended by adding at the end the following: “31151. Roadability.” SEC. 1403 TOLL FACILITIES WORKPLACE SAFETY STUDY (a) In General. The Secretary shall conduct a study on the safety of highway toll collection facilities, including toll booths, to determine the safety of the facilities for the toll collectors who work in and around the facilities, including consideration of- (1) the effect of design or construction of the facilities on the likelihood of vehicle collisions with the facilities; (2) the safety of crosswalks used by toll collectors in transit to and from toll booths; (3) the extent of the enforcement of speed limits in the vicinity of the facilities; (4) the use of warning devices, such as vibration and rumble strips to alert drivers approaching the facilities;

Appendix E 83 Highway Accident Report (5) the use of cameras to record traffic violations in the vicinity of the facilities; (6) the use of traffic control arms in the vicinity of the facilities; (7) law enforcement practices and jurisdictional issues that affect safety in the vicinity of the facilities; and (8) the incidence of accidents and injuries in the vicinity of toll booths. (b) Data Collection. As part of the study, the Secretary shall collect data regarding the incidence of accidents and injuries in the vicinity of highway toll collection facilities. (c) Report. Not later than 1 year after the date of enactment of this Act, the Secretary shall submit to the Committee on Transportation and Infrastructure of the House of Representatives and the Committee on Environment and Public Works of the Senate a report on the results of the study, together with recommendations for improving toll facilities workplace safety. (d) Funding. (1) Authorization of Appropriations. There is authorized to be appropriated to carry out this section, out of the Highway Trust Fund (other than the Mass Transit Account), $500,000 for fiscal year 2006. (2) Contract Authority. Funds authorized to be appropriated by this section shall be available for obligation in the same manner and to the same extent as if the funds were apportioned under chapter 1 of title 23, United States Code, except that the Federal share of the cost of the project shall be 100 percent, and the funds shall remain available until expended and shall not be transferable.

84 Highway Accident Report Appendix F Illinois Vehicle Code, Intermodal Equipment Exchange The following language is a verbatim excerpt from the Illinois Vehicle Code, P.A. 91-622, effective July 1, 2000: 625 ILCS 5/18b-112 Sec. 18b-112. Intermodal trailer, chassis, and safety. (a) Definitions. For purposes of this Section: “Department” means the Department of State Police. “Equipment interchange agreement” means a written document executed by the intermodal equipment provider and operator at the time the equipment is interchanged by the provider to the operator. “Equipment provider” is the owner of the intermodal trailer, chassis, or container. This includes any forwarding company, water carrier, steamship line, railroad, vehicle equipment leasing company, and their subsidiary or affiliated companies, owning the equipment. “Federal motor carrier safety regulations” means regulations promulgated by the United States Department of Transportation governing the condition and maintenance of commercial motor vehicles contained in Title 49 of the United States Code of Federal Regulations on the day of enactment of this Act or as amended or revised by the United States Department of Transportation thereafter. “Interchange [means] the act of providing a vehicle to a motor carrier by an equipment provider for the purpose of transporting the vehicle for loading or unloading by another party or the reposition of the vehicle for the benefit of the equipment provider. “Interchange” does not include the leasing of the vehicle by a motor carrier from an owner-operator pursuant to subpart B of Part 376 of Title 49 of the Code of Federal Regulations or the leasing of a vehicle to a motor carrier for use in the motor carrier’s over-the-road freight hauling operation. “Operator” means a motor carrier or driver of a commercial motor vehicle. “Vehicle” means an intermodal trailer, chassis, or container. (b) Responsibility of equipment provider. An equipment provider shall not interchange or offer for interchange a vehicle with an operator for use on a highway which vehicle is in violation of the requirements contained in the federal motor carrier safety regulations. It is

Appendix F 85 Highway Accident Report the responsibility of the equipment provider to inspect and, if a vehicle at the time of inspection does not comply with all federal motor carrier safety regulation requirements, perform the necessary repairs on, all vehicles prior to interchange or offering for interchange. (c) Duty of inspection by the operator. Before interchanging a vehicle with an operator, an equipment provider must provide the operator the opportunity and facilities to perform a visual inspection of the equipment. The operator must determine if it complies with the provisions of the federal motor carrier safety regulation capable of being determined from an inspection. If the operator determines that the vehicle does not comply with the provisions of the federal motor carrier safety regulations, the equipment provider shall immediately perform the necessary repairs to the vehicle [so] that [it] complies with the federal motor carrier safety regulations or shall immediately provide the operator with another vehicle. . . . (e) Fines and penalties. Any person violating the provisions of this Section shall be fined no less than $50 and not more than $500 for each violation. (f) Obligation of motor carrier. Nothing in this Section is intended to eliminate the responsibility and obligation of a motor carrier and operator to maintain and operate vehicles in accordance with the Federal Motor Carrier Safety Regulations and applicable State and local laws and regulations. (g) This Section shall not be applied, construed, or implemented in any manner inconsistent with, or in conflict with, any provision of the Federal Motor Carrier Safety Regulations.

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FD07320 ｜ 2006_美国_MAB2006.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2006 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

1 NTSB/MAB-20/06

National Transportation Safety Board Marine Accident Brief Collision Between Miss Dixie Tow and D.& R. Boney Tow Accident type Collision No. DCA19FM017 Vessel names Miss Dixie, D.& R. Boney, and barges AEP 7235, 005024, 005028, 005492, and 005495 Location Lower Mississippi River, Mile 104, New Orleans, Louisiana 29°56.91’ N, 90°8.44’ W Date February 13, 2019 Time 1917 central standard time (coordinated universal time – 6 hours) Injuries None Property damage $294,530 for barges AEP 7235, 005024, 005028, 005495 Environmental damage None Weather Visibility 15 miles, clear, winds from the south at 5 miles per hour (mph), air temperature 51°F Waterway information Carrollton Bend at mile 104 near Nine Mile Point in the Lower Mississippi River, approximately 2 miles downriver from Huey P. Long Bridge.1 Current estimated at 4–5 mph. The Carrollton river gage was 13.6 feet. At 1917 local time on February 13, 2019, the towing vessel Miss Dixie was transiting downbound with a crew of four and pushing five barges on the Lower Mississippi River near New Orleans, Louisiana, when it collided with the upbound towing vessel D.& R. Boney, which was pushing nine barges. Several barges broke loose from their tows and were subsequently gathered up by the crews of the towing vessels. No injuries or pollution were reported. The cost of damages to four barges was $294,530.

The towing vessel Miss Dixie docked in New Orleans after the accident.

1 Unless otherwise noted, all miles in this report are statute miles.

Collision Between Miss Dixie Tow and D.& R. Boney Tow

2 NTSB/MAB-20/06

Location of the collision between the tows of Miss Dixie and D.& R. Boney. (Background source: Google Maps) Background The Miss Dixie, a twin-propeller towboat built in 1961, was owned by several companies before being acquired by JRC Marine in 2018. The vessel was equipped with two 1,200- horsepower diesel engines. The D.& R. Boney was a twin-propeller towboat built in 1976 that was owned and operated by several companies before being purchased by American Commercial Barge Lines in 2015. The vessel was equipped with two 2,800-horsepower diesel engines. Accident Events On February 13, the Miss Dixie, with a crew of four consisting of a captain, a relief captain, and two deckhands, departed Baton Rouge, Louisiana, on the Lower Mississippi River, en route to New Orleans to deliver five barges loaded with crushed rock. The tow was three barges long on the port side and two barges long on the starboard side. The D.& R. Boney, with a crew of eight, departed a fleeting area near Poydras, Louisiana, at mile 82 and was proceeding northbound with nine barges loaded with fertilizer, aluminum bars, and diesel fuel, en route to a facility near Harahan, Louisiana, at mile 107, to offload the barges. The tow was five barges long on the port side and four long on the starboard side.

Collision Between Miss Dixie Tow and D.& R. Boney Tow

3 NTSB/MAB-20/06

Simplified towing arrangements of the Miss Dixie and the D.& R. Boney on the evening of the accident (not to scale). Initially, the Miss Dixie’s downbound transit proceeded as expected; no issues with any machinery or equipment were reported. The captain came on watch at 1800, and the vessel continued down the river, meeting and passing several vessels and maneuvering through several turns. The captain was in communication with other vessels via VHF radio to make meeting and passing arrangements. He stated that in this area, it was “standard procedure” to meet “on the 2 whistles,” meaning that the vessels would pass each other starboard side to starboard side. On the day of the accident, the captain of the Miss Dixie estimated that the following current was running about 4–5 miles per hour (mph), which the captain considered normal, and that the southerly winds were light, about 5 mph. The river gage was 13.6 feet on the day of the accident, which the captain considered normal height for this time of year.

Location of the Miss Dixie, D.& R. Boney, and Mary Parker at 1900 and approximate tracklines of the Miss Dixie and the D.& R. Boney, with the accident location marked with a red triangle. (Source: US Coast Guard Vessel Traffic Service [VTS])

Collision Between Miss Dixie Tow and D.& R. Boney Tow

4 NTSB/MAB-20/06 At 1902, the Miss Dixie passed under the Huey Long Bridge at 10 mph. About 1912, the vessel was maneuvering around a sharp turn between mile 105 and 104, near Nine Mile Point, where the current created an eddy around the bend, which pushed the bow of the Miss Dixie’s tow to the starboard side, and the vessel’s speed dropped to about 6 mph. The D.& R. Boney’s captain described the eddy as a “whirlpool in the water caused by water wrapping around a point in the river” that would “really affect your maneuvering.” The Miss Dixie was lined up to meet two northbound tows: the Mary Parker and the D.& R. Boney. The Miss Dixie’s captain had arranged to meet the Mary Parker starboard to starboard but had not communicated with the D.& R. Boney. At 1915, after passing the Mary Parker near mile 104, the Miss Dixie’s captain noticed that the vessel was not responding to his steering and propulsion commands and he was unable to execute the sharp turn as expected. About this time, a deckhand saw smoke in the engine room and reported that there was a fire in the engine room in the area of the port clutch. The captain rang the general alarm, contacted the D.& R. Boney, and requested to meet the upbound vessel on “the one whistle,” meaning that the vessels would pass each other port side to port side. The captain of the D.& R. Boney repeated the request and said, “it don’t look good for that,” and, “I sure wish you’d go for the two, but all right, I’ll shoot her over.” Five seconds later, the D.& R. Boney’s captain said that he was going to stop his vessel because the vessels would collide if they attempted to meet port side to port side. Fifteen seconds later, the D.& R. Boney’s captain took evasive action and broadcasted that he was “backing like hell” (meaning his engines were at maximum astern). About this time, the deckhands aboard the Miss Dixie returned to the engine room with a fire extinguisher and searched for the source of the fire. After finding no flames, the deckhands ventilated the space to clear the smoke by opening the engine room doors and then vacated the space. None of the crew reported hearing any fire or smoke alarms during the incident.

Location of the Miss Dixie and D.& R. Boney at 1914:30. (Coast Guard VTS) At 1917, the captain of the Miss Dixie broadcasted over VHF radio that he had “lost an engine,” and about 30 seconds afterwards, the lead barge in the Miss Dixie’s tow collided with the lead barge of the D.& R. Boney’s tow, bringing the tows to a stop, breaking securing wires, and releasing several barges adrift into the river. Shortly afterwards, the Miss Dixie’s captain

Collision Between Miss Dixie Tow and D.& R. Boney Tow

5 NTSB/MAB-20/06 announced over VHF that there was a fire in the engine room. Immediately after the collision, the Coast Guard VTS contacted nearby vessels to assist and subsequently closed the river at 1922 between miles 101 and 106. Shortly afterwards, the deckhand reported to the captain that there was no fire in the engine room, and the port clutch had “burned up.”

Left: The AEP 7235 laying across the 005492 after the collision. Right: Damage to port bow of the AEP 7235. Four barges were damaged in the collision. As a result of the impact, the bow of Miss Dixie’s lead barge, 005492, was pinned under the damaged rake of the D.& R. Boney’s lead barge, AEP 7235 (the 005492 was dented, but not repaired). The hull of AEP 7235 was breeched, creating a 20-by-20-foot hole in the bow void compartment, which resulted in flooding. Damage to three other barges in the Miss Dixie’s tow consisted of several areas of inset plating, framing, and side shell. Additional Information After the collision, the crew of the Miss Dixie determined that the port clutch was the source of the smoke. The propulsion system was arranged such that each output shaft of the main engines was connected to their respective propellers via a Lufkin LST reduction gear set. The directional commands (ahead, neutral, astern) from the wheelhouse to the gear sets were controlled through air-actuated marine clutches. Each clutch consisted of two 35-inch-diameter steel rings (one for ahead and one for astern) lined with a tire-like neoprene rubber actuating tube that expanded radially inward when air pressure was applied. The constricting tube forced friction shoe assemblies against an outer cylindrical drum surface on the reduction gear input shaft transmitting engine torque to the propeller shaft. A directional valve delivered compressed air to the respective rings for ahead or astern operation. As actuating air was released, the shoe assemblies retracted, disengaging the propeller shaft from the engine output shaft. If there was a failure of the clutch components or actuating tubes, the rotating components may not have rotated at the same speeds, resulting in friction, increased heat, and overheating of friction pads or rubber tubes. Additionally, the output speed of the propeller shaft would not be consistent with the speed of the engine and would be classified as “slippage.” After the accident, a service representative specializing in marine industrial gears inspected the port clutch aboard the Miss Dixie and determined that the port clutch had “excessive wear” and

Collision Between Miss Dixie Tow and D.& R. Boney Tow

6 NTSB/MAB-20/06 that the clutch would slip and was “40% operational.” The report also indicated that the bearings of the reduction gears were in satisfactory condition, and the gears had pitting and some sharp edges. Another service company inspected the pneumatic system for the clutch and reported that the control system was operating satisfactorily. After the accident, the port clutch was repaired.

Left: Port clutch assembly steel rings removed from the Miss Dixie after the collision during postaccident inspection. Right: Condition of the port engine clutch friction pads aboard the Miss Dixie after the accident. According to the owner of the Miss Dixie’s operating company, the vessel was acquired about six months before the accident. The owner indicated that a purchase survey was completed and that the maintenance records came with the vessel. Prior to acquiring the vessel, both main engines were overhauled, but he did not know if this overhaul included the clutches. After the overhaul and before the purchase of Miss Dixie, the engines had been operated for 40 hours. He believed that the clutches were inspected, was told that they were in “good standing,” and did not believe that it was necessary to rebuild them. He was not aware of the maintenance requirements and periodic inspections for the type of clutches aboard Miss Dixie. When asked about a preventive maintenance system for the vessel, the owner stated that the crews performed daily visual checks on the machinery, and if any issues were detected that exceeded the ability of the crew to address, outside vendors would be hired to effect repairs. Additionally, none of the vessels in the fleet had yet to be inspected under 46 Code of Federal Regulations (CFR) Subchapter M.2 The owner did not provide any maintenance records to investigators. The clutch manufacturer’s instructions for periodic inspections included checking the air control component settings, the friction lining for signs of wear, and the shoes or drum for contamination. The maintenance section also provided guidance for checking for drum diameter wear, the condition of the air actuating tube, and the friction shoe surfaces. According to the vessel operator, these instructions were not aboard the vessel.

2 In July 2016, the Coast Guard released 46 CFR Subchapter M, establishing towing vessel safety regulations to oversee inspections, standards, and options for safety management systems. Existing vessels were required to comply by July 2018.

Collision Between Miss Dixie Tow and D.& R. Boney Tow

7 NTSB/MAB-20/06 The Miss Dixie was involved in two other casualties in the weeks after the collision with the D.& R. Boney tow. Ten days after, while pushing three barges, the tow of the Miss Dixie struck a stationary barge near New Orleans. Two weeks later, the Miss Dixie experienced a crankcase explosion in the starboard engine, causing a fire in the engine room. After the fire was extinguished, the Miss Dixie was towed to shore. On March 3, 2019 the Miss Dixie was removed from active service and subsequently scrapped. Analysis As the captain was maneuvering around the bend at Nine Mile Point, he experienced a reduction in thrust from the port propeller, which reduced his ability to steer around the sharp turn. About the same time, a deckhand in the engine room observed smoke in the area of the port clutch and smelled rubber burning. In a hairpin turn, with an eddy from the current and several other vessels transiting the area, the captain needed thrust from both propellers to successfully maneuver the 700-foot tow; without sufficient thrust from the port propeller, the captain was unable to effectively control the tow. After the accident, based on the location of the smoke and the reduction of power from the port propeller, the crew believed that the clutch had been slipping and overheating, which reduced thrust to the port propeller. The crew determined that there had been an issue with the port clutch. Further, a postaccident inspection by a service representative found that the port clutch had excessive wear, would slip, and was only 40% operational. The air-actuated clutch was designed to transfer torque from the engine to the propeller by inflating a rubber air tube within a steel ring, forcing friction shoes onto the rotating assemblies, which would rotate the propeller at a proportional speed to the engine. Heat is generated by a slipping clutch, producing smoke from the overheating of components in the clutch system, such as the rubber tube, and results in a reduction of power being transferred to the propeller. Without records to show any previous maintenance or inspections of the clutches aboard the Miss Dixie, the condition of the units before, or at the time of, the accident is unknown. The owner indicated that the engines had been overhauled prior to the acquisition of the Miss Dixie but was not sure if the overhaul included the clutches. The clutches were not inspected over the 6 months of ownership, and the owner had not developed periodic inspection or maintenance procedures per manufacturer’s guidance associated with the clutches, which are critical components of the propulsion system. Probable Cause The National Transportation Safety Board determines that the probable cause of the collision between the tows of the towing vessels Miss Dixie and D.& R. Boney was the lack of an effective maintenance program aboard the Miss Dixie, resulting in excessive and undetected wear of the port clutch, which compromised the vessel’s maneuverability.

Inspection of Propulsion System Clutch Assemblies Owners and operators should ensure that all critical equipment associated with propulsion systems, such as clutches, are included in preventative maintenance systems and that they follow the manufacturer’s maintenance and inspection interval recommendations.

Collision Between Miss Dixie Tow and D.& R. Boney Tow 8

NTSB/MAB-20/06 Vessel Particulars Vessel Miss Dixie D.& R. Boney AEP 7235 005024 005028 005492 005495 Owner/operator Hex Stone, Inc. / JRC Marine American Commercial Barge Line / Inland Marine Service American Commercial Barge Line U.S. Bank National Association U.S. Bank National Association U.S. Bank National Association U.S. Bank National Association Port of registry Baton Rouge, Louisiana Lakin, West Virginia St. Louis, Missouri Cincinnati, Ohio Cincinnati, Ohio Cincinnati, Ohio Cincinnati, Ohio Flag United States United States United States United States United States United States United States Type Towing Vessel Towing Vessel Freight barge Freight barge Freight barge Freight barge Freight barge Year built 1961 1976 2008 2000 2000 2000 2000 Official number (US) 280525 575824 1216665 1103341 1103346 1097119 1097120 IMO number N/A N/A N/A N/A N/A N/A N/A Construction Steel Steel Steel Steel Steel Steel Steel Length 102 ft (31 m) 128 ft (39 m) 200 ft (61 m) 200 ft (61 m) 200 ft (61 m) 200 ft (61 m) 200 ft (61 m) Draft 9 ft (2.7 m) 9.5 ft (2.9 m) 13 ft (4 m) 13 ft (4 m) 13 ft (4 m) 13 ft (4 m) 13 ft (4 m) Beam/width 34 ft (10.4 m) 42 ft (12.8 m) 35 ft (10.7 m) 35 ft (10.7 m) 35 ft (10.7 m) 35 ft (10.7 m) 35 ft (10.7 m) Tonnage 201 GRT 483 GRT 764 GRT 764 GRT 764 GRT 764 GRT 764 GRT Engine power; manufacturer 2,400 hp (1,790 kw); GM L12-645-E2 6,000 hp (4474 kw) GM 16-645-E7 N/A N/A N/A N/A N/A Persons on board 4 8 0 0 0 0 0 NTSB investigators worked closely with our counterparts from Coast Guard Sector New Orleans, Louisiana, throughout this investigation.

For more details about this accident, visit www.ntsb.gov and search for NTSB accident ID DCA19FM017. Issued: February 5, 2020

The NTSB has authority to investigate and establish the probable cause of any major marine casualty or any marine casualty involving both public and nonpublic vessels under Title 49 United States Code, Section 1131(b)(1). This report is based on factual information either gathered by NTSB investigators or provided by the Coast Guard from its informal investigation of the accident.

Collision Between Miss Dixie Tow and D.& R. Boney Tow 9

NTSB/MAB-20/06 The NTSB does not assign fault or blame for a marine casualty; rather, as specified by NTSB regulation, “[NTSB] investigations are fact-finding proceedings with no formal issues and no adverse parties . . . and are not conducted for the purpose of determining the rights or liabilities of any person.” Title 49 Code of Federal Regulations, Section 831.4. Assignment of fault or legal liability is not relevant to the NTSB’s statutory mission to improve transportation safety by conducting investigations and issuing safety recommendations. In addition, statutory language prohibits the admission into evidence or use of any part of an NTSB report related to an accident in a civil action for damages resulting from a matter mentioned in the report. Title 49 United States Code, Section 1154(b).

FD07321 ｜ 2006_美国_NTSB_AAR0707_InFlight_Cargo_Fire_United_Parcel_Service_Company_Flight_130.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2006 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

aviation Inflight Cargo Fire United Parcel Service Company Flight 1307 McDonnell Douglas DC-8-71F, N748UP, Philadelphia, Pennsylvania February 7, 2006 ACCIDENT REPORT NTSB/AAR-07/07 PB2007-910408

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National Transportation Safety Board 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 Aircraft Accident Report Inflight Cargo Fire United Parcel Service Company Flight 1307 McDonnell Douglas DC-8-71F, N748UP, Philadelphia, Pennsylvania February 7, 2006 NTSB/AAR-07/07 PB2007-910408 Notation 7772C Adopted December 4, 2007

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Web at http://www.ntsb.gov. Other information about available publications also may be obtained from the Web site or by contacting: National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (800) 877-6799 or (202) 314-6551 Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2007-910408 from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605-6000 The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. National Transportation Safety Board. 2007. Inflight Cargo Fire, United Parcel Service Company Flight  1307, McDonnell Douglas DC-8-71F, N748UP, Philadelphia, Pennsylvania, February 7, 2006. Aircraft Accident Report NTSB/AAR-07/07. Washington, DC. Abstract: This report explains the accident involving a McDonnell Douglas DC-8-71F, N748UP, operated by United Parcel Service Company, which landed at its destination airport, Philadelphia International Airport, Philadelphia, Pennsylvania, after a cargo smoke indication in the cockpit. The safety issues discussed in this report include inadequacies in the following areas: guidance and checklists relating to in-flight fire and smoke, smoke and fire detection system test certification requirements, fire suppression system requirements, aircraft rescue and firefighting training, cargo airplane emergency exit requirements, hazardous materials information dissemination procedures, and transport of lithium batteries on board aircraft. Safety recommendations concerning these issues are addressed to the Federal Aviation Administration, the Cargo Airline Association, and the Pipeline and Hazardous Materials Safety Administration.

National Transportation Safety Board A I R C R A F T Accident Report iii Contents Figures...............................................................................................................................vi Abbreviations and Acronyms.....................................................................................vii Executive Summary........................................................................................................ ix

1. Factual Information.....................................................................................................1
2. 1  History of Flight.............................................................................................................................. 1
3. 2  Injuries to Persons........................................................................................................................... 4
4. 3  Damage to Airplane........................................................................................................................ 4
5. 4  Other Damage.................................................................................................................................. 4
6. 5  Personnel Information.................................................................................................................... 4
7. 5.1  The Captain.............................................................................................................................. 4
8. 5.2  The First Officer....................................................................................................................... 5
9. 5.3  The Flight Engineer................................................................................................................ 6
10. 6  Airplane Information...................................................................................................................... 7
11. 6.1  Airplane Configuration ......................................................................................................... 7
12. 6.1.1  Emergency Exits................................................................................................................ 8
13. 6.1.2  Main Cargo Door .............................................................................................................. 9
14. 6.2  Smoke and Fire Detection and Warning System................................................................ 9
15. 6.2.1  Main Cargo Compartment Smoke Detectors ............................................................. 10
16. 6.2.2  Lower Cargo Compartment Smoke and Fire Detectors............................................ 10
17. 6.2.3  Certification Requirements for Smoke and Fire Detection Systems ....................... 11
18. 6.3  Air Conditioning and Pressurization System................................................................... 12
19. 7  Meteorological Information ........................................................................................................ 12
20. 8  Aids to Navigation........................................................................................................................ 13
21. 9  Communications........................................................................................................................... 13
22. 10  Airport Information.................................................................................................................... 13
23. 10.1  Aircraft Rescue and Firefighting Information................................................................ 13
24. 10.1.1  Aircraft Rescue and Firefighting Training................................................................. 13
25. 10.1.2  Aircraft Familiarization Training and Equipment Use Training........................... 14
26. 10.1.3  Postaccident Aircraft Rescue and Firefighting Training Changes......................... 15
27. 11  Flight Recorders........................................................................................................................... 16
28. 11.1  Cockpit Voice Recorder...................................................................................................... 16
29. 11.2  Flight Data Recorder........................................................................................................... 16
30. 12  Wreckage and Impact Information........................................................................................... 17
31. 13  Medical and Pathological Information..................................................................................... 17
32. 14  Fire................................................................................................................................................. 17
33. 14.1  Fire Damage to Exterior Fuselage .................................................................................... 17
34. 14.2  Fire Damage to Lower Cargo Compartments................................................................ 18
35. 14.3  Fire Damage to Fuselage Interior and Main Cargo Compartment ............................. 18
36. 14.4  Fire Damage to Main Cargo Compartment Containers and Contents....................... 19
37. 15  Survival Aspects.......................................................................................................................... 21
38. 15.1  Emergency Evacuation....................................................................................................... 21
39. 15.2  Emergency Response.......................................................................................................... 22
40. 15.3  Hazardous Materials Information Retrieval................................................................... 24

Contents National Transportation Safety Board A I R C R A F T Accident Report iv 1.16  Tests and Research...................................................................................................................... 25 1.16.1  Laboratory Examinations of the Main Cargo Container Contents ............................. 25 1.16.2  Shipment Identification Effort........................................................................................... 25 1.16.3  Hazardous Materials Identification ................................................................................. 26 1.17  Organizational and Management Information....................................................................... 26 1.17.1  Operational Guidance ....................................................................................................... 26 1.17.1.1  Pack Smoke Checklist................................................................................................... 27 1.17.1.2  Fumes Evacuation Checklist........................................................................................ 27 1.17.1.3  Lower and/or Main Cargo Compartment Smoke or Fire Checklist..................... 28 1.17.1.4  Smoke of Unknown Origin or Suspected Electrical Fire Checklist........................ 29 1.17.2  On-Board Hazardous Materials Procedures .................................................................. 29 1.17.3  Postaccident Actions........................................................................................................... 30 1.18  Additional Information.............................................................................................................. 31 1.18.1  Industry Initiatives on Smoke, Fire, and Fumes Checklist Procedures...................... 31 1.18.2  Previously Issued Safety Recommendations Resulting from This Accident............. 33 1.18.3  Previous Related Safety Recommendations.................................................................... 34 1.18.3.1  Smoke and Fire Detection, Suppression, and Extinguishment.............................. 34 1.18.3.2  Retrieval and Availability of Hazardous Materials Information .......................... 36 1.18.3.3  Air Transport of Lithium Batteries............................................................................. 37 1.18.4  Related Federal Aviation Administration Guidance..................................................... 40 1.18.5  Recent Developments in Fire Detection and Suppression Systems............................ 41 1.18.5.1  Federal Aviation Administration Rulemaking Initiatives...................................... 41 1.18.5.2  Federal Express System Developments..................................................................... 42 1.18.6  Lithium Batteries................................................................................................................. 43 1.18.6.1  Incidents Involving Lithium Batteries........................................................................ 43 1.18.6.2  Recent Lithium Battery-Related Safety Alerts ......................................................... 44

1. Analysis.......................................................................................................................46
2. 1  General............................................................................................................................................ 46
3. 2  Flight Crew Performance............................................................................................................. 46
4. 2.1  Actions During Descent and Landing Sequence.............................................................. 46
5. 2.2  Decision to Continue to Philadelphia International Airport.......................................... 47
6. 2.3  Use and Adequacy of Smoke, Fire, or Fumes Checklists................................................ 48
7. 3  Fire Detection and Growth.......................................................................................................... 49
8. 4  Origin and Cause of Fire.............................................................................................................. 50
9. 5  Smoke or Fire Detection System Certification Tests................................................................ 52
10. 6  Smoke Detection and Fire Suppression Systems on Cargo Airplanes.................................. 53
11. 7  Emergency Response Issues........................................................................................................ 54
12. 7.1  Emergency Response Timeliness........................................................................................ 54
13. 7.2  High-Reach Extendable Turret With Skin-Penetrating Nozzle

Training for Aircraft Rescue and Firefighting.................................................................. 55 2.7.3  Aircraft Rescue and Firefighting Cargo Familiarization Training................................. 56 2.7.4  Cargo Airplane Emergency Exit Requirements............................................................... 57 2.8  Retrieval and Dissemination of Hazardous Materials Information...................................... 59 2.9  Air Transport of Lithium Batteries ............................................................................................ 61

1. Conclusions.................................................................................................................64
2. 1  Findings.......................................................................................................................................... 64
3. 2  Probable Cause.............................................................................................................................. 66
4. Safety Recommendations.........................................................................................67
5. 1  New Safety Recommendations................................................................................................... 67

Contents National Transportation Safety Board A I R C R A F T Accident Report v 4.2  Previously Issued Safety Recommendations Resulting From This Accident Investigation......................................................................................................... 69 4.3  Previously Issued Safety Recommendations Classified in this Report................................. 69

1. Appendixes.................................................................................................................71

A: Investigation and Public Hearing.......................................................................................... 71 B: Cockpit Voice Recorder Transcript........................................................................................ 72

National Transportation Safety Board A I R C R A F T Accident Report vi Figures 1.  Diagram of the airplane’s cargo configuration............................................................................. 7 2.  Diagram of the airplane’s doors and exits..................................................................................... 8 3.  Damage to the fuselage crown...................................................................................................... 18

National Transportation Safety Board A I R C R A F T Accident Report vii Abbreviations and Acronyms AC advisory circular AEP Airport Emergency Plan AFFF aqueous film-forming foam ALPA Air Line Pilots Association AOM Aircraft Operating Manual AOMM Airport Operations Methods Manual ARFF aircraft rescue and firefighting ASOS Automated Surface Observing System ATC air traffic control ATCT air traffic control tower ATL Hartsfield-Jackson Atlanta International Airport ATP airline transport pilot C Celsius CAM cockpit area microphone CAR Civil Aviation Regulations CD compact disc CDU control display unit CFR Code of Federal Regulations CPSC Consumer Product Safety Commission CVR cockpit voice recorder DG dangerous goods DOT Department of Transportation FAA Federal Aviation Administration FDR flight data recorder FedEx Federal Express Corporation FOM Flight Operations Manual g gram HMIS Hazardous Materials Information System HMR Hazardous Materials Regulations HRET/SPN high-reach extendable turret with skin-penetrating nozzle ICAO International Civil Aviation Organization IFSTA International Fire Service Training Association

Abbreviations and Acronyms National Transportation Safety Board A I R C R A F T Accident Report viii InFO Information for Operators IPA Independent Pilots Association kg kilogram METAR meteorological aerodrome report msl mean sea level NPRM notice of proposed rulemaking NOTOC notice to captain PHL Philadelphia International Airport PHMSA Pipeline and Hazardous Materials Safety Administration PIC pilot-in-command QRH Quick Reference Handbook RSPA Research and Special Programs Administration SAFO safety alert for operators SAFT Specialized Aircraft Fire Training sm statute mile TEB Teterboro Airport TSB Transportation Safety Board of Canada UN United Nations UPS United Parcel Service Company

National Transportation Safety Board A I R C R A F T Accident Report ix Executive Summary On February 7, 2006, about 2359 eastern standard time, United Parcel Service Company flight 1307, a McDonnell Douglas DC-8-71F, N748UP, landed at its destination airport, Philadelphia International Airport, Philadelphia, Pennsylvania, after a cargo smoke indication in the cockpit. The captain, first officer, and flight engineer evacuated the airplane after landing. The flight crewmembers sustained minor injuries, and the airplane and most of the cargo were destroyed by fire after landing. The scheduled cargo flight was operating under the provisions of 14 Code of Federal Regulations Part 121 on an instrument flight rules flight plan. Night visual conditions prevailed at the time of the accident. The National Transportation Safety Board determines that the probable cause of this accident was an in-flight cargo fire that initiated from an unknown source, which was most likely located within cargo container 12, 13, or 14. Contributing to the loss of the aircraft were the inadequate certification test requirements for smoke and fire detection systems and the lack of an on-board fire suppression system. The safety issues discussed in this report include inadequacies in the following areas: guidance and checklists relating to in-flight fire and smoke, smoke and fire detection system test certification requirements, fire suppression system requirements, aircraft rescue and firefighting training, cargo airplane emergency exit requirements, hazardous materials information dissemination procedures, and transport of lithium batteries on board aircraft. Safety recommendations concerning these issues are addressed to the Federal Aviation Administration, the Cargo Airline Association, and the Pipeline and Hazardous Materials Safety Administration.

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National Transportation Safety Board A I R C R A F T Accident Report 1 Factual Information

History of Flight 1.1  On February 7, 2006, about 2359 eastern standard time,1 United Parcel Service Company (UPS) flight 1307, a McDonnell Douglas DC-8-71F,2 N748UP, landed at its destination airport, Philadelphia International Airport (PHL), Philadelphia, Pennsylvania, after a cargo smoke indication in the cockpit. The captain, first officer, and flight engineer evacuated the airplane after landing. The flight crewmembers sustained minor injuries, and the airplane and most of the cargo were destroyed by fire after landing. The scheduled cargo flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 on an instrument flight rules flight plan. Night visual conditions prevailed at the time of the accident. The accident occurred on the second day of a 5-day, 8-leg trip sequence for the flight crew. The airplane pushed back from the gate at Hartsfield-Jackson Atlanta International Airport (ATL), Atlanta, Georgia, and departed for PHL about 2241. The first officer was the flying pilot, and the captain performed the duties of the pilot monitoring. The accident flight crew reported that the flight was uneventful until just after beginning the descent to PHL. At 2334:39, while the airplane was descending through flight level 3103 about 50 nautical miles southwest of Washington, D.C., the cockpit voice recorder (CVR)4 recorded the first officer asking the captain and the flight engineer if they detected an odor that smelled “like wood burning.” The flight engineer replied that he had “smelled it for a couple of seconds.” About 1 minute later, the first officer stated, “[it’s] pretty strong now.” Subsequently, the CVR recorded a sound similar to the cockpit door or seat operating and the flight engineer stating, “[it’s] more in the back.”5 About 3 1/2 minutes later, the first officer again stated that the odor smelled like wood, and the flight engineer agreed that the odor did smell like wood burning and stated that it did not smell electrical in nature. 1  Unless otherwise indicated, all times in this report are eastern standard time based on a 24-hour clock. 2  McDonnell Douglas is now owned by the Boeing Commercial Airplane Group. 3  Flight level 310 is an altitude of 31,000 feet mean sea level (msl) based on an altimeter setting of 29.92 inches of mercury. Unless otherwise indicated, all altitudes referenced in this report are reported as height above msl. 4  Correlation of the CVR recording to eastern standard time was established using times from the air traffic control transcript prepared by the Federal Aviation Administration. 5  In postaccident interviews, the flight engineer stated that he pulled back the smoke curtain and shined a flashlight along the left wall of the main cargo compartment. He stated that he could smell the odor but that he did not see any smoke or fire. The smoke curtain is a ventilation barrier that covers the cargo netting, which is located between the forward galley area and the main cargo compartment.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 2 During postaccident interviews, the captain stated that he considered diverting to another airport soon after the odor was first detected but that he chose to continue to PHL because there was no evidence of a problem, such as the illumination of the cargo smoke warning lights. The first officer stated that the odor did not appear to be a threat because the flight engineer did not see any visible smoke; therefore, the first officer did not believe that there was any need to divert. Further, the accident flight crew stated that unusual odors could be common from nonthreatening factors (such as flying over forest fires or unusual cargo). Over the next 4 minutes, the captain and flight engineer tried to identify the source of the odor by conducting several emergency checklist steps,6 including increasing the bleed air flow and checking the bleed air switches. As the airplane was descending through about 18,000 feet and was about 65 miles from PHL, the CVR recorded the flight engineer stating that he set the air conditioning packs to maximum flow and turned off the recirculation fan. Shortly thereafter, the flight engineer and captain conducted the Approach checklist. At 2344:59, the first officer contacted the PHL Terminal Radar Approach Control, and the approach controller instructed the flight to descend to 6,000 feet. The CVR then recorded the captain asking, “can you still smell it in the back there?” The flight engineer replied, “yeah . . . smells like it was more to the back there.” The first officer then asked, “smells like cardboard burning doesn’t it? you didn’t see smoke though something like that?” The flight engineer again went back to check the main cargo compartment with his flashlight, and he stated that the odor was “definitely stronger in the back” but that there was no smoke or haze. Over the next 10 minutes, the captain and flight engineer continued to troubleshoot the problem. At 2354:42, as the airplane was descending through about 3,600 feet, the flight engineer stated, “we got cargo smoke.”7 The captain replied, “let’s do that checklist if you got time.” The first officer then stated that he would be turning toward the airport. At 2355:01, the PHL approach controller cleared the visual approach to runway 27R and then instructed the flight crew to contact the air traffic control tower (ATCT). Ten seconds later, the captain made initial contact with the ATCT local controller, who cleared the flight to land on runway 27R. After acknowledging the clearance, the captain reported that the cargo smoke indicator had illuminated and requested that emergency response equipment meet them upon landing. The local controller immediately activated the crash phone and advised approach control of the emergency. 6  The UPS DC-8 Aircraft Operating Manual does not contain specific procedures on how to respond to in‑flight smoke, fire, or fumes in the absence of a cockpit warning. See section 1.17 for additional information about these procedures. 7  The flight engineer stated that his comment referred to the illumination of the Cargo Smoke warning light, which indicates the detection of smoke in the main cargo compartment.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 3 At 2355:57, the flight engineer stated, “[it’s] showing that we have a lower aft cargo fire section C.”8 Subsequently, the captain told the first officer and flight engineer to don their oxygen masks if they had not done so already. The captain then asked the flight engineer to accomplish the Lower and/or Main Cargo Compartment Smoke or Fire checklist by himself, and the flight engineer proceeded to execute the checklist. According to air traffic control (ATC) transcripts, the Philadelphia approach controller asked the PHL ATCT local controller whether the flight was going to land on the left side, referring to runway 27L, which is the runway at PHL designated for use in emergency situations. At 2356:12, the local controller cleared the flight to land on runway 27L, and the captain acknowledged the landing clearance but not the change in landing runway.9 The flight engineer continued the Lower and/or Main Cargo Compartment Smoke or Fire checklist items. When he reached the step to close the cargo air shutoff valve, he stated that he had to “go in the back and do that.”10 During postaccident interviews, the flight engineer stated that, when he opened the door of the access panel to the cargo air shutoff valve, black smoke billowed out of the access panel. At 2357:47, the first officer called for the Landing checklist. About 21 seconds later, the ATCT local controller stated, “just confirmed you are lined up for the left side it appears that you are lined up for the right.” The first officer replied, “I thought we were cleared for the right . . . are we cleared to land on the right?” At 2358:16, the local controller replied, “you are cleared to land on the right we will just tell fire.” The airplane landed on runway 27R about 2359. Immediately after touchdown, the flight engineer reported smoke in the cockpit. After the airplane came to a stop, the first officer called for an emergency evacuation, and the captain and first officer conducted the Emergency Evacuation checklist. All of the flight crewmembers successfully evacuated the airplane using the emergency slide located at the left forward (L1) door. Section 1.15.1 discusses the flight crew’s evacuation, and section 1.15.2 discusses the emergency response. 8  During postaccident interviews, the captain stated that, soon after the Lower Cargo Fire warning light illuminated, his electronic flight instrument system failed. He stated that, although there was power to the displays, no information was displayed. 9  The PHL local controller did not tell the pilot that he had changed the landing runway assignment. FAA Order 7440.65, “Air Traffic Control,” does not contain any specific rules or guidance to controllers regarding how to clearly communicate a change in runway assignment after an arriving aircraft has been cleared to land. See section 1.18.2 for information about a previously issued safety recommendation related to this issue. 10  The cargo air shutoff valve is located on the right cabin wall just aft of the cockpit bulkhead.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 4 Injuries to Persons 1.2  Injury chart. Table 1.  Injuries Flight Crew Cabin Crew Passengers Other Total Fatal 0 0 0 0 0 Serious 0 0 0 0 0 Minor 3 0 0 0 3 None 0 0 0 0 0 Total 3 0 0 0 3 Note: Title 14 CFR 830.2 states that a minor injury is any injury that does not qualify as a fatal or serious injury. The regulation defines a serious injury as any injury that (1) requires hospitalization for more than 48 hours, starting within 7 days from the date that the injury was received; (2) results in a fracture of any bone, except simple fractures of fingers, toes, or the nose; (3) causes severe hemorrhages or nerve, muscle, or tendon damage; (4) involves any internal organ; or (5) involves second- or third-degree burns or any burns affecting more than 5 percent of the body surface. Damage to Airplane 1.3  The airplane was destroyed by fire after landing. Other Damage 1.4  Most of the cargo on board the airplane was destroyed or damaged by fire. Personnel Information 1.5  The Captain 1.5.1  The captain, age 59, was hired by UPS on September 19, 1988. He held a multiengine airline transport pilot (ATP) certificate, issued April 2, 1982, with a type rating in DC-8 airplanes. The captain held a first-class Federal Aviation Administration (FAA) airman medical certificate, dated February 3, 2006, with the limitation that he “must wear corrective lenses.” According to the captain, he worked as a charter pilot for Allegheny Commuter, Harrisburg, Pennsylvania, from September 1973 to June 1978. From July 1978 to November 1981, he worked as a first officer for several companies flying Convair, Learjet, and DC-8 airplanes. From December 1981 to September 1988, he worked as a first officer and captain flying DC-8 airplanes for Evergreen Airlines, McMinnville, Oregon.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 5 UPS records indicated that the captain had accumulated about 25,000 total flight hours, including 16,000 hours as pilot-in-command (PIC) in DC-8 airplanes. He had flown about 41, 5 1/2, and 4 hours in the 90 days, 30 days, and 24 hours, respectively, before the accident flight. The captain’s last line check occurred on July 21, 2005, and his last DC-8 series proficiency check and recurrent ground training occurred on September 8, 2005. A search of FAA records revealed no accident or incident history, enforcement action, or pilot certificate or rating failure or retest history. A search of the National Driver Register found no record of driver’s license suspension or revocation. According to the captain, when he was off duty, he typically went to bed between 0100 and 0200 and awoke about 0930. He stated that it was hard going back and forth between the night schedule that he kept when he was at work and the day schedule that he kept when he was at home. On February 4 and 5, 2006, he was off duty and engaged in routine activities and slept according to his off-duty night schedule. On February 6, he awoke about 0630 and later flew from his home in Orlando, Florida, to ATL to report for duty at 2115. He then flew from ATL to PHL with the accident flight crew and napped for about 1 1/2 hours in a recliner chair at the airport during cargo loading. He returned with the flight crew to ATL, slept in the hotel from about 0600 to 1200, and ate dinner about 1700 before reporting for the accident flight. The First Officer 1.5.2  The first officer, age 40, was hired by UPS on February 19, 1996. He held a multiengine ATP certificate, issued January 4, 2006, with type ratings in British Aerospace BA-3100 and DC‑8 series airplanes. The first officer held a first-class FAA airman medical certificate, dated February 1, 2006, with no limitations. According to the first officer, he worked as a flight instructor for Acme School of Aeronautics, Fort Worth, Texas, from August 1988 to January 1990. From February 1990 to March 1991, he worked as a charter pilot flying BA-3100 airplanes for Alpha-Century Corporation in Fort Worth. From 1991 to 1995, he flew commuter flights in BA-3100 and Saab 340 airplanes for Express Airlines (now Pinnacle Airlines). UPS records indicated that the first officer had accumulated 7,500 total flight hours, including 2,100 hours as second-in-command in DC-8 airplanes. He had flown about 5 1/2 and 4 hours in the 30 days and 24 hours, respectively, before the accident flight.11 The first officer’s last line check occurred on April 16, 1998, and his last DC-8 series proficiency check and recurrent ground training occurred on January 6, 2006. A search of FAA records revealed no accident or incident history, enforcement action, or pilot certificate or rating failure or retest history. A search of the National Driver Register found no record of driver’s license suspension or revocation. According to the first officer, when he was off duty, he typically went to bed about 0000 or 0100 and awoke about 0800 or 0900. On February 4, 2006, he engaged in routine activities at home in Crestwood, Kentucky, and went to bed about 2300. On February 5, 11  The first officer did not fly in the 30 to 90 days before the accident flight.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 6 he awoke about 0700, conducted routine activities at home, and went to bed about 2200. On February 6, he awoke between 0415 to 0430 to commute to ATL. He arrived at his hotel room, napped from about 1330 to 1800, exercised, skipped dinner, and got picked up at the hotel about 2110 for the flight to PHL. He stated that the first night of a trip sequence was normally the hardest for him because of the change to a night schedule. On February 7, he went to bed about 1000 and slept until 1200. Before reporting for the accident flight, he napped for a few hours in the afternoon, exercised, and skipped dinner. The Flight Engineer 1.5.3  The flight engineer, age 61, was hired by UPS on January 24, 1994. He held a multiengine ATP certificate, issued March 29, 2002, with type ratings in Boeing 737, 757, and 767 airplanes. The flight engineer held a second-class FAA airman medical certificate, dated March 15, 2005, with no limitations. The flight engineer stated that, from 1967 to 1989, he flew airplanes for the U.S. Air Force. He stated that he worked as a flight engineer on Boeing 747 airplanes for Trans World Airlines in 1990 and for America West Airlines from 1990 to 1992.12 UPS records indicated that the flight engineer had accumulated 9,000 total flight hours, including 2,000 hours as a flight engineer, 430 hours of which were in DC-8 airplanes. He had flown about 63, 43, and 4 hours in the 90 days, 30 days, and 24 hours, respectively, before the accident. The flight engineer’s last line check occurred on April 17, 2004, and his last DC-8 series proficiency check and recurrent ground training occurred on June 4, 2005. A search of FAA records revealed no accident or incident history, enforcement action, or pilot certificate or rating failure or retest history. A search of the National Driver Register found no record of driver’s license suspension or revocation. According to the flight engineer, when he was off duty, he typically went to bed about 2200 and awoke about 0630. On February 4, 2006, he engaged in routine activities at home in Tucson, Arizona, and went to bed about 2200. On February 5, he awoke about 0700, worked around the house, and went to bed about 2130. On February 6, he awoke about 0500, flew to ATL, napped in the hotel from 1500 to 1730, ate dinner, and returned to the airport about 2100. On February 7, he flew to PHL about 2100 and then returned to ATL about 0520. He slept from about 0600 to 1100, and, later that day, napped from 1600 to 1800, ate dinner, and reported to ATL about 2100. He indicated that this was his normal layover routine and that he felt rested. 12  From December 1992 to January 1993, the flight engineer was a flight test analyst for the Air Force National Guard, and he did not fly aircraft during this time.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 7 Airplane Information 1.6  The accident airplane was manufactured as a convertible freighter by McDonnell Douglas in December 1967.13 UPS bought the airplane in 1985, and the airplane was in a cargo configuration at that time. Interstate Airlines operated the airplane for UPS until July 2, 1988, at which time UPS took over operation of the airplane. At the time of the accident, the airplane had accumulated about 67,675 total flight hours. The airplane was equipped with four CFM International CFM56 engines. According to the load manifest for the accident airplane, the airplane’s estimated landing weight was about 229,586 pounds, including 36,300 pounds of fuel and 58,312 pounds of baggage and cargo, which was within the landing weight limit of 258,000 pounds. Airplane Configuration 1.6.1  The airplane was configured with three flight crew seats and two observer seats in the cockpit and two seats across from the L1 door. The airplane had a main cargo compartment, which was configured to accommodate 18 cargo containers, and 4 lower cargo compartments. (See figure 1 for a diagram of the airplane’s cargo configuration.) A smoke curtain, which had cargo netting behind it, was located between the forward crew galley and the cargo area to maintain a smoke barrier. A closable opening in the smoke curtain provided access to the cargo area; however, with the cargo containers in place, no room is available to walk aft into the cargo area.14 Diagram of the airplane’s cargo configuration. Figure 1.  The airplane had eight floor level doors (L1 to L4 on the left side of the airplane and R1 to R4 on the right side of the airplane) and four overwing hatches. (See figure 2 for 13  The airplane was and remains certificated under Civil Aviation Regulations (CAR) 4b. The CARs were recodified in 1965 as Part 25 of the Federal Aviation Regulations. 14  To gain access to the cargo area, it is also necessary to remove or move aside the cargo netting.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 8 a diagram of the airplane’s doors and exits.) Five of the floor level doors (L2, L3, R1, R2, and R3) and the two aft overwing hatches had been deactivated such that they could not be opened from the outside. The L1, L4, and R4 doors, the two forward overwing hatches, and the two cockpit windows (designated as emergency exits) were operable from the outside. The airplane had four lower cargo compartment doors located on the right side of the airplane (two forward of the wing and two aft of the wing) and a main cargo door located on the left forward fuselage. Section 1.6.1.2 discusses the airplane’s main cargo door in more detail. Diagram of the airplane’s doors and exits. Figure 2.  Emergency Exits 1.6.1.1  In accordance with Civil Aviation Regulations (CAR) 4b, the accident airplane was required to have two emergency exits, one on each side of the airplane. Two of the airplane’s cockpit windows (one on each side of the cockpit) were designated as “emergency exits” in the UPS DC-8 Aircraft Operating Manual (AOM) and on the emergency briefing card and were operable from both inside and outside the airplane. CAR 4b also stated, “all emergency exits and their means of opening shall be marked on the outside of the airplane for guidance of rescue personnel.”15 Each cockpit window exit had two exterior placards that provided instructions for its operation. 15  Passenger airplanes certified after June 7, 1965, are required under 14 CFR 25.811(f) to have a 2‑inch contrasting colored band outlining emergency exits in addition to exterior markings providing instructions on their operation. Cargo airplanes are not required to have such bands around the emergency exits.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 9 The L1 door, which was the entry and exit door for crewmembers during normal operations, was also designated as an “emergency exit” in the UPS DC-8 AOM and on the emergency briefing card. According to the FAA, operators often designate the L1 door (with slide installed) as an alternate emergency exit. Further, the pilot’s Emergency Evacuation checklist stated, “All crewmembers and ACMs [additional crewmembers] evacuate through the cockpit window exits or forward cabin door [L1].” Although the interior of the L1 door included instructions for emergency door operation, the door did not have exterior operational placards. Main Cargo Door 1.6.1.2  The main cargo door is held in place by latches, which are, in turn, held in place by lockpins. A small vent door, which prevents the main cargo door from being opened while the airplane is still pressurized, is located on the aft portion of the cargo door and is mechanically linked to the lockpin mechanism. The vent door is designed so that it cannot be closed unless the cargo door is closed, latched, and locked; similarly, the cargo door cannot be opened until the vent door is opened. Opening the vent door moves the lockpins clear of the latches, allowing them to be rotated to the unlatched position. The door is then hydraulically opened. Normal operation of the vent door, like operation on all UPS DC-8s, is accomplished by activating an electrical switch on the interior wall adjacent to the L1 door entryway.16 Once the vent door has been opened, another switch under the floor panel near the L1 door entryway is then placed into the ON position to energize the hydraulic pump that operates the cargo door. Manual movement of the door’s control valve, which is adjacent to the hydraulic pump switch, to the OPEN position hydraulically opens the door’s lockpin and latch mechanisms and begins raising the cargo door. Manual operation of the main cargo door, which is used when airplane or auxiliary power is not available, requires that the vent door be opened by manually rotating the exterior handle located above the vent door. At this point, the cargo door can be unlocked and unlatched by either manually operating the door’s hydraulic pump inside the airplane or by manipulating the lockpin and latch mechanisms on the exterior of the door. This latter method requires that the latch fitting be rotated to the OPEN position while the lockpin lever is held in the unlocked position. Once the latch fitting is rotated to the OPEN position, the door can be manually raised. Regardless of the method used for unlocking and unlatching, the door can be raised by continuous manual operation of the hydraulic pump or by use of a sling or other mechanical means. Smoke and Fire Detection and Warning System 1.6.2  The airplane was equipped with a smoke and fire detection and warning system to provide flight crews with a visual indication in the cockpit of smoke or fire in the 16  UPS modified its DC-8s to allow the vent door to be electrically opened and closed. Originally, operation of the vent door required manual movement of a handle on the exterior of the door.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 10 cargo compartments. The airplane had 7 smoke detectors installed in the main cargo compartment, and 19 smoke detectors installed in the 4 lower cargo compartments. The flight crew tested the operation of the smoke detectors by enabling their test function from the cockpit during the preflight check. The flight engineer reported that no problems were encountered during the functional check of the smoke detectors before the accident flight. Main Cargo Compartment Smoke Detectors 1.6.2.1  The main cargo compartment smoke detector system, which was installed at the time of the airplane’s manufacture, comprised detectors located in the compartment ceiling that were designed to provide a smoke indication whenever the smoke around a detector reached a certain density (80 to 90 percent of normal light transmission). Five of the seven smoke detectors were mounted on the left side of the ceiling at locations corresponding to cargo containers 2, 5, 8, 11/12, and 14. The other two detectors were mounted next to each other near the ceiling centerline at locations corresponding to cargo containers 17 and 18. (See figure 1.) The smoke detector switch, which is located on the flight engineer’s upper panel, provides a means for testing the smoke detectors and the system wiring. The smoke detector switch has the following labeled positions: OFF, NOR [normal], and 1 through 7. Positions 1 through 7 are used during preflight to test the integrity of the alerting circuit for each detector;17 however, the system is not able to identify the specific sensor(s) detecting smoke in the event of an actual alert. The smoke detector system is operational as long as the smoke detector switch is not in the OFF position, and a cockpit smoke indication will be triggered whenever smoke at any of the seven detectors is sensed.18 When smoke is detected, the amber Cargo Smoke light on the flight engineer’s panel is illuminated. The main cargo smoke detectors on the accident airplane were all damaged or destroyed by fire, and no postaccident functional testing was possible. Lower Cargo Compartment Smoke and Fire Detectors 1.6.2.2  On March 30, 2001, to comply with 14 CFR 121.314,19 the 19 lower cargo compartment smoke detectors were installed on the airplane: 6 in the forward compartment, 4 in the forward middle compartment, 5 in the aft middle compartment, and 4 in the aft compartment. The smoke detection system for the lower cargo compartments has a control display unit (CDU), located in the cockpit to the right of the flight engineer’s station, which displays system status information and alarms to the flight crew. The CDU receives 17  Flight crew preflight procedures include testing each of the main cargo smoke detector circuits by rotating the switch and noting illumination of the test light. 18  The smoke detector switch was found in the NOR position post accident. 19  As of March 19, 2001, 14 CFR 121.314 specified that cargo compartments such as the lower compartments on the accident airplane were required to be equipped with a smoke or fire detection system.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 11 inputs from a central control unit that monitors signals from the 19 detectors. When the control unit receives signals (either smoke or smoke and temperature more than 150o Fahrenheit)20 from two detectors in the same compartment, the CDU illuminates the Lower Cargo Fire and Master Warning lights and indicates the compartment in which the smoke/fire was detected. Examination of the smoke detection system components for the lower cargo compartments revealed that the smoke/fire alert that activated in the cockpit during the flight was initially triggered by detectors in the aft middle compartment, which is located below main cargo containers 12 to 15, and that the detectors subsequently registered smoke in the aft cargo compartment. Postaccident tests of the smoke detection system revealed no anomalies. Certification Requirements for Smoke and Fire Detection Systems 1.6.2.3  At the time that the DC-8 was certified, regulations did not specify the time frame for smoke detection; however, an FAA letter to Boeing dated March 12, 1965, stated the following: the maximum smoke detection time to demonstrate compliance with the regulations for any class of cargo compartment is five (5) minutes. The time is measured from the initiation of smoke generation until the time that an acceptable indication is available to the crew. A review of the manufacturer’s records indicated that the DC-8 certification tests used smoke generators that were ignited and placed in a vented steel box, which was placed at a determined critical location,21 and the smoke light located in the cockpit was monitored. During the tests, the detection times varied from 12 seconds to 3 minutes. The cargo compartment was empty during these tests. According to the FAA, cargo compartment smoke detection certification tests are typically conducted with no cargo containers in the cargo compartments and with the smoke-generating device in the open area of the cargo compartment, located at a point farthest from any smoke detectors. Boeing also indicated that cargo compartment smoke detector certification tests were conducted without cargo containers in place and that this was an industrywide practice. In 1980, the FAA adopted 14 CFR 25.858,22 which contained more explicit performance objectives, including the following: a) The detection system must provide a visual indication to the flight crew within 1 minute after the start of the fire. 20  The control unit provides an alarm condition when smoke indications or smoke and high temperature indications are received from two different detectors within the same compartment. 21  The critical location is a position located farthest from any of the smoke and fire detectors and is intended to provide the most challenging position for the tests. 22  See section 1.18.4 for information on Advisory Circular 25-9A, which provided guidance on how operators could conduct certification tests to meet compliance with 14 CFR 25.858.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 12 b) The system must be capable of detecting a fire at a temperature significantly below that at which the structural integrity of the airplane is substantially decreased. c) There must be means to allow the crew to check in flight the functioning of each fire detector circuit. d) The effectiveness of the detection system must be shown for all approved operating configurations and conditions. However, 14 CFR 25.858 only applied to newly certificated aircraft, allowing previously certificated smoke detection systems, including the one installed on the accident airplane, to maintain the 5-minute detection time limit specified in the FAA’s March 1965 letter. Air Conditioning and Pressurization System 1.6.3  The airplane’s air conditioning and pressurization system distributed air for cooling and heating the airplane’s cockpit and cargo areas. The airplane is pressurized by the air entering the cabin and cockpit from the air conditioning packs. Proper cabin pressure is maintained by controlling the amount of air exhausted overboard through the outflow valves, which are located in the rear of the airplane and can be controlled automatically or manually. One electrically driven recirculation fan is installed in the forward accessory compartment to recirculate the cabin and cockpit air. The recirculation fan can be operated independently or along with one or both of the air conditioning packs. The system has one main duct through which cabin supply air is routed. The main duct is located behind the cargo liner and runs the length of the main cargo compartment along the centerline of the ceiling. The main duct has supply ducts on either side of it, which provide outlets for the conditioned air. Meteorological Information 1.7  Weather observations at PHL are made by an automated surface observing system (ASOS). The ASOS records continuous information on wind speed and direction, cloud cover, temperature, precipitation, and visibility and transmits an official meteorological aerodrome report (known as a METAR) each hour. The  2354 METAR indicated the following: wind 270° at 7 knots, visibility 10 statute miles (sm), clear sky, and temperature 0° Celsius (C). The 0054 METAR on February 8, 2006, indicated the following: wind 300° at 8 knots, visibility 10 sm, clear sky, and temperature ‑1° C.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 13 Aids to Navigation 1.8  No problems with any navigational aids were reported. Communications 1.9  No communications difficulties between the pilots and any of the air traffic controllers who handled the accident flight were reported. Airport Information 1.10  PHL is located about 5 miles southwest of downtown Philadelphia at an elevation of about 36 feet. The airport has one set of parallel runways, 9L/27R and 9R/27L, and two nonparallel runways, 8/26 and 17/35. The airport has 24-hour ATCT service. Aircraft Rescue and Firefighting Information 1.10.1  PHL has an FAA-approved airport emergency plan (AEP), which requires the airport to respond to all on-site accidents, and maintains a 14 CFR Part 139 Index E23 aircraft rescue and firefighting (ARFF) facility, which is operated by the City of Philadelphia, on the airfield. The PHL ATCT has a crash phone, which serves as a direct phone link and activates a buzzer and lights at the ARFF facility, the airport communications center, and the city fire dispatcher at the fire communication center. The ARFF facility provides services for the airport 24 hours a day, 7 days a week. A minimum of 13 ARFF personnel is present at the facility at all times. Aircraft Rescue and Firefighting Training 1.10.1.1  In accordance with 14 CFR 139.319(i), each holder of an airport operating certificate must ensure that ARFF personnel are properly trained to perform their duties. ARFF personnel are required to receive initial training and participate in at least one live-fire drill before initially performing ARFF duties and in recurrent training and drills every 12  months thereafter. Further, the curriculum for initial and recurrent training must include at least the following subject areas: airport familiarization, including airport signs, marking, and lighting; • aircraft familiarization; • ARFF personnel safety; • 23  Part 139 establishes minimum standards for aircraft rescue and firefighting (ARFF) equipment based on the number, frequency, and size of passenger-carrying aircraft that use the airport. Index E refers to ARFF requirements for airports used by air carrier aircraft of at least 200 feet in length.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 14 emergency communications systems on the airport, including fire alarms; • use of the fire hoses, nozzles, turrets, and other required appliances; • application of types of required extinguishing agents; • emergency aircraft evacuation assistance; • firefighting operations; • adaptation and use of structural rescue and firefighting equipment for ARFF; • aircraft cargo hazards, including hazardous materials/dangerous goods (DG) • incidents; and familiarization with firefighters’ duties under the AEP. • According to the PHL ARFF training officer, the facility had no formal training syllabus or curriculum for its in-house training. He stated that, for its in-house training, the facility used PowerPoint presentations from other airports’ training curricula, an FAA ARFF training compact disc (CD), and a Specialized Aircraft Fire Training (SAFT) mockup, which is shaped like a Boeing 737. Aircraft Familiarization Training and Equipment Use Training 1.10.1.2  FAA Advisory Circular (AC) 150/5210-17A, “Programs for Training of Aircraft Rescue and Firefighting Personnel,” dated April 28, 2006, provides guidance on how to meet the provisions of 14 CFR 139.139(i) and details on what should be included in the training program for each of the FAA-required subject areas. Regarding aircraft familiarization training, AC 150/5210-17A recommends that ARFF personnel be trained such that they are able to “identify the types of aircraft operating at the airport . . . [and] locate normal entry doors, emergency exit openings, and evacuation slides for a given aircraft.” According to a captain at the PHL ARFF facility, at the time of the accident, ARFF personnel received passenger aircraft familiarization training. However, PHL did not schedule cargo aircraft familiarization training, including training on the operation of the doors of the aircraft used by UPS, for the other cargo operators who operate at the airport; these operators include Federal Express Corporation (FedEx), DHL, and BAX Global. PHL ARFF personnel experienced problems opening the main cargo door during the emergency response. Regarding training on ARFF equipment use, AC 150/5210-17A states that ARFF personnel should be able to “identify the proper procedures for use and maintenance of each hose, nozzle, and adapter used locally.” AC 150/5220-10C, “Guide Specification for Water/Foam Aircraft Rescue and Firefighting Vehicles,” dated February 18, 2002, also

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 15 addresses equipment training. However, neither AC specifically addresses the use of a high-reach extendable turret with skin-penetrating nozzle (HRET/SPN).24 In 2005, the FAA conducted research to evaluate and compare the ability of ARFF vehicles to extinguish a fire using a roof turret and handlines or an HRET/SPN. In its final report on this research, the FAA concluded that, in all aspects of the evaluation, the HRET/SPN outperformed the standard roof-mounted turret and handline, including the ability to control and contain the spread of interior fire and reduce high cabin temperatures.25 In its Aircraft Rescue and Fire Fighting Computer-Based Training CD,26 the FAA indicated that the “successful use of elevating waterways and aircraft skin penetrating nozzles is dependent on the skill level and dexterity of the operator.” Additionally, the International Fire Service Training Association’s (IFSTA) textbook, Aircraft Rescue and Fire Fighting,27 states that HRET/SPNs are complicated devices to operate and that drivers and operators will require continual training in their operations, tactics, and strategies. Interviews with an HRET/SPN manufacturer revealed that it has developed a computer‑based training simulator program that uses an HRET/SPN joystick and foot- pedal mockup. According to the manufacturer, this training program is “self-teaching” and allows beginner students or advanced operators to practice the skills needed to successfully operate the HRET/SPN and to progress and test skills at their own pace. According to the manufacturer, it has delivered about 150 HRET/SPNs to U.S. airports, and 11 of these airports, not including PHL, have the training simulator. The PHL ARFF facility obtained an HRET/SPN in 1991. At the time of the accident, the facility had a small general aviation airplane that ARFF personnel used to practice penetrating the fuselage with the HRET/SPN. The facility currently uses a SAFT, which is designed to allow a piece of sheet metal to be inserted into its side, for piercing practice. PHL ARFF did not routinely practice hands-on HRET/SPN piercing skills. PHL ARFF personnel used an HRET/SPN during the emergency response for this accident and experienced some difficulties with its use. Section 1.15.2 discusses the problems PHL ARFF personnel had trying to open the main cargo door and using the HRET/SPN during the emergency response. Postaccident Aircraft Rescue and Firefighting Training Changes 1.10.1.3  After the accident, PHL ARFF personnel began conducting cargo aircraft familiarization training, which included procedures on the manual operation of the 24  An HRET/SPN is a piece of equipment that can be attached to some ARFF vehicles to improve firefighting capabilities inside aircraft. The device consists of an elevated extendable boom and a multifunction nozzle/turret, which can be equipped with options such as piercing tips of varying lengths, aerial nozzles, halogen lights, a color video camera, and a forward-looking infrared camera. 25  U.S. Department of Transportation, Federal Aviation Administration, High-Reach Extendable Turrets with Skin-Penetrating Nozzle, DOT/AR-05/53 (Washington, DC: FAA, 2005). 26  U.S. Department of Transportation, Federal Aviation Administration, ARFF: Aircraft Rescue and Fire Fighting Computer-Based Training, Version 1.0 (Washington, DC: FAA, 2002). 27  International Fire Service Training Association, Aircraft Rescue and Fire Fighting, 4th Edition (Still Water, Oklahoma: IFSTA, 2001).

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 16 main cargo door, at UPS and the other cargo operators at PHL. All ARFF personnel have completed the aircraft familiarization training on the aircraft operated by UPS and are conducting familiarization training with the other cargo operators at PHL as airplanes become available (for example, during layovers or overnight parking). PHL training records have been modified to show when the training has been completed. According to the PHL ARFF training officer, cargo aircraft familiarization training will be continued as part of PHL’s initial and annual training for all ARFF personnel. In addition, UPS provided PHL ARFF with Emergency Rescue Response diagrams, which provide information on the locations and operation of exits and doors, including the cargo compartment doors, for all of the airplanes it operates out of PHL, including the DC-8. Since the accident, these diagrams have also been uploaded to a laptop computer carried in the PHL command vehicle. However, a review of the DC-8 diagrams by National Transportation Safety Board investigators revealed that they did not accurately depict the DC-8 accident airplane. For example, a general note on one of the diagrams states that there is a “2-inch wide band of contrasting color indicating all doors, hatches and windows [are] externally operable.” However, the airplane did not have the 2-inch contrasting color band. Further the diagram showed the deactivated aft overwing hatches as “externally operable,” and the diagram providing guidance on the operation of the main cargo door does not mention that the vent door must be opened before any of the listed steps can be successfully performed. Flight Recorders 1.11  Cockpit Voice Recorder 1.11.1  The accident airplane was equipped with a Fairchild Model A-100 CVR. The CVR was sent to the Safety Board’s laboratory in Washington, D.C., for readout and evaluation. The exterior of the CVR exhibited heat damage, but the interior was undamaged. The tape was played back normally and without difficulty. The recording consisted of four separate channels: the captain, first officer, and second officer audio panels and the cockpit area microphone (CAM). The captain and first officer audio panels provided fair quality audio information, and the CAM and second officer audio panels provided good quality audio information.28 A transcript was prepared of the entire 31‑minute, 17-second recording (see appendix B). Flight Data Recorder 1.11.2  The accident airplane was equipped with a solid-state L3 Communications Fairchild model F-1000 flight data recorder (FDR). The exterior of the FDR exhibited smoke and 28  The Safety Board rates the quality of CVR recordings according to a five-category scale: excellent, good, fair, poor, and unusable. See appendix B for a description of these ratings.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 17 heat damage, but the interior was undamaged. The FDR was sent to the Safety Board’s laboratory for readout and evaluation. The FDR recorded data for the entire accident flight. Seventeen parameters were recorded by the FDR. Throughout the last 2 minutes 17 seconds of the flight, data for 12 of the parameters became unreliable. Wreckage and Impact Information 1.12  No impact occurred during the landing of the airplane. All of the airplane and cargo damage resulted from the fire, and this damage is discussed in section 1.14. Medical and Pathological Information 1.13  Specimens were obtained from the captain, first officer, and flight engineer and were tested by UPS. The specimens tested negative for alcohol and drugs of abuse.29 Fire 1.14  Examination of the airplane’s wiring revealed no fused wires, metal balls (beading) on the ends of broken wires, or other indications consistent with an electrical short circuit or fire initiation. Fire Damage to Exterior Fuselage 1.14.1  The fuselage had two complete burnthrough holes in the crown (located over cargo containers 12, 13, and 14 and 15 and 16) and two areas of partial burnthrough (located at cargo containers 12 and 17)30 on the right side of the airplane aft of the wing. (See figure 3 for a photograph showing the fire damage to the fuselage.) Except for the areas around the two complete burnthrough holes, the exterior paint was mostly present. The area around the forward entrance door, the four overwing hatches, and the right aft service door was sooted. The paint around the main outflow valve was heavily sooted and lightly bubbled. No other significant exterior damage to the airplane was noted. 29  In accordance with the requirements of the National Institute for Drug Abuse, the drugs tested for by UPS included marijuana, cocaine, opiates, phencyclidine, and amphetamines. 30  A complete burnthrough means that large portions of fuselage material are missing and significant structural damage has occurred. A partial burnthrough means that the fuselage skin has ruptured but that little structural damage has occurred.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 18 Damage to the fuselage crown. Figure 3.  Fire Damage to Lower Cargo Compartments 1.14.2  No smoke or heat damage was observed inside the lower cargo compartments. Areas behind the cargo liners were also examined, and no signs of soot or thermal damage were found in compartments 31, 32, or 34. Some of the structure behind the sides of the cargo liner in compartment 33 was sooted, and examinations of the soot deposits revealed progressively heavier sooting toward the front end of the compartment and lighter sooting toward the aft end. Melted aluminum and Lexan material (a heavy-duty plastic used for the cargo container walls), which had dripped down through the floor vents above the container, had also adhered to some of the structure behind the liner. The entire underside of the ceiling above compartment 33 exhibited soot. No discernible smoke patterns were found. Fire Damage to Fuselage Interior and Main Cargo 1.14.3  Compartment The main cargo compartment forward of container 8 was heavily sooted but structurally intact. Progressively more fire damage to the cargo compartment was documented moving aft from container positions 8 to 12. Upper portions of most of the fuselage frames from near the middle of cargo container 8 to the middle of container 12

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 19 had been consumed by fire, and the upper structure was sagging in several areas above containers 9, 10, and 11. None of the individual container floors or the main cargo compartment floor exhibited fire damage. (See figure 1.) Fuselage structure above cargo containers 12 to 14 exhibited severe thermal damage. Fire had consumed the upper portions of the fuselage frames above the forward section of container 12, and the skin was sagging in these areas. Severe thermal damage to the right fuselage adjacent to container 12 extended down to the floor and included a small burnthrough of the skin located near the bottom of the window. Most of the upper frame structure and a portion of the fuselage crown above containers 12 and 13 had been destroyed by fire. The fuselage crown had been burned through, and several of the upper frames had been destroyed in the areas above container 13 and the forward portion of container 14. A large area of the fuselage crown over the aft portion of container 15 and the forward portion of container 16 had been consumed by fire, and the fuselage skin was sagging around the perimeter of the burned area. The area of the burnthrough extended down to just above the windows on the left side of the fuselage. Thermal damage to the fuselage extended from the crown to the windows on the right side of the fuselage, adjacent to container 17, and included a small burnthrough of the fuselage skin. Fire Damage to Main Cargo Compartment Containers and 1.14.4  Contents Main cargo compartment containers 1 to 17 were similar in size and construction and comprised an aluminum floor, frame, and roof and Lexan walls. Cargo position 18 consisted of a flat aluminum cargo sheet. The container contents, except for those in containers 15 and 18, primarily consisted of shipments packaged in cardboard boxes. Cargo container 15 was loaded with a large shipment of bulk paper, and container 18 was loaded with boxed spools of extruded thread on top of which hydraulic valves were placed, all of which were wrapped with shrink‑wrap. Fire damage to the cargo containers varied from the forward-most containers, which exhibited minor sooting, to the containers adjacent to and aft of the wings, which exhibited the most severe thermal damage and consumed material. The severity of the fire damage to the cargo containers was greatest to those containers starting just aft of the overwing hatches, from cargo containers 8 and 9, to the aft end of the main cargo compartment, aft of cargo container 18. Examinations revealed that the heaviest fire damage to the interior and the cargo container contents occurred between cargo containers 12 and 17 and that the lowest point of fire damage to the fuselage occurred on the right side of the airplane near cargo container 12. Table 2 summarizes the damage to each of the main cargo containers, liners, and contents. Numerous items were removed from the main cargo compartment and sent to the Safety Board’s Materials Laboratory in Washington, D.C., for further examination. See section 1.16.1 for more information about these items and the laboratory examinations.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 20 Summary of damage to main cargo containers, liners, and contents. Table 2.  Container Number Fire Damage to Container and Liners Fire Damage to Container Contents 1 The container was intact. The roof, upper portion of the curtain, and the ceiling liner were sooted. The curtain is located between the two front walls. No fire damage was observed. 2 The container was intact. The roof, upper portion of the curtain, and the ceiling liner were sooted. No fire damage was observed. 3 The forward wall was warped along the top, and the roof was sagging. The ceiling liner was sooted. No fire damage was observed. 4 The upper portions of the forward wall were sagging. The aft wall was melted along the top and was sagging to midheight. The roof was sooted and sagging. The ceiling liner was sooted. The container was empty. 5 The forward wall was sagging, and other walls were heavily sooted. The roof was heavily sooted and sagging. The ceiling liner was sooted. No fire damage was observed. 6 The forward and aft walls were melted and sagging down to midheight. The container frame was intact. The right side of the ceiling liner was sooted. Smoke damage to the contents was observed. Several packages in the aft portion of the container were singed. 7 The forward and aft walls were melted down to midheight. The roof was burned through. The upper halves of both sidewalls were sooted. The aft portion of the ceiling liner was hanging down. Smoke damage to the contents was observed. The contents were not damaged by fire because they only filled the container to midheight. 8 Portions of the forward wall were melted or consumed by fire. The roof was melted. The aft panels were consumed by fire, except for a small portion in the aft left corner. The ceiling liner was consumed by fire. Fire damage, mainly to the exposed tops and sides of some of the contents, was observed. 9 Most of the forward wall and roof were consumed by fire. The aft panels were consumed by fire, except for a small portion in the center of the panel near the floor. The ceiling liner was consumed by fire. The contents on the left side of the container exhibited the most damage, extending to a depth of about 12 to 18 inches. In the lesser- damaged areas, the damage only extended to midheight. 10 The roof, walls, and framing were consumed by fire down to midheight. The ceiling was consumed by fire. The contents on the right side of the container exhibited the most fire damage. Fire damage to the contents extended to a depth of about 12 to 18 inches at the lowest level of damage. 11 Most of the container was destroyed by fire. The floor was intact. The ceiling was consumed by fire. The contents in the aft portion of the container exhibited the most fire damage. The damage to the contents extended to a depth of about 12 inches at the lowest level of damage.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 21 Container Number Fire Damage to Container and Liners Fire Damage to Container Contents 12 Most of the container walls and roof were destroyed by fire, except in the aft left corner. The floor was intact. The ceiling liner was consumed by fire. The fire damage was heaviest around the edges of the container and between the right forward corner and center of container. Fire damage to the center contents extended to a depth of about 18 to 24 inches, and the rest of the contents were damaged down to the floor of the container. 13 The lower left wall remained intact but was melted down to midheight. The roof was destroyed, except for the aft left corner. The rest of the container walls were consumed by fire, and the remaining framing was burned down to midheight. The ceiling was consumed by fire. Fire damage to the contents extended to a depth of about 12 inches in the right forward corner and to midheight in the aft left corner. 14 The left wall and the door were melted down to midheight. The rest of the container and the ceiling liner were consumed by fire. Fire damage to the contents in the right aft corner extended to a depth of about 12 inches. The remaining contents exhibited less fire damage. 15 The roof and most of the walls were consumed by fire. The framing was melted down past midheight. The ceiling liner was consumed by fire. Most of the contents were intact. Some fire damage to the exposed outer surfaces was observed. 16 The roof, most of the walls, and the ceiling lining were consumed by fire. Fire damage to all of the contents extended to a depth of about 12 inches. 17 The upper half of the aft wall was melted and sagging. The roof was consumed by fire, except for the aft left corner. The ceiling was consumed by fire. The contents near the front and sides of the container exhibited the heaviest damage, and the damage extended to a depth of about 12 inches. The damage to the contents lessened toward the middle of the container. 18 The pallet was intact and exhibited no smoke or fire damage. The ceiling liner was consumed by fire. Some of the contents were destroyed by fire. Fire damage to the remaining contents extended to a depth of about 12 inches. Survival Aspects 1.15  Emergency Evacuation 1.15.1  After the airplane landed and stopped, the flight crew conducted the Emergency Evacuation checklist and then proceeded to evacuate the airplane. During postaccident interviews, the flight engineer stated that he took a breath of oxygen from his mask before evacuating and that he then went to open the L1 door. He stated that he reached down and deployed the L1 door slide and evacuated using the slide and that he then yelled back to the other flight crewmembers that the slide was “good.” The first officer stated that he leaned out his window to get fresh air but that he inhaled smoke. The first officer stated that, after he transmitted to the ATCT that they were evacuating the airplane, the smoke was so heavy that he could not see his hand in front of

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 22 him. He stated that he grabbed his flashlight and reached behind the captain’s seat for the notice to captain (NOTOC),31 which is typically contained in an air DG envelope behind the captain’s seat, but could not locate it. He proceeded to evacuate using the L1 door slide while black smoke was rolling out of the door. He stated that, after he evacuated the airplane, he could see black smoke billowing out of the windows and the door but that there were neither flames nor heat. The captain stated that, after the airplane came to a stop, he heard the L1 door slide deploy. He stated that he reached behind him, grabbed the escape rope, opened the window, and threw the rope through the window. He stated that, although he had initially planned on using the escape rope to evacuate the airplane, he decided to use the L1 slide because he wanted to make sure that the first officer got out of the airplane. The captain stated that he searched around behind his seat but was unable to locate the NOTOC. The captain stated that he became concerned about whether the first officer had exited the airplane, so he then headed toward the galley area behind the cockpit. He stated that he did not see the first officer and evacuated the airplane via the L1 door slide. The captain stated that the ARFF vehicles were waiting when he evacuated the airplane and that he informed ARFF personnel that there were hazardous materials on board and that he had not been able to locate the NOTOC. After the three flight crewmembers safely evacuated the airplane, they were transported to a local hospital and treated for smoke inhalation. Emergency Response 1.15.2  Immediately after being notified by the captain of the cargo smoke indication, the tower controller activated the crash phone to announce an Alert  132 to the PHL Airport Operations Center, the PHL ARFF facility, and the Philadelphia Fire Department. Originally, the ARFF vehicles were headed to the standby positions for runway 27L; however, the change in landing runways (from 27L to 27R) resulted in a subsequent change in standby positions. ARFF personnel reported that the change in runways resulted in a 60- to 90‑second delay in responding to the accident scene. Seven PHL ARFF vehicles responded. According to postaccident interviews with ARFF personnel, the airplane came to a complete stop on runway 27R as the ARFF units approached. They reported that no fire was visible at that point but that smoke could be seen emanating from the open L1 door and the outflow vent in the tail. 31  Title 49 CFR 175.33 requires operators to provide the PIC with certain information about hazardous materials on board the flight, in writing, before departure. UPS satisfies this requirement through the use of a NOTOC, which contains the shipping documentation describing the hazardous materials on the airplane, including the customer‑prepared shipping papers that accompany each hazardous materials package. The shipping papers include, in part, a shipping description, package reference and UPS account number, label information, and shipper’s certification. For more information about UPS’ on-board hazardous materials procedures, see section 1.17.2. 32  According to the PHL Airport Certification Manual, an Alert 1 indicates a reported aircraft emergency or problem (for example, a hydraulic failure or bad gear indication).

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 23 After the flight crew had evacuated the airplane, ARFF personnel entered the flight deck area through the L1 door. ARFF personnel pulled back the smoke curtain and observed smoke in the main cargo compartment; however, no fire was observed. ARFF personnel opened all of the lower cargo compartments to look for smoke and fire, and no smoke or fire was observed. ARFF personnel also opened the L4 door and then the R4 door, through which they off-loaded some cargo and began water extinguishment operations. The incident commander used a thermal imaging camera to locate hot spots but observed none at this time. Several attempts were made by ARFF personnel to open the main cargo door by rotating the lockpin handle on the exterior of the door. However, because they could not rotate the handle, they used a Halligan tool33 to force the handle’s movement, which caused the handle to spin freely and rendered it ineffective. Subsequent attempts to open the main cargo door, including efforts to manually operate the door’s hydraulic system and to cut through the door’s mechanical latches, were also unsuccessful. About 0040, ARFF personnel opened the right forward overwing hatch using its handle. Flames were observed just aft of the hatch opening, between the tops of the cargo containers and the cabin ceiling. Shortly thereafter, a firefighter began opening the right aft hatch using an axe.34 ARFF personnel began attacking the fire through the right hatch openings by aiming a water‑charged handline over the top of the cargo containers. ARFF personnel subsequently opened the left forward overwing hatch using the handle and the deactivated left aft hatch using an axe. After the left hatches were opened, ARFF personnel began using a water-charged handline from that side. A thermal imaging camera was again used to locate hot spots to determine where HRET/SPN piercing operations should be concentrated.35 After locating a hot spot on the crown on the right side of the airplane, forward of the wing, ARFF personnel began piercing attempts at this location. After unsuccessful piercing attempts in which the nozzle tip slipped and moved out of place, the ARFF vehicle was repositioned aft of the right wing, and another attempt was made to pierce the top of the airplane; however, the nozzle tip again slipped and moved out of place. Piercing operations with the HRET/SPN moved to the left side of the airplane and were successful, and water was applied to the interior of the airplane. The piercing locations began aft of the aft overwing hatch, continued aft toward the tail, and were just above the windows. While piercing operations were conducted on the left side of 33  A Halligan tool is a multipurpose tool commonly used in ARFF responses for prying, twisting, punching, or striking. The tool has a fork at one end and a wedge and tapered pick on the other. 34  At the time of the accident, the Emergency Response diagrams that the ARFF responders had were for the passenger version, not the cargo version, of the DC-8 and did not show which hatches were deactivated. ARFF responders stated that they did not know that some of the hatches were deactivated and their handles inoperable. 35  According to one of the fire chiefs, burnthrough had not yet occurred at the time that the thermal imaging and piercing operations began.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 24 the airplane, aqueous film-forming foam (AFFF)36 was also directed through the R4 door opening. The first fuselage burnthrough occurred about 0200 and was located in the crown of the fuselage aft of the wings. About this time (about 2 hours after landing), ARFF units began discharging AFFF from the HRET/SPN’s primary turret through the pierced skin of the airplane and the area of the fuselage that had burned through. All of the fire was located between the overwing hatches and the tail of the airplane. The fire was characterized as being “fully involved” around 0220. ARFF personnel reported that the fire was under control about 0407. Hazardous Materials Information Retrieval 1.15.3  As noted, during the evacuation, both the captain and the first officer were unsuccessful in their attempts to locate the NOTOC, which they believed should have been behind the captain’s seat. The flight engineer stated that the NOTOC fell onto the floor during the flight and that he picked it up and “wedged it in the crash axe sheath on the bulkhead aft of the flight engineer’s station.” After a firefighter entered the cockpit and could not locate the NOTOC, the incident commander requested that an airport operations duty officer obtain a flight manifest from UPS so that the hazardous materials could be identified. The duty officer returned to the accident scene with information about the location of the hazardous materials on board the airplane (but not the type of hazardous materials), as provided by a UPS ramp supervisor. The duty officer told ARFF personnel that he could not specifically identify the hazardous materials on the airplane because the UPS ramp supervisor had indicated that such information is only contained in the NOTOC. The UPS representative then told a firefighter that the NOTOC should be either in the pocket behind the captain’s seat or in a pouch on the wall behind the cockpit. Subsequently, a firefighter reentered the cockpit, eventually located the NOTOC, and threw it out of the airplane. The UPS representative stated that he picked up the NOTOC and provided the information to the incident commander. At this point, about 35 minutes had passed since the airplane had landed. No record was found indicating that any information was exchanged on the day of the accident between UPS personnel at PHL and Flight Control in Louisville, Kentucky, which is responsible for providing information to ARFF personnel regarding the hazardous materials loaded on board an aircraft during in-flight emergencies. The only copy of the NOTOC present at the scene postaccident was the original copy of the documentation recovered from the airplane. 36  According to an ARFF representative, extinguishing operations initially used water because they were unsure which hazardous materials were on board and because the AFFF was being saved to fight a possible fuel-fed fire.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 25 Tests and Research 1.16  Laboratory Examinations of the Main Cargo Container 1.16.1  Contents About 34 items were removed from the main cargo compartment for further examination at the Safety Board’s Materials Laboratory.37 These items included numerous laptop computers of various makes and models, secondary (lithium-ion) lithium battery packs,38 several loose secondary lithium battery cells, several unidentified electronic devices without power supplies, and one electronic device with a power supply. The exact location of these items when originally loaded could not be determined because they might have been moved from their original locations during firefighting efforts. Each item was photographed and examined in detail, and its condition was fully documented. Some items were taken apart to examine the interior components. Most of the laptop computer outer cases were sooted and melted. All of the batteries within the laptop computers were found intact. Almost all of the secondary lithium battery packs were found intact. Several of the laptop batteries exhibited a white substance on their caps, and a few exhibited slight bulging. The loose secondary lithium battery cells were found intact with some extrusion through the caps and slight bulging. All of the unidentified electronic devices were sooted and scorched, and some of the material was consumed by fire. The secondary lithium battery in the powered electronic device was found intact and exhibited a white substance on the cap. Shipment Identification Effort 1.16.2  Because the fire damage was greatest in cargo containers 12, 13, 14, 16, and 17, efforts were made to identify the items shipped in these containers.39 A joint group consisting of Safety Board investigators and FAA and UPS representatives attempted to contact each shipper by telephone. Most of the shippers were contacted and were able to provide some information on the contents of the packages. As a result of the calls, about 25 of the items were identified as electronic devices that potentially contained batteries, including laptop computers, two uninterrupted power supplies, a digital video recorder, and several credit card readers and bar code scanners. The remainder of the items were identified as general freight, including clothing, food, machine parts, CDs, digital video discs, medical supplies, documents, and computer parts. Many of the shippers could not be contacted. Seventy-three of the items, including most of the laptop computers,40 were identified by claim information provided by UPS, 37  Investigators eliminated completely intact and identifiable items or damaged items in which the internal power source was intact and undamaged. 38  There are basically two types of lithium batteries: secondary (rechargeable) and primary (nonrechargeable). For more information about lithium batteries, see section 1.18.6. 39  All of the cargo in containers 15 and 18 was accounted for during the on-scene examination. 40  The claim information for the laptop computers did not have the manufacturer information.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 26 and 184 of the items had no claim information and could not be identified. None of the contacted shippers stated that they shipped any items that would be regulated by the Department of Transportation (DOT) as a hazardous material. Hazardous Materials Identification 1.16.3  Two packages of declared hazardous materials were recovered during the initial phase of the cargo debris examination. According to the material safety data sheets provided by UPS for these items, a class 3 flammable liquid was located in cargo container 3, and a consumer commodity shipment41 was located in cargo container 14. Both items were found in their original outer packaging: DOT-authorized fiberboard boxes, which were properly labeled. The contents were found completely intact and undamaged. In addition, UPS records indicated that dry ice (class 9 miscellaneous hazardous material) was located in main cargo container 8 and lower cargo compartment 33. Additional hazardous materials were also found during the examinations of the cargo debris, but the items had not been declared as hazardous materials and, therefore, had not been included in the flight manifest. These undeclared items included an uninterruptible power source (class 8 corrosive material) located in cargo container 11, neoseal gasket cement (class 3 flammable liquid) located in cargo container 13, and a flexible utility lighter with butane refill (division 2.1 flammable gas), nail polish remover (class 3 flammable liquid), and an unidentified polish remover (hazardous class unknown), all located in cargo container 17. All of the items were found completely intact, except for the uninterruptible power source and the various plastic polish remover bottles. The uninterruptible power source was found relatively intact, with its outer casing partially melted. The nail polish remover bottles were found moderately melted, and the unidentified polish remover bottles were found mostly melted. Organizational and Management Information 1.17  UPS is a global package delivery service operating in more than 200 countries and territories worldwide. The company’s corporate office is in Atlanta, Georgia, and the airline is based in Louisville, Kentucky. At the time of the accident, UPS operated a fleet of airplanes consisting of Airbus 300s; Boeing 727s, 747s, 757s, and 767s; DC-8s; and McDonnell Douglas MD‑11s. Operational Guidance 1.17.1  The UPS DC-8 AOM contains emergency and abnormal checklists and procedures. The AOM states, “the first priority is always to fly the airplane and maintain control.” The manual also states the following: 41  Title 49 CFR 171.8 defines a consumer commodity as “any material that is packaged and distributed in a form intended or suitable for sale through retail sales agencies or instrumentalities for consumption by individuals for purposes of personal care or household use.”

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 27 the successful handling of emergencies is largely dependent on proper cockpit resource management under the leadership of the captain . . . the pilot flying initially determines the exact nature of the problem and calls for a specific emergency or abnormal checklist. In the event the first officer is PF [pilot flying] when a malfunction occurs, decision[s] regarding which checklist to accomplish . . . are always subject to final determination by the captain. Further, the AOM states, “it is not possible to develop a procedure for all conceivable situations . . . crews may have to combine elements of more than one procedure or exercise judgment to determine the safest course of action.” The AOM contains four checklists that could have been applied to address the situation on the accident flight: the Pack Smoke checklist, the Fumes Evacuation checklist, the Lower and/or Main Cargo Compartment Smoke or Fire checklist, and the Smoke of Unknown Origin or Suspected Electrical Fire checklist.42 Pack Smoke Checklist 1.17.1.1  According to the UPS DC-8 AOM, smoke entering the cockpit through the air conditioning ducts can generally be attributed to one of the engines, one of the air conditioning packs, or the air conditioning ducting. The manual states that the Pack Smoke checklist procedures are geared to identify the air conditioning pack or engine from which the smoke is emanating and then to either turn it off or cut off its bleed air output. The first few steps of the Pack Smoke checklist are as follows: don oxygen masks and smoke goggles, • turn off the recirculation fan, • close the pneumatic crossfeed valve, and • turn off each air conditioning pack to try and identify the faulty pack. • 43 The checklist states that, if the smoke dissipates, the flight crew should leave the identified pack off and make specified operational adjustments to cruise altitude and/or operable pack flow as necessary. Fumes Evacuation Checklist 1.17.1.2  The UPS DC-8 AOM contains a Fumes Evacuation checklist; however, the manual does not provide guidance on when to use the checklist. The Fumes Evacuation checklist includes, in part, the following steps: don oxygen masks (set to 100 percent and ON) and goggles, • 42  The Quick Reference Handbook in the cockpit, which is available for rapid recovery and reference by the flight crew, also contained these four emergency checklists. 43  The manual states that, after turning off an air conditioning pack, it is necessary to wait about 30 to 60 seconds to see if the smoke clears.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 28 turn air conditioning packs on and set at maximum flow (to provide maximum • airflow through the aircraft to reduce the concentration of fumes), turn off the recirculation fan (to prevent fumes from being introduced into air • distribution ducts and contaminating the flow of fresh pack air), close cockpit door and louvers (to create a barrier between the flight station • and the cargo compartment; airflow will move toward the tail of the aircraft, reducing fumes in the cockpit), fully open all cockpit air outlets (to provide maximum airflow through the • cockpit), initiate descent to 10,000 feet (to begin to reduce cabin differential pressure), • maintain cabin altitude (Manually maintaining the cabin altitude at the existing • altitude reduces cabin differential pressure. Increasing cabin differential will reduce airflow through the aircraft and may increase fume concentration. A higher cabin altitude could increase evaporation or aggravate leakage of the substance causing fumes.), and evacuate aircraft as required. • Further, the Fumes Evacuation checklist in UPS’ Quick Reference Handbook (QRH) has an additional step stating that, after maintaining cabin altitude, the flight crew should land the airplane as soon as possible. This step was highlighted by a revision bar in the QRH dated December 1, 2005, which was effective at the time of the accident. UPS indicated that this step was added to the QRH as a result of the September 2, 1998, Swissair Transport Limited accident involving an MD-11.44 Lower and/or Main Cargo Compartment Smoke or Fire Checklist 1.17.1.3  According to the Lower and/or Main Cargo Compartment Smoke or Fire checklist contained in the UPS DC-8 AOM, when smoke and/or fire are detected in the aircraft, all flight crewmembers must don their oxygen masks and smoke goggles as soon as possible. The checklist states that, if a warning in the cockpit indicates lower cargo smoke or fire and/or main cargo compartment smoke or fire, the following steps should be taken: shut off one air conditioning pack and select minimum flow for the other • pack, turn off the recirculation fan, • open the overhead diffuser valves, • close the main cargo air shutoff valve, • close the cockpit doors and louvers, • turn off the radio rack blower switch, • 44  For more information, see Transportation Safety Board of Canada, In-flight Fire Leading to Collision with Water, Swissair Transport Limited, McDonnell Douglas MD-11, HB-IWF, Peggy’s Cove, Nova Scotia, 5 nm SW, 2 September 1998, Aviation Investigation Report A98H0003 (Quebec, Canada: TSB, 2003).

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 29 manually set and maintain cabin differential pressure at 0.5 pounds per square • inch, and land as soon as possible. • The checklist contains additional steps to take if an immediate landing is not possible or if the cabin altitude exceeds certain limits. After the accident, UPS revised its Lower and/or Main Cargo Compartment Smoke or Fire checklist (effective August 1, 2006) by renaming it the “Cargo Smoke or Fire” checklist and changing the second step of the checklist to “land as soon as possible.” Further, the revised checklist was expanded to incorporate both the Approach and Landing checklists. Smoke of Unknown Origin or Suspected Electrical Fire Checklist 1.17.1.4  The UPS DC-8 AOM states that, before starting the checklist, all cockpit indications must be checked to ensure that the fire is electrical in nature (or unknown) and not related to another source, such as cargo fire or air conditioning packs. The manual states that, if the smoke or fire is not electrical in nature, the Cargo Smoke and Lower Cargo Fire lights and the cockpit air conditioning outlets should be checked. The AOM further states that all electrical indications must be thoroughly scanned to note any obvious signs of electrical anomaly. The checklist contains the following steps, in part: put on oxygen masks and goggles, • notify ATC, • land as soon as possible, • lock the manual pressure control lever, and • turn off the recirculation fan. • The procedure continues with additional steps to isolate the electrical source of the smoke or suspected electrical fire. On-Board Hazardous Materials Procedures 1.17.2  As noted, UPS uses a NOTOC to provide all shipping documentation about the hazardous materials on the airplane to the PIC. The NOTOC consists of customer-prepared shipping papers, which accompany each hazardous materials package and are placed inside individual container pouches. The shipping papers include, in part, a shipping description, package reference and UPS account number, label information, and shipper’s certification. According to the UPS Flight Operations Manual (FOM) in effect at the time of the accident, company acceptance auditors review the shipping papers for accuracy and completeness before hazardous materials shipments are accepted from customers and loaded onto the airplane. The FOM further states that pilots should familiarize themselves

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 30 with the hazardous materials shipments on board and their container positions. The NOTOC is provided to the captain by the load supervisor before departure. The FOM also states that the NOTOC should be placed in an air DG envelope and that the envelope should be located at some easily accessible location in the cockpit. The UPS FOM states that, if an emergency is declared and hazardous materials are on board the airplane, ARFF personnel should be informed of the nature and location of the materials, if practicable. The manual also states that the DG envelope should be taken off the airplane by the flight crew during egress and given to ARFF personnel. The UPS corporate regulated goods manager testified at the Safety Board’s public hearing on the UPS accident, which was held in Washington, D.C., on July 12 and 13, 2006, that UPS’ Flight Control Group in Louisville, Kentucky, is responsible for providing information to ARFF personnel regarding the hazardous materials loaded on board an aircraft during in-flight emergencies, upon request, and that no specific individual is responsible for contacting Flight Control about an emergency. He indicated that the call could be made by ATC, a flight crewmember, or UPS ground personnel and that, if the airplane landed at an airport other than its destination, ATC or the flight crew would be responsible for contacting Flight Control. He stated that, once a request is received, Flight Control retrieves the information from UPS’ Hazardous Materials Information System (HMIS) and proceeds to either e-mail or fax the information to the destination or emergency airport to ensure that the information can be relayed to ARFF responders. The HMIS was available at PHL when the accident occurred. However, only some UPS personnel were authorized to use it, and they had limited access, which allowed them to view only the number and location of DG shipments on board an aircraft. Further, UPS personnel at PHL were not directed to retrieve the information from the HMIS because all inquiries are supposed to go through Flight Control. Postaccident Actions 1.17.3  Since the accident, UPS has revised its FOM, Airport Operations Methods Manual (AOMM), and Airline Emergency Response Manual, which guide flight crews, ground personnel at UPS gateways, and Flight Control personnel, respectively. On April 14, 2006, UPS published Must Read Bulletin 06-11, which informed flight crews of Flight Control’s capabilities and clarified Flight Control’s accessibility to both UPS and outside parties in emergency situations. The information contained in this bulletin was subsequently incorporated into the company’s FOM, effective November 15,

1. The new paragraph incorporated into the FOM states the following:

From the duration of block-out to block-in, UPS Flight Control personnel have access to an electronic database regarding the type, quantity and load position of Dangerous Goods aboard each aircraft. If necessary during an in-flight emergency, the Flight Crew can provide the following telephone contact number . . . when addressing outside inquiries from ARFF

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 31 personnel or other persons deemed necessary as to the Dangerous Goods being transported aboard aircraft. UPS revised its AOMM, effective June 23, 2006, to instruct UPS airport personnel to contact Flight Control for hazardous materials information in the event of an emergency. The revised AOMM included the following language: Contact Flight Control for an inventory of any hazardous material transported aboard the aircraft involved in the incident. This information should be made available to airport rescue, firefighting and/or control tower personnel upon request. NOTE: Flight Control personnel have access to the type, quantity and load position of any hazardous material utilizing the Hazardous Material Information System (HMIS). UPS revised the emergency response checklist for the Flight Control shift manager, which is found in both the Airport Emergency Response Manual and the Flight Control Department Procedure Manual, effective June 30, 2006, to ensure that hazardous materials information is disseminated to the appropriate parties as quickly as possible. The checklist now requires that the shift manager check HMIS to identify any hazardous materials on board an airplane immediately upon notification of an emergency; communicate to ARFF the results of the search, indicating whether hazardous materials are on board; if unable to contact ARFF, contact the ATCT; and record the name and time of contact. Additional Information 1.18  Industry Initiatives on Smoke, Fire, and Fumes Checklist 1.18.1  Procedures In late 2004, the Flight Safety Foundation began an international initiative to improve checklist procedures for airline pilots confronting smoke, fire, or fumes when no alerts are annunciated in the cockpit.45 Manufacturers, airlines, pilots, and government representatives participated in the initiative, which included conference calls, workshops, 45  The industry initiative was developed partially in response to the 1998 Swissair accident at Peggy’s Cove, Nova Scotia, Canada, in which a momentary smoke event evolved, after several minutes, into a sudden and severe in-flight fire. As a result of this accident, the Transportation Safety Board of Canada (TSB) issued Recommendation A00-18 to Transport Canada, the FAA, and the Aircraft Accident Investigation Bureau of Switzerland on December 4, 2000, which asked that “appropriate regulatory authorities take action to ensure that industry standards reflect a philosophy that when odour/smoke from an unknown source appears in an aircraft, the most appropriate course of action is to prepare to land the aircraft expeditiously.” Recommendation A00-18 is classified “Fully Satisfactory” as a result of regulatory/industry response. The TSB also issued recommendation A00-19 to Transport Canada, which asked that “appropriate regulatory authorities ensure that emergency checklist procedures for the condition of odour/smoke of unknown origin be designed so as to be completed in a timeframe that will minimize the possibility of an in-flight fire being ignited or sustained.” Recommendation A00-19 is classified “Satisfactory In Part” awaiting further action.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 32 and an industry symposium on March 2 and 3, 2005. As a result of the initiative, the Flight Safety Foundation published a report titled, “Flight Crew Procedures Streamlined for Smoke/Fire/Fumes.”46 The report contained a Smoke, Fire, and Fumes checklist template to standardize and optimize flight crew responses to such events. The proposed industry checklist guidelines remind pilots that a “diversion may be required” if evidence of smoke, fire, or fumes exists and contain steps to eliminate any operational procedures that would delay a diversion. The initial steps of the proposed checklist consist of a series of simple, rapid actions to address the most likely sources of fire. The guidelines state that these actions should require no decision-making by the flight crew, be airplane-specific, and be determined by the manufacturer based on event history for each specific model airplane. According to the proposed checklist guidelines, unless clear visual evidence exists that all fire hazards are resolved after the initial steps, the flight crew should initiate a diversion, and the crew should not delay landing to continue the checklist for additional source identification and/or source isolation or elimination. The guidelines also recommend the development of an integrated checklist with initial steps that do not require the flight crew to choose among competing checklists, such as Electrical or Air Conditioning based on smoke, fire, or fumes. Specifically, there are instructions that an operator’s Smoke or Fumes Evacuation checklist should be performed only after the fire has been extinguished or at such time as smoke or fumes become the greatest threat. The guidelines further state that smoke removal may change the airflow and worsen the situation by fanning or masking an ignition source. In April 2007, Boeing issued a Flight Operations Technical Bulletin titled, “New Unannunciated Smoke, Fire, and Fumes Non-Normal Checklist,” which advised its customers of upcoming new checklist procedures related to unalerted smoke, fire, and fumes events. Boeing indicated that it plans to issue revised flight and operations manuals for each of its most current model airplanes to reflect the smoke, fire, and fumes industry initiative by the end of 2007.47 Specifically, the new manuals will provide recommended smoke, fire, and fumes checklists and QRH guidance based on the industry-developed template that will include airplane-specific initial actions to be taken by pilots based on Boeing’s analysis of the event history for each specific model airplane. Boeing indicated that, for older airplanes like the DC-8,48 it would not provide updated manuals because many of these airplanes have also undergone extensive changes and modifications by the operators (for which no Boeing records exist). Also, the industry smoke, fire, and fumes philosophy was developed on the basis of new generation aircraft with two-person flight crews. Instead, Boeing indicated that it plans to act as a general resource for customers 46  Flight Safety Foundation, “Flight Crew Procedures Streamlined for Smoke/Fire/Fumes,” Flight Safety Digest (Alexandria, Virginia: FSF, 2005), pp. 31-35. 47  Boeing indicated that it will publish revised manuals by the end of 2007 for Boeing 737 (models 200 through 900), 747 (models 400 and Classic), 757, 767, 777, and Boeing Business Jet airplanes and that it will publish revised manuals in spring 2008 for 717, MD-10, MD-11, and MD-80/90 airplanes. 48  Boeing indicated that models not currently scheduled to receive revised manuals include Boeing 707, 727, DC-8, DC-9, and DC‑10 airplanes.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 33 to upgrade pilot guidelines in accordance with the procedures advocated by the industry initiative. On January 8, 2004, the FAA issued AC 120-80, “In-Flight Fires,”49 which provides crewmembers guidance on how to deal with in-flight fires, emphasizing the importance of flight crewmembers taking immediate and aggressive action when signs of an in- flight fire are present. The AC also discusses the importance of recognizing and quickly assessing the conditions that may be associated with hidden fires. The AC does not contain guidance related to specific checklist usage during such situations. Although the FAA was a participant in the industry group’s efforts to address nonalerted in-flight smoke, fire, and fumes events, it has not revised existing guidance to reflect the initiative’s recommendations. On January 24, 2007, the FAA held a Cabin Smoke and Fire Workshop, which was prompted by ongoing FAA concerns about in-flight smoke incidents and diversions. The FAA reported at the workshop that about two-thirds of the in-flight cockpit or cabin smoke reports received from 2000 to 2006 involved no smoke or fire and that most of the reports were related to air conditioning and distribution sources or faulty smoke and fire detection systems. The FAA did note that the events were not without risk because they often led to diversions, rushed approaches, overweight landings, and evacuations. Previously Issued Safety Recommendations Resulting from 1.18.2  This Accident Safety Recommendation A-06-65 As a result of the UPS accident, on September 25, 2006, the Safety Board issued Safety Recommendation A-06-65 to the FAA to address the potential safety consequences if a pilot fails to notice that a runway change has been incorporated in a new landing clearance provided by ATC. Safety Recommendation A-06-65 asked the FAA to do the following: Amend FAA Order 7110.65, “Air Traffic Control,” to require that, when amending a runway assignment, controllers provide a specific instruction to the pilot advising of the runway change. For example, “UPS 1307, change to runway 25L, cleared to land.” On December 19, 2006, the FAA responded that it was evaluating the potential operational effects of implementing the procedural change recommended by the Safety 49  AC 120-80 was issued in response to Safety Recommendation A-01-83, which the Safety Board issued on January 4, 2002, as a result of several commercial aviation accidents involving in-flight fires. Safety Recommendation A-01-83 asked the FAA to “issue an AC that describes the need for crewmembers to take immediate and aggressive action in response to signs of an in-flight fire.” The recommendation further stated that “the AC should stress that fires often are hidden behind interior panels and therefore may require a crewmember to remove or otherwise gain access to the area behind interior panels in order to effectively apply extinguishing agents to the source of the fire.” The Board classified Safety Recommendation A-01-83 “Closed—Acceptable Action” on April 15, 2004.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 34 Board and its associated revision to FAA Order 7110.65. The FAA stated that it should have the evaluation completed and further response provided to the Board in 120 days. Pending the results of the FAA’s evaluation and appropriate changes to FAA Order 7110.65, the Board classified Safety Recommendation A-06-65 “Open—Acceptable Response” on May 2, 2007. In correspondence dated November 27, 2007, the FAA stated that it would be issuing a notice implementing the change to add the phraseology “runway change” to FAA Order 7110.65, “Air Traffic Control,” by the end of 2007. Previous Related Safety Recommendations 1.18.3  Smoke and Fire Detection, Suppression, and Extinguishment 1.18.3.1  The Safety Board has had longstanding concerns about smoke and fire detection, suppression, and extinguishment on cargo airplanes and has issued several safety recommendations as a result of its investigations of accidents related to these issues. Safety Recommendations A-88-122 and -123 On February 3, 1988, an in-flight fire occurred on American Airlines flight 132 while it was en route to Nashville, Tennessee. The Safety Board determined that undeclared and improperly packaged hazardous materials had been loaded in the midcargo compartment with the passenger luggage and had caused the fire.50 On October 24, 1988, the Board issued Safety Recommendations A-88-122 and -123, which asked the FAA to require fire and smoke detection systems and fire extinguishment systems, respectively, in all class D cargo compartments. In a January 5, 1989, letter, the FAA stated that it was considering a notice of proposed rulemaking (NPRM) to “amend 14 CFR Parts 25, 121, and 135 to require fire and smoke detection and fire extinguishing systems for all class D cargo compartments that are more than 200 cubic feet in volume.” However, in an August 10, 1993, letter, the FAA stated that it had conducted economic and cost‑benefit analyses, which found that “the proposed rule would not have provided a significant degree of protection to the occupants from the extremely severe fire.” As a result, the FAA terminated the rulemaking action, and, on October 14, 1993, the Safety Board classified Safety Recommendations A-88-122 and ‑123 “Closed—Unacceptable Action.” Safety Recommendation A-97-56 On May 11, 1996, ValuJet Airlines, Inc., flight 592, crashed into the Everglades about 10 minutes after takeoff from Miami International Airport, Miami, Florida. The Safety Board determined that one of the probable causes of the accident was the FAA’s failure to 50  National Transportation Safety Board, In-Flight Fire, McDonnell Douglas DC-9-83, N569AA, Nashville, Tennessee, February 3, 1988, Hazardous Materials Report NTSB/HZM-88/02 (Washington, DC: NTSB, 1997).

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 35 require smoke detection and fire suppression systems in class D cargo compartments.51 As a result, on September 9, 1997, the Safety Board issued Safety Recommendation A-97-56, which asked the FAA to “expedite final rulemaking to require smoke detection and fire suppression systems for all class D cargo compartments.” On June  13, 1997, the FAA issued an NPRM, which proposed to require the installation of smoke detection and fire suppression systems in class D cargo compartments. According to the NPRM, the airline industry would have 3 years from the effective date of the final rule to meet the new standards. The FAA indicated that it anticipated issuing a final rule by the end of 1997. On February 12, 1998, the FAA issued a final rule, 14 CFR 121.314, which eliminated class D compartments as an option for future type certification and required that compartments that could no longer be classified as “class D” compartments be classified as “class C” or “class E” compartments, as applicable. Further, the class D compartments in certain transport‑category airplanes manufactured under existing type certificates and used in passenger service were required to meet the smoke detection and fire suppression standards for class C compartments by March 2001 for air carrier or most other commercial services. Cargo-only operations were allowed to reclassify “class D” compartments as “class E”52 compartments. On the basis of the FAA’s actions, the Board classified Safety Recommendation A-97-56 “Closed—Acceptable Action” on August 13, 1998. Safety Recommendations A-98-78 and -79 On September 5, 1996, FedEx flight 1406 made an emergency landing at Stewart International Airport, Newburgh, New York, after the flight crew determined that there was smoke in the cabin cargo compartment. The Safety Board determined that the probable cause of this accident was an in-fight cargo fire of undetermined origin.53 In its final report on the accident, the Board concluded that, at that time, “inadequate means exist[ed] for extinguishing on-board aircraft fire.” As a result, the Board issued Safety Recommendation A-98-78, which asked the FAA to “reexamine the feasibility of on‑board airplane cabin interior fire extinguishing systems for airplanes operating under 14 CFR Part 121 and, if found feasible, require the use of such systems.” On October 27, 1998, the FAA responded that cargo operations differ from passenger operations and that ventilation shutoff and depressurization were sufficient means to control a fire in a class E compartment until the flight crew could land. The FAA stated that, although it had a test program in progress to evaluate the feasibility of built-in systems for use in the cabins of very large, high-capacity passenger airplanes, it 51  National Transportation Safety Board, In-Flight Fire and Impact with Terrain, ValuJet Airlines, Inc., Flight  592, DC9-32, N904VJ, Everglades Near Miami, Florida, May 11, 1996, Aircraft Accident Report NTSB/AAR‑97/06 (Washington, DC: NTSB, 1997). 52  Class E compartments are required to have fire and smoke detection systems but are not required to have fire suppression systems. 53  National Transportation Safety Board, In-Flight Fire/Emergency Landing, Newburgh, New York, Federal Express Flight 1406, Douglas DC-10-10, N68055, September 5, 1996, Aircraft Accident Report NTSB/AAR-98/03 (Washington, DC: NTSB, 1998).

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 36 had no plans to initiate rulemaking for such systems. In addition, the FAA stated that the requirement of a fire suppression system would add “considerable weight” to the aircraft and reduce the amount of cargo that could be carried. The Safety Board found the FAA’s actions to be consistent with Safety Recommendation A-98-78 and, on April 22, 1999, classified the recommendation “Closed—Acceptable Action,” and the Board encouraged the FAA to continue evaluating fire suppression systems for use in the cabin areas of cargo operations. The Safety Board also issued Safety Recommendation A-98-79, which asked the FAA to do the following: Review the aircraft cabin interior firefighting policies, tactics, and procedures currently in use, and take action to develop and implement improvements in firefighter training and equipment to enable firefighters to extinguish aircraft interior fires more rapidly. In its October 27, 1998, response letter, the FAA stated that, as a result of its research and development, an HRET/SPN had been developed. In 1999, the Safety Board responded that it appreciated the FAA’s actions and encouraged it to continue its efforts to improve fighting interior cabin fires. On the basis of the FAA’s actions and its continued support of firefighting programs nationwide, the Safety Board classified Safety Recommendation A-98-79 “Closed—Acceptable Action” on April 22, 1999. Retrieval and Availability of Hazardous Materials Information 1.18.3.2  Safety Recommendation A-98-80 In its final report on the investigation of the in-flight fire and emergency landing involving FedEx flight 1406 in Newburgh, the Safety Board addressed the importance of quickly providing hazardous materials information to emergency responders. The investigation revealed that emergency responders did not receive specific information concerning the identity of hazardous materials, their quantities, or the number of packages on the aircraft during the firefighting phase of the emergency response. Although the unavailability of such information did not affect the firefighting efforts, the overall importance of the timeliness in which emergency responders receive specific information about hazardous materials and the potential implications of unawareness were emphasized in the Board’s report. In the Newburgh report, the Safety Board also noted that the survivability of shipping documents on board aircraft is much less likely than that for surface modes of transportation because of the inherent risk of fire or total destruction associated with aviation accidents. The Board also noted that it would be very unlikely that flight crewmembers would be able to retrieve shipping papers before evacuating an airplane because of the dangers of on-board fires. As a result, operators needed to provide the information contained in these documents to emergency responders. During its investigation, the Board determined that Federal regulations did not adequately address the need for hazardous materials information on file at a carrier to be quickly retrievable in a format useful to

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 37 emergency responders. As a result, the Board issued Safety Recommendation A‑98‑80 to the Research and Special Programs Administration (RSPA), which stated the following:54 Require, within 2 years, that air carriers transporting hazardous materials have the means, 24 hours per day, to quickly retrieve and provide consolidated, specific information about the identity (including proper shipping name), hazard class, quantity, number of packages, and location of all hazardous materials on an airplane in a timely manner to emergency responders. On March 25, 2003, RSPA published a final rule, which revised 49 CFR 175.33 to mandate that air carriers have hazardous materials information immediately available for emergency responders. Specifically, 49 CFR 175.33(d), as revised, stated the following: The aircraft operator must have . . . a copy of the [NOTOC], an electronic image thereof, or the information contained therein readily accessible at the airport of departure and the intended airport of arrival for the duration of the flight leg and, upon request, must make the information immediately available, in an accurate and legible format, to any representative of a Federal, State, or local government agency (including an emergency responder) who is responding to an incident involving the flight. (emphasis in original) The Safety Board stated that it appreciated RSPA’s action to require air carriers to be able to immediately provide hazardous materials information upon request. However, because the revision did not address the need for providing such information in the form of a consolidated list that would be more easily read and understandable, the Board classified Safety Recommendation A-98-80 “Closed—Unacceptable Action” on August 18, 2003. Air Transport of Lithium Batteries 1.18.3.3  Safety Recommendations A-99-80 and -82 On April 28, 1999, a fire destroyed freight, including lithium batteries, on two aircraft cargo pallets at the Northwest Airlines cargo facility at Los Angeles International Airport, Los Angeles, California. The cargo pallets had been taken off an inbound passenger-carrying flight from Osaka, Japan. The Safety Board’s investigation of this incident revealed that lithium batteries likely presented an unacceptable risk to aircraft and passengers that required immediate attention. As a result, on November 16, 1999, the 54  The Safety Board concurrently issued Safety Recommendation A-98-75, which contained the same text, to the FAA. On April 22, 1999, the FAA responded that RSPA would act as the lead agency on this issue and would keep the Board informed on the progress. RSPA responded that it was working jointly with the FAA to address Safety Recommendation A-98-75. Therefore, on April 22, 1999, the Board classified Safety Recommendation A‑98‑75 “Closed—No Longer Applicable.”

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 38 Safety Board issued Safety Recommendations A-99-80 and -82,55 which asked RSPA to do the following: With the FAA, evaluate the fire hazards posed by lithium batteries in [an] air transportation environment and require that appropriate safety measures be taken to protect aircraft and occupants. The evaluation should consider the testing requirements for lithium batteries in the United Nations’ [UN] Transport of Dangerous Goods Manual of Tests and Criteria, the involvement of packages containing large quantities of tightly packed batteries in a cargo compartment fire, and the possible exposure of batteries to rough handling in an air transportation environment, including being crushed or abraded open. (A-99-80) 56 Require that packages containing lithium batteries be identified as hazardous materials, including appropriate marking and labeling of the packages and proper identification in shipping documents, when transported on aircraft. (A-99-82) In a September 26, 2002, letter regarding these recommendations, the Safety Board stated that, although PHMSA and the FAA had fully responded to Safety Recommendation  A-99-80 with respect to primary lithium batteries, the actions did not address the risks posed by the shipment of secondary lithium batteries. The Board classified Safety Recommendation A-99-80 “Open—Acceptable Response,” pending investigation of the fire risks posed by the shipment of secondary lithium batteries and appropriate rulemaking. Further, the Board stated that the proposed requirements did not fully address the Board’s concerns regarding the need for cargo handlers to be properly alerted to the dangers posed by lithium batteries. The Board added that, if cargo handlers can determine from shipping documents and the marking and labeling on packages of lithium batteries that the contents contain a hazardous material, they would be more likely to handle the package carefully. The Board urged PHMSA to consider the need to classify packages containing more than 12 small lithium batteries or 24 lithium cells as a class 9 miscellaneous hazardous material, subject to the requirements in the hazardous materials regulations for labeling of the package and shipping papers. The Board classified Safety Recommendation A-99-82 “Open—Acceptable Response,” pending issuance of such a requirement. On December 15, 2004, in response to these safety recommendations and as a result of previous primary (metallic lithium) lithium battery fires in air transportation and FAA primary lithium battery flammability tests conducted in 2004,57 the Pipeline 55  For more information about these safety recommendations, see the Safety Board’s Web site at http://www.ntsb.gov. 56  The Safety Board concurrently issued companion Safety Recommendation A-99-85, which is classified “Open—Acceptable Response,” to the FAA. 57  Department of Transportation, Flammability Assessment of Bulk-Packed, Nonrechargeable Lithium Primary Batteries in Transport Category Aircraft, DOT/FAA-AR-04/26 (Washington DC: DOT, 2004).

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 39 and Hazardous Materials Safety Administration (PHMSA)58 published an interim final rule. The rule prohibited the transportation of cargo shipments of all individual primary lithium batteries and cells, as well as equipment containing or packed with large lithium batteries (containing more than 25 grams [g] lithium), on board passenger-carrying aircraft. However, the transportation of small (containing no more than 2 g lithium) and medium (containing from 2 to 25 g lithium) primary lithium batteries contained in or packed with equipment was still permitted on board passenger-carrying aircraft. Shipment of equipment with small and medium primary batteries remained exempted from most requirements for class 9 hazardous materials provided that the batteries and cells complied with 49 CFR 173.185, were packed in strong packaging, and did not exceed a net weight of 5 kilograms (kg) and that the packages contained only the number of batteries needed to power the equipment. Title 49 CFR 173.185 specifies that all shipments of primary lithium batteries, including those contained in or packed with equipment, weighing 35 kg or less may be transported on board cargo-only aircraft; each cell must contain less than 5 g lithium content; each battery must contain less than 25 g lithium content; and the outside of the package must be marked, “PRIMARY LITHIUM BATTERIES – FORBIDDEN FOR TRANSPORT ABOARD PASSENGER AIRCRAFT.” Cargo shipments of secondary lithium batteries and cells, including those contained in or packed with equipment, were still permitted on board passenger-carrying aircraft when the package’s gross weight was no more than 5 kg and on board cargo-only aircraft when the gross weight was 35 kg or less. Further, shipments of secondary lithium batteries continued to be exempted from the requirements for class 9 hazardous materials packaging, labeling, marking, and reporting provided that each secondary lithium cell contained no more than 1.5 g of equivalent lithium content and that the secondary lithium battery contained no more that 8 g of equivalent lithium content. The interim final rule was in effect at the time of the UPS flight 1307 accident, and all of the secondary lithium batteries found in the accident debris would have been subject to these exemptions. On August 9, 2007, PHMSA issued final rule, “Hazardous Materials: Transportation of Lithium Batteries,” effective date January 1, 2008, which tightened the regulations contained in 49 CFR Parts 171 to 174 regarding the safe transportation of both primary and secondary lithium batteries. As a result of this final rule, the changes contained in the December 2004 interim final rule were adopted with minor changes. In addition, the following changes were made: packaging for small lithium batteries were required to be tested in accordance • with the UN Manual of Tests and Criteria;59 communications and packaging requirements for small batteries, applicable • to single packages containing more that 24 cells or 12 batteries, were established; 58  RSPA no longer exists, and PHMSA has assumed its responsibilities, which are discussed in section 1.18.6. 59  The UN test manual describes the types of tests, including drop, vibration, and crushing tests.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 40 the exemption for medium lithium cells and batteries, including those packed • with or contained in equipment, was eliminated, and these cells and batteries were required to be transported and identified as class 9 hazardous materials and to meet associated hazard communication and packaging requirements when transported by aircraft or vessel; and airline passengers and flight and cabin crew are allowed to carry spare lithium • batteries on board as carry-on items only.60 In the preamble for this rulemaking, PHMSA noted that the Air Line Pilots Association (ALPA) and the International Brotherhood of the Teamsters had expressed concern that primary lithium batteries may still be shipped as cargo on cargo-only aircraft. ALPA suggested that bulk shipments of primary lithium batteries and cells should only be transported on board cargo aircraft if they are subject to all of the applicable packaging, labeling, and marking requirements. The Teamsters suggested that primary lithium batteries should not be transported on board either passenger or cargo aircraft until the risks from these batteries could be mitigated by improved packaging standards, specific labeling and marking requirements, strict quantity limitations, and appropriate hazard communications standards (including pilot notification). In addressing these comments, PHMSA noted that the FAA agreed with its assessment that the greatest risk to public safety is in passenger-carrying operations and that extending the prohibition of transporting primary lithium batteries to cargo operations was beyond the scope of the August 2007 rulemaking. PHMSA noted that it would, therefore, not extend the prohibition of transporting primary lithium batteries to cargo-only aircraft. In a July 31, 2007, response letter, PHMSA stated that, in addition to issuing the final rule, it was continuing to evaluate the fire hazards posed by the transportation of secondary lithium batteries with the FAA and was currently evaluating a report on this issue prepared by the FAA’s Technical Center. PHMSA also stated that it was working with the UN Subcommittee of Experts on the Transport of Dangerous Goods and the International Civil Aviation Organization (ICAO) to develop additional enhanced safety measures for the transportation of lithium batteries and that it had initiated a comprehensive strategy, bringing together public and private-sector stakeholders, aimed at reducing the transportation risks posed by batteries of all types. Related Federal Aviation Administration Guidance 1.18.4  AC 25-9A, “Smoke Detection, Penetration, and Evacuation Tests and Related Flight Manual Emergency Procedures,” revised January 6, 1994,61 contains guidelines on how to conduct certification tests in compliance with 14 CFR 25.858. The AC states that the objective of the smoke detection test is to “demonstrate that the smoke detection system installation will detect a smoldering fire producing a small amount of smoke.” The AC further states the following: 60  The final rule also describes how to protect the spare batteries to prevent short-circuiting. 61  AC 25-9, which was issued in 1986, provided guidance to manufacturers on how to conduct certification tests in compliance with 14 CFR 25.858 (see section 1.6.2.3). Before 1986, no such guidance existed.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 41 A smoldering fire producing a small amount of smoke in conjunction with the applicable detection time has been selected as a fire or failure condition that could be detected early enough to ensure that the fire or smoke procedures would be effective. Subjective judgment, considering the failure, size of compartment, materials contained in the compartment, and the containment methods and procedures, is needed to assess the significance of a small amount of smoke. AC 25-9A proposes various acceptable smoke generators and materials to be used in the tests, but it does not indicate the exact amount of smoke that needs to be produced for various size cargo compartments. The guidelines suggest that the smoke should be generated at a location that would be considered “critical with respect to the detector’s area of coverage” and “in areas where cargo can be loaded and secured by the airplane’s onboard loading and restraint system,” which would be determined by the aircraft certifying official. Regarding test conditions, AC 25-9A states the following: Flight tests are required to demonstrate compartment accessibility, and exclusion of hazardous quantities of smoke or extinguishing agent from entering into compartments occupied by the crew or passengers. Because detector sensitivity and in-flight compartment airflows differ from those found in ground tests, smoke detection tests should also be conducted in flight . . . The smoke detection system effectiveness test should be conducted during cruise at normal cabin-to-ambient pressure differential with maximum normal ventilation flow rate. The airplane should be operated in the various dispatchable ventilation and pressurization configurations (one air conditioning pack, two air conditioning packs, unpressurized, etc.) for the cruise condition. AC 25-9A also states, “the results of these tests are valid only if the airplane is maintained in the condition and configuration that was tested.” However, the AC does not indicate whether the tests should be conducted with cargo loaded in the cargo compartment, whether cargo containers should be used, or where the detectors should be placed during the tests. Recent Developments in Fire Detection and Suppression 1.18.5  Systems Federal Aviation Administration Rulemaking Initiatives 1.18.5.1  At the Safety Board’s public hearing on the UPS accident, the FAA’s branch manager of propulsion and mechanical systems recognized that recent new technologies, including lighter fire suppression materials, have made fire detection and suppression systems for main cargo compartments more feasible to operators. He encouraged the industry to submit new ideas and technologies in fire suppression on board aircraft through

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 42 rulemaking changes. Further, according to the manager, the FAA is currently reviewing a draft NPRM, which proposes the development of a new compartment classification, class F, to be added to 14 CFR Part 25. The manager stated that the new classification would allow fire detection and suppression systems to use any means of chemical suppression agent and access and could be used on passenger and cargo aircraft.62 He also stated that all-cargo operations would continue to have class E compartments. Federal Express System Developments 1.18.5.2  According to testimony from FedEx’s vice president of strategic projects, after the fire‑related accidents in Newburgh and Uruguay,63 the company began developing a main cargo compartment fire extinguishing system that would meet the requirements for the proposed class F compartments.64 FedEx stated that, once the system is developed and approved, it would initially be used on all FedEx airplanes that fly internationally and that, eventually, the system would be installed on all FedEx aircraft. In addition, FedEx has redesigned its standard cargo containers to include all-aluminum construction and improved the cargo door design to better contain fire within an individual container. Each container is monitored with infrared sensors to measure the rate of temperature change in the container. On the main compartment, the system has individual piercing nozzles for each container that are actuated when a set rate of temperature increase occurs in the container. The nozzle pierces the top of the container and injects nitrogen-expanded AFFF into the container. In tests conducted by FedEx, the system activated within 11 minutes of ignition and completely extinguished the fire before it breached the container. FedEx has also developed a fire-resistant cover called the “Peltz bag,” which encases shipments in pallets. Infrared sensors also monitor the rate of temperature change in the pallets. In testing conducted by FedEx, the Peltz bag contained a fire within a pallet for up to 4 hours. 62  Currently, class C compartments must have fire suppression systems that have been approved by the FAA, and only Halon suppression systems have been approved by the FAA at this time. Class F systems would allow for the development of new fire containment systems, including fire suppression through agent application. 63  The Safety Board assisted in the investigation of the April 27, 2004, in-flight fire on board FedEx flight 7145 in Uruguay. About 45 minutes into the flight, the flight crew was alerted about a fire toward the rear of the cargo compartment. Examinations revealed that the debris contained residue of a flammable liquid; however, the source of the residue was not determined. 64  Other developments in fire detection and suppression systems have been made. For example, as a result of the 1998 accident involving a Swissair MD-11, Swissair and Boeing developed an improved fire detection and suppression system for its MD-11s. The system has dual-channel smoke detectors and infrared detectors mounted in the avionics compartment and in the overhead areas of the forward galley and cockpit. The cockpit was modified to incorporate additional aural and visual warnings, as well as a video display unit for viewing the camera areas. A Halon suppression system was installed to enable suppressant in the cockpit and galley overhead areas. The FAA was involved in reviewing and approving the system through the approval of the certification plans, the flight test plans, and the final Halon suppression capability analysis.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 43 Lithium Batteries 1.18.6  A number of secondary lithium batteries, which are described in more detail below, were found loose and in laptop computers and cell phones in the accident debris. No primary batteries were found in the accident debris. There are basically two types of lithium batteries: secondary (rechargeable) and primary (nonrechargeable). Secondary lithium batteries, which are commonly used in items such as cameras, cell phones, and laptop computers, contain lithium ions (charged molecules) in a flammable liquid electrolyte. Halon suppression systems (the only fire suppression systems certified for aviation) are effective in extinguishing fires involving secondary lithium batteries. Primary batteries, which are commonly used in items such as watches and pocket calculators, contain metallic lithium that is sealed in a metal casing. The metallic lithium will burn when exposed to air if the metal casing is damaged, compromised, or exposed to sustained heating. Halon suppression systems are not effective in extinguishing fires involving primary lithium batteries. Both primary and secondary lithium batteries are regulated as hazardous materials for the purposes of transportation. PHMSA is the designated agency within the DOT charged with the safe and secure transport of hazardous materials by all modes of transportation. PHMSA is responsible for the creation and promulgation of the Hazardous Materials Regulations (HMR). Other modal administrations within the DOT, such as the FAA, are responsible for enforcing the HMR for their respective modes. For example, the FAA ensures that air carriers transporting hazardous materials do so in compliance with HMR requirements. Incidents Involving Lithium Batteries 1.18.6.1  According to an FAA document (titled, “Batteries & Battery-Powered Devices: Aviation Incidents Involving Smoke, Fire, Extreme Heat or Explosion,” revised July 25, 2007) compiling known battery incident data, since February 1996, 82 incidents directly related to all types of batteries were reported to have occurred in the aviation industry. The data showed that 14 of these incidents involved secondary lithium batteries and that 13 of these incidents involved primary lithium batteries.65 Of the 14 secondary battery-related incidents, 7 involved items shipped on cargo- only aircraft, 6 involved checked baggage and carry-on items intended for passenger flights, and 1 involved a package shipped as cargo on board a passenger aircraft. Of the seven incidents involving cargo-only aircraft, four occurred post flight, either during unloading or sorting operations or customs inspections; two occurred or were detected before the items were loaded onto the aircraft; and one occurred in flight. Of the seven incidents involving passenger aircraft, two occurred in flight, one causing the flight crew to divert; three occurred on board before takeoff; and two occurred in the airports before boarding the aircraft. 65  None of these incidents were required to be reported to the FAA because they were exempt from the class 9 hazardous materials reporting requirements.

National Transportation Safety Board A I R C R A F T Accident Report 44 Of the 13 primary battery-related incidents, 5 involved items shipped or carried by crew on cargo-only aircraft, 6 involved carry-on items intended for passenger flights, and 2 involved packages shipped as cargo on passenger flights. Of the five incidents involving cargo-only aircraft, three occurred post flight, either during unloading or sorting operations; one occurred while en route to a cargo center; and one occurred in flight. Of the eight incidents involving passenger flights, four occurred in flight, two causing the flight crew to divert or land; two occurred or were detected post flight, either during unloading or sorting operations; and two occurred before boarding the aircraft. Although the causes of these lithium battery incidents were not all determined, some of the modes of failure identified in the FAA document included short‑circuiting, dropping or mishandling of items, loose batteries packed in bags, and charging of the batteries. However, during the Safety Board’s public hearing, representatives of the FAA, PHMSA, Consumer Product Safety Commission (CSPC), and the battery industry noted that the causes of overheating of secondary lithium batteries were not completely understandable or clearly identifiable. Testing and quality control concerns, state of charge, and other damage were discussed as factors or causes of the incidents involving secondary lithium batteries. A 2006 Safety Board review of the reported battery incident data for the previous 10 years showed an increase in aviation incidents involving both secondary and primary lithium batteries. Specifically, from February 2001 to February 2006, secondary lithium batteries were involved in four aviation incidents compared to the one incident involving secondary lithium batteries in the previous 5-year period. Data from February 2006 to July 2007 showed that the number of incidents (nine) involving secondary lithium batteries was nearly double that of the previous 10 years. Similarly, primary lithium batteries were involved in three incidents from February 1996 to 2001, four in the following 5-year period, and six from February 2006 to July 2007. A review of FAA records confirmed these statistics. Since August 2006, the CPSC, in cooperation with Dell, Apple, Lenovo, and IBM, has recalled more than 9 million laptops containing secondary lithium batteries, which were prompted by reports of batteries overheating, resulting in two minor injuries and several cases of property damage. The recall warned consumers of the potential for the batteries to overheat in laptop computers and the possible fire hazard to their users. Further, the CSPC has issued five additional recalls for other products containing secondary lithium batteries. During the Safety Board’s public hearing, the CPSC predicted that more incidents and recalls would occur if the deficiencies with the secondary lithium batteries were not addressed. Recent Lithium Battery-Related Safety Alerts 1.18.6.2  On March 22, 2007, PHMSA issued Safety Advisory 07-02, “Transportation of Batteries and Battery-Powered Devices by Airline Passengers and Crew Members,” to “inform the traveling public and airline employees about the importance of properly packing and handling batteries and battery-powered devices when they are carried aboard aircraft.” The advisory suggested measures for complying with regulations and minimizing transportation risks associated with batteries and battery-powered devices. Concurrently, ALPA issued Safety Alert 2007-03, “Responding to In Flight Passenger

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 45 Electronic Equipment Fires,” to “educate its members as to the characteristics of a fire involving a portable electronic device.” On August 3, 2007, the FAA issued Information for Operators (InFO) 07016, “PHMSA Guidance on the Carriage of Batteries and Battery-Powered Devices,” because it continued to receive reports of cabin smoke or fire suspected to have originated from batteries or battery‑powered devices carried in the cabin.66 The InFO provided the guidance contained in PHMSA Safety Advisory 07-02. The InFO reminded operators to be aware of the risks associated with using primary and secondary batteries and battery-powered devices in the passenger cabin and readdressed the availability of guidance for the safe transport of batteries and battery‑powered devices on board aircraft. 66  InFO 07016 superseded Safety Alert for Operators (SAFO) 07002, which the FAA issued on January 5, 2007, and noted that, since December 2005, “there have been several occurrences of smoke and fires erupting from failures of lithium-ion batteries such as those used within laptop computers.” The SAFO alerted crewmembers about the smoke and fire hazards associated with high-energy batteries and reemphasized AC 120‑80 and its guidance on how to handle hidden fires.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 46 Analysis

General 2.1  The flight crewmembers were properly certificated and qualified under Federal regulations. No evidence indicated any preexisting medical or physical condition that might have adversely affected the flight crew’s performance during the accident flight. Although overnight flight schedules can be tiring and produce cumulative fatigue over successive nights,67 the accident occurred on only the second night of the trip sequence, and all of the flight crewmembers had made use of sleep opportunities during the day before the flight. Further, the accident occurred less than 2 hours into the trip, about 0000, a time at which neither pilot typically slept.68 Finally, there was no evidence of performance deficiencies that were clearly discernible and consistent with the known effects of fatigue. Therefore, the Safety Board concludes that no evidence was found indicating that fatigue degraded the performance of any of the flight crewmembers on the day of the accident. Examinations of the recovered components revealed no evidence of any preexisting powerplant, structural, or system failures. This analysis discusses the accident sequence, including the flight crew’s performance; the quality of fire and smoke emergency checklists; smoke and fire detection and suppression systems on cargo aircraft; cargo aircraft smoke and fire detection systems test certification requirements; ARFF training inadequacies; cargo airplane emergency exit requirements; hazardous materials information dissemination procedures; and issues related to the transport of lithium batteries on cargo airplanes. Flight Crew Performance 2.2  Actions During Descent and Landing Sequence 2.2.1  The accident flight was uneventful until just after the descent to PHL began, about 2335, at which time, the first officer detected an odor and asked the captain and flight engineer if they smelled anything. The captain stated during postaccident interviews that 67  P.H. Grander, K.B. Gregory, L.J. Connell, R.C. Graeber, D.L. Miller, and M.R. Rosekind, “Flight Crew Fatigue IV: Overnight Cargo Operations,” Aviation, Space, and Environmental Medicine, Vol. 69 (1998), pp. B26‑B36. 68  When off duty, the captain typically went to bed between 0100 and 0200 and the first officer between 0000 and 0100.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 47 he evaluated diversion alternatives at this time but decided to continue to PHL. The flight crew’s decision to continue to PHL is discussed further in section 2.2.2. After the first officer’s query, the flight crew began to actively analyze the situation and take action, including looking for visible evidence of smoke or fire in the area behind the cockpit. The flight crew also proactively began troubleshooting to determine the source of the odor. Neither the UPS DC‑8 AOM nor the DC-8 Airplane Flight Manual states what procedures should be accomplished in the event that only fumes are present. The flight crew’s use of UPS fire and smoke‑related checklists and industry efforts to upgrade such checklists are discussed in detail in section 2.2.3. The Cargo Smoke warning light in the main cargo compartment illuminated about 20  minutes after the first officer first mentioned the presence of an odor. One minute 15 seconds later, the Lower Cargo Fire warning light illuminated and indicated that smoke was in the lower aft middle cargo compartment. After the first warning light illuminated, the flight crew began to execute the Lower and/or Main Cargo Compartment Smoke or Fire checklist, and the first officer turned the airplane toward the airport. CVR evidence indicates that, during this portion of the flight, the first officer maintained control of the airplane and the captain oversaw the crew actions and worked with the flight engineer to handle troubleshooting, communication, and emergency efforts. Decision to Continue to Philadelphia International Airport 2.2.2  Investigators considered whether the flight crew should have executed a diversion to another airport when the odor was first detected. The flight crewmembers stated during postaccident interviews that they decided to continue to PHL because no smoke detector warning lights illuminated in the cockpit and no smoke was visually evident, which minimized their belief that an actual hazard existed. Further, the crewmembers also noted that unusual odors could be common from nonthreatening factors, such as flying over forest fires or from unusual cargo. Without supporting evidence, such as visible smoke and aural alerts, odor is an elusive and highly subjective factor for determining the presence of a hazard. Safety Board calculations indicated that, if the flight crew had begun a diversion at the first indication of an odor and performed a standard or emergency descent into Washington Dulles International Airport, Andrews Air Force Base, or Baltimore Washington International Airport, it would have taken about 17 to 18 minutes69 to land, compared to the 24 minutes it took to land at PHL. Because the flight was already established on the descent to PHL, a diversion would have added cockpit workload that might have affected the crew’s ability to focus its attention on the potential smoke or fire hazard. The Safety Board concludes that the flight crew’s continued descent to PHL was not inappropriate given that there was no evidence of abnormalities other than the odor and that no cockpit alerts had activated. 69  This time was based on the 12.5 minutes that calculations showed would have been required for the airplane to descend and reach any of the alternate airports and about 5 minutes for the flight crew to discuss and execute a diversion and to prepare and coordinate the approach with ATC.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 48 Use and Adequacy of Smoke, Fire, or Fumes Checklists 2.2.3  During the review of the flight crew’s actions and decision-making, investigators found that company guidance and checklists regarding smoke, fire, or fumes in the absence of a cockpit warning were not adequate because neither UPS nor Boeing provided specific flight crew procedures for responding to such a situation. Instead, the UPS DC-8 AOM provided four checklists that could have been applied to such a situation, three of which were predicated on visible evidence of smoke or fire or an alert activation in the cockpit. As noted, during this period, no smoke or fire warning lights illuminated in the cockpit, no visible evidence of smoke or fire existed, the CVR recorded no comments by the flight crew about burning eyes or headaches, and no evidence of abnormalities other than odor existed. Although one of the checklists, the Fumes Evacuation checklist, did apply specifically to fumes, the AOM did not provide guidance on when to use the checklist. Increasing both air conditioning packs to maximum flow (as part of the Fumes Evacuation checklist) would have increased the airflow through the cabin. This would have evacuated the smoke more quickly, diluting the air and inhibiting the flight crew’s ability to identify the source of the odor and the smoke detectors’ ability to detect the smoke. Further, additional oxygen would have been provided to the smoldering fire. Although these would be appropriate steps to take in a situation involving fumes that might, for example, cause irritation or otherwise prevent the flight crew’s ability to operate the airplane, they are not appropriate in a situation in which a fire is suspected. Therefore, the Safety Board concludes that the increased airflow that resulted from the Fumes Evacuation checklist actions diluted the smoke and inhibited its detection by either the smoke detection system or flight crewmembers and provided the fire with additional oxygen. Although the FAA provides guidance to crewmembers on issues related to in- flight fires in AC 120-80, the AC does not provide guidance to flight crews on how to respond to evidence of smoke, fire, and fumes in the absence of a cockpit alert. In 2004, an international initiative was undertaken to improve guidance and checklist procedures in this area. The initiative developed a smoke, fire, and fumes checklist template to standardize and optimize responses to such events. Recognizing that time is critical in responding to any event, the proposed smoke, fire, and fumes checklist guidelines emphasize that flight crews should balance efforts to diagnose and resolve any fire hazard with efforts to evaluate the possibility of diverting; that a crew should have a simple, rapid, integrated checklist for responding to such a situation; and that the operator’s Smoke or Fumes Evacuation checklist should be performed only after the fire has been extinguished or at such time as smoke or fumes become the greatest threat. The guidelines further state that smoke removal may change the airflow and worsen the situation by fanning or masking an ignition source. Boeing is currently updating the flight and operations manuals for most of its product line to provide revised smoke, fire, and fumes checklists based on the template of the industry initiative. However, Boeing does not currently plan to revise the manuals of older airplanes like the DC-8, which will require individual operators of this airplane to work with the manufacturer and the FAA to develop such revisions for their own

Analysis National Transportation Safety Board A I R C R A F T Accident Report 49 operations. Therefore, the need for FAA guidance remains especially important for older airplanes, including the accident airplane model. If UPS procedures had contained guidance similar to that in the 2004 smoke, fire, and fumes industry checklist, the flight crew would have had a simplified, appropriate procedure to address the problem. Therefore, the Safety Board concludes that the aviation industry initiative on smoke, fire, and fumes provides specific guidance on when and how flight crews should respond to evidence of a fire in the absence of a cockpit smoke and/or fire warning. The Safety Board believes that the FAA should provide clear guidance to operators of passenger and cargo aircraft operating under 14 CFR Parts 121, 135, and 91K on flight crew procedures for responding to evidence of a fire in the absence of a cockpit alert based on the guidance developed by the 2004 smoke, fire, and fumes industry initiative. Fire Detection and Growth 2.3  The first indication of the fire was the first officer’s query to the other crewmembers about the smell of burning wood, which occurred about 20 minutes before the main cargo compartment Cargo Smoke warning light activated, indicating that the fire had been burning for at least that long. However, the flight engineer saw no smoke either of the two times that he visually checked the main cargo compartment. This evidence indicates that the fire initially did not generate a significant amount of smoke and was most likely initiated as a smoldering fire inside a cargo container. The construction of the cargo containers, which results in restricted airflow in or out of the container, likely inhibited the growth and detection of the fire in its initial stages. On the basis of this evidence, the Safety Board concludes that the fire on board the accident airplane initiated as a smoldering fire. Once the fire breached the cargo container in which it initiated, it would have begun to spread to adjacent containers. Detection of the fire by the main cargo compartment smoke detectors most likely occurred around the time of the first container burnthrough. The smoke detector in lower cargo compartment 33 alerted about 1 minute after the main cargo compartment alert, and some of the captain’s displays then began to falter, indicating the continued progression of the fire. The flight engineer first saw smoke when he exited the cockpit to close the main cargo air shutoff valve and black smoke emanated from the valve’s access panel. About 2 minutes later, almost immediately after touchdown, the flight engineer reported that smoke had begun entering the cockpit. The smoke continued to worsen after the airplane came to a stop, and the smoke in the cockpit became so thick that the two pilots could not see each other before evacuating the airplane. ARFF personnel who entered the airplane through the L1 door observed smoke but no fire in the main cargo compartment. Flames were first observed about 40 minutes after the airplane landed when ARFF personnel opened the right-forward overwing hatch

Analysis National Transportation Safety Board A I R C R A F T Accident Report 50 and noticed flames above the containers just aft of the opening. The continued growth of the fire after the airplane landed was probably affected by the introduction of fresh air through the openings in the airplane, both through its open doors and eventually through holes created in the fuselage as the fire ultimately burned through the fuselage crown. The growth of the fire was also affected by the combustible nature of the packages and packing materials in the cargo containers, which provided a readily ignitable fuel source for the growing fire. The fuselage burned through aft of the wings (near containers 12, 13, and 14) about 2 hours after landing. On the basis of this evidence, the Safety Board concludes that the fire was detected by the airplane’s smoke and fire detection system after the fire breached a cargo container, at which time, it proceeded to spread and that the growth of the fire after landing was fed by air entering through open doors and burnthrough holes. Origin and Cause of Fire 2.4  Despite the length of time that the fire burned and the resulting destruction of potentially helpful evidence, the postfire condition of the cargo containers and contents and the surrounding airplane structure were examined for any evidence indicating the location from which the fire initiated. As a result of these examinations, the lower cargo compartments were eliminated as the origin of the fire because they sustained no heat‑related damage, and the outer surfaces of their ceiling liners only exhibited sooting and smoke damage. The fire/smoke detector activations in lower cargo compartments 33 and 34 resulted from smoke infiltrating the lower compartments from the main cargo compartment above this area. Cargo containers 1 to 11 were eliminated as the fire initiation location because they sustained minimal to moderate thermal damage and the surrounding fuselage sustained little to no structural damage. Further, the ceiling liners were still in place for containers 1 to

1. Although the ceiling liners in containers 8 to 11 sustained thermal damage, it most likely

resulted after the overwing hatches were opened. Containers 15 and 18 were eliminated as the fire initiation location because the cargo in these containers was accounted for during the on-scene examination and no evidence of ignition sources was found. The contents in containers 16 and 17 were heavily damaged, and fuselage burnthoughs were located near both containers. However, containers 16 and 17 were eliminated as the fire initiation location, in part, because the aftward movement of air in flight and on the ground would have made it unlikely that the fire started in either of these containers. Further, the amount of damage sustained near cargo container 17 might have resulted when ARFF personnel opened the L4 and R4 doors soon after they arrived on scene. ARFF personnel indicated that no fire was observed inside the rear of the airplane at this time. Pictures taken soon after the response began do not show any visible fire in that area, but pictures taken 2 hours into the emergency response show this area heavily involved in fire.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 51 Conversely, ARFF personnel did report first observing flames inside the airplane in an area near containers 12 and 13, and this area is also the area above where the first smoke detector activated in the lower cargo compartments. Further, the amount of damage to containers 12, 13, and 14, their contents, and the areas surrounding these containers, including two complete and a partial fuselage burnthrough, indicates that the fire most likely originated in one of these cargo containers. The lowest point of fuselage damage, which could be indicative of the point of origin of the fire, was located in the right aft portion of container 12 near container  13, where the damage extended down to the cargo compartment floor. Container 14 exhibited heavy damage to the contents and was relatively near the areas of the fuselage with the most damage. In addition, a large number of the items in this container were not identified either during the on-scene examination or through the shipper interview calls. As a result, container 14 could not be eliminated as a source of the fire. No evidence of explosion or high-temperature fire (for example, melted steel components) was found. Several factors eliminated the airplane’s wiring as a possible source of the fire, including the lack of any electrical burning odor, the lack of fused wires or damage associated with arcing wires, and the lack of system or display anomalies until almost 20 minutes after the flight crew first detected an odor. Other than secondary lithium batteries, which are discussed below, all of the recovered declared and undeclared hazardous materials were eliminated as ignition sources because they were found intact and relatively undamaged. No additional hazardous or questionable items (that is, undeclared hazardous, chemical, or flammable materials) were identified during the identification effort. Examinations of the cargo containers and their contents revealed that a number of electronic devices, such as laptop computers, contained some type of power source, specifically secondary lithium cells. All electronic devices and battery packs and cells that had any type of thermal damage were examined on scene; however, most of the items were too damaged for further documentation. Several laptop computers, loose battery cells, and battery packs with severe damage were retained and sent to the Safety Board’s laboratory for further examination. During the cargo examinations, no batteries were found that exhibited any damage identifying a source of ignition. Because the fire most likely originated in cargo container 12, 13, or 14, investigators attempted to determine the contents of the packages that were not accounted for on scene by contacting the shippers of the packages in these containers. This effort was unable to determine the contents of all of the packages in these containers; however, the effort did reveal that several electronic devices likely containing secondary lithium batteries were shipped in these containers. Unfortunately, the lack of information about the devices or the batteries prevented any determination of whether these batteries were associated with previously known recalls. The Safety Board concludes that the exact origin and cause of the in-flight fire on board the airplane could not be determined due to the destruction of potentially helpful evidence; however, the available evidence suggests that the fire most likely originated in container 12, 13, or 14.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 52 Smoke or Fire Detection System Certification Tests 2.5  Because the first smoke detector system activation did not occur until at least 20 minutes after the fire had initiated, the system did not perform in accordance with the performance standards established by the FAA (smoke detector system activation within 5 minutes of fire initiation). The Safety Board’s investigation revealed that the smoke detection system certification tests for the DC-8 were not conducted with cargo loaded on the airplane, nor were they required to be, and, therefore, the tests did not account for the effects of a loaded cargo area on smoke detection. The investigation also revealed that current smoke and fire detection system certification tests do not adequately test for “all approved operating configurations and conditions,” as required by 14 CFR 25.858. Although the accident airplane was certificated under CAR 4b, not Part 25, the Safety Board is concerned that current certification methods do not ensure that smoke and fire detection systems are operating in compliance with FAA regulations for smoke detection timeliness. AC 25-9A contains guidelines on how to conduct certification tests in compliance with FAA regulations and states that the tests should demonstrate that the system can detect a smoldering fire. However, although the AC proposes various acceptable smoke generators and materials to be used in the tests, it does not indicate whether the tests should be conducted with cargo loaded in the cargo compartment or whether cargo containers should be used. Information provided by FAA and Boeing personnel indicates that smoke and fire detection system certification tests are typically conducted with a smoke‑generating device in the open area of the compartment, which is more representative of a passenger airplane configuration than a cargo configuration with containers. They indicated that the tests were conducted without cargo containers because using an empty compartment results in greater smoke dilution, requiring the smoke detectors to be sensitive to a small amount of smoke. With cargo containers loaded in the cargo compartment, air exiting the air conditioning vents in the ceiling is primarily directed outward and downward toward the floor. The cargo containers also create a barrier that the smoke must traverse before it enters the open space of the cargo compartment where it can be detected by the smoke detection system. Neither of the effects of cargo containers—the ventilation changes and the smoke barrier—are accounted for during the certification tests; therefore, the tests do not ensure compliance with the performance criteria contained in 14 CFR 25.858, which requires that all approved operating configurations and conditions be tested. The Safety Board concludes that the current certification test standards and guidance for smoke and fire detection systems on board many aircraft are not adequate because they do not account for the effects of cargo and cargo containers on airflow around the detection sensors and on the containment of smoke from a fire inside a container. The Board is concerned that a fire producing a small amount of smoke within a sealed cargo container may not be promptly detected by existing smoke detection systems. Therefore, the Safety Board believes that the FAA should ensure that the performance requirements for smoke and fire detection systems on cargo airplanes account for the effects of cargo

Analysis National Transportation Safety Board A I R C R A F T Accident Report 53 containers on airflow around the detection sensors and on the containment of smoke from a fire inside a container and should establish standardized methods of demonstrating compliance with those requirements. Smoke Detection and Fire Suppression Systems on 2.6  Cargo Airplanes The accident airplane was not required to be equipped with a fire suppression system, and, as a result, the fire, which began as a smoldering fire in one of the cargo containers, was able to develop into a substantial fire that burned through the container and ceiling liner while the airplane was airborne. The Safety Board has had longstanding concerns about the lack of fire suppression systems in cargo compartments and has issued several safety recommendations in the last 20 years to address this issue. For example, as a result of the investigation into the May 11, 1996, accident involving ValuJet flight 592, the Safety Board issued Safety Recommendation A-97-56, which asked the FAA to expedite final rulemaking to require smoke detection and fire suppression systems for all class D cargo compartments. On February 12, 1998, the FAA issued a final rule that required the installation of fire suppression equipment in cargo compartments on board passenger aircraft; however, the requirement for a fire suppression system did not apply to cargo airplanes. In addition, as a result of its investigation of the September 5, 1996, fire involving FedEx flight 1406, the Safety Board issued Safety Recommendation A-98-78, which asked the FAA to require on-board fire extinguishing systems if they were deemed feasible. In response, the FAA indicated that current procedures regarding ventilation and depressurization were sufficient means to control a fire until the flight could land and that an on-board suppression system would add “considerable” weight to the airplane and reduce the amount of cargo that could be carried on board. At the UPS flight 1307 public hearing, the FAA indicated that it was considering an NPRM for the development of a new compartment classification, class F, which would require fire detection and suppression systems in which any means of chemical extinguishment and crew access could be used. Class E compartments would continue to be used in all-cargo operations. The FAA acknowledged at the hearing that recent technologies have made fire suppression systems on board cargo airplanes more feasible to operators and that it expects to receive input on new ideas and technologies for fire suppression systems on cargo airplanes as a result of the NPRM. FedEx stated at the public hearing that it has already developed an on-board cargo compartment fire extinguishing system, which testing showed completely extinguished a fire before it breached the container. The Safety Board commends the actions taken by FedEx to voluntarily develop a fire suppression system for its airplanes. The Safety Board concludes that the threat from cargo fires could be mitigated by the installation of fire suppression systems. Therefore,

Analysis National Transportation Safety Board A I R C R A F T Accident Report 54 the Safety Board believes that the FAA should require that fire suppression systems be installed in the cargo compartments of all cargo airplanes operating under 14 CFR Part 121. As previously mentioned, FAA primary lithium battery flammability tests have concluded that Halon is not an effective means to suppress fires involving primary lithium batteries. Currently, the Safety Board is unaware of any fire suppression system that is effective on primary lithium battery fires. Therefore, although the installation of fire suppression systems in all cargo compartments on cargo-only aircraft, as recommended by the Board, would reduce the risks from a fire involving most cargo items, including secondary lithium batteries, this action would essentially have no effect on a primary lithium battery fire. Further, until such time that fire suppression systems are installed on cargo-only aircraft, secondary lithium batteries will continue to typically be transported in compartments without fire suppression systems. Therefore, the Safety Board concludes that flight crews on cargo-only aircraft remain at risk from in‑flight fires involving both primary and secondary lithium batteries. The Safety Board believes that PHMSA should require aircraft operators to implement measures to reduce the risk of primary lithium batteries becoming involved in fires on cargo-only aircraft, such as transporting such batteries in fire resistant containers and/or in restricted quantities at any single location on the aircraft. The Safety Board further believes that, until fire suppression systems are required on cargo-only aircraft, as asked for in Safety Recommendation A-07-99, PHMSA should require that cargo shipments of secondary lithium batteries, including those contained in or packed with equipment, be transported in crew-accessible locations where portable fire suppression systems can be used. Emergency Response Issues 2.7  Emergency Response Timeliness 2.7.1  After the flight had been cleared to land on runway 27R, the PHL ATCT local controller changed the landing runway to 27L because it was the runway designated for emergencies at PHL. The captain acknowledged the landing clearance, but he did not specifically acknowledge the runway change. When it became apparent that the airplane was still aligned with runway 27R, the controller provided clearance to land on runway 27R. The local controller notified the PHL ARFF facility of the emergency immediately after being notified by the captain about a cargo smoke indication. ARFF vehicles proceeded to the standby positions for runway 27L. When the clearance was changed to runway 27R, ARFF vehicles moved toward that runway. Although the change in runway caused a 60- to 90-second delay, ARFF personnel arrived on scene about 4 minutes after the initial emergency notification was made and as the flight crew was evacuating the airplane. Therefore, the Safety Board concludes that the emergency response for this accident was timely.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 55 Although the flight crew safely evacuated the airplane and the emergency response was timely, several emergency response-related safety issues were identified during the investigation. Section 2.7.2 discusses a safety issue related to ARFF equipment training, section 2.7.3 discusses a safety issue related to cargo aircraft familiarization training, and section 2.7.4 discusses a safety issue related to cargo airplane emergency exit requirements. High-Reach Extendable Turret With Skin-Penetrating Nozzle 2.7.2  Training for Aircraft Rescue and Firefighting PHL ARFF personnel used an HRET/SPN during the UPS emergency response in an attempt to pierce the fuselage and fight the interior fire. The ARFF personnel who used the HRET/SPN during the emergency response stated, during postaccident interviews, that they experienced problems penetrating the fuselage with the device and had to reposition the tip of the nozzle a few times before successfully piercing the airplane’s fuselage. The emergency response to this accident has not been the only response during which ARFF personnel experienced problems using an HRET/SPN. For example, during the response to the February 2005 runway overrun at Teterboro Airport (TEB), Teterboro, New Jersey,70 the HRET/SPN operators experienced problems similar to those experienced by the UPS responders. Specifically, the piercing tip folded back and had to be reset during piercing attempts. In 2005, the FAA conducted research that determined that the HRET/SPN outperformed the standard roof-mounted turret and handline, including the ability to better control and contain the spread of interior fires and reduce high cabin temperatures. FAA and IFSTA training materials state that the successful use of the device depended on the skill level of the operator and required continual training in operations, tactics, and strategies. Although ACs 150/5210‑17A and 150/5220-10C state that ARFF personnel should be trained to identify the proper procedures for the use of each hose, nozzle, and adapter used locally and should be provided guidance on equipment training, neither of the ACs specifically address training on the use of the HRET/SPN. Since PHL ARFF obtained its HRET/SPN in 1991, it has used two different devices to train its ARFF personnel on how to penetrate a fuselage: a small general aviation airplane, which PHL no longer uses, and a SAFT mockup. The HRET/SPN-equipped vehicle at TEB was operated by two police officers who had been cross-trained in ARFF. Both officers stated that they had training on an HRET/SPN-equipped vehicle. One of the officers stated that he thought that the training had helped him during the accident response but that he also believed that “you have to practice every day.” Despite having received some training on the HRET/SPN, ARFF personnel at both PHL and TEB encountered problems using the device. Further, because of aviation’s excellent safety record, most ARFF personnel may not have any actual experience fighting 70  National Transportation Safety Board, Runway Overrun and Collision, Platinum Jet Management, LLC, Bombardier Challenger CL-600-1A11, N370V, Teterboro, New Jersey, February 2, 2005, Aircraft Accident Report NTSB/AAR-06/04 (Washington, DC: NTSB, 2006).

Analysis National Transportation Safety Board A I R C R A F T Accident Report 56 an interior fire. The Safety Board notes that the PHL and TEB ARFF personnel who used the HRET/SPN during the emergency responses had never used the device during an actual emergency response up to that time. The Safety Board concludes that some ARFF personnel are not adequately trained on the use of the HRET/SPN, reducing the effectiveness of the device in fighting interior aircraft fires. Therefore, the Safety Board believes that the FAA should provide guidance to ARFF personnel on the best training methods to obtain and maintain proficiency with the HRET/SPN. Aircraft Rescue and Firefighting Cargo Familiarization 2.7.3  Training Although PHL’s AEP required ARFF personnel to respond to all accidents at the airport, PHL ARFF did not typically conduct aircraft familiarization training on cargo aircraft before the accident, and ARFF personnel were not familiar with the accident airplane. During the emergency response, PHL ARFF personnel had problems opening the main cargo door, most likely because they did not understand its manual operation. Specifically, one of the responders broke the exterior cargo door handle when he tried to force it open and rendered it inoperable. As a result, PHL ARFF personnel were unable to off-load cargo containers, which affected their ability to locate, access, and suppress the fire. Similar problems were noted in the Safety Board’s report on the September 5, 1996, Newburgh, New York, accident, which indicated that ARFF personnel were also not familiar with the operation of the main cargo door and initially were unable to open it. In accordance with 14 CFR 139.139(i), ARFF personnel are required to receive initial and recurrent training in 12 subject areas. AC 150/5210-17A, “Programs for Training of Aircraft Rescue and Firefighting Personnel,” provides guidance on how to meet the regulations and specifies what should be included in the training program for aircraft familiarization. The AC recommends that ARFF personnel be trained to “identify the types of aircraft operating at the airport . . . [and] locate normal entry doors [and] emergency exit openings.” Although neither the regulations nor the AC excludes cargo airplanes from aircraft familiarization training for ARFF personnel, evidence from the UPS and Newburgh accident investigations indicates that some airports do not provide such training and that such training is needed to facilitate emergency response efforts. The Safety Board concludes that PHL ARFF personnel were not familiar with the accident airplane’s main cargo door, which adversely affected their ability to access the airplane’s interior to fight the fire. Even though PHL has substantial cargo operations and an AEP that requires the airport to respond to all on-site accidents, PHL ARFF personnel indicated that they did not schedule familiarization training on cargo aircraft. Although the Board is encouraged that PHL ARFF has initiated cargo familiarization training since the accident, it is concerned that cargo aircraft familiarization training may not be emphasized at other airports. Therefore, the Safety Board believes that the FAA should require airport inspectors to ensure that

Analysis National Transportation Safety Board A I R C R A F T Accident Report 57 Part 139 airports with cargo operations include cargo aircraft in their ARFF aircraft familiarization training programs. A review of the DC-8 Emergency Response diagrams that UPS provided to PHL ARFF after the accident found that they included information on locating and opening exits and cargo doors; however, the diagrams were not accurate or complete. For example, no information was provided about the main cargo door’s vent door, including the fact that the vent door had to be opened before the cargo door could be opened. Further, the diagrams incorrectly identified the aft overwing hatches as operational and incorrectly noted that the doors contained external contrasting colors to help ARFF personnel locate the doors. The Safety Board concludes that the availability of accurate and complete airplane diagrams would improve ARFF personnel’s knowledge and familiarity with fleet configurations and would facilitate emergency response operations. Accordingly, the Safety Board believes that the Cargo Airline Association71 should work with its member airlines and other groups, such as the Air Transport Association, major aircraft manufacturers, and the ARFF Working Group,72 to develop and disseminate accurate and complete airplane Emergency Response diagrams for ARFF personnel at airports with cargo operations. Cargo Airplane Emergency Exit Requirements 2.7.4  The accident airplane’s two side cockpit windows had been designated as the airplane’s emergency exits. The L1 door, which was used as the primary means of entry and exit for the airplane, was also identified as an emergency exit in the UPS DC-8 AOM and on the airplane’s emergency briefing card. Although the two cockpit windows provide one means of flight crew emergency egress from the airplane, a floor level emergency exit provides an additional egress point. Further, although cargo aircraft do not carry passengers, Federal regulations allow cargo operators to carry additional personnel.73 The accident airplane was configured to carry up to 7 occupants, and the Safety Board has learned that some cargo operators’ wide-body airplanes can be configured to carry up to 27 occupants.74 Although the two cockpit windows provide a means for the flight crew to evacuate the airplane, a floor level emergency exit with an evacuation slide would provide a more efficient and expedient way for all occupants to exit a cargo airplane in the event of an emergency. 71  The Cargo Airline Association is an association for members of the all-cargo air carrier industry. 72  The ARFF Working Group is an association that promotes the improvement of the methods of aviation fire protection and prevention. 73  Title 14 CFR 121.583 allows cargo operators to carry additional personnel, including, but not limited to, additional crewmembers, company or government personnel, and other individuals necessary for the safety of flight or monitoring the cargo. 74  An FAA CertAlert dated January 21, 2004, regarding an accident involving an MD-10 cargo airplane noted that ARFF personnel responding to the scene were surprised to see seven people exit the airplane. The alert stated that as many as 27 personnel could be on board the operator’s MD-10 airplanes at any time.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 58 In addition, ARFF personnel may also need to enter an airplane to rescue occupants, fight a fire, or search for the NOTOC. A floor level exit provides ARFF personnel with the most efficient means to enter an airplane wearing protective gear or breathing apparatus that could prevent their entry through a cockpit window. Further, as seen in the UPS and the Newburgh, New York, cargo accidents, ARFF personnel may need to access the area inside the L1 door to manually operate the main cargo door. If the L1 door were a designated emergency exit, it would be required to have instructional placards. Although ARFF personnel did not open the L1 door during this emergency response, instructional placards would benefit ARFF personnel as well as other first responders (such as mutual aid, ramp personnel, and airport operations). The FAA acknowledged that, although a forward floor level emergency exit is not required on cargo airplanes, operators often designate the L1 door as an alternate emergency exit. Further, as evidenced by the UPS and FedEx accidents, even if the cockpit window exits are accessible, the floor level exit is often the preferred emergency exit for use by occupants to egress the airplane under emergency conditions. The Safety Board is concerned that the L1 door is not required to be designated as an “emergency exit” despite evidence that floor level exits are often used by cargo airplane occupants in the event of an emergency and provide a faster and more efficient means for the flight crew and other occupants to exit the airplane. At the time of the DC-8’s certification, Federal regulations required emergency exits and their means of opening to be marked on the outside of the airplane to assist ARFF personnel. Although the cockpit windows had exterior placards providing instructions on their operation, they were not visually identifiable as emergency exits because they had no contrasting colored band around them nor were they required to be by Federal regulations. Further, the L1 door did not have either exterior instructional placards or a visual indication that it was an emergency exit. The Safety Board is concerned that cargo airplane emergency exits are not required to have visual markings indicating them as emergency exits even though such markings are required on passenger airplanes and would provide ARFF with a rapid method of identifying such exits. Therefore, the Safety Board concludes that a floor level emergency exit, including one equipped (when appropriate) with an evacuation slide, would enable more efficient emergency egress for airplane occupants than cockpit window exits and that the associated, instructional placarding of such an exit would assist emergency responders with locating and operating the exit door and accessing the interior of the airplane. Therefore, the Safety Board recommends that the FAA require cargo operators to designate at least one floor level door as a required emergency exit and equip the door with an evacuation slide, when appropriate. Further, the Safety Board recommends that the FAA require all emergency exits on cargo aircraft that are operable from the outside to have a 2-inch contrasting colored band outlining the exit.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 59 Retrieval and Dissemination of Hazardous Materials 2.8  Information The captain and first officer were not able to find the NOTOC, which contained information on the hazardous materials on board the airplane, during the evacuation because of the smoke in the cockpit and because they did not know that the flight engineer had moved it. ARFF personnel who entered the cockpit after the evacuation were also unable to locate the NOTOC. When asked for the hazardous materials information, the UPS ramp supervisor stated that he could only provide the locations of the hazardous materials, not their identity, and that the NOTOC on board the airplane was the only source he was aware of that contained this information. About 40 minutes after the airplane landed, ARFF personnel reentered the airplane without knowing whether any potential safety hazards existed, found the NOTOC, and provided it to the incident commander. According to UPS management, in the event of an emergency, airport ground personnel were supposed to contact the UPS Flight Control Group in Louisville, Kentucky, to obtain specific information related to hazardous materials on board UPS flights from the HMIS. However, UPS ground personnel at PHL did not contact the UPS Flight Control Group on the day of the accident. Although the HMIS was on line at PHL, UPS ground personnel were only authorized to access information about the quantity and locations of hazardous materials, not their identity. According to Flight Control personnel, once they heard about the accident, they retrieved the hazardous materials information for the flight from the HMIS; however, Flight Control did not provide this information to PHL Airport Operations or UPS ground or ARFF personnel. Additionally, both Airport Operations and ARFF personnel requested the hazardous information from UPS ground personnel at PHL; however, UPS ground personnel did not have access to the electronic system containing the desired information and did not contact UPS Flight Control in Louisville to obtain a copy of it. Although emergency responders eventually located the NOTOC on the airplane and ARFF efforts were not significantly delayed, UPS personnel’s failure to quickly access specific hazardous materials information and provide it to ARFF personnel could have potentially created a safety hazard. The Safety Board concludes that UPS guidance on hazardous materials information retrieval and dissemination was inadequate, which resulted in UPS personnel not providing emergency responders with detailed information about the hazardous materials on board the airplane in a timely manner. Since the accident, UPS has revised its operations manuals to clarify personnel reporting responsibilities and the role and capabilities of Flight Control, promoting a more proactive approach to emergency response and hazardous materials communication. However, although these changes are an improvement and should result in hazardous materials information being provided in a timelier manner, the Safety Board is concerned that other operators might not have adequate guidance on hazardous materials information dissemination. The Board has previously addressed the importance of providing detailed hazardous materials information to emergency responders in a timely manner in its investigation of the in-flight fire and emergency landing in Newburgh, New York. The

Analysis National Transportation Safety Board A I R C R A F T Accident Report 60 investigation revealed that emergency responders did not receive specific information concerning the identity of hazardous materials, their quantities, or the number of packages on the airplane during the firefighting phase of the emergency. Although the unavailability of such information did not affect firefighting efforts, the overall importance of the timeliness in which emergency responders receive specific information about hazardous materials and the potential implications of unawareness were emphasized in the Board’s report. In the Newburgh report, the Safety Board noted that shipping documents are inherently at risk of destruction by fire and that flight crewmembers would most likely be unable to retrieve such paperwork because of the dangers of on-board fire, leaving it to the operator to provide the information to emergency responders. At the time of the Newburgh accident, Federal regulations did not adequately address the need for hazardous materials information on file with an air carrier to be quickly retrievable in a format useful to emergency responders. As a result, the Board issued Safety Recommendation A‑98-80 to RSPA, proposing that it require air carriers to have a means to quickly retrieve and provide consolidated, specific hazardous materials information to emergency responders, 24 hours per day. In response, on March 25, 2003, RSPA published a final rule, which revised 49 CFR 175.33 to mandate that air carriers have a copy of the NOTOC at the departure and intended arrival airports and, upon request, make the information available to emergency responders. In an August 18, 2003, letter, the Safety Board stated that it was pleased that RSPA had made it a requirement that hazardous materials information be made available immediately upon request but that it was disappointed that the revision did not address the need for providing such information in a consolidated format. Consequently, the Board classified Safety Recommendation A-98-80 “Closed—Unacceptable Action.” Because 49 CFR 175.33(d) requires air carriers to make a copy of the NOTOC information available to emergency responders “upon request,” the regulatory requirement suggests that the voluntary transfer of hazardous materials information, without a formal request, is optional for the carrier. In contrast, the ICAO document, “Technical Instructions for the Safe Transport of Dangerous Goods by Air,” provides the following guidance on the transfer of hazardous materials information between aircraft operators and emergency personnel: In the event of an aircraft accident or serious incident, the operator of an aircraft carrying dangerous goods as cargo must provide information, without delay, to emergency services responding to the accident or serious incident about the dangerous goods on board, as shown on the copy of the information to the pilot-in-command. The ICAO document promotes a proactive approach to the transfer of hazardous materials information during an emergency, which improves the likelihood that this information will get to emergency responders in a timely manner. In the case of this accident, UPS Flight Control personnel’s actions satisfied the intent of the requirements as they are written. Flight Control had the on-board hazardous materials information

Analysis National Transportation Safety Board A I R C R A F T Accident Report 61 readily available; however, they stated that they did not volunteer the information because they did not receive a request for it, therefore, they were not obligated to volunteer it, as stipulated by the regulations. The Safety Board concludes that the requirements of 49 CFR 175.33(d) are not adequate because they do not require operators to provide hazardous materials information to emergency responders immediately upon notification of an accident. Therefore, the Safety Board believes that PHMSA should require aircraft operators that transport hazardous materials to immediately provide consolidated and specific information about hazardous materials on board an aircraft, including proper shipping name, hazard class, quantity, number of packages, and location, to on-scene emergency responders upon notification of an accident or incident. Air Transport of Lithium Batteries 2.9  Although it could not be determined whether lithium batteries played a role in the UPS cargo fire, public hearing testimony and the continued occurrence of incidents involving these batteries on board airplanes suggest the need for greater attention to the risks posed by transporting these batteries on commercial aircraft. A review of FAA and CPSC records shows that the number of both secondary and primary lithium battery- related incidents (many of which involved laptop computer fires that resulted from either internal or external short-circuiting of the secondary lithium batteries) has increased consistently over the years.75 Since February 2006, the CPSC has recalled more than 9 million laptops containing secondary lithium batteries and has issued additional recalls for other products containing secondary lithium batteries. During the Safety Board’s public hearing, the CPSC predicted that more incidents and recalls would occur if the deficiencies were not addressed. Further, the increasing popularity of portable electronic devices suggests that lithium battery-related incidents, particularly those involving secondary lithium batteries, will continue to increase. The Safety Board concludes that testing and incident data indicate that lithium batteries can pose a fire hazard. In response to recent secondary lithium battery-related incidents and issues addressed during the Safety Board’s public hearing, the FAA, ALPA, and PHMSA all issued safety alerts or advisories in 2007, which addressed smoke and fire hazards, recommended crew actions in the event of a battery fire, the availability of guidance for the safe transport of batteries and battery-powered devices on board aircraft, and proper packing and handling procedures for these batteries. On August 9, 2007, PHMSA issued new requirements that tightened the safety standards governing the air transportation of both primary and secondary lithium batteries. The final rule prohibits the transport of primary lithium batteries and cells as cargo on passenger‑carrying aircraft. Additionally, spare lithium batteries can only be transported 75  Incidents involving small secondary battery-related incidents are not required to be reported, and the reporting level might have increased, in part, as a result of greater awareness of the hazards associated with these batteries.

National Transportation Safety Board A I R C R A F T Accident Report 62 as carry-on items. Further, the exemptions for medium primary and secondary lithium batteries were eliminated, and new marking paperwork requirements were added for those batteries transported as cargo by air or vessel. The new requirements in the August 2007 rulemaking address the comments in the Safety Board’s September 26, 2002, letter to PHMSA regarding Safety Recommendations A-99-80 and -82. The rulemaking also addresses Safety Recommendation A-99-85 to the FAA. Under this rule, on the basis of the FAA’s initial testing of the fire risks posed by secondary lithium batteries and PHMSA’s elimination of many of the exemptions for primary and secondary lithium batteries, greater shipments of lithium batteries will be transported by air as declared hazardous materials that will be required to comply with enhanced packaging and identification standards. Therefore, the Safety Board classifies Safety Recommendations A-99-80, -82, and -85 “Closed—Acceptable Action.” The issuance of the safety alerts and advisories and the new, more stringent requirements demonstrate the growing awareness and concern within the DOT and the airline industry over the air transportation of primary and secondary lithium batteries and electronic equipment containing such batteries. These initiatives will also heighten awareness about the common risks associated with both primary and secondary lithium batteries. Although the Safety Board is encouraged by these efforts, other concerns still remain. The FAA currently maintains records of aviation incidents involving batteries and battery‑powered devices, including those involving primary and secondary lithium batteries. The records likely do not provide a complete listing because many of the incidents involved lithium batteries that were exempted from incident reporting requirements. As a result, many operators have most likely not reported similar incidents. In addition, although PHMSA’s August 2007 final rule includes a marking and paperwork requirement for small secondary and primary cells and batteries, the new requirement only applies to packages containing 24 or more cells or 12 or more batteries and does not include batteries packed with or contained in equipment. As a result, shipments of batteries and electronic equipment with fewer than 24 cells or 12 batteries, such as laptop computers, are still exempt from reporting requirements, and, therefore, incidents involving such shipments are likely to remain largely unreported. Consequently, the Safety Board concludes that, because many incidents involving lithium batteries are exempt from reporting requirements, the data regarding such incidents are incomplete, which has prevented a thorough assessment of the causes of these failures and the risks associated with transporting lithium batteries. Therefore, the Safety Board believes that PHMSA should require commercial cargo and passenger operators to report to PHMSA all incidents involving primary and secondary lithium batteries, including those contained in or packed with equipment, that occur either on board or during loading or unloading operations and retain the failed items for evaluation purposes. The Board also remains concerned that the causes of secondary lithium battery failures are not well understood or documented. This may be due, in part, to the fact that proper evaluation of failed lithium batteries is not always performed and that, in many cases, these batteries are disposed of before the incident is reported, precluding

Analysis National Transportation Safety Board A I R C R A F T Accident Report 63 an accurate analysis of the failures. Regarding primary lithium batteries, although it is understood that physical damage and exposure to heat and fire are major concerns, the impact of clustering several thousand primary batteries on a single pallet or in a single cargo container has not been considered or evaluated. Given that Halon is not an effective suppressant for a primary lithium battery fire, the risk of battery involvement in any type of fire needs to be determined. Analyzing future secondary and primary lithium battery-related incidents should help determine the causes of the failures and, in turn, allow the most appropriate transportation requirements to be established. Therefore, the Safety Board concludes that an in-depth analysis of the causes of secondary and primary lithium battery failures would improve the safe transportation of these batteries. Therefore, the Safety Board believes that PHMSA should analyze the causes of all thermal failures and fires involving secondary and primary lithium batteries and, based on this analysis, take appropriate action to mitigate any risks determined to be posed by transporting lithium batteries, including those contained in or packed with equipment, on board cargo and passenger aircraft as cargo; checked baggage; or carry-on items. The Safety Board is also concerned about the remaining exemptions for small secondary lithium batteries, such as those used to power laptop computers, cameras, cell phones, and other personal electronic devices, which are allowed to be shipped on passenger and cargo aircraft even though these types of batteries have been involved in at least nine aviation incidents. Cargo shipments of small secondary lithium batteries should be subject to the same packaging and identification requirements that apply to medium and large secondary lithium batteries to increase general awareness of the risks of these batteries and to alert package handlers to exercise greater care when loading and unloading packages containing lithium batteries. Until the causes of the failures of secondary lithium batteries are understood and effectively addressed, the prudent course of action is to eliminate these exceptions, particularly with respect to packaging and identification. Therefore, the Safety Board concludes that PHMSA’s August 2007 final rule regarding the transportation of lithium batteries did not establish sufficient levels of safety for air transportation of small secondary lithium batteries (no more than 8 g equivalent lithium content). Therefore, the Safety Board believes that PHMSA should eliminate regulatory exemptions for the packaging, marking, and labeling of cargo shipments of small secondary lithium batteries (no more than 8 g equivalent lithium content) until the analysis of the failures and the implementation of risk-based requirements asked for in Safety Recommendation A-07-108 are completed.

National Transportation Safety Board A I R C R A F T Accident Report 64 Conclusions

Findings 3.1  The flight crewmembers were properly certificated and qualified under Federal

regulations. No evidence indicated any preexisting medical or physical condition that might have adversely affected the flight crew’s performance during the accident flight. No evidence was found indicating that fatigue degraded the performance of any of

the flight crewmembers on the day of the accident. Examinations of the recovered components revealed no evidence of any preexisting

powerplant, structural, or system failures. The flight crew’s continued descent to Philadelphia International Airport was not

inappropriate given that there was no evidence of abnormalities other than the odor and that no cockpit alerts had activated. The increased airflow that resulted from the Fumes Evacuation checklist actions

diluted the smoke and inhibited its detection by either the smoke detection system or flight crewmembers and provided the fire with additional oxygen. The aviation industry initiative on smoke, fire, and fumes provides specific guidance

on when and how flight crews should respond to evidence of a fire in the absence of a cockpit smoke and/or fire warning. The fire on board the accident airplane initiated as a smoldering fire.

The fire was detected by the airplane’s smoke and fire detection system after the fire

breached a cargo container, at which time, it proceeded to spread, and the growth of the fire after landing was fed by air entering through open doors and burnthrough holes. The exact origin and cause of the in-flight fire on board the airplane could not be

determined due to the destruction of potentially helpful evidence; however, the available evidence suggests that the fire most likely originated in container 12, 13, or 14. The current certification test standards and guidance for smoke or fire detection

systems on board many aircraft are not adequate because they do not account for the effects of cargo and cargo containers on airflow around the detection sensors and on the containment of smoke from a fire inside a container.

Conclusions National Transportation Safety Board A I R C R A F T Accident Report 65 The threat from cargo fires could be mitigated by the installation of fire suppression

systems. Flight crews on cargo-only aircraft remain at risk from in-flight fires involving both

primary and secondary lithium batteries. The emergency response for this accident was timely.

Some aircraft rescue and firefighting personnel are not adequately trained on the

use of the high-reach extendable turret with skin-penetrating nozzle, reducing the effectiveness of the device in fighting interior aircraft fires. Philadelphia International Airport aircraft rescue and firefighting personnel were not

familiar with the accident airplane’s main cargo door, which adversely affected their ability to access the airplane’s interior to fight the fire. The availability of accurate and complete airplane diagrams would improve aircraft

rescue and firefighting personnel’s knowledge and familiarity with fleet configurations and would facilitate emergency response operations. A floor level emergency exit, including one equipped (when appropriate) with an

evacuation slide, would enable more efficient emergency egress for airplane occupants than cockpit window exits, and the associated, instructional placarding of such an exit would assist emergency responders with locating and operating the exit door and accessing the interior of the airplane. United Parcel Service Company (UPS) guidance on hazardous materials information

retrieval and dissemination was inadequate, which resulted in UPS personnel not providing emergency responders with detailed information about the hazardous materials on board the airplane in a timely manner. The requirements of 49

Code of Federal Regulations 175.33(d) are not adequate because they do not require operators to provide hazardous materials information to emergency responders immediately upon notification of an accident. Testing and incident data indicate that lithium batteries can pose a fire hazard.

Because many incidents involving lithium batteries are exempt from reporting

requirements, the data regarding such incidents are incomplete, which has prevented a thorough assessment of the causes of these failures and the risks associated with transporting lithium batteries. An in-depth analysis of the causes of secondary and primary lithium battery failures

would improve the safe transportation of these batteries. The Pipeline and Hazardous Materials Safety Administration’s August 2007 final rule

regarding the transportation of lithium batteries did not establish sufficient levels

Conclusions National Transportation Safety Board A I R C R A F T Accident Report 66 of safety for air transportation of small secondary lithium batteries (no more than 8 grams equivalent lithium content). Probable Cause 3.2  The National Transportation Safety Board determines that the probable cause of this accident was an in-flight cargo fire that initiated from an unknown source, which was most likely located within cargo container 12, 13, or 14. Contributing to the loss of the aircraft were the inadequate certification test requirements for smoke and fire detection systems and the lack of an on-board fire suppression system.

National Transportation Safety Board A I R C R A F T Accident Report 67 Safety Recommendations

New Safety Recommendations 4.1  As a result of its investigation of the February 7, 2006, accident involving United Parcel Service Company flight 1307, the National Transportation Safety Board makes the following recommendations to the Federal Aviation Administration: Provide clear guidance to operators of passenger and cargo aircraft operating under 14 Code of Federal Regulations Parts 121, 135, and 91K on flight crew procedures for responding to evidence of a fire in the absence of a cockpit alert based on the guidance developed by the 2004 smoke, fire, and fumes industry initiative. (A‑07-97) Ensure that the performance requirements for smoke and fire detection systems on cargo airplanes account for the effects of cargo containers on airflow around the detection sensors and on the containment of smoke from a fire inside a container, and establish standardized methods of demonstrating compliance with those requirements. (A‑07‑98) Require that fire suppression systems be installed in the cargo compartments of all cargo airplanes operating under 14 Code of Federal Regulations Part 121. (A‑07‑99) Provide guidance to aircraft rescue and firefighting personnel on the best training methods to obtain and maintain proficiency with the high‑reach extendable turret with skin-penetrating nozzle. (A‑07-100) Require airport inspectors to ensure that Part 139 airports with cargo operations include cargo aircraft in their aircraft rescue and firefighting aircraft familiarization training programs. (A‑07-101) Require cargo operators to designate at least one floor level door  as a required emergency exit and equip the door with an evacuation slide, when appropriate. (A‑07-102) Require all emergency exits on cargo aircraft that are operable from the outside to have a 2-inch contrasting colored band outlining the exit. (A‑07‑103) As a result of this investigation, the National Transportation Safety Board makes the following recommendations to the Pipeline and Hazardous Materials Safety Administration:

Safety Recommendations National Transportation Safety Board A I R C R A F T Accident Report 68 Require aircraft operators to implement measures to reduce the risk of primary lithium batteries becoming involved in fires on cargo-only aircraft, such as transporting such batteries in fire resistant containers and/or in restricted quantities at any single location on the aircraft. (A-07-104) Until fire suppression systems are required on cargo-only aircraft, as asked for in Safety Recommendation A-07-99, require that cargo shipments of secondary lithium batteries, including those contained in or packed with equipment, be transported in crew-accessible locations where portable fire suppression systems can be used. (A-07-105) Require aircraft operators that transport hazardous materials to immediately provide consolidated and specific information about hazardous materials on board an aircraft, including proper shipping name, hazard class, quantity, number of packages, and location, to on‑scene emergency responders upon notification of an accident or incident. (A‑07‑106) Require commercial cargo and passenger operators to report to the Pipeline and Hazardous Materials Safety Administration all incidents involving primary and secondary lithium batteries, including those contained in or packed with equipment, that occur either on board or during loading or unloading operations and retain the failed items for evaluation purposes. (A‑07-107) Analyze the causes of all thermal failures and fires involving secondary and primary lithium batteries and, based on this analysis, take appropriate action to mitigate any risks determined to be posed by transporting lithium batteries, including those contained in or packed with equipment, on board cargo and passenger aircraft as cargo; checked baggage; or carry-on items. (A‑07‑108) Eliminate regulatory exemptions for the packaging, marking, and labeling of cargo shipments of small secondary lithium batteries (no more than 8 grams equivalent lithium content) until the analysis of the failures and the implementation of risk‑based requirements asked for in Safety Recommendation A-07-108 are completed. (A-07-109) As a result of this investigation, the National Transportation Safety Board makes the following recommendation to the Cargo Airline Association: Work with your member airlines and other groups, such as the Air Transport Association, major aircraft manufacturers, and the Aircraft Rescue and Firefighting (ARFF) Working Group, to develop and disseminate accurate and complete airplane Emergency Response diagrams for ARFF personnel at airports with cargo operations. (A-07-110)

Safety Recommendations National Transportation Safety Board A I R C R A F T Accident Report 69 Previously Issued Safety Recommendations Resulting 4.2  From This Accident Investigation As a result of its investigation of this accident, the Safety Board issued the following safety recommendation to the Federal Aviation Administration on September 25, 2006: Amend Federal Aviation Administration Order 7110.65, “Air Traffic Control,” to require that, when amending a runway assignment, controllers provide a specific instruction to the pilot advising of the runway change. For example, “UPS 1307, change to runway 25L, cleared to land.” (A‑06‑65) Safety Recommendation A-06-65 is classified “Open–Unacceptable Response” in this report. For additional information about this safety recommendation, see section 1.18.2. Previously Issued Safety Recommendations Classified 4.3  in this Report As a result of the April 28, 1999, fire that destroyed freight, including lithium batteries, on two aircraft cargo pallets at a Northwest Airlines cargo facility, the Safety Board issued the following safety recommendations to the Research and Special Programs Administration on November 16, 1999: With the Federal Aviation Administration, evaluate the fire hazards posed by lithium batteries in an air transportation environment and require that appropriate safety measures be taken to protect aircraft and occupants. The evaluation should consider the testing requirements for lithium batteries in the United Nations’ Transport of Dangerous Goods Manual of Tests and Criteria, the involvement of packages containing large quantities of tightly packed batteries in a cargo compartment fire, and the possible exposure of batteries to rough handling in an air transportation environment, including being crushed or abraded open. (A‑99‑80) Require that packages containing lithium batteries be identified as hazardous materials, including appropriate marking and labeling of the packages and proper identification in shipping documents, when transported on aircraft. (A-99-82) The Safety Board also issued the following safety recommendation to the Federal Aviation Administration on November 16, 1999: With the Research and Special Programs Administration, evaluate the fire hazards posed by lithium batteries in an air transportation environment and require that appropriate safety measures be taken to protect aircraft and occupants. The evaluation should consider the testing requirements

Safety Recommendations National Transportation Safety Board A I R C R A F T Accident Report 70 for lithium batteries in the United Nations’ Transport of Dangerous Goods Manual of Tests and Criteria, the involvement of packages containing large quantities of tightly packed batteries in a cargo compartment fire, and the possible exposure of batteries to rough handling in an air transportation environment, including being crushed or abraded open. (A‑99‑85) Safety Recommendations A-99-80, -82, and -85 (previously classified “Open— Acceptable Response”) are classified “Closed—Acceptable Action” in this report. These classifications are discussed in section 2.9 of this report. BY THE NATIONAL TRANSPORTATION SAFETY BOARD Mark V. Rosenker

Deborah A. P. Hersman Chairman

Member Robert L. Sumwalt

Kathryn O’Leary Higgins Vice Chairman

Member

Steven R. Chealander

Member Adopted: December 4, 2007

National Transportation Safety Board A I R C R A F T Accident Report 71 Appendixes

Appendix A Investigation and Public Hearing Investigation The National Transportation Safety Board was initially notified about this accident on February 8, 2006. A full go-team was assembled in Washington, D.C., and traveled to the accident scene. The go-team was accompanied by former Member Ellen Engleman Connors and Member Kathryn O’Leary Higgins. The following investigative groups were formed: Operations, Maintenance Records, Aircraft Systems, Cargo/Fire, Hazardous Materials, Airport and Survival Factors, Human Performance. While the investigative teams were in Philadelphia, specialists were assigned to conduct the readout of the flight data recorder and to transcribe the cockpit voice recorder at the Safety Board’s laboratory in Washington, D.C. Parties to the investigation were the Federal Aviation Administration (FAA), United Parcel Service Company (UPS), Pipeline and Hazardous Materials Safety Administration (PHMSA), Boeing Commercial Airplane Group, Independent Pilots Association (IPA), and the City of Philadelphia. Public Hearing A public hearing was held for this accident on July 12 and 13, 2006, in Washington, D.C. Member Deborah Hersman presided over the hearing. The issues presented at the public hearing were airport rescue and firefighting response; design, testing, and failure modes of lithium batteries; operations and regulations concerning lithium batteries; and aircraft fire detection and suppression systems and regulations. Parties to the public hearing were the FAA, UPS, Boeing, PHMSA, IPA, and the City of Philadelphia.

National Transportation Safety Board A I R C R A F T Accident Report 72 Appendix B Cockpit Voice Recorder Transcript The following is the transcript of the Fairchild Model A-100 cockpit voice recorder, serial number 928, installed on a Douglas DC-8-71F that landed at Philadelphia International Airport, Philadelphia, Pennsylvania, on February 7, 2006, after reporting a cargo smoke indication. LEGEND CAM Cockpit area microphone voice or sound source RDO Radio transmissions from N748UP CTR Radio transmission from ATC center controller APR Radio transmission from the Philadelphia approach controller TWR Radio transmission from the Philadelphia Local East airport tower controller O2 Transmission using oxygen mask RO2 Radio transmission using oxygen mask A10 Airport 10, Philadelphia Airport Duty Officer ARFF Airport Rescue and Firefighting -1 Voice identified as the Captain -2 Voice identified as the First Officer -3 Voice identified as the Second Officer -? Voice unidentified -A Radio transmission from Atlanta center -B Radio transmission from first controller at Washington center -C Radio transmission from second controller at Washington center * Unintelligible word @ Non-pertinent word [ ] Editorial insertion Note 1: Times are expressed in eastern standard time (EST). Note 2: Generally, only radio transmissions to and from the accident aircraft were transcribed. Note 3: Words shown with excess vowels, letters, or drawn out syllables are a phonetic representation of the words as spoken. Note 4: A non-pertinent word, where noted, refers to a word not directly related to the operation, control or condition of the aircraft.

Appendixes National Transportation Safety Board A I R C R A F T Accident Report 73 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME and TIME and SOURCE CONTENT SOURCE CONTENT 2328:28

START of RECORDING

START of TRANSCRIPT

2328:29

CAM-1 we went down to *.

2328:30 CTR-A UPS thirteen oh seven contact Washington center on one two six point eight seven. 2328:35 RDO-1 two six seven UPS thirteen oh seven good day. 2328:38 CTR-A good day. 2328:59 RDO-1 and Washington good day its ups thirteen zero seven with you level three three zero. 2329:03 CTR-B UPS thirteen zero seven Washington center roger cleared direct Woodstown direct Philly. 2329:07 RDO-1 direct Woodstown direct Philly UPS thirteen oh seven.

Appendixes National Transportation Safety Board A I R C R A F T Accident Report 74 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME and TIME and SOURCE CONTENT SOURCE CONTENT 2329:14

CAM-?

• O-O-D.

2330:04

CAM-2

well that was nice of 'em.

2330:06

CAM-1

yes.

2330:30 CTR-B UPS thirteen oh seven descend at pilot's discretion to flight level two four zero. 2330:35 RDO-1 discretion two four zero UPS thirteen oh seven. 2330:44

CAM-2

two four zero.

2330:45

CAM-1

cleared.

2332:33

CAM

[non-pertinent conversation between three crew members regarding Jet Blue stocks and company until 2334:39.]

Appendixes National Transportation Safety Board A I R C R A F T Accident Report 75 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME and TIME and SOURCE CONTENT SOURCE CONTENT 2333:44 RDO-1 eh Washington eh UPS thirteen oh seven is out of three three zero for two four zero. 2333:49 CTR-B UPS thirteen oh seven roger thank you. 2334:39

CAM-2

smells like wood burning smell that?

2334:42

CAM-3

** yeah.

2334:43

CAM-3

I smelled it for a couple of seconds.

2334:45

CAM-?

***.

2335:03

CAM

[sound similar to increase in air noise]

2335:40

CAM-2

its pretty strong now.

2335:43

CAM-1

**.

Appendixes National Transportation Safety Board A I R C R A F T Accident Report 76 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME and TIME and SOURCE CONTENT SOURCE CONTENT 2335:49

CAM

[sound similar to cockpit door or seat operating]

2335:54

CAM-3

its more in the back.

2336:01

CAM-2

• temp.

2336:04

CAM-1

no eh yeah it was a little in the yellow but uh.

2336:08

CAM-2

what were you looking at?

2336:12

CAM-1

I was looking at it at one of the high.

2336:13

CAM-2

manifold temp?

2336:15

CAM-1

high stage was on.

2336:20

CAM-1

on one side.

Appendixes National Transportation Safety Board A I R C R A F T Accident Report 77 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME and TIME and SOURCE CONTENT SOURCE CONTENT 2336:23 CTR-B UPS thirteen oh seven contact Washington center one two five point four five. 2336:28 RDO-1 two five four five UPS thirteen oh seven thank you. 2336:31 CTR-B good day. 2336:39

CAM-1

you might try turning like a pack off uh @ see if that makes any difference.

2337:18 RDO-1 uh center good day its uh UPS thirteen oh seven with you passing two seven five for two four zero. 2337:23 CTR-C UPS thirteen oh seven Washington center roger. 2338:58

CAM

[sound of tone similar to altitude alert]

2339:00

CAM-2

twenty five twenty four.

2339:01

CAM-1

twenty five twenty four.

Appendixes National Transportation Safety Board A I R C R A F T Accident Report 78 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME and TIME and SOURCE CONTENT SOURCE CONTENT 2339:16

CAM-?

why would it *.

2339:17

CAM-2

smell like wood.

2339:19

CAM-3

yeah it does smell like wood.

2339:22

CAM-3

it doesn't smell electrical smells *.

2339:25

CAM-1

uh.

2339:26

CAM-2

that's just duct that's just duct work but there's no wood.

2339:30

CAM-1

yeah.

2339:30

CAM-2

there's no brace around any of that stuff is there?

2339:34

CAM-1

no.

Appendixes National Transportation Safety Board A I R C R A F T Accident Report 79 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME and TIME and SOURCE CONTENT SOURCE CONTENT 2339:36

CAM-2

like a wood burning kit.

2340:30

CAM-1

might need to increase that flow on the left side @.

2341:04 CTR-C UPS thirteen oh seven cross ten miles south of Woodstown at and maintain one one thousand Philly altimeter three zero zero five. 2341:11 RDO-1 ten south of Woodstown at one one thousand UPS thirteen oh seven. 2343:18

CAM-1

might try those bleeds uh switches too @.

2343:22

CAM-3

*** fume evacuation.

2343:26

CAM-1

yeah.

2343:27

CAM-3

said put the pack to max flow.

2343:28

CAM-1

okay.

Appendixes National Transportation Safety Board A I R C R A F T Accident Report 80 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME and TIME and SOURCE CONTENT SOURCE CONTENT 2343:29

CAM-3

set pack to max flow.

2343:32

CAM-3

recirc fan off? recirc fan off.

2343:34

CAM-1

it may be coming from one of those bleeds you know.

2343:46

CAM-2

I got go around set in there.

2343:53

CAM-2

visual backed up with the I-L-S two seven right one oh eight ninety five eleven touchdown zone *. 2344:06

CAM-?

***.

2344:09

CAM-2

three zero zero five approach check.

2344:14

CAM-3

approach checklist. pressurization set.

2344:20

CAM-3

reverser shut off switch?

Appendixes National Transportation Safety Board A I R C R A F T Accident Report 81 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME and TIME and SOURCE CONTENT SOURCE CONTENT 2344:22

CAM-1

open.

2344:22

CAM-3

P-T-C?

2344:23

CAM-1

override retracted.

2344:25

CAM-3

airspeed bugs?

2344:27

CAM-1

thirty nine set.

2344:29

CAM-3

N one bugs.

2344:31

CAM-?

*.

2344:34 CTR-C UPS thirteen oh seven contact Philly approach one two four point three five. 2344:38

CAM-2

thirty nine set.

2344:39

Appendixes National Transportation Safety Board A I R C R A F T Accident Report 82 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME and TIME and SOURCE CONTENT SOURCE CONTENT RDO-1 two four three five ups thirteen oh seven good day. 2344:42 CTR-C good day. 2344:45

CAM-1

eighty seven one set.

2344:48

CAM-3

okay. approach brief?

2344:49

CAM-2

complete.

2344:50

CAM-3

altimeter?

2344:52

CAM-1

thirty oh five set.

2344:54

CAM-2

thirty oh five set.

2344:55

CAM-3

thirty oh five set approach checklist complete.

Appendixes National Transportation Safety Board A I R C R A F T Accident Report 83 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME and TIME and SOURCE CONTENT SOURCE CONTENT 2344:59 RDO-1 And Philly approach good day its UPS thirteen oh seven heavy with you passing one five five for one one thousand with Charlie. 2345:19 APR UPS thirteen oh seven heavy Philly runway two seven right altimeter three zero zero four. 2345:25 RDO-1 thirty oh four two seven right UPS thirteen oh seven heavy. 2346:29 APR UPS thirteen oh seven heavy fly heading of zero five zero and descend and maintain six thousand. 2346:33 RDO-1 zero five zero down six thousand UPS thirteen oh seven heavy. 2347:02

CAM-1

can you still smell it in the back there @?

2347:06

CAM-3

yeah its uh *** smells like it was more to the back there.

2347:12

CAM-?

**.

Appendixes National Transportation Safety Board A I R C R A F T Accident Report 84 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME and TIME and SOURCE CONTENT SOURCE CONTENT 2347:13

CAM-?

**.

2347:14

CAM-1

smell like it more (strong) back there.

2347:18

CAM-2

smells like cardboard burning doesn't it? you didn't see smoke though something like that? 2347:29

CAM

[sound similar to cockpit door operating]

2347:58

CAM

[sound similar to cockpit door operating]

2347:59

CAM-3

it is definitely stronger in the back.

2348:01

CAM-1

is that right?

2348:02

CAM-3

yeah it is definitely stronger in the back.

2348:04

CAM-1

huh.

Appendixes National Transportation Safety Board A I R C R A F T Accident Report 85 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME and TIME and SOURCE CONTENT SOURCE CONTENT 2348:07

CAM-3

well does not appear to be any smoke or haze.

2348:10

CAM-1

what's that?

2348:10

CAM-3

I just shined my light back there I can't see any haze or anything. 2348:14

CAM-1

no *.

2348:21

CAM-1

did you did you try all the bleeds?

2348:23

CAM-3

well I tried the second one off now maybe another one off. 2348:27

CAM-1

okay.

2348:27 APR UPS thirteen oh seven heavy fly heading zero six zero descend and maintain four thousand.

Appendixes National Transportation Safety Board A I R C R A F T Accident Report 86 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME and TIME and SOURCE CONTENT SOURCE CONTENT 2348:31 RDO-1 zero six zero down to four thousand UPS thirteen oh seven heavy. 2348:41

CAM-2

four thousand *.

2348:52 RDO [sound of beeps similar to IPDP Morse code identifier for I- L-S two seven right approach] 2352:30

CAM-1

does it seem to get any better with the packs smoke uh checklist? 2352:35

CAM-2

flaps ten please.

2352:38

CAM

[sound of click and beep similar to configuration horn]

2352:41

CAM-3

pack smoke warning.

2352:42

CAM-1

yeah that what I am doing under the pack smoke.

2352:46

CAM-1

** fumes evacuation.

Appendixes National Transportation Safety Board A I R C R A F T Accident Report 87 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME and TIME and SOURCE CONTENT SOURCE CONTENT 2352:47

CAM-3

** smoke yeah? no smoke detectors.

2352:52

CAM-1

yeah yeah no smoke detectors going off.

2352:54

CAM-3

**.

2352:57

CAM-?

fumes evacuation because the packs the packs off **. 2353:05

CAM-?

***.

2353:07

CAM-?

***.

2353:09

CAM-?

***.

2353:19

CAM-2

flaps twenty five.

2353:21

CAM

[sound of three clicks, similar to flap handle movement]

Appendixes National Transportation Safety Board A I R C R A F T Accident Report 88 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME and TIME and SOURCE CONTENT SOURCE CONTENT 2353:27 RDO [sound of beeps similar to IPDP Morse code identifier for I- L-S two seven right approach] 2353:52

CAM

[sound of tone similar to altitude alert]

2353:56

CAM-1

five for four.

2354:07 APR UPS thirteen oh seven heavy turn left to zero one zero descend and maintain two thousand one hundred. 2354:12 RDO-1 zero one zero down to two point one UPS thirteen oh seven heavy. 2354:20

CAM-2

two thousand one hundred.

2354:42

CAM-3

okay we got cargo smoke.

2354:45

CAM-1

you got cargo smoke?

2354:47

CAM-3

**.

Appendixes National Transportation Safety Board A I R C R A F T Accident Report 89 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME and TIME and SOURCE CONTENT SOURCE CONTENT 2354:50

CAM-1

let's do that checklist if you got time.

2354:52

CAM-2

all right I am turning into the airport then.

2354:57

CAM

[sound of tone similar to altitude alert]

2354:59 RDO-1 and ah UPS thirteen oh seven heavy has the field in sight. 2355:01 APR UPS thirteen zero seven heavy cleared for the visual approach runway two seven right contact the tower one eighteen five. 2355:06 RDO-1 eighteen five seeya. 2355:11 RDO-1 tower good day it is UPS thirteen oh seven heavy with you visual for two seven right. 2355:15 TWR thirteen oh seven heavy two seven right wind two six zero at six cleared to land.

Appendixes National Transportation Safety Board A I R C R A F T Accident Report 90 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME and TIME and SOURCE CONTENT SOURCE CONTENT 2355:19 RDO-1 cleared to land and uh listen we just got a cargo smoke indicator come on can we have the equipment meet us? 2355:27 TWR okay I'll do that for you. cargo smoke indicator. [sound of ARFF alarm in background] uh uh just souls on board amount of fuel sir. 2355:34 RDO-1 uh three souls uh two hours of fuel. 2355:37 TWR two hours of fuel roger that sir uh we are bringing them out now. 2355:40 RDO-1 thanks. 2355:41

CAM

[sound similar to autopilot disconnect]

2355:45

O2-2

gear down.

2355:46

CAM-1

gear.

Appendixes National Transportation Safety Board A I R C R A F T Accident Report 91 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME and TIME and SOURCE CONTENT SOURCE CONTENT 2355:48

CAM

[sound similar to landing gear operation]

2355:48

O2-2

landing checklist.

2355:57

O2-3

okay its showing that we have a lower aft cargo fire section C. 2355:57

CAM

[sound similar to altitude alerter]

2355:58

CAM-1

oxygen masks on if you don't have 'em and uh run through that checklist @ by yourself okay? 2356:03

O2-3

okay lower and uh or main cargo fire. oxygen masks on a hundred percent. 2356:12 TWR UPS thirteen oh seven heavy is cleared to land runway two seven left the wind is uh two six zero at six. 2356:18 RO2-1 cleared to land two seven left UPS thirteen oh seven.

Appendixes National Transportation Safety Board A I R C R A F T Accident Report 92 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME and TIME and SOURCE CONTENT SOURCE CONTENT 2356:22

O2-3

okay I got.

2356:22 TWR I am sorry last call on ground say again.

2356:24

O2-3

I got packs one off one on min flow. recirc fan is off. off. oxygen air diffuser valve open... 2356:35 TWR and uh when you get a chance I know you are busy thirteen oh seven heavy can you give me fuel in pounds please? 2356:44 RO2-1 twenty one thousand seven hundred. 2356:46 TWR thank you. 2356:48

O2-2

flaps thirty five.

2356:50

O2-3

okay main cargo air shutoff valve is closed I gotta go in the back and do that. 2356:56

CAM

[sound similar to cockpit door operating]

Appendixes National Transportation Safety Board A I R C R A F T Accident Report 93 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME and TIME and SOURCE CONTENT SOURCE CONTENT 2356:57

O2-2

smelling pretty good now.

2356:58

O2-1

yeah.

2357:02

O2-2

flaps full.

2357:04

CAM

[sound similar to cockpit door operating]

2357:05

O2-2

prepare to get that uh prepare to get that uh paperwork.

2357:09

O2-3

yeah were going to have to do an evacuation 'kay. tell them we are going to have to do an evacuation when we get down. 2357:19

O2-3

ok I got that valve shut off back there. there is smoke. radio pack blower switch off. 2357:19

O2-2

I got it **.

Appendixes National Transportation Safety Board A I R C R A F T Accident Report 94 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME and TIME and SOURCE CONTENT SOURCE CONTENT 2357:33

O2-3

cabin differential pressure maintain at point five P-S-I.

2357:39

O2-3

we are almost on the ground.

2357:44

O2-3

land as soon as possible.

2357:47

O2-2

landing checklist when you get a chance.

2357:51

O2-2

cleared to land?

2357:57

O2-3

landing checklist.

2357:59

O2-1

five hundred feet on speed sink is eight.

2357:59

O2-3

flight instruments and radios.

2358:03

CAM

glideslope. [GPWS voice]

Appendixes National Transportation Safety Board A I R C R A F T Accident Report 95 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME and TIME and SOURCE CONTENT SOURCE CONTENT 2358:04

CAM

five hundred. [GPWS voice]

2358:06

O2-3

ignition. gear. anti-skid.

2358:08 TWR and thirteen oh seven heavy just confirmed you are lined up for the left side it appears you are lined up for the right. 2358:13 RO2-1 I'm sorry I thought we were cleared for the right uh are we cleared to land on the right? 2358:16 TWR uh you are cleared to land on the right we will just tell fire. 2358:20 RO2-1 okay. 2358:23

CAM

glideslope glideslope glideslope. [GPWS voice]

2358:27 TWR uh Foxtrot nine tower just be advised the aircraft is going to landing twenty seven right short final twenty seven right if you are on tower.

Appendixes National Transportation Safety Board A I R C R A F T Accident Report 96 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME and TIME and SOURCE CONTENT SOURCE CONTENT 2358:40

CAM

glideslope. [GPWS voice]

2358:46

O2-3

landing checks complete.

2358:50

CAM

one hundred. [GPWS voice]

2358:51 A10 Philadelphia tower airport ten. 2358:52 TWR airport ten if you can just let the uh fire departments know we cannot reach them on the frequencies. the aircraft is landing twenty seven right. 2358:54

CAM

fifty. [GPWS voice]

2358:55

CAM

thirty. [GPWS voice]

2358:56

CAM

twenty. [GPWS voice]

2358:57

CAM

ten. [GPWS voice]

Appendixes National Transportation Safety Board A I R C R A F T Accident Report 97 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME and TIME and SOURCE CONTENT SOURCE CONTENT 2359:00

CAM

[sound similar to spoiler handle movement]

2359:00 TWR

he is rolling out flaring as we speak. 2359:01 A10

airport ten copies. 2359:02

O2-3

okay we got smoke in the cockpit now.

2359:05

CAM

[sound similar to reverser deployment and engine acceleration] 2359:11

O2-1

eighty.

2359:13

O2-3

tell 'em we have smoke in the cockpit we are evacuating. 2359:14

O2-1

seventy.

2359:18

CAM-2

you have the aircraft.

Appendixes National Transportation Safety Board A I R C R A F T Accident Report 98 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME and TIME and SOURCE CONTENT SOURCE CONTENT 2359:21

CAM

[sound similar to window(s) being operated]

2359:25

CAM-2

okay emergency evacuation.

2359:26

CAM-1

evacuation checklist.

2359:27 ARFF Philadelphia tower can we show two seven right closed and allow ARFF vehicles to the runway? 2359:29

CAM

[sound similar to coughing]

2359:30

CAM-1

parking brake set.

2359:32 TWR ah two zero nine proceed onto runway two seven right. 2359:33

CAM-2

fuel shut off levers off.

2359:35

CAM-1

battery switch battery.

Appendixes National Transportation Safety Board A I R C R A F T Accident Report 99 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME and TIME and SOURCE CONTENT SOURCE CONTENT 2359:38 RDO-2 UPS thirteen oh seven evacuating the aircraft. 2359:40

CAM-?

• right to be closed.

2359:41 TWR two seven right is closed and the aircrew is evacuating the aircraft. 2359:41

CAM-2

fire handles full forward.

2359:45

End of transcript

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FD07322 ｜ 2006_美国_NTSB_MAB0701_Fire_on_Board_US_Small_Passenger_Vessel_Massachusetts.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2006 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

NTSB/MAB/07-01 E

P L U R IB US UN U M

N A T I O N A L

T R A S P O R T A T I O N

B O A R D S A FE T Y N National Transportation Safety Board Washington, D.C. 20594

Marine Accident Brief

Accident No.: DCA-06-MF-016 Vessel: M/V Massachusetts, 87.6 feet long, 99 gross tons, aluminum construction, built in 1988 Accident Type: Engineroom fire Location: Boston Harbor, Massachusetts Date: June 12, 2006 Time: 1615 eastern daylight time1 Owner/Operator: Massachusetts Bay Lines Damages: $800,000 Complement: 4 crew, 65 passengers Injuries: 2 minor (passengers) Synopsis On Monday afternoon, June 12, 2006, the commuter ferry Massachusetts (figure 1) was en route from Rowe’s Wharf in Boston Harbor to Hingham, Massachusetts, carrying 65 passengers and 4 crewmembers, when a fire broke out in the engineroom. The Massachusetts, owned and operated by Massachusetts Bay Lines, was inspected and certificated by the U.S. Coast Guard under the small passenger vessel regulations at 46 Code of Federal Regulations (CFR) Parts 114-122 (subchapter K).2 The vessel’s certificate of inspection (COI), valid for 5 years, was issued on November 14, 2002.3 The COI allowed a total of 350 persons on board, including 346 passengers (adults and children) and 4 crewmembers (a master and 3 deckhands). At the time of the fire, the Massachusetts was operating pursuant to a subcontract with Boston Harbor Cruises, which had a 5-year contract with the Massachusetts Bay Transit Authority to provide

1 Times in this brief are given in eastern daylight time according to the 24-hour clock. 2 Small passenger vessels are defined by Title 46 United States Code section 2101 as vessels of less than 100 gross tons that carry more than 6 passengers, including at least 1 passenger for hire. “Passenger for hire” is defined as “a passenger for whom consideration is contributed as a condition of carriage on the vessel, whether directly or indirectly flowing to the owner, charterer, operator, agent, or any other person having an interest in the vessel.” Title 46 CFR subchapter K governs small passenger vessels that are certified to carry more than 150 passengers or have accommodations for more than 49 overnight passengers. 3 Sector Boston was the local Coast Guard office in charge of inspecting the Massachusetts. The vessel’s last drydock (hull) examination was on October 20, 2005.

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2 ferry service between Rowe’s Wharf and Hingham Shipyard. The contract specified that vessels had to comply with Coast Guard requirements. The Massachusetts crew was alerted to the fire about 1615, when the ferry was near the Long Island Bridge (figure 2), by black smoke at the stern and an engine high- water-temperature alarm. The vessel did not have, and was not required to have, an engineroom fire detection system. The master maneuvered the vessel into shallow water southeast of the bridge, anchored, and waited for firefighters. Before a fireboat from the Boston Fire Department’s marine unit arrived, all the passengers safely transferred to the Laura, another commuter vessel in the vicinity. The fireboat extinguished the fire. The accident did not result in any serious injuries or fatalities.4 Damage, estimated at $800,000, was confined mostly to the engineroom.

Figure 1. Commuter ferry Massachusetts at Rowe’s Wharf, Boston. (Photo courtesy Massachusetts Bay Lines)

4 One passenger suffered an asthma attack brought on by smoke inhalation and was treated at the scene. Another passenger was treated and released at a local hospital for minor smoke inhalation and a spike in a preexisting blood pressure condition.

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3

Figure 2. Commuter route of Massachusetts between Rowe’s Wharf and Hingham Shipyard. Accident site is at anchor symbol southeast of Long Island Bridge. Accident Narrative Engine Repair. At 1230 on June 12, after completing three morning commuter runs and two sightseeing tours of Boston Harbor, the Massachusetts left Rowe’s Wharf and traveled 15 minutes away to a dock at Charlestown, Massachusetts. The master had arranged that morning to meet the company’s marine repair contractor at the Charlestown dock because the Massachusetts was experiencing a number of mechanical problems. The repair shop had three employees (diesel mechanic, welder, and mechanic-in- training), in addition to the owner. The diesel mechanic had been employed at the shop for almost 12 years and normally worked on the Massachusetts Bay Line vessels. He said that his knowledge of diesel repair and maintenance had been acquired solely through on-the-job experience and estimated that 80 percent of the diesel engines he worked on were manufactured by Detroit Diesel. The Massachusetts was powered by four 675-horsepower, 12-cylinder turbocharged model 12V-71 Detroit Diesel engines and had two generators (see “Vessel Information” section for details). The diesel mechanic met the Massachusetts at the dock. The Massachusetts master and the mechanic discussed the work to be performed—(1) examining the starboard outboard engine for excessive blowby (venting) of combustion gases through

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4 the valve cover breathers;5 (2) examining the port generator for sparking, which a crewmember had reported over the weekend; and (3) examining the port inboard engine, which had been idling at a higher speed than normal. For the first item, the mechanic diagnosed a leaking head gasket on the starboard outboard engine, which he and the master decided to defer repairing until later in the week.6 The owner of the repair shop arrived while the mechanic was working on the second item, examining the port generator. Although the mechanic found no sparking on the generator, the master decided to use only the vessel’s starboard generator until a marine electrician could examine the port generator. For the third item, the port inboard engine, the shop’s owner advised the mechanic to look for a faulty injector, which the mechanic said he agreed might be the cause of the high idle speed. The owner left the vessel before the mechanic started work on the port inboard engine. The mechanic said that he removed the inboard valve cover to check the six fuel injectors on that side of the engine (figure 3). His inspection revealed that the injector on the No. 3 cylinder was faulty. The mechanic proceeded to replace the injector. First, he removed the fuel supply and return lines (“jumper lines”) connected to the injector.7 Then he unbolted the fasteners holding the injector to the engine, removed the faulty injector, and bolted another in its place. The mechanic stated that in replacing an injector on a Detroit Diesel engine of that type, no calibrations or settings were necessary once the new injector was in place. He had access to the manufacturer’s service manuals but said, “Generally, I don’t need them,” noting that he had memorized the torque specifications. He told investigators that he used a torque wrench to torque the rocker stand bolts to 104 foot-pounds8 and the injector hold-down clamp to 25 foot-pounds. He said that he did not use a torque wrench on the fuel lines because “If you overtighten them, you could split the side of the fuel line.” The engine manufacturer’s service manual warns, “When installing fuel jumper lines, Do Not Overtighten.”9 The mechanic told investigators that after replacing the injector on the No. 3 cylinder, he ran the engine with the valve cover off to “inspect the fuel lines to make sure they’re not leaking.” The engine manufacturer’s service manual warns that leaking fuel oil can dilute the lubricating oil and damage the engine:

5 Each of the two valve covers on each engine was fitted with a breather to release vapors that might build up in the crankcase. 6 Before leaving on the first commuter run the morning of the fire, the master had replaced the impeller in the cooling-water pump for the starboard outboard engine, which had been overheating. 7 Each injector had two steel jumper lines: one leading from the fuel supply line into the inlet side of the injector, and the other leading from the outlet side of the injector to the fuel return line and then back to the fuel tank. 8 One foot-pound is 1 pound of force acting through a distance of 1 foot in the direction of the force. 9 Detroit Diesel Corporation, V-71 Service Manual, section 2.0, “Shop Notes” (Detroit, Michigan: 1989), p. 2-13.

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5 Maintenance and service personnel should be aware that severe engine damage could result from fuel oil leakage into the lubricating oil and should therefore follow proper procedures when removing, handling and installing fuel jumper lines . . . . The manual also warns specifically of the fire danger posed by undetected leaks in the fuel jumper lines: Severe fuel leakage, if not detected, can also result in an over-filled crankcase (oil pan) which can cause an abnormal amount of fuel and lubricating oil vapor to escape from the engine and crankcase breathers. An abnormal concentration of fuel and lube oil vapors is flammable and could ignite in a closed engine compartment. The procedure in the manufacturer’s service manual for ensuring that fuel jumper lines are securely in place after replacing the lines is to run the engine with the valve cover off, which makes it possible to observe the jumper lines for any leaks. A Detroit Diesel marine service engineer stated that running the engine with a disconnected fuel jumper line would be like “‘running a garden hose inside the engineroom.” If the valve cover was off, the mechanic should have been able to see fuel leaking from the jumper line that investigators found disconnected after the fire (see “Wreckage” section). Detroit Diesel Corporation, Diesel V-71 Service Manual Figure 3. Typical fuel injector assembly in Detroit Diesel engine cylinder.

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6 The master said that the idle on the port inboard engine was back to normal after the mechanic changed the injector. The mechanic completed his work between 1430 and 1500, according to the master, and left the vessel about 1530. The Massachusetts then departed Charlestown to begin its afternoon commuter schedule. The master said that he ran only the two outboard engines on the return trip to Rowe’s Wharf, but that he always used all four engines on the commuter runs. Departure. Back at Rowe’s Wharf, the Massachusetts boarded 65 passengers for the 1600 trip to Hingham Shipyard. Before departing, the master, who had been employed by Massachusetts Bay Lines for over 20 years, delivered a passenger safety briefing over the vessel’s public address system. The master informed passengers about the location and type of lifesaving equipment on board and told them to follow crewmembers’ instructions in case of emergency.10 According to data from Logan International Airport, about 5 miles away, skies were clear, with unrestricted visibility at 10 miles and a broken cloud cover, the air temperature was 71° F, and winds were from the southeast at 12 knots. The Massachusetts departed the dock on schedule (1600), running on all four engines, with the mate at the helm. Soon after leaving Rowe’s Wharf, the master went to the engineroom to bleed air from the air conditioning system. He said that he did not detect anything out of the ordinary. He then returned to the pilothouse. Fire. About 1615, the upper deck deckhand entered the pilothouse to report black smoke at the vessel’s stern. At the same time, the high-water-temperature alarm for the port inboard engine sounded. The mate stopped the port inboard engine and slowed the remaining three engines from 2000 to 1300 rpm, as directed by the master. The master went to the engineroom to investigate. The master said that when he opened the door to the starboard ladderway leading to the engineroom, he encountered heavy smoke and immediately closed the door. He went to the phone at the main deck bar and called the pilothouse, informing the mate of the situation and instructing him to shut down two of the remaining engines. The mate shut down the port outboard engine, which had already lost some power, and the starboard outboard engine, leaving only the starboard inboard engine running. On his way back to the pilothouse, the master directed the main deck passengers and the main deck deckhand to go to the upper deck and told the deckhands to give the

10 Federal regulations at 46 CFR 122.506 require, in part, that before getting under way on a voyage or as soon as practicable thereafter, the master will ensure that “suitable public announcements are made informing all passengers” where emergency exits and lifejackets are located and how lifejackets should be donned. The Massachusetts carried 366 adult lifejackets and 36 child lifejackets, stored in marked compartments underneath the bench seats throughout the interior accommodation spaces on both decks, as required by regulations (46 CFR 117.78). Eight 22-person lifefloats were stowed on the roof of the upper deck cabin, four on each side. According to 46 CFR 117.204, vessels certificated to operate on a coastwise route within 3 miles of land “may be provided with life floats of an aggregate capacity that will accommodate at least 50% of the total number of persons permitted on board.” Lifefloats are buoyant apparatus that have a line attached around the outside. Survivors in the water can hold onto the line. The apparatus is not designed to keep survivors out of the water.

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7 passengers lifejackets. One of the passengers happened to be a Coast Guard officer commuting home. The master told the Coast Guard officer about the fire and asked for his help in contacting the Coast Guard. The officer used his cell phone to alert the local Coast Guard office, Sector Boston, about the fire. By that time, the vessel had passed south of the Long Island Bridge. The master relieved the mate at the helm and ordered him and one deckhand to the bow to prepare to drop anchor. The mate instructed the other deckhand to help. Passenger Evacuation. Meanwhile, the master used very-high-frequency (VHF) channel 1311 to contact the commuter ferry Laura, operated by Boston Harbor Cruises. The Laura was about 1/2 mile south, en route from Hingham to Rowe’s Wharf with three passengers on board. The Massachusetts master told the Laura master that his vessel had an engineroom fire and asked the Laura to come alongside and receive his passengers “expeditiously.” The Laura immediately altered course to assist the Massachusetts. The Coast Guard officer entered the pilothouse and reminded the master to turn off the engineroom’s ventilation supply blowers.12 After turning off the blowers, the master navigated the Massachusetts just outside the channel to the east, about 1/2 mile south of the Long Island Bridge (figure 2), and ordered the mate to drop the anchor. After the vessel was anchored, the master sent the mate to the main deck to close the emergency fuel shutoff valves, located in the bar area. The deckhands returned to the upper deck to attend to the passengers, and the master turned off the inboard starboard engine. The generator shut down from fuel starvation about 30 seconds after the mate closed the emergency fuel shutoff valves. About 1630, the Laura came alongside the Massachusetts and tied up on the starboard side. The Massachusetts crew then led the vessel’s 65 passengers, wearing lifejackets, down the forward starboard ladder to the main deck and out through the starboard forward side door directly onto the Laura. Once on board the Laura, the Coast Guard officer again used his cell phone to call Sector Boston about the fire. The transfer of passengers was orderly, taking around 5 minutes, according to crew statements. The Massachusetts crew did not remember counting passengers as they left the vessel, but a count was taken and logged on board the Laura. At 1635, the Laura untied from the Massachusetts and moved to a safe distance. After the state police boarded and checked for casualties, the Laura departed for Hingham Shipyard.13 Crew Decision on Firefighting. Once the passengers had transferred to the Laura, the master and crew discussed fighting the fire themselves. The Massachusetts carried approved firefighting equipment, including seven fire extinguishers14 and two fire

11 Marine radio channel for communication between the navigation bridges of vessels. 12 The two blowers that supplied air to the engineroom could be turned off from the bridge, but because the supply and exhaust ducts had no ventilation dampers, airflow through the ducts to the fire could not be restricted. 13 When the passengers reached Hingham, members of the Hingham Fire Department checked them again for injuries. 14 One B-I portable fire extinguisher was kept in the pilothouse, and six B-II portable fire extinguishers were placed throughout the ship, including two mounted in the engineroom. Class B extinguishers are

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8 pumps, both located in the engineroom and run by the generators,15 capable of providing a stream of water to any space on the ship by way of two fire stations (one behind the bar on the main deck and one at the top of the interior ladderway). The master stated, “I flatly decided we weren’t going to open either engineroom door. We weren’t going to do anything to give the fire any oxygen.” Throughout the accident, the master’s prudent decisions promoted the safety of his passengers and crew. Police Boat. Meanwhile, the Protector, a police boat from Quincy, Massachusetts,16 had been approaching the Long Island Bridge from the southwest when the crew observed the Massachusetts “dead in the water with smoke showing from its stern.” About 1635, the Protector came alongside the Massachusetts on the port side, and the Massachusetts mate told the Protector crew that the engineroom was on fire. Police on board the Protector immediately notified the Coast Guard, using VHF channel 16,17 and requested a fireboat. The Protector crew also notified Quincy police headquarters about the fire. At approximately 1645, at the Coast Guard’s request, the crew transferred from the Massachusetts to the Protector, which remained on scene but at a distance from the burning vessel. Emergency Response. According to emergency records provided by the Boston Fire Department, the dispatch operations center (known as “Fire Alarm”) received nearly simultaneous calls reporting the Massachusetts fire from the Coast Guard (at 1641) and Quincy police (at 1642). At 1644, the center dispatched the fire department’s marine unit to the Long Island Bridge from its station at Burroughs Wharf in Boston’s North End, about 6 nautical miles from the accident site. After receiving the call from the dispatch center, marine unit personnel boarded the vessel Firefighter and were under way in 2 or 3 minutes, according to the pilot.18 At 1656, the dispatch center dispatched Engine Company 2 and Ladder Company 19 to the Paul W. Conley terminal, located at the southeast end of the reserved channel19 in South Boston, to be picked up by the marine unit. At 1703, the dispatch center dispatched the District 6 fire chief to the Conley terminal, also to be picked up by the marine unit. Firefighters told investigators that it took 10 minutes to load personnel and gear at the terminal.

intended for fires involving flammable liquid, grease, or gas. B-I extinguishers hold 2.5 pounds of dry chemical; B-II extinguishers, 10 pounds of dry chemical. 15 The fire pumps could be started only by entering the engineroom. Fire pumps on small passenger vessels built after March 11, 1996, are required to “be capable of both remote operation from the operating station and local operations at the pump” (46 CFR 118.300[e] and 181.300[e]). These regulations did not apply to the Massachusetts because it was built in 1988. 16 A small city about 7 miles southeast of downtown Boston. 17 Channel 16 (156.8 megahertz), which the Coast Guard monitors continuously, is the international calling and distress frequency. 18 The marine unit’s other vessel, the St. Florian, was out of service because an electrical problem had drained its batteries. According to the marine unit’s standard operating procedures, the smaller, faster St. Florian would normally have been launched first, with the Firefighter following later and land companies deploying if necessary. 19 A dredged, unmarked channel lined with freight terminals.

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9 The Firefighter (maximum speed 9 to 10 knots) arrived at the accident scene at 1730 and approached the burning Massachusetts on its port side. All passengers and crew had disembarked. The Firefighter crew noted heavy black smoke coming out the vents and doorways at the Massachusetts’s stern. Vessels were already on scene from the Quincy Police Department (the Protector and the Guardian), the Massachusetts Environmental Police Department, the Massachusetts State Police, and the Coast Guard (which had launched a 41-foot utility boat from Station Pt. Allerton, about 2 nautical miles east of the accident site20). A MassPort fireboat21 also stood by. The District 6 fire chief assumed on-scene command. The Firefighter was secured to the Massachusetts and five firefighters went on board. According to the fire chief, the firefighters placed a 2 1/2-inch-diameter fire hose down each of the two engineroom ventilation shafts on the aft main deck, with two men operating each hose. Because of the intensity of the fire (the fire chief said the main deck had “steam coming out of the carpet”), firefighters could not enter the engineroom. They poured water into the engineroom and pumped firefighting foam down the port engineroom ventilation shaft, but their actions did not extinguish the fire. Firefighters sought help from the Massachusetts crew, now on the Quincy police boat Protector, in finding better engineroom access. The mate and two deckhands of the Massachusetts transferred from the Protector to the Quincy police boat Guardian, and the Protector delivered the master to the Firefighter. The master told the firefighters about “soft patches” (metal hatches) in the main deck, directly above the engines, that could be opened. Firefighters removed enough screws so they could pry open the hatch over the port inboard engine and fight the fire from above. Their efforts filled the engine compartment with water nearly to the main deck level, above the tops of the engines. Out of concern for the vessel’s stability, the fighters began pumping water out of the engineroom. After they had lowered the water level by 5 to 6 feet, the firefighters entered the engineroom and checked for hot spots. At 1848, firefighters reported that the fire appeared to be out but set a reflash watch in case the fire should reignite. Firefighters left the scene at 2040. Aftermath. The Massachusetts crew, which had transferred to the Coast Guard 41-foot utility boat, was transported to the Hingham Shipyard dock, arriving at 2130. The Massachusetts was taken under tow by a local harbor tug at 2240 and moved to a pier at Deer Island (figure 2). Vessel Information The Massachusetts, a double-deck vessel constructed entirely of aluminum (figure 4), was built for Massachusetts Bay Lines by Gulf Craft, Inc., of Patterson, Louisiana. The builder began construction in 1987 and delivered the Massachusetts in

20 The Coast Guard utility boat arrived at the accident scene at 1649, according to the Coast Guard station log. 21 A fire and rescue boat launched from Logan International Airport.

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10

1. Massachusetts Bay Lines immediately put the vessel to use in the Boston Harbor

commuter trade. Figure 4. Profile view of the Massachusetts. Passengers were carried in the enclosed cabins on the main and upper decks. The enclosed pilothouse at the bow of the vessel was accessed by a short ladder from the upper deck. The pilothouse was equipped with the following navigation and communication equipment: X-band and S-band Furuno® radars,22 two Raytheon® VHF radios, an International® depth sounder, a Magellan® global positioning system unit, a horn, a searchlight, and a compass. A control panel in the pilothouse registered alarms for high water temperatures in individual engines and for high water in the compartments equipped with bilge alarms. The pilothouse was also equipped with an engineroom air high-temperature alarm.23 A public address system in the pilothouse was used to communicate with passengers and crew throughout the vessel and to deliver predeparture safety briefings and other announcements. The upper deck contained both fixed and movable chairs for passenger seating. An enclosed passenger section in the middle contained a bar. The upper deck was connected to the main (lower) deck by an exterior ladderway (stairway) on the port side aft and by an interior ladderway on the starboard side forward. The main deck was almost entirely enclosed to protect commuters from the weather. Seating consisted of chairs placed throughout and fixed seats in the forward

22 Marine radars are available in X-band (shorter wavelength, greater resolution) and S-band (longer wavelength, longer range). 23 According to the Massachusetts Bay Lines’s general manager, the device was installed as original equipment and intended to warn the operator if the air temperature rose in the engineroom, possibly signifying an overheated engine. The device was not regularly tested or logged. The vessel master was not certain whether the alarm sounded during the fire.

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11 area. A small bar/serving area was located amidships on the starboard side. Next to the bar were the emergency fuel shutoff levers for the propulsion engines and generators, as well as a fire station containing a fire hose. Restrooms were located at the aft end of the main deck. A small open deck aft of the restrooms allowed crewmembers to handle the lines during docking. Two sliding doors on each side of the main deck provided egress from the vessel. Passengers and crew could also exit through the door at the stern that led to the open deck.24 The belowdecks area was divided into six compartments separated by transverse watertight aluminum bulkheads extending upward from the bilges to the main deck (figure 5). The forwardmost compartment (forepeak) contained anchor rope and spare lines. The next compartment (forward compartment) contained a sewage holding tank and macerator pump.25 Aft of the forward compartment was a space that was used to store supplies such as coffee and also contained a small workshop; it was accessible from the main deck by a ladderway forward of the bar area. Immediately behind the work/storage space was a narrow compartment that held the fuel tanks and potable water tanks. Aft of that was the engineroom, accessed by ladderways forward of the restrooms on each side of the main deck. The engineroom could also be accessed from the main deck by unscrewing any of four large hatches, one over each engine (as shown in figure 5). The aftmost belowdecks compartment (lazarette) contained exhaust piping, a hydraulic cylinder for the steering system, and the vessel’s hot water heater. Each of the belowdecks compartments contained a bilge suction well. The lazarette, engineroom, work/storage space, and forepeak were also equipped with high-water bilge alarms. The engineroom contained four 675-horsepower Detroit Diesel engines direct- coupled to individual drive shafts through reduction gears. The two outboard engines were mounted approximately 2 feet higher than the two inboard engines. Each engine had two turbochargers, inboard and outboard, and 12 cylinders, each fitted with a fuel injector. No. 2 diesel fuel was drawn from the fuel tank into the fuel pump, where it was forced under pressure through a fuel filter and then through the fuel lines into the injectors. According to a Detroit Diesel marine engineer, the pressure on the fuel lines at the injectors ranged from 5 psi at engine idle to 55 psi at full engine throttle. Surplus fuel went from the injectors through return lines and back to the fuel tank.

24 The Massachusetts met the requirements for emergency egress applicable at the time it was built (46 CFR 177.15-1, in effect until March 1990) and the requirements now in effect (46 CFR 115.500). The earlier requirements stated: “all vessels shall be provided with not less than two avenues of escape from all general areas accessible to the passengers or where the crew may be quartered or normally applied, so located that if one is not available the other may be. At least one of the avenues of escape shall be independent of watertight doors. Windows and windshields of sufficient size and proper accessibility may be used as one avenue of escape.” Current regulations are that “each space accessible to passengers or used by the crew on a regular basis must have at least two means of escape, one of which must not be a watertight door” (46 CFR 116.500[a]). Only one means of escape is required in certain circumstances, such as from deck areas of less than 322 square feet (46 CFR 116.500[p]). For further information on the history of small passenger vessel regulations, see the “Fire Protection Regulations” section of this brief. 25 A macerator pump breaks up waste solids and empties the sewage holding tank.

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12

Figure 5. Belowdecks plan of the Massachusetts showing compartments and equipment. Shaded areas indicate hatches (covered openings) in the main deck that provided belowdecks access.

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13 The engines were cooled by water whose temperature was automatically controlled by a thermostat. According to the engine manufacturer’s service manual, the thermostat sounded an alarm if the water temperature exceeded 215° F. Areas that were not water-cooled, such as the outside of the exhaust manifold, reached a maximum temperature of 600° F under ordinary operating conditions, according to a Detroit Diesel marine service engineer. Engine lubricating oil was drawn by suction from the oil pan and into the oil pump, where it was pressurized. The pressurized oil flowed to the cylinder block, providing lubrication for the bearings, pistons, gears, and other moving parts. In addition to the standard oil filters mounted on the engine block, each engine had an external oil filter, mounted on the engineroom bulkhead and connected to the engine by oil lines running along the engineroom deck. Electrical power was produced by two three-cylinder Detroit Diesel generators, each producing 30 kilowatts of power. The generators were generally used one at a time and were alternated daily. On the day of the fire, the starboard generator was online. The port generator was idle, awaiting service. The vessel had an electrohydraulic steering system. Rudder commands from the pilothouse steering wheel went to the pump control in the engineroom, which would change the hydraulic cylinder position in the lazarette. The hydraulic cylinder was linked to two rudders that would move simultaneously. Other equipment in the engineroom included two 12-volt battery banks (aft) and two 32-volt battery banks (forward) for supplying direct-current power to vessel equipment. The engineroom also contained two bilge pumps that could also operate as emergency fire pumps and other piping and pumps used in the vessel’s engineering systems. The engineroom ventilation system consisted of two air intake vents in the forward part of the engineroom, one port and one starboard, and two exhaust vents at the rear. The forward intake vents provided forced ventilation through aluminum ducts fitted with electric blowers. The rear vents, which shared the ladderway shafts, provided natural exhaust. Wreckage Investigators examined the wreckage of the Massachusetts between June 13 and June 21, first at Deer Island in Boston Harbor and then at a berth in Chelsea, Massachusetts, where the vessel was taken after the fire. Investigators examined the exterior and interior spaces of the vessel, both abovedecks and belowdecks. The engines and generators were inspected for the integrity of their components and the overall degree of fire damage. Potential sources of combustible material, such as hydraulic fluid, fuel distribution lines, and lubricating oils, were also examined to determine whether they were involved in the fire.

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14 Structural Damage The pilothouse and upper deck were not damaged by the fire. The exterior of the main deck exhibited soot stains at the ventilation grills on both sides of the vessel, more pronounced on the starboard side (figure 6). The carpet in the interior of the main deck was charred on the port side, next to the port engineroom air intake duct. Seven windows around the main deck were broken (firefighters had broken them to vent smoke while fighting the fire), and surfaces on the upper and main decks were dusted with soot.

Figure 6. Smoke damage to outside of Massachusetts’s main deck, starboard side. In the engineroom, the pattern of damage indicated that a hot smoke layer had formed throughout the space and radiated heat to the components below it. Plastic light fixtures and the insulation on wiring cables close to the overhead (main deck) had melted, with similar damage on the tops of machinery and other items, such as the insulation lining the overhead and bulkheads. The aluminum ventilation duct to the fresh air intake on the engineroom’s port side had melted,26 and the blower had fallen to the deck below. Thermal damage was most severe above and beside the port inboard engine. Above the engine, aluminum bars approximately 1/4 inch thick and 2 inches deep that spanned the length of the overhead were melted and sagging, and a vertical aluminum column extending from the floor to the overhead had softened, fractured, and bent out of alignment. Between the port and starboard inboard engines, a hole approximately 1 1/2 feet in diameter had melted through the aluminum decking, and the decking’s support structure was melted and deformed (figure 7).

26 Most aluminum alloys start to melt at about 1,000° F.

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15

Figure 7. Melted and deformed floor supports and decking next to port inboard engine, looking down. (Large green hose on right and small green garden hose behind it were inserted to control water in bilges after accident; neither was part of vessel's normal equipment.) Equipment Damage Engines. The most extensive fire damage was to the port inboard engine, which had especially severe thermal damage on the inboard side.27 In that area, the valve cover was deformed, and the gasket protruded from underneath (figure 8). After removing the valve cover, investigators found a disconnected fuel jumper line to the injector on the No. 3 cylinder (figure 9).

27 Refer to figure 5 for engineroom layout.

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16

Figure 8. Inboard valve cover and protruding gasket, port inboard engine.

The wire-reinforced rubber fuel and lubricating lines on the port inboard engine were burned through or missing. Only the wire reinforcement remained on the fuel line at the top of the engine that ran to the return fuel cooler. The oil return line from the external oil treatment system was burned through and lying in the bilge, and an oil line was missing on the inboard side of the engine block. Plastic components of the fuel and oil filters were melted or missing, and the paint on the engine block had burned off, blackening the engine. The turbocharger on the inboard side of the port inboard engine showed severe damage to aluminum elements such as the air intake manifold leading away from the turbocharger, which was heavily oxidized, deformed, and sagging. The compressor blades on the inside of the inboard turbocharger were blackened and heat-deformed. Fire damage to the port outboard, starboard inboard, and starboard outboard engines was generally limited to burned-through water-coolant lines, which consisted of wire-reinforced rubber, and melted plastic wiring insulation. Firefighting efforts had filled the engine compartment with salt water and submerged all the engines, rendering them inoperable.

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17

Figure 9. Disconnected fuel line on No. 3 cylinder of port inboard engine.

Other Equipment. The wire-reinforced rubber coolant lines at the top of both generators were burned through, but other generator components, such as steel fuel supply and return lines, oil lines, wiring, and paint, were undamaged by the fire. Only the batteries on the forward starboard side of the engineroom showed signs of thermal damage. The cables to and from the battery banks had lost insulation along their runs, but investigators found no evidence of arcing against conductive surfaces or between the conductors themselves. The two hydraulic steering gear pumps and the four stainless-steel hydraulic lines that ran through the engineroom showed no signs of damage or leaks. The hydraulic reservoir, which was toward the rear of the engineroom, was undamaged and full of hydraulic fluid.

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18 Origin of Fire When investigators examined the wreckage of the Massachusetts, they discovered, as described above, that one of the fuel jumper lines on the port inboard engine was disconnected. The disconnected jumper line had been attached to the fuel injector on the No. 3 cylinder on the engine’s inboard side. The fuel jumper line and its mating surface were sent to the Safety Board’s materials laboratory in Washington, D.C., for examination. The examination found no mechanical damage to the threads of the connector fittings or any other mechanical reason for the jumper line to have become disconnected. Fuel leakage from the disconnected fuel jumper line would have allowed fuel to flow to the engine crankcase, accumulate, escape through the crankcase vent, contact the hot surface of the exhaust manifold below, and ignite. The exhaust manifold was not cooled and, under ordinary operating conditions, reached a temperature of about 600° F. However, the engine would have been running hotter than normal because the lubricating oil had been diluted by the fuel oil from the leaking jumper line.28 The fuel would autoignite (ignite by heat without spark or flame) at a temperature of 637° F, according to the product’s material safety data sheets. The fuel’s ignition temperature (the temperature at which spark or flame will cause fuel to burn) was 494° F.29 The exterior of the exhaust manifold leading from the overheated engine would have exceeded both temperatures. Personnel Information The 55-year-old master of the Massachusetts on the day of the accident was the vessel’s permanent master.30 He had worked aboard the vessel during its construction in the shipyard, and he had delivered it to Boston Harbor on its completion in 1988. He held a Coast Guard license as “master of steam, motor or auxiliary sail vessels of not more than 100 gross tons upon near coastal waters” reissued in February 2005. In addition to his duties regarding daily operation of the Massachusetts, he was responsible for the material condition of the vessel, arranged for repairs, and ensured that the repairs were satisfactory. He operated the vessel 4 days a week—Monday, Tuesday, Thursday, and Friday. He said that he reported to work at 0600 and generally left work about 1845. On weekends, he usually went to bed around 2300 and got up about 0730. He characterized his work/rest periods as “pretty routine” and said that there had been no events to affect his schedule before the accident. The mate, age 27, started work with Massachusetts Bay Lines as a deckhand in May 1997. He held a Coast Guard license as “master of steam or motor vessels of not

28 The Detroit Diesel service manual states (section 2.0, “Shop Notes,” p. 11): “Always check the fuel system for leaks after injector or fuel pipe replacement and any time the fuel connections under the rocker cover are suspected of leaking. Failure to correct a serious fuel leak in this area can lead to dilution of the fuel oil and bearing and/or cylinder kit [components] damage.” 29 National Fire Protection Association, Guide for Fire and Explosion Investigations, NFPA 921 (Quincy, Massachusetts: 2004). 30 Each of the seven vessels operated by Massachusetts Bay Lines had one permanently assigned master who was in charge of the vessel’s operation, maintenance, and repair.

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19 more than 100 gross tons upon near coastal waters” reissued in March 2006 but served as the mate on the Massachusetts when the permanent master operated the vessel. He normally worked 50 to 55 hours per week. He said that 3 days before the accident (Friday), he went to bed about 0030. The next day, he worked two cruises, one in the afternoon and one that began Saturday night and lasted until 0230 Sunday morning. He finished work about 0400 and went to bed about 0445. He said that he went to bed about 2200 or 2230 on Sunday and felt rested when he got up Monday morning at 0430, his usual time. The lower deck deckhand, age 55, had been employed as a deckhand for approximately 8 months. All his marine experience had been on the Massachusetts. His duties involved line handling, serving coffee to passengers on the main deck, counting passengers as they boarded, and checking the engineroom at the midpoint of each commuter trip, near the Long Island Bridge. He said that before he started the job, the master had taken him on a “walkthrough” of the vessel’s emergency equipment, engineroom, and procedures for shutting down the fuel supply in an emergency. After starting the job, he took part in man-overboard drills with the master and for the Coast Guard, and he had also watched safety training videos. The upper deck deckhand, age 20, had been employed by Massachusetts Bay Lines for 3 weeks—her first maritime employment. She said that the master had given her a familiarization tour of the vessel and pointed out the storage areas for the lifejackets and other safety equipment but that she had not yet participated in any emergency drills at the time of the accident. Her responsibilities included line handling, assisting passengers, and serving drinks at the upper deck bar. Toxicological Testing None of the crewmembers was tested for the presence of alcohol after the fire.31 Sometime before 1700 on June 12, the general manager of Massachusetts Bay Lines attempted to reach the contractor who conducted toxicology testing for the company, but no one answered the contractor’s afterhours telephone number. When the crew arrived in Hingham about 2130 on board a 41-foot Coast Guard utility boat, the company president met them and transported them to a local hospital for testing. The hospital emergency room was too busy to conduct the tests, and a hospital employee advised the crewmembers to return the next day. About 0900 on the morning of June 13, the crewmembers were taken to the office of the testing contractor, where they provided urine specimens for drug testing. The contractor did not conduct alcohol testing because too much time (16 hours) had elapsed

31 Postaccident alcohol and drug testing is required by Federal regulations at 46 CFR 4.06 for any accident meeting the criteria of a serious marine incident, defined at 46 CFR 4.03-2 as (a) a marine casualty or accident that results in any of the following: (1) one or more deaths, (2) injury that requires medical treatment beyond first aid and renders the individual unfit to perform routine duties, (3) property damage exceeding $100,000, (4) actual or constructive total loss of an inspected vessel, or (5) actual or constructive total loss of any uninspected vessel that exceeds 100 gross tons; (b) discharge of 10,000 or more gallons of oil into U.S. waters; or (c) the release of a reportable substance into the environment of the United States.

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20 since the accident. Test results for all four crewmembers were negative for the five drugs of abuse (marijuana, cocaine, opiates, amphetamines, and phencyclidine) for which screening in postaccident testing is required by Federal regulations at 46 CFR 16.113 and elsewhere. The drug tests were administered within the required time limits. The Massachusetts master was not tested for alcohol within the time limits of the regulations, in part because he remained at the accident scene to assist the firefighters (he helped them gain access to the engineroom). According to 46 CFR 4.06 (“Mandatory Chemical Testing Following Serious Marine Incidents Involving Vessels in Commercial Service”), paragraph 4.06-1(d), The requirements of this subpart shall not prevent vessel personnel who are required to be tested from performing duties in the aftermath of a serious marine incident when their performance is necessary for the preservation of life or property or the protection of the environment. On June 20, 2006 (8 days after the Massachusetts fire), new Coast Guard regulations (46 CFR 4.06-3) went into effect requiring alcohol testing within 2 hours of a serious marine accident.32 Coast Guard headquarters informed the Safety Board on August 24, 2006, that the new regulations will be enforced by levying civil penalties against any marine employer who fails to conduct the alcohol testing as prescribed.33 Failing to collect urine specimens for drug testing within 32 hours of an accident, as required by the regulations, will also result in civil penalties. Since the fire, Massachusetts Bay Lines has acquired saliva test kits for alcohol testing and has trained its office staff and vessel crews to use the kits. The Safety Board placed the issue of improving postaccident drug and alcohol testing in the marine industry on its “Most Wanted” list in 2002. The list is intended to increase the public’s awareness of, and support for, action to adopt safety steps that can help prevent accidents and save lives. Because of the new Coast Guard regulations for crew drug and alcohol testing after serious marine incidents, the Board removed the issue from its “Most Wanted” list on November 14, 2006. Fire Protection Regulations The Massachusetts had the firefighting equipment (fire pumps, hoses, and portable extinguishers) required by its COI. The vessel was not equipped with fixed fire

32 The Safety Board recommended this and other improvements to the Coast Guard’s regulations regarding postaccident toxicological testing in a special investigation report issued in 1998 (National Transportation Safety Board, Postaccident Testing for Alcohol and Other Drugs in the Marine Industry and the Ramming of the Portland–South Portland [Million Dollar] Bridge at Portland, Maine, by the Liberian Tankship Julie N on September 27, 1996, Special Investigation Report NTSB/SIR-98/02 [Washington, DC: NTSB, 1998]). 33 To test for alcohol, either a breath, blood, or saliva (but not urine) specimen can be collected. Internal Coast Guard directives require Coast Guard personnel to conduct the alcohol tests if the marine employer does not or cannot conduct them within 2 hours.

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21 suppression or detection systems in its engineroom, nor (as explained below) was it required by Coast Guard regulations to have such systems.34 When the Massachusetts began operating in 1988, the Coast Guard inspected vessels of less than 100 gross tons that could carry more than six passengers (that is, small passenger vessels) according to regulations at 46 CFR subchapter T.35 On March 11, 1996, after a lengthy rulemaking process, a complete revision to the regulations governing small passenger vessels went into effect. In its rulemaking, the Coast Guard significantly changed the organization of the regulations. Vessels carrying 150 or fewer passengers continued to be regulated by subchapter T (46 CFR Parts 175-185). New subchapter K (46 CFR Parts 114-122) was created for regulations pertaining to small passenger vessels, such as the Massachusetts, that were permitted to carry more than 150 passengers. Under the revised regulations, new vessels (defined at 46 CFR 114.400 as those built after March 10, 1996) were required to be equipped with a fixed gas fire extinguishing system and an approved fire detecting system for any spaces containing propulsion machinery.36 Vessels built before the revised regulations took effect (“existing vessels”) that had a hull or machinery space boundary made of combustible material such as wood or fiber-reinforced plastic (fiberglass), which the Coast Guard considered a higher risk category, were required to be retrofitted with fixed fire extinguishing and detecting systems by March 11, 1999.37 The Coast Guard did not require retrofitting all existing vessels because “it would have a substantial cost impact on the small passenger vessel industry.”38 Thus, existing vessels whose hulls were made of noncombustible material such as steel or aluminum, including the Massachusetts, were subject to the previous regulations, which required a fixed fire extinguishing system in the machinery and fuel tank spaces only if a vessel was powered by gasoline or other fuel having a flash point of 110° F or lower. Because it was constructed before the revised regulations went into effect and

34 Massachusetts Bay Lines has had Coast Guard–approved fixed fire suppression and detection systems installed in the rebuilt engineroom of the Massachusetts. 35 The initial subchapter T regulations were promulgated in the Federal Register of October 5, 1957. Originally, subchapter T regulated vessels of 65 feet or less in length. In 1963, subchapter T was revised to include vessels (known as subchapter T-L vessels) that were more than 65 feet long and had a gross tonnage of less than 100. 36 Title 46 CFR 118.400 (a) and (c). 37 Federal Register, vol. 59, no. 9 (January 13, 1994), p. 2046. 38 The original notice of proposed rulemaking required only existing fiberglass vessels to have fixed fire extinguishing and detecting systems. The Coast Guard stated that it had studied casualty data and determined that fires on fiberglass vessels accounted for 34 percent of machinery space fires from 1981 to 1986, although such vessels composed only 20 percent of the small passenger vessel fleet, yielding a fleet percentage to fire percentage ratio of 1.7:1 (Federal Register, vol. 54, no. 18 [January 30, 1989], p. 4436). Wooden vessels were originally excluded from the requirement for fixed fire extinguishing and detecting systems because their ratio was lower (1.25:1), but they were added in the supplemental notice (Federal Register, vol. 59, no. 9 [January 13, 1994]) because of comments received. Vessels made of steel or aluminum were found to have “much lower” ratios and were not included in the requirement.

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22 because its hull was aluminum, the new fire detection and suppression requirements did not apply to the Massachusetts. Probable Cause The National Transportation Safety Board determines that the probable cause of the fire on board the Massachusetts was the ignition of diesel fuel by contact with a hot engine surface, which occurred because a fuel line attached to a fuel injector was not properly connected during engine maintenance by a contract mechanic. Contributing to the extent of the damage was the absence of a fixed fire detection and suppression system, which precluded the crew from receiving timely notification of the fire and which allowed the blaze to spread throughout the engineroom. Recommendation As a result of its investigation into the fire on board the Massachusetts, the National Transportation Safety Board makes the following safety recommendation.39 To the U.S. Coast Guard: Require that all small passenger vessels certificated to carry more than 49 passengers, regardless of date of build or hull material, be fitted with an approved fire detection system and a fixed fire suppression system in their enginerooms. (M-07-1) (Supersedes Safety Recommendations M-02-6 and M-02-8.)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD MARK V. ROSENKER

ROBERT L. SUMWALT Chairman

Vice Chairman DEBORAH A. P. HERSMAN

KATHRYN O’LEARY HIGGINS Member

Member

STEVEN R. CHEALANDER Member

Adopted: March 20, 2007

39 For more information, see the Safety Board’s safety recommendation letter to the Coast Guard, available on the Board’s website .

FD07323 ｜ 2006_美国_NTSB_MAR0701_Fire_Aboard_Construction_Barge_Athena_106.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2006 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

ACCIDENT REPORT NTSB/MAR-07/01 PB2007-916401 National Transportation Safety Board marine Fire Aboard Construction Barge Athena 106 West Cote Blanche Bay, Louisiana October 12, 2006

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Marine Accident Report Fire Aboard Construction Barge Athena 106 West Cote Blanche Bay, Louisiana October 12, 2006 NTSB/MAR-07/01 PB2007-916401 National Transportation Safety Board Notation 7856B 490 L’Enfant Plaza, S.W. Adopted June 14, 2007 Washington, D.C. 20594

National Transportation Safety Board. 2007. Fire Aboard Construction Barge Athena 106, West Cote Blanche Bay, Louisiana, October 12, 2006. Marine Accident Report NTSB/MAR-07/01. Washington, DC.

Abstract: This report discusses the accident in which a 5-ton spud (mooring shaft) unintentionally released from the uninspected construction barge Athena 106 and struck a natural gas pipeline buried in West Cote Blanche Bay, Louisiana. The Athena 106 and another barge were both being pushed by the towing vessel Miss Megan. The gas ignited and created a fireball that engulfed the Miss Megan and both barges. Five people were killed and two survived; one barge worker was officially listed as missing as of the report date. Damages were estimated at $150,000 for the Athena 106 and $650,000 for the Miss Megan. The estimated value of the released natural gas was $6,800; replacing the ruptured pipeline cost an estimated $800,000. The National Transportation Safety Board identified the following safety issues during its accident investigation: the failure to use safety devices, and the limited oversight of vessels not subject to inspection. On the basis of its findings, the Safety Board made recommendations to the Occupational Safety and Health Administration, the U.S. Coast Guard, Athena Construction (Athena 106 owner/operator), and Central Boat Rentals (Miss Megan owner/operator). The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Web at http://www.ntsb.gov. Other information about available publications also may be obtained from the Web site or by contacting: National Transportation Safety Board Records Management, CIO-40 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (800) 877-6799 or (202) 314-6551 Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2007-916401 from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605-6000

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

iii Marine Accident Report Contents Acronyms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Synopsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Accident Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Damages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Miss Megan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Athena 106 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Vessel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Miss Megan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Athena 106 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 IBR 234 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Spud Winch Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Construction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Safety Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Wreckage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Vessels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 On-Scene Spud and Spud Winch Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Postaccident Pipe Recovery and Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Waterway and Pipeline Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Medical Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Toxicology Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Company Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Central Boat Rentals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Athena Construction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Survival Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Emergency Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Regulators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Coast Guard Authority . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 OSHA Authority . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Coast Guard/OSHA Relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 State of Louisiana Authority . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Sonar Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Spud Winch Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Material Analysis of Pipeline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Contents iv Marine Accident Report Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Cause of Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Failure to Use Safety Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Limited Oversight of Vessels Not Subject to Inspection . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Response to Emergency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 New Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Previously Issued Recommendations Classified in This Report . . . . . . . . . . . . . . . . . . . . . 44 Appendixes A: Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 B: Memorandum of Understanding Between Coast Guard and OSHA . . . . . . . . 46 C: OSHA Guidance Document (CPL 2-1.20) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 D: OSHA Citation of Athena Construction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

v Marine Accident Report Acronyms and Abbreviations CFR Code of Federal Regulations MACOSH Maritime Advisory Committee for Occupational Safety and Health OSHA Occupational Safety and Health Administration psig pounds per square inch, gauge SCADA Supervisory Control and Data Acquisition

vi Marine Accident Report Executive Summary About 1155 central daylight time on Thursday, October 12, 2006, the uninspected towing vessel Miss Megan was pushing two deck barges in the West Cote Blanche Bay oil field in Louisiana, en route to a pile-driving location. Barge Athena 106 was tied along the port side of barge IBR 234. The Miss Megan was secured astern of IBR 234, pushing both barges. The Miss Megan was crewed by a licensed master and a deckhand. The construction barge had six workers on board, consisting of one foreman, one crane operator, and four barge hands. While the vessels were under way, the aft spud (a 5-ton steel shaft used as a mooring device) on the Athena 106 released from its fully raised position. The spud dropped into the water and struck a submerged, buried high-pressure natural gas pipeline. The resulting gas release ignited and created a fireball that engulfed the towing vessel and both barges. The master of the towing vessel was killed, along with four barge workers. The Miss Megan deckhand and one barge worker survived. One barge worker is officially listed as missing. The National Transportation Safety Board determines that the probable cause of the accident was Athena Construction’s failure to require its crews to pin the spuds securely in place on its barges, which allowed the sudden, unintentional release of the Athena 106’s aft spud, rupturing a buried pipeline and causing natural gas to surface and ignite. Contributing to the accident was the failure of Central Boat Rentals to require, and of the Miss Megan master to ensure, that the barge spuds were securely pinned before getting under way. The Safety Board’s investigation of this accident identified the following safety issues: • Failure to use safety devices. • Limited oversight of vessels not subject to inspection. As a result of its investigation, the Safety Board makes recommendations to the Occupational Safety and Health Administration, the U.S. Coast Guard, Athena Construction, and Central Boat Rentals.

1 Marine Accident Report Factual Information Synopsis On Thursday, October 12, 2006, about 1155 central daylight time,1 the uninspected towing vessel Miss Megan, owned and operated by Central Boat Rentals, Inc., of Morgan City, Louisiana, was pushing two uninspected deck barges through the West Cote Blanche Bay oil field in St. Mary Parish, Louisiana (figure 1).2 The tow was en route to a pile- driving site in the northwest area of the oil field. Construction barge Athena 106 (also known as a spud barge), owned and operated by Athena Construction of Morgan City, was tied along the port side of an unmanned deck barge, the IBR 234, owned by Inland Barge Rentals of Berwick, Louisiana. The Miss Megan was secured astern of the IBR 234, pushing both barges. The oil field was operated by Gulfport Energy Corporation. A natural gas pipeline that was involved in the accident was operated by Chevron U.S.A., Inc. The Miss Megan was crewed by one licensed master and one deckhand. The Athena 106 had six workers on board—a foreman, a crane operator, and four barge hands. While the construction barge was under way, the aft spud (a vertical steel shaft extending through a well in the bottom of the boat and used for mooring) dropped from its fully raised position. The steel spud was 20 inches square, had an overall length of 40 feet, and weighed 10,900 pounds.3 Spuds, rather than anchors, are used to hold deck barges in place during marine construction work (anchor chains would allow the barges to swing). Two spuds are required to keep a barge stationary. The spud dropped into the water and struck a submerged, buried high-pressure natural gas pipeline. An unknown source ignited the resulting gas release, creating a fireball that engulfed the towing vessel and both barges. The Miss Megan master was killed, as were four barge workers. One barge worker and the Miss Megan deckhand survived. One barge worker was officially listed as missing at the time of this report. 1  Times in this report are given in central daylight time according to the 24-hour clock. 2  A deck barge is a manned or unmanned barge that has a continuous, flat main deck. Deck barges are employed to carry deck cargo and are also used in the marine construction industry for such work as pier or bulkhead construction, dredging, and marine oil service. Deck barges that operate on inland waters are uninspected by the U.S. Coast Guard. Coast Guard regulations contain a category called “uninspected vessels,” which includes towing vessels like the Miss Megan that are subject to certain regulations, such as those concerning lifesaving apparatus, but that are not subject to Coast Guard inspection. This report uses “uninspected” to refer both to vessels that are regulated but not inspected (the Miss Megan) and those that do not fall under the regulations for uninspected vessels (the deck barges). 3  The aft spud was weighed on a calibrated crane scale at the Athena Construction facility after the accident.

Figure 1. Site where construction barge Athena 106 dropped a 5-ton mooring spud on the West Cote Blanche Bay natural gas sales pipeline. The pipeline carried excess natural gas from the Gulfport sales platform (where extracted natural gas was processed and injected back into oil-producing wells to aid in oil production) to a junction with Chevron’s Vermilion Bay gas sales pipeline. The pipeline between the Gulfport sales platform and the Chevron bay junction platform was about 19,650 feet long. The pipeline between the Vermilion Bay platform and the bay junction platform was about 32,300 feet long. Factual Information 2 Marine Accident Report Accident Narrative The day of the accident began uneventfully, according to the operator of the winch that controlled the two spuds on the Athena 106 (figure 2). The spud winch operator stated that between 0800 and 0830 that morning, he and the other crewmembers (a foreman, a crane operator, and three other barge hands) boarded a crew transport boat docked at Ivanhoe, Louisiana, for the 30-minute trip to the Athena 106 barge. When they arrived at the Athena 106, the crewmembers set about their daily routine. They were scheduled to

Factual Information 3 Marine Accident Report extract (pull) pilings that morning until a towboat arrived to push them to their next work location in the same oil field, where they were scheduled to drive (install) pilings around an oil field rig (Parker barge rig 8B). Figure 2. Athena 106 after the fire. The construction barge was equipped with two mooring spuds (shown in the lowered position), both on the port side, one forward and one aft, controlled by a single winch. At the front of the barge was the crane used to hoist and position pilings for driving or to maneuver them to a barge alongside for storage. The spud winch operator’s first duties of the day included checking the diesel and oil levels on the barge crane, checking the barge’s air compressor, and checking the oil level in the spud winch gearcase as well as the general condition of the winch. Both spuds were raised and lowered by a single winch equipped with two steel cables, each wound around a drum and attached to one of the spuds (figure 3).4 The spud winch operator said that he would periodically adjust the winch’s foot brakes, which were used to control the speed of the winch drums as they raised or lowered the spuds. He said that on the day of the accident, the foot brakes “felt fine” and did not need adjusting. He stated that he also checked the condition of the spud-lifting cables daily. Both spud winch cables had been 4  See “Spud Winch Information” section for detailed explanations and illustrations of the spud winch apparatus.

Factual Information 4 Marine Accident Report replaced 2 months before the accident, according to documentation provided by the Athena Construction maintenance supervisor. Figure 3. Computer-generated image of a spud winch unit. The spud-lifting cables are wound on the drums to the left of the operator’s seat. The winch’s foot brakes are below and forward of the seat. After completing the morning checks, the Athena 106 crew began extracting pilings. The IBR 234 was secured alongside the Athena 106 to store the extracted pilings (figure 4). The barge also housed new pilings that would be driven later. The extraction work continued until about 1130, when the towboat Miss Megan arrived and was secured to the aft end of the IBR 234 in preparation for propelling the two barges to their next work location (figure 5). While the towboat master and deckhand made fast to the barges, the barge crew stopped its work of extracting pilings. The Athena 106 spud winch operator, at the barge foreman’s direction, then retracted both spuds to release the barges from their anchorage. The operator said that he encountered no problems with the winch in lifting the spuds. He set the foot brake for each spud drum on the winch to lock the spuds in their fully retracted (lifted) position for the transit to the next work location. The operator said that although the winch was equipped with other safeguards to prevent the unintentional release of a spud, the foot brakes were the only holding or braking mechanism engaged for the transit.

Figure 4. Barge IBR 234 loaded with pilings (being pushed by the Miss Megan). Factual Information 5 Marine Accident Report After the towboat was in position for the transit and the Athena 106’s spuds were retracted, the barge crew began assembling for lunch in the crew shelter, which they called the “doghouse.” The crewmembers heated their lunch in a microwave oven connected by an extension cord to a small portable generator on the deck. The generator also powered a cooling fan in the doghouse. The Miss Megan master got the towboat under way about 1145. The deckhand then joined the barge crew in the doghouse for lunch. The Athena 106 spud winch operator said that he and the other three barge hands removed their work vest flotation devices while they ate lunch in the doghouse, as was customary. The towboat deckhand, still wearing his work vest, stood outside the doghouse door to chat while the barge hands ate lunch inside. The deckhand said that neither the barge crane operator nor the foreman was in the doghouse during that time. At some point while the spud winch operator and the other barge hands were eating, one barge hand left the doghouse, leaving the spud winch operator and two barge hands inside and the towboat deckhand standing outside the door. After finishing his meal, the Athena 106 spud winch operator called his mother on his cell phone from the doghouse. He said that during the conversation, he heard a large “bam” outside. He estimated that the Athena 106 had been under way, pushed by the Miss Megan, for 8 to 10 minutes. When he heard the noise, he looked out the doghouse door and saw that the aft spud had released and dropped to its fully deployed (down) position.

Figure 5. Towing arrangement of the Miss Megan and the two barges. The barges were tied together, with the Miss Megan secured to the aft end of the IBR 234 and pushing both barges. Factual Information 6 Marine Accident Report

Factual Information 7 Marine Accident Report The spud winch operator told investigators that he had felt the barge stop, “like the towboat stopped,” before the spud dropped but that he had paid “no attention” because “that’s been known to happen out there . . . the water’s shallow.”5 Unbeknownst to the crewmembers, the spud had struck a high-pressure natural gas pipeline buried in the bay immediately below them. The spud winch operator said that he wondered what had caused the spud to drop, looked at the winch, and saw no one near it who might have accidentally released the brake. He noticed that the cable on the upper drum connecting the aft spud to the winch was fouled (“birdnested like [the reel on] a fishing pole”) on the drum (figure 6). The spud winch operator said that he then saw a large “burst” in the water alongside the barge “right where the [aft] spud was.” He was looking toward the towboat behind the barge when a large fireball erupted between the aft end of the Athena 106 and the towboat, with “flames and water . . . going everywhere.” The fire engulfed the Miss Megan. By that time, the barge’s crane operator was beside the spud winch operator and told him to run to the front of the barge, where the crane was stationed. The spud winch operator did not have time to don his flotation work vest after the fireball erupted. Figure 6. Photo showing cable “birdnested” on the winch drum (upper rear) that led to the Athena 106’s aft spud. The cable on the lower winch, which led to the forward spud, is properly wound. 5  The Miss Megan deckhand, the other survivor, remembered that the barge was “moving slow” before the accident.

Factual Information 8 Marine Accident Report At the forward end of the Athena 106, the barge hand who had left the doghouse earlier met the crane and spud winch operators. The spud winch operator and the barge hand jumped from the Athena 106’s forward end into the water and swam away from the barge to escape the flames. The spud winch operator recalled looking back at the barge and seeing the crane operator attempting to untie the barges. The spud winch operator also saw the Miss Megan’s deckhand, the only other survivor of the accident, in the water at the forward end of the Athena 106. He told investigators that he noticed that the deckhand wore his flotation work vest. The Athena 106 spud winch operator swam away from the flames and the barge, eventually finding a short piece of lumber to hold onto. He estimated that he had swum 40 yards from the barge when a crew transport boat in the area, the Captain Mitch, arrived about 5 minutes after the accident and picked him up while it searched for survivors. The Miss Megan deckhand swam away from the burning Athena 106 and was rescued by four Athena Construction workers in a small boat carried on their nearby barge. Workers on both the Captain Mitch and the small boat reported seeing other Athena 106 crew on or around the burning barge but could not move close enough to help because of the fire’s heat. Pressure readings from Chevron’s SCADA system6 indicated that the natural gas pipeline ruptured about 1155. The SCADA system enabled a rapid shutdown (by about 1210) of the Vermilion Bay gas sales pipeline downstream of the rupture. Pressure gauges sensed a pressure decline in the Vermilion Bay gas sales pipeline, from 700 pounds per square inch, gauge (psig), to 400 psig, and the SCADA system automatically shut it down. As part of the automatic shutdown, a check valve on Chevron’s bay junction platform closed and prevented natural gas from backflowing into the ruptured pipeline from the downstream pipeline system. The shutdown of the failed pipeline upstream of the failure was expedited because a workman on the Gulfport sales platform recognized the emergency and, just after 1206, manually shut an upstream valve feeding gas into the failed pipeline. Injuries Table 1. Injuries sustained in the Athena 106 accident. Type of Injury Athena 106 Miss Megan Total Fatal 4 1 5 Serious 0 1 1 Minor 1 0 1 Missing1 1 0 1 Total 6 2 8 NOTE: Title 49 Code of Federal Regulations (CFR) 830.2 defines a fatal injury as any injury that results in death within 30 days of an accident. Serious injury means any injury that (1) requires hospitalization for more than 48 hours, commencing within 7 days from the date the injury was received; (2) results in a fracture of any bone (except simple fractures of fingers, toes, or nose); (3) causes severe hemorrhages, nerve, muscle, or tendon damage; (4) involves any internal organ; or (5) involves second- or third-degree burns, or any burns affecting more than 5 percent of the body surface. 1 At the time of the report, one barge worker was officially listed as missing. After the accident, two barge workers were missing. One was declared dead and is included in the fatalities. 6  SCADA, an acronym for Supervisory Control and Data Acquisition, is a system that monitors or controls water and power supply systems, gas and oil pipelines, and other distribution systems.

Factual Information 9 Marine Accident Report Damages Damages to the Athena 106 and its equipment were estimated at $150,000. The replacement value of the Miss Megan towboat was estimated at $650,000 in an August 2005 vessel survey. The Miss Megan was a total constructive loss. Chevron estimated that about 973,000 standard cubic feet of natural gas escaped from the pipeline in the 15 minutes before it was shut down after the rupture.7 Chevron estimated the value of the released gas at $6,800 and the cost of removing and replacing the ruptured pipeline at $800,000. Personnel Information Miss Megan Master. Central Boat Rentals hired the 48-year-old master of the Miss Megan in June 2001. Because the Miss Megan was over 26 feet long, it was required by Federal regulations to be operated by a licensed master.8 The master of the Miss Megan held the required U.S. Coast Guard license, issued in April 2003, as “master of towing vessels upon Great Lakes, inland waters, and western rivers; excepting waters subject to the International Regulations for Preventing Collisions at Sea, 1972; also, radar observer–inland.” The license was due to expire in April 2008. The Coast Guard in Morgan City reported to investigators that the master had not been the subject of any suspension or revocation proceedings. The master’s work schedule was 21 days on duty, 7 days off duty. When he was on duty, he worked from 0600 until 1630. Deckhand. The Miss Megan deckhand, age 44, had been employed by Central Boat Rentals since January 2003. He was one of two survivors of the accident. The deckhand reported no unusual events in his schedule before the accident. His work schedule was 21 days on duty, 7 days off duty. When he was on duty, he worked from 0600 until 1630. Athena 106 Spud Winch Operator. The Athena 106 spud winch operator, age 25, had been employed by Athena Construction since May 2006. The operator, who survived the accident, reported no unusual events in his schedule beforehand. He was on a regular work schedule that he described as “repetitious.” He arrived home the previous day around 1730 and went to sleep by 2130. On the morning of the accident, he awoke at 0530 and was 7  Standard cubic feet of gas is the volume of gas at standard temperature (60° F) and atmospheric pressure (14.7 pounds per square inch). 8  Title 46 CFR 15.610 states: “Every towing vessel at least 8 meters (26 feet) in length, measured from end to end over the deck (excluding sheer), must be under the direction of a person licensed as master or mate (pilot) of towing vessels . . . .” The regulation excludes certain towing vessels, such as those engaged in assistance towing or those of less than 200 gross tons engaged in offshore mineral or oil exploitation.

Factual Information 10 Marine Accident Report picked up by two other barge crewmembers at 0620 for the ride to the Ivanhoe dock. From the dock, they were taken out to the barge by a crew transport boat, about a half-hour ride. The spud winch operator indicated that this was his normal daily routine. Other Crew. Four crewmembers on the Athena 106 died in the accident. The barge foreman was 51 years old at the time of the accident, the crane operator was 59, and the two barge hands were 36. One barge worker, age 33, was officially listed as missing at the time of this report. The foreman had been employed by Athena Construction since 2000. All the other crewmembers were hired in 2006. Vessel Information Miss Megan The steel-hulled towing vessel Miss Megan was built in 1996 in Morgan City, Louisiana, and was previously owned by Gaudet Boat Rentals of Morgan City. According to the certificate of documentation issued by the Coast Guard in June 2006, the 52-gross- registered-ton9 vessel was 52 feet long and 20 feet wide. Its draft10 was about 5 feet and its transit speed was about 6 knots. The Miss Megan was not inspected by the Coast Guard, nor was it required to be. Athena 106 Construction. Documents provided by Athena Construction indicate that the construction barge Athena 106 was delivered new in May 1982 at a cost of $143,000. The barge, which had a steel hull, was built by Gulf Coast Fabrication, Inc., in Pass Christian, Mississippi. The barge was not inspected by the Coast Guard, nor was it required to be. The Athena 106 was 110 feet long, 36 feet wide, and measured 7 feet from the bottom of its hull to the deck where the crew worked. Both ends were raked, or sloped (figure 2). The bottom of the hull was flat. The draft of the Athena 106 was approximately 4 1/2 feet. Equipment. The Athena 106 was the primary working platform for the crew (figure 7). Its deck contained all the equipment necessary for extracting and driving pilings around docks, oil rigs, and other platforms in the oil field. The equipment included the spud winch (described in detail below) used to raise and lower the spuds that anchored the Athena 106, and a crane to hoist and position the pilings for driving or to maneuver them onto the barge alongside for storage. Other equipment included a piling extractor with hydraulic powerpack, oxygen and acetylene bottles, chainsaw, deck generator for electrical equipment in the doghouse, air compressor, hand tools, and crane accessories. 9  Gross tonnage represents the total internal volume of a vessel, with some exemptions for nonproductive spaces. 10  Draft is the vertical distance from the lowest point of a ship’s hull to the waterline.

Figure 7. General layout of the Athena 106 construction barge. Fire damage to equipment on the barge deck was greatest in the dark-shaded area. Factual Information 11 Marine Accident Report

Factual Information 12 Marine Accident Report IBR 234 Deck barge IBR 234 was used as a storage platform for the pilings being extracted or installed by the crew of the Athena 106. The IBR 234 had a steel hull and was 120 feet long, 30 feet wide, and 7 feet from the bottom of the hull to the deck. The vessel’s draft was about 4 feet. The barge was not inspected by the Coast Guard, nor was it required to be. Spud Winch Information Construction The spud-lifting winch used on board the Athena 106 was manufactured by American Hoist and Derrick Company. It was a model 120B, manufactured during the 1950s and no longer in production. According to company documents, it had a rated capacity of 12,000 pounds of pull at 270 feet per minute and was chain-driven through a twin-disk clutch by a Detroit Diesel engine, model 3-71, rated at 120 horsepower. The winch was 9 feet long, 6 feet wide, and weighed about 8,000 pounds. According to industry professionals, this make and model of winch is used extensively on marine construction barges and is known for its simple, reliable design and operation. The Detroit Diesel engine powering the winch was mounted aft of the winch. The engine was fitted with a clutch on its output shaft, which was connected by a chain to the winch’s drive gears for the drums. A lever connected to the clutch at the operator’s seat allowed the operator to engage or disengage the drive engine from the winch drum drives. The winch was a two-drum design. The upper drum controlled the raising and lowering of the aft spud, and the lower drum controlled the forward spud. Steel cables 7/8 inch in diameter led from the drums to the spuds through a series of pulleys and sheaves (one for each spud). The cables allowed the winch operator to lower the spuds into the soft bay bottom to anchor the barge or to lift the spuds so the barge could move. Operation The spud winch operator could control the drums independently, working from a seat mounted on the inboard side of the winch, facing the forward end of the barge (figure 8). Each winch drum had two brake bands, one on the outside and one on the inside nearest the operator. Both bands were controlled from the operator’s seat, the outer band by a foot lever and the inner band by a hand control lever. Thus, the operator had two foot brake pedals and two hand levers that acted as friction brakes to control the speed of the winch drums as they lowered or raised the spuds. The operator’s winch controls also included (1) a single-lever throttle to control the diesel engine’s speed, (2) a lever for engaging or disengaging the diesel engine’s clutch from the winch drum driveshaft (used only while lifting the spud; lowering the spud was accomplished by gravity), and (3) a lever for each drum to engage or disengage the drum pawls into a notched ring on the drum’s outer edge and prevent its cable from paying out accidentally.

Figure 8. Operator in position at the spud winch on another Athena barge, not the Athena 106, used in the salvage operation after the accident. Highlighted are the foot brake pedals and hand levers that controlled the speed of the winch drums as they lowered or raised the spuds, and one of the levers that engaged or disengaged the drum pawls into a notched ring on the drums' outer edge to prevent the cables from paying out. Note the operator's work vest, the flotation device worn by barge workers on the job. Factual Information 13 Marine Accident Report According to the Athena 106 spud winch operator, if the spuds were deployed (lowered) and it was necessary to move to a different work site, he would, at the direction of his foreman, raise the spuds as follows. First, he would start the diesel engine and move to the operator’s seat. He would engage the clutch to the winch using the left lever, then increase the engine speed using the throttle lever to develop enough power to lift the 5-ton spuds. The winch drum would not rotate until he actuated the hand friction levers, which controlled the friction between the winch driveshaft and the drums. With the engine running and the clutch engaged, the spud winch operator would pull back on the appropriate (forward or aft) spud’s hand lever to increase friction to that drum, thereby rotating the drum and lifting the spud at the end of its cable. Once the spud was fully raised, the operator would latch the foot brake in place by depressing it. He would press down on the heel section of the foot pedal and secure the depressed pedal to a fixed piece of steel connected to the winch frame (figure 9). After the foot pedal had locked the spud’s drum in place, the operator would relax the hand friction control lever and shut down the diesel engine.

Figure 9. Operation of Athena 106 foot brake pedals On the right, both pedals are engaged (depressed) and latched in place by the fixed steel piece shown pressing on a triangular section at the bottom of the pedals. On the left, the front pedal is released and the back pedal is still engaged. To release the pedal, the operator would push down on the pedal and twist the latch out of place, allowing a spring to raise the pedal. Factual Information 14 Marine Accident Report Dropping a spud from its raised position was a matter of engaging the hand friction control lever, releasing the latched foot brake, and easing the spud down with the friction of the brake. The spud winch operator explained that tension had to be kept on the cable while the spud was being lowered, as opposed to letting it freefall, to avoid having the cable recoil and foul (“birdnest”) on the drum. Care had to be taken in lowering the spuds. Investigators observed that if operators felt a spud touch something while it was being lowered, they moved the barge slightly to avoid hitting one of the pipelines buried under the bay. Safety Features The winch and its associated equipment offered three methods of holding a raised spud in position so it would not drop or slip from its retracted (raised) position: • Drum brake band foot pedals controlled from the operator’s seat. • A steel pawl that, when engaged, fit into a notched ring fastened to the outer periphery of the drum to keep it from turning backward if the brake failed (figure 10).

Factual Information 15 Marine Accident Report • A 36-inch-long by 2-inch-diameter steel securing pin (figure 11) that could be inserted directly through the spud once it was fully retracted to prevent it from freefalling in the event of a winch or cable failure. When asked whether he would typically insert the securing pin in a spud after raising it, the Athena 106 spud winch operator said, We never put pins in a spud . . . we never had to. We stayed in the field, you know. Usually when you’re going a short destination [distance] . . . a couple of hundred yards away, you really don’t put a pin through the spud. I mean I’m sure it’s a lot safer to do it, but we don’t. I don’t know why. Figure 10. Operation of the winch pawl on the Athena 106. The operator engages or disengages the pawls using the lever, shown in white, that extends downward across the gear. The pawl is the tongue-shaped piece at the bottom of the lever. When disengaged (left illustration), the pawl is outside the gear teeth, allowing the gear to move freely in either direction. When engaged (right illustration), the pawl falls into the spaces between the notches so the gear can move in only one direction. (See figure 8 for location of pawl lever at operator’s station.)

Figure 11. Photos showing spud with securing pin lying alongside (left) and with securing pin inserted (right). Factual Information 16 Marine Accident Report Wreckage Vessels Two days after the accident, on October 14, Safety Board investigators documented the damage to the vessels involved in the accident. The Miss Megan and barge IBR 234 were anchored at a separate location from the Athena 106, which was still at the accident site. Miss Megan. The Miss Megan, which was secured to the aft end of the barges and in the direct path of the flames from the failed pipeline, had been engulfed by the fire. Above the waterline, paint was intact only on the starboard aft side of the vessel. The vessel’s entire forward-facing exterior steel structure was scorched to the steel base metal. All windows facing forward or to port had been severely damaged by the heat, as well as all wheelhouse windows. The starboard wheelhouse entrance door was reduced to molten aluminum. The top of the port side wheelhouse door was also melted, but the bottom was intact. Inside the wheelhouse, all navigational aids and maneuvering equipment sustained extensive damage, leaving the wheelhouse virtually an empty shell.

Factual Information 17 Marine Accident Report On the main deck, which was one deck below the wheelhouse, the port aluminum door leading to the vessel’s engine space was intact. Flame patterns indicated that the port engine space door was open during the fire. The windows next to the engine space were damaged by the heat, and both of the vessel’s propulsion engines sustained extensive heat damage. The engine control devices in the wheelhouse were severely damaged, but the position of the transmission shift levers indicated that both engines were in the neutral position at the time of the fire. The deck winch and other equipment in the forward area of the main deck also suffered extensive heat damage. The hull below the main deck appeared structurally sound. It showed limited heat damage and no signs of flooding or of having taken on excess seawater after the accident. Investigators did not examine the hull out of the water. Athena 106. Investigators found both the forward and aft spuds on the Athena 106 in the lowered position (as noted below, they were informed by the recovery crew that the forward spud had been in the raised position until it fell during the recovery effort). The 7/8-inch steel cables connecting the spuds to the barge’s winch were examined for signs of preexisting damage and found to be free of any fraying or other visible defects. The cable leading from the winch to the forward spud exhibited a light strain condition, with its remaining turns wrapped uniformly around the lower winch drum. The cable connecting the aft spud to the winch was found completely fouled on the upper winch drum, or “birdnested,” with none of its remaining cable turns on the drum still wrapped on the inner drum surface (figure 6). The brake pedal for the aft spud was found elevated in relation to that of the brake pedal for the forward spud. Investigators noted a 3/32-inch indentation on the leading edge of the fixed steel piece to which the brake pedal latched. No further wear was found on the underside of the fixed piece. On the brake pedal, the latching mechanism displayed no wear. Both the upper and lower winch drum hand friction control levers were found disengaged. Both spud winch drum pawls were found in the disengaged position. The spud winch’s fuel tank, integral with the winch frame, was split open and deformed by the fire’s heat. The 36-inch-by-2-inch spud securing pins were found lying next to their respective spud bases, not inserted into the spuds. Investigators could not enter the barge’s tool room, accessible by a steel door leading belowdecks forward of the doghouse, because of the water that had accumulated during the firefighting effort. The surviving barge hand reported that water would accumulate daily in the tool room. As part of their daily morning checks, the crew would check to see how much water had accumulated and pump it out as necessary. The barge hand estimated that they would pump out from 6 to 10 inches a day. The crew had been pumping the compartment during the 2 weeks before the accident but had not determined the source of the bilge water. The barge suffered the greatest damage on its port side and aft end, where the fire severely damaged the doghouse, the deck generator, the deck air compressor, and the spud winch. Some small portable equipment and hand tools in the area, such as a chainsaw, were also consumed by the fire. Several oxygen and acetylene bottles used by the crew in their day-to-day operations had exploded from the heat of the fire and were strewn about the deck.

Factual Information 18 Marine Accident Report The forward end and starboard side of the barge sustained less heat damage. The hydraulic powerpack (which powered the piling extractor) sustained limited fire damage to its outer housing and minimal damage to the engine and hydraulic equipment inside. The only other piece of significant equipment in the forward area of the barge was the crane, with its boom facing aft toward the doghouse. The wooden support on which the crane was mounted, the crane operator’s cab area, and the outer right side of the crane operator’s cab showed signs of the fire, but they did not display the same catastrophic effects as did the equipment at the aft end of the barge. Immediately aft and to the port side of the crane was a large diesel fuel storage tank that showed virtually no signs of heat damage, although the equipment immediately aft of it was destroyed by the fire. IBR 234. Barge IBR 234 was secured along the starboard side of the Athena 106 at the time of the fire. The load of wooden pilings on the deck of the IBR 234 extended nearly the entire length of the barge. Because the IBR 234 was close to the Athena 106, all its pilings sustained heavy fire damage. The paint was burned off the barge’s deck, but the deck appeared structurally sound and intact. The exposed hull periphery of the IBR 234 sustained minimal damage, except that the paint was burned off, exposing the hull’s bare steel. On-Scene Spud and Spud Winch Examination Salvage Operation. The recovery crew found the forward spud on the Athena 106 in the lowered position. According to the Athena Construction barge supervisor who participated in the recovery, the forward spud was in the raised position after the accident but then “just dropped” during the recovery effort. The day after the accident, a diving company inspected the pipeline and the crater caused by the gas eruption, as described in the “Postaccident Pipe Recovery and Examination” section. The divers believed that the aft spud was tangled with at least one pipe and was possibly close to several others, according to dive reports. The Coast Guard organized a salvage group to develop a plan to extricate the Athena 106 from the submerged gas pipeline. Nearby oil and gas production facilities and pipelines were secured, awaiting the repair of the ruptured pipe. After investigators had surveyed the Miss Megan and the IBR 234, the vessels were moved from the area. Another Athena barge was dispatched to assist with the salvage of the Athena 106. The barge waited a quarter-mile from the accident site, then once the sonar surveys were complete, moved to a position alongside the Athena 106. Investigators observed that during the move, the spud winch operator on the salvage barge used only the foot brakes, not the pawls or the securing pins, to secure the barge’s spuds in the raised position. The deck end of the aft spud cable was cut and marked. The crane on the salvage barge pulled the Athena 106 aft spud out of the water for examination. According to markings on the spud and measurements taken at the scene, the lower end of the spud had been submerged in the mud an estimated 17 feet. The cable, sheave, and deck pulleys were found to be in good working order during the recovery. The 4-inch tip of the aft spud displayed a slight concavity (figure 12).

Figure 12. Aft spud of the Athena 106 when raised after it had released from its fully raised position and hit a submerged, buried high-pressure natural gas pipeline. Factual Information 19 Marine Accident Report The forward spud was then recovered. The cable, sheave, and pulleys for the forward spud were found to be in good working order. Spud and Cable Examination. Investigators inspected the aft spud and its support cable 9 days after the accident, on October 21, 2006. The cable was disconnected from the spud so that the underwater portions of the spud could be inspected. The cable was reexamined along its entire length. No fraying or other damage was found. Athena Construction’s maintenance supervisor stated that the cables to both spuds on the Athena 106 had been changed about 2 months before the accident. The maintenance supervisor supplied documentation of the purchase of two spud support cables in July

1. No written maintenance records for changing the cable could be produced because,

as stated by the maintenance supervisor, such records were not kept. During the same inspection, all deck pulleys and sheaves through which the spud cables led were examined and found to be working satisfactorily. The aft spud was checked for damage sustained during the accident. The only accident-related damage was cosmetic—paint exposed to the fire’s heat had burned from the spud’s surface.

Factual Information 20 Marine Accident Report Postaccident Pipe Recovery and Examination On October 13, 2006, a diving company, Caldive International, Inc., hired by Gulfport, inspected the pipeline and the crater caused by the gas eruption. Underwater visibility was described as very poor. Divers found a 3-1/2-foot-deep crater centered on the spud. The soil around the crater wall was muddy clay. A diagram completed by Caldive showed the spud between two fractured ends of the gas sales pipeline. Caldive performed a second survey on October 19 and produced another, nearly identical, diagram showing the spud between two fractured ends of the gas sales pipeline. Athena Construction hired a diving company, River Services Company, to examine the underwater damage on October 13-14, 2006. The River Services Company report states: “The west side of the 6-inch [8-inch]11 pipeline is making contact with the spud” and “the aft spud apparently made contact and cut a 6-inch [8-inch] pipeline.” Chevron then contracted to have the pipe recovered. Two lengths of pipe, an east piece and a west piece, each approximately 50 feet long, were recovered from each side of a transverse (circumferential-like) fracture (figure 13) on November 17, 2006. After a Safety Board investigator photographed the damaged pipe, it was sent to Stress Engineering Services for analysis (see “Tests and Research” section). Figure 13. Fracture on the east piece of the ruptured pipeline. 11  The pipe was actually 8 inches in diameter, but at the time of the underwater assessment, its diameter was thought to be 6 inches.

Factual Information 21 Marine Accident Report Waterway and Pipeline Information According to the United States Coast Pilot,12 East Cote Blanche Bay, West Cote Blanche Bay, and Vermilion Bay form a large body of water separated from the Gulf of Mexico by Marsh Island (figure 1). The water area, which extends west-northwest from Atchafalaya Bay, is about 32 miles long and 5 to 15 miles wide. The water averages from 5 to 9 feet deep, and “the shores of the bays and Marsh Island are low and marshy.” The Miss Megan was on a northwesterly heading moving through the area. Hydrographic surveys completed after the accident by John Chance Land Surveys, Inc. (see “Tests and Research” section), found that the water in the accident area was between 6 and 7 feet deep, corrected for tidal height. The survey reported that the crater created by the accident was “approximately 3.5 and 4.0 feet lower in elevation than that of the normal seafloor elevation, which is probably a result from the explosion.” The pipeline was an 8.625-inch (outer diameter), X46-grade, electric-resistance- welded steel pipe with a 0.250-inch wall thickness. The pipe was manufactured in Bethlehem Steel’s factory at Sparrows Point, Maryland, in November 1965. The pipeline was externally coated with a spiral-wrapped, asphalt-type material, followed by a 1.5- inch-thick concrete coating. A postaccident dive survey estimated that the pipeline had about 3 feet of cover when the accident occurred. Texaco13 had performed a depth-of-cover survey on the pipeline in 1992 that showed a burial depth of between 2 and 2 1/2 feet. The pipeline was cathodically protected to inhibit corrosion. During a cathodic protection survey on August 24, 2005, readings of -1.323 and -1.069 volts were recorded at two different platforms, meeting the criteria of NACE International14 publication RP0176-2003, Corrosion Control of Steel Fixed Offshore Structures Associated with Petroleum Production. In a February 2006 pressure test after Hurricane Katrina, the pipeline held a pressure of 1,000 psig for 4 hours. Chevron reported that the pipeline did not need repairs and that there were no problems with it until it ruptured on October 12, 2006. At the point where it was struck, the gas sales pipeline ran roughly east to west under the bay (figure 1). West of where it was struck, the pipeline made a 90-degree turn north. At the east end, the pipeline began at the Gulfport sales platform (figure 14). The sales platform was in Gulfport’s West Cote Blanche Bay production field (state lease 340). At the west end, the pipeline terminated at Chevron’s bay junction platform, where it tied into Chevron’s Vermilion Bay gas sales pipeline. A check valve downstream of the tie-in prevented backflow from the downstream gas-gathering system. 12  National Oceanic and Atmospheric Administration, National Ocean Service, United States Coast Pilot, vol. 4 (Gulf of Mexico, Puerto Rico, and Virgin Islands), 32nd ed., 2004, p. 466. 13  Texaco constructed the pipeline about 1966 (the date when the pipeline construction bid was approved). In 1987, Texaco sold a 50 percent interest in the pipeline and in the West Cote Blanche Bay production field to Tesla Resources, Inc., the predecessor to Gulfport. In 2001, Texaco merged with Chevron, and Texaco’s 50 percent interest stayed with the new company. 14  NACE International is an organization concerned with corrosion issues. The organization produces consensus standards.

Figure 14. Beginning of the gas sales pipeline (vertical pipe entering water) at the Gulfport sales platform in the West Cote Blanche Bay oil field. The pipeline was ruptured by the Athena 106’s aft spud in an east-west section near the Gulfport platform. The pipe’s concrete coating is visible above the waterline. Factual Information 22 Marine Accident Report Meteorological Information According to National Weather Service data from its station in Patterson, Louisiana, 25 nautical miles east of the accident site, skies were clear at 1155 on the day of the accident and visibility was 10 miles. The temperature was 81° F and the wind was from the south at 6 knots. The area forecast was for seas of 1 to 3 feet.

Factual Information 23 Marine Accident Report Medical and Pathological Information Medical Information The Athena Construction workers who rescued the Miss Megan deckhand also recovered the body of the barge foreman from the water. The deckhand and the foreman’s body were brought to the Ivanhoe dock, where St. Mary Parish sheriff’s officers and Acadian Ambulance personnel met them. Acadian Ambulance Unit 24 transported the Miss Megan deckhand to Iberia General Hospital in New Iberia, Louisiana, about 16 miles away. He suffered second- degree burns over 27 percent of his body and spent one night in the hospital’s emergency room before being transferred to a nearby burn unit. The Athena 106 spud winch operator, who swam away from the fire and was rescued by the crew boat Captain Mitch, did not suffer any injuries as a result of the accident and was not hospitalized. The Miss Megan master died on the towing vessel. His remains were found on the Miss Megan’s deck outside the wheelhouse. Searchers recovered three bodies of barge personnel, each suffering varying degrees of burns. The bodies of two barge hands were not found. One of those individuals has been declared dead and the other was officially listed as missing at the time of this report. Toxicology Testing Coast Guard regulations at 46 CFR 4.06 require that drug tests be conducted within 32 hours of a serious marine incident and that alcohol tests be conducted within 2 hours “unless precluded by safety concerns directly related to the incident.” 15 Alcohol testing is not required more than 8 hours after a serious marine incident. The bodies of the four recovered crewmembers were tested for both drugs and alcohol. The results were negative. The two survivors were tested for drugs but not alcohol. The Athena 106 spud winch operator was tested for drugs immediately after his rescue. The Miss Megan deckhand was not tested until 6 days after the fire because of his injuries. Both drug tests were negative. The deckhand was taken to the hospital immediately after he returned to shore and was not tested for alcohol. The spud winch operator did not return to shore within the 2- hour testing limit because, after the crew boat rescued him, he stayed on board while the 15  Federal regulations at 46 CFR 4.06 require postaccident drug and alcohol testing on “each individual engaged or employed on board the vessel who is directly involved in” any accident meeting the criteria of a serious marine incident, defined at 46 CFR 4.03-2 as (a) a marine casualty or accident that results in any of the following: (1) one or more deaths, (2) injury that requires medical treatment beyond first aid and renders the individual unfit to perform routine duties, (3) property damage exceeding $100,000, (4) actual or constructive total loss of an inspected vessel, or (5) actual or constructive total loss of any uninspected vessel that exceeds 100 gross tons; (b) discharge of 10,000 or more gallons of oil into U.S. waters; or (c) the release of a reportable substance into the environment of the United States.

Factual Information 24 Marine Accident Report crew shut off valves for wells to secure the oil field. A sergeant from the St. Mary Parish sheriff’s office met both survivors as they arrived at the Ivanhoe dock. The sergeant did not report evidence of alcohol use by either survivor. Company Information Central Boat Rentals Central Boat Rentals, Inc., owned and operated the Miss Megan. The company had been in business since 1967 in the inland and offshore waters of Louisiana, Texas, Mississippi, and Alabama. The company primarily serviced the inland and offshore oil and gas industry. Central Boat operated 20 vessels and 118 barges, including 7 spud barges. Central Boat Rentals had a health and safety manual and an employee-training program. The manual outlined the company’s safety policies and contained guidance for its workers on safe workplace practices. It did not contain specific guidance or any requirement for a barge in tow to have its equipment properly secured before getting under way. Athena Construction Athena Construction was under contract to Gulfport Energy of Oklahoma City, Oklahoma, to perform construction operations in its oil field in the West Cote Blanche Bay area. The company operated nine spud barges, had 40 employees, and had been in the marine construction business for over 30 years at the time of the accident. Each barge was equipped for a variety of work, including driving and extracting pilings. The Athena 106 barge worked steadily in the Gulfport Energy oil field after hurricanes Katrina and Rita. At the time of the accident, Athena Construction was repairing the pilings used to secure oil and gas drilling and production facilities. Gulfport officials would tell the Athena supervisors what needed to be done, and the barge supervisors would complete the work. Athena Construction had a health and safety manual and an employee-training program. The manual outlined the company’s safety policies and contained guidance for its workers on safe workplace practices. The manual included a procedure for securing barge spuds when performing electrical work, but it did not contain specific guidance or requirements for securing the spuds with safety devices before moving a barge during normal operations. Athena Construction was involved in a previous spud barge accident. On February 7, 1997, the Athena 107 barge was “spudded down” in the Rabbit Island Field in Atchafalaya Bay, Louisiana, installing pipe. The barge had been left unmanned. In the early morning hours of February 8, 1997, wind and sea moved the Athena 107, causing it to strike and rupture a 20-inch natural gas pipeline owned by Bridgeline Gas Distribution, LLC. No fire was reported as a result of the accident.

Factual Information 25 Marine Accident Report Survival Factors Emergency Response The local 911 dispatcher received a call at 1158 from a man on a boat in West Cote Blanche Bay, near Marsh Island. The caller reported what he thought was a platform or a boat on fire in the bay. Dispatch transferred the call to the Coast Guard District 8 Command Center, which transferred him to the Coast Guard Sector New Orleans Command Center. Sector New Orleans is responsible for the traditional Coast Guard services of search and rescue of the Captain of the Port Morgan City area, including West Cote Blanche Bay. Marine Safety Unit Morgan City is responsible for the traditional Coast Guard services of the Captain of the Port and the Officer in Charge of Marine Inspection for the area. At 1205, Sector New Orleans received notification of the fire and began coordinating the Coast Guard response. Sector New Orleans briefed District 8 and requested air support. Within 15 minutes, at 1220, an HU-25 Falcon jet aircraft (CG 2127) launched from the Coast Guard Aviation Training Center in Mobile, Alabama, about 225 miles from the accident site, and proceeded to the accident site. At 1223, an HH-65 Dolphin helicopter (CG 6565) took off from Coast Guard Air Station New Orleans, about 100 miles from the accident site. Sector New Orleans contacted St. Mary and Iberia parishes to request surface search and rescue support. The parishes each launched two patrol boats, based about 12 miles from the accident site. The Louisiana Department of Wildlife and Fisheries, also notified by 911 dispatch, sent several boats. The Coast Guard HU-25 Falcon aircraft, the first official response asset on scene, confirmed flames on the Miss Megan and both barges, as well as flames from the ruptured pipeline rising approximately 100 feet from the water surface. Two Louisiana Department of Wildlife and Fisheries officers were the first law enforcement personnel to arrive. They were working 15 miles away from the closest boat launch at Cypremort Point, about 2 miles from the accident site, when they received a call from 911 dispatch. They said they saw smoke from miles away as they drove to the boat launch. It took approximately 20 minutes for them to get to Cypremort Point, launch the boat (a 19-foot Boston Whaler), and travel to the accident site. Marine units from St. Mary and Iberia parishes were on scene by 1300, along with the Coast Guard Dolphin helicopter and two additional Louisiana Department of Wildlife and Fisheries patrol boats. Law enforcement and Coast Guard assets organized grid searches for survivors. Also assisting with the search efforts were various crew boats, small boats, and fishing vessels in the area. An incident command post was established at Cypremort Point at 1615 and staffed by personnel from St. Mary and Iberia parishes and Coast Guard personnel. Two land-based fire departments responded to the emergency. Cypremort Point Volunteer Fire Department was closest to the accident site. Four Corners Volunteer Fire Department provided medical assistance at the Ivanhoe dock. Neither fire department had

Factual Information 26 Marine Accident Report marine firefighting capabilities. Two towing vessels equipped with fire pumps and hoses,16 the Yancy O and the Miss Joann, and one jack-up boat,17 the Tiger, all of which were working in the field, diverted to assist after seeing flames and smoke. Over the course of several hours, the three vessels extinguished the fires on the Miss Megan and the two barges (figure 15). Figure 15. Towboats Miss Joann and Yancy O fighting the fire on the Miss Megan and the deck barge IBR 234. (Photo courtesy Louisiana Department of Wildlife and Fisheries) The first towing vessel to arrive on scene was the Yancy O. The captain of the Yancy O estimated that he was working 3/4 mile from the fire when he noticed it. The captain stated that the only part of the three vessels not engulfed in flames was the stern of the Miss Megan. He got under way immediately but said that it took him between 15 and 20 minutes to reach the scene because his vessel was slowed by a low tide. 16  Requirements for fire suppression equipment on towing vessels are found at 46 CFR 27.301. 17  A jack-up boat is a self-propelled motorized boat with three or four adjustable legs that ratchet up to lift the boat out of the water.

Factual Information 27 Marine Accident Report At first, because of the intensity of the fire, all he and his deckhand could do was scan the water for survivors and wait for the fire to calm. After 15 to 20 minutes, the lines holding the two barges together burned away, and the Miss Megan and barge IBR 234 began to drift into the oil field. As soon as the towboat and the deck barge cleared the Athena 106, the Yancy O began to fight the fire. The captain piloted the vessel while the deckhand manned the firehose. The Yancy O put water on the fire for over 30 minutes, then maneuvered close enough to attach a 20-foot towline to the Miss Megan’s port quarter and tow the Miss Megan and the IBR 234 to a perimeter light,18 where they were secured. Meanwhile, another tugboat, the Miss Joann, arrived, followed shortly by the jack-up boat Tiger. Both vessels helped fight the fire while the Miss Megan and barge IBR 234 were being towed. According to the Miss Joann captain, it took 2 1/2 to 3 hours to put out the fires on the Miss Megan and the IBR 234 and another hour to extinguish the fire on the Athena 106. The Coast Guard reported that the fires were extinguished at approximately 1530. Emergency Equipment The Miss Megan was considered an uninspected towing vessel for the purpose of Coast Guard regulations. As the name implies, uninspected towing vessels are not required to be regularly inspected. They must, however, comply with minimum Federal safety regulations. Civil penalties can be assessed if uninspected towing vessels are boarded by the Coast Guard and found to be noncompliant. The regulations for uninspected vessels are found at 46 CFR Parts 24-28 (subchapter C). The last Coast Guard examination of the Miss Megan was on May 11, 2006. Deck barges such as the Athena 106 and IBR 234 are not subject to Coast Guard inspection. Lifesaving Equipment. The Miss Megan was required by 46 CFR 25.25-5(c) and (d) to carry a serviceable Coast Guard–approved life preserver for each person on board and one approved ring buoy. The deckhand was recovered wearing a flotation work vest. The master was not wearing a flotation device at the time of the accident. According to Athena Construction company policy, employees were required to wear Coast Guard–approved flotation-type work vests when working on the deck of a barge or other vessel. The flotation vest was to be fastened when worn.19 The only body recovered wearing a flotation work vest was that of the barge foreman. All crewmembers in the Athena 106 doghouse had taken their work vests off while eating lunch, a normal practice allowed by company policy. A ring buoy was found attached to the crane’s catwalk after the accident. Firefighting Equipment. As a towing vessel, the Miss Megan was required by 46 CFR 27.303 to carry three B-I hand-portable fire extinguishers based on its length, and either 18  A four-piling cluster with a blinking light on a platform used to mark the perimeter of an oil field. 19  Athena Construction Company Policy Manual, section 2, pp. 14 and 40.

Factual Information 28 Marine Accident Report an approved B-V semiportable fire-extinguishing system or a fixed fire-extinguishing system to protect the engineroom.20 According to a Coast Guard inspector stationed in Morgan City, the Miss Megan carried a type B-V extinguisher. The vessel survey done in 2005 lists two 20- pound extinguishers in the engineroom and one extinguisher each in the wheelhouse, upper bunkroom, and galley. Investigators were unable to examine the firefighting equipment on board at the time of the accident because of the extensive fire damage. Athena Construction company policy contained general instructions for preventing workplace fires. The policy did not include requirements for firefighting equipment on barges. According to a company representative, the Athena 106 carried at least three fire extinguishers. Two identifiable extinguishers were found during the postaccident examination. Regulators Coast Guard Authority Although the towing vessel Miss Megan was not inspected, the Coast Guard and Maritime Transportation Act of 2004 (Public Law 108-293, enacted August 9, 2004) added towing vessels to “Vessels Subject to Inspection” under Title 46 United States Code, section 3301. In addition, section 3306 was amended by adding the following: “The Secretary [of Homeland Security] may establish by regulation a safety management system appropriate for the characteristics, methods of operation, and nature of service of towing vessels.” Therefore, the Coast Guard now has the authority the Safety Board recommended it seek after a 1998 accident in which a tow rammed a bridge in St. Louis Harbor, Missouri, causing three barges to break away and strike a moored casino vessel.21 No deaths resulted from the accident. The Board’s accident report made the following recommendation to the Coast Guard: M-00-10 Seek authority to require domestic towing companies to develop and implement an effective safety management system to ensure adequate management oversight of the maintenance and operation of all towing vessels. On April 21, 2005, the Safety Board classified Safety Recommendation M-00-10 as “Open—Acceptable Response” after the Coast Guard advised the Board of the changes 20  Class B extinguishers are for fires involving flammable liquid, grease, or gas. B-I extinguishers hold 2.5 pounds of dry chemical. B-V extinguishers are available in a variety of sizes and with different types of extinguishing agents. 21  National Transportation Safety Board, Ramming of the Eads Bridge by Barges in Tow of the M/V Anne Holly With Subsequent Ramming and Near Breakaway of the President Casino on the Admiral, St. Louis Harbor, Missouri, April 4, 1998, Marine Accident Report NTSB/MAR-00/01 (Washington, DC: NTSB, 2000).

Factual Information 29 Marine Accident Report to the United States Code described above. The Board’s classification was made “pending confirmation from the Coast Guard that requirements for safety management systems will be promulgated for all towing companies.” The Coast Guard is expected to propose a safety management system that would place towboat masters clearly in charge of safety, and that would require companies to establish safe operating procedures that take into account the risks of each voyage. The new law will apply to the Miss Megan, if it is brought back into service. At the time of this report, the Coast Guard was drafting the new regulations. Deck barges such as the Athena 106 will remain not subject to inspection.22 According to American Waterway Operators, the national trade association for the U.S. tugboat, towboat and barge industry, more than 4,000 deck barges operate across the country, using different types of winches and other equipment in a variety of different operations. Coast Guard data show that 305 people were fatally injured on barge/tow combinations between 1997 and 2006 and that 379 explosions or fires occurred on barges or towboats during the same period, killing 14 people. The Coast Guard regulates all aspects of maritime safety on inspected vessels. The Occupational Safety and Health Administration (OSHA), an agency of the U.S. Department of Labor, refers complaints regarding workplace conditions of seamen on inspected vessels to the Coast Guard, but regulates workplace safety for employees other than seamen working on inspected vessels. OSHA has jurisdiction over workplace safety for workers on uninspected vessels. On the same vessels, Coast Guard oversight is limited to fire and lifesaving equipment and overall navigational matters. In 1983, the Coast Guard and OSHA signed a memorandum of understanding describing their respective roles in relation to inspected vessels (appendix B). The memorandum of understanding was “intended to eliminate confusion among members of the public with regard to the relative authorities of the two agencies.” The memorandum of understanding did not address uninspected vessels. OSHA Authority The maritime safety role of OSHA involves primarily the regulation of shipyards, longshoring, and marine terminals. The agency acts when there is an accident, a complaint, or as part of a nationwide “special emphasis program” focused on particular workplace safety hazards. The Maritime Advisory Committee for Occupational Safety and Health (MACOSH) was reestablished in 2006 to advise OSHA on matters relevant to the safety and health of workers in the maritime industry, including enforcement, training, and outreach. OSHA issued guidance about its role in marine safety on November 8, 1996.23 22  The Coast Guard inspects barges that carry hazardous materials, petroleum products, or other oils (46 CFR subchapters D and O). 23  Occupational Safety and Health Administration, “OSHA/U.S. Coast Guard Authority Over Vessels,” OSHA Instruction CPL 2-1.20 (see appendix C).

Factual Information 30 Marine Accident Report The state of Louisiana defers to the Federal Department of Labor and does not have its own occupational health and safety rules. After the accident, Athena Construction notified OSHA that it had been involved in an accident resulting in fatalities. The local OSHA office in Baton Rouge was first told that it was a marine accident and deferred to the Coast Guard to investigate. OSHA later joined the Safety Board investigation as a party. OSHA also conducted its own enforcement investigation to determine whether any of its standards had been violated. On March 29, 2007, OSHA issued a citation to Athena Construction (appendix D) for a serious violation of section 5(a)(1) of the Occupational Safety and Health Act of 1970. According to information received from Athena Construction, OSHA and Athena reached a settlement agreement on April 20, 2007, in which they agreed that setting the brakes and pinning the spuds in the raised position could be safely done. The agreement contained the following abatement method and remedial measures: All employees have been instructed that before a barge is moved, the spuds are to be raised such that the pin hole is above the resting area of the pin. Each spud is to be pinned in the up position. Each spud and the winch are to be manned throughout the barge’s move. In the event of a power failure of the tug or an imminent collision or allision, and it is necessary to lower the spuds to stop the barge, the Supervisor will direct the workers at the spuds to remove the pins, and the winch operator will be directed by the Supervisor on how and when to lower the spuds. When the equipment is not manned and is under tow, the spuds will be raised and pinned. Coast Guard/OSHA Relationship The OSHA instruction of November 1996 broadly outlines the role of each agency. Regarding the Coast Guard, the instruction states (p. 9): The U.S. Coast Guard conducts limited safety checks on “uninspected vessels.” The Coast Guard has regulations dealing with, and conducts safety checks of, working conditions on commercial uninspected vessels involving personal flotation devices, lifesaving equipment, fire extinguishing equipment, fire fighting equipment, ventilation of engine bilges and fuel tank compartments, and back-fire traps/flame arresters on inboard engine carburetors using gasoline as a fuel. Any other working condition on board a commercial uninspected vessel is subject to OSHA authority. Regarding OSHA, the instruction states (p. 10): OSHA may exercise its authority to cite all employers for all violative working conditions affecting their employees on uninspected vessels when such violations occur within OSHA’s geographical jurisdiction and when such violations are not specifically addressed by a Coast Guard regulation.

1. An owner, operator, agent or master of an uninspected vessel may be cited for

hazards to which any employees, including seamen [emphasis in original], it employs are exposed if the hazard is not regulated by the U.S. Coast Guard.

Factual Information 31 Marine Accident Report a. . . . b. Identified recognized hazardous situations that are causing or are likely to cause death or serious physical harm for which there are no specific standards will be cited under the provisions of Section 5 (a) (1) of the OH Act. In October 2001, the U.S. Supreme Court heard the Chao v. Mallard Bay Drilling Company case (00-927). The case involved an explosion on an uninspected oil and gas exploration barge (rig 52) in Louisiana that killed or injured several workers. The Coast Guard did not cite the operator for violations, but OSHA did. The operator challenged OSHA on jurisdictional grounds, but in a decision dated January 9, 2002,24 the Supreme Court held 8-0 that in areas where the Coast Guard did not exercise inspection authority, OSHA could. Specifically, [t]o determine whether Coast Guard regulations have pre-empted jurisdiction over Rig 52’s working conditions, it is thus necessary to examine the contours of the Guard’s exercise of its statutory authority. With respect to inspected vessels, the parties do not dispute that OSHA’s regulations have been pre-empted because the Coast Guard has exercised its broad statutory authority over workers’ occupational health and safety, 46 U.S.C. §3306. Indeed, OSHA and the Coast Guard signed a Memorandum of Understanding recognizing that the Guard has displaced OSHA’s jurisdiction over all working conditions on inspected vessels, including those not addressed by specific regulations. In contrast, the Guard’s regulatory authority over uninspected vessels is more limited. Its general maritime regulations do not address the occupational safety and health concerns faced by inland drilling operations on such vessels and, thus, do not pre-empt OSHA’s authority in this case. And, although the Guard has engaged in a limited exercise of its authority to regulate specific working conditions on certain types of uninspected vessels, respondent has not identified any specific regulations addressing the types of risk and vessel at issue here. State of Louisiana Authority As noted above, Louisiana does not exercise any occupational health jurisdiction and defers to the Federal agency (OSHA). The state does not inspect commercial vessels in navigable waters, a role reserved for the Coast Guard. The state’s Department of Natural Resources exercises limited authority over the pipelines in Louisiana and was a party to this investigation. Tests and Research Sonar Survey Chevron contracted with John Chance Land Surveys, Inc., by agreement of the National Oceanic and Atmospheric Administration and the Coast Guard, to conduct extensive sonar surveys of the area after the accident to determine the water depths and to detect any hazards to the salvage operation. A preliminary sonar scan around the Athena 106 showed a 24  Chao v. Mallard Bay Drilling, Inc., 534 U.S. 235 (2002).

Factual Information 32 Marine Accident Report depression in the bay floor and extensive scarring of the area. On the basis of the sonar scan, a hydrographic survey, using a side-scan sonar and a single-beam echo sounder, was conducted to map the water bottom near the accident site. The echo sounder results indicated that the corrected mean lower low water depths in the vicinity of the accident were 6 to 7 feet. The surveyors could not determine exactly what caused the scarring of the bay floor, although some scars were identifiable as made by a propeller. The report stated: “the depression in the seafloor near the pipeline has disturbed the natural bottom significantly enough that a determination of the ATHENA barge dragging an object, which may have caused the pipeline to rupture, cannot be made.” Spud Winch Examination On December 6, 2006, Safety Board investigators visited Athena Construction’s maintenance facility in Morgan City to further examine the Athena 106’s spud winch. The winch, still secured to the deck of the barge, was unfastened and lifted by crane to shore where it could be examined in detail. The team first briefly reexamined the physical condition of the winch. The paint had burned from all external surfaces, and the top of the fuel tank, mounted on the winch’s base, had split open. The diesel engine powering the winch also sustained extensive damage. The winch’s chain guard, on the aft end of the winch opposite the operator’s seat, was removed to access the chain and drive sprockets on the clutch and winch drive ends. The drive chain, sprockets, gearing, and all associated components appeared in satisfactory condition, with no sign of accident-related or preexisting damage. The metal guard covering the winch drum drive gears was removed. Both the drum drive gears and the pinion gear driving them were inspected for shaft, bearing, or tooth failure or other signs of damage. All components were found in satisfactory condition, with no signs of damage or failure. Both drum pawls were inspected and found to be working satisfactorily, with no signs of damage or wear. The connections and linkages for both the foot pedal brakes and the hand lever friction controls were found in satisfactory condition, with no signs of wear, damage, or disconnected components except for the small amount of wear, noted in the postaccident examination, where the hooked edge of the brake pedal would engage the steel latching bar. The turnbuckles25 used to adjust the brake bands for both control mechanisms were inspected and found to have threads remaining for further adjustment. The brake band on the upper drum was removed to check for damage to the drum or to the lining on its inside surface. The lining, which was fastened to the inside surface of the steel brake band with steel rivets, was removed and checked for thickness along its entire 5-foot length. The material thickness of the brake band lining for the upper spud winch drum varied from 0.172 to 0.314 inch. 25  Devices consisting of a link with screw threads at both ends, used to bring the ends closer together and adjust the length of a linkage or connection.

Factual Information 33 Marine Accident Report Investigators were unable to acquire a complete, original owner’s manual for the winch26 to determine the allowable minimum thickness for the lining material. However, once the lining was removed, all the lining fastening rivets, still fastened in place on the band, were checked for wear. None of the rivet heads showed any signs of wear, damage, or fracturing, which could have occurred if insufficient brake lining material had allowed the drum’s steel surface to contact the outer steel brake band surface. Material Analysis of Pipeline At the Safety Board’s request and in coordination with Safety Board investigators, Stress Engineering Services, Inc., in Houston, Texas, examined and tested samples of the ruptured pipeline. The stated objectives of the Stress Engineering Services work were to document the overall condition of the pipe, including fracture and weld locations; identify fracture mechanisms, directions, and origins; inspect for foreign object damage and pre-existing conditions; measure the pipe diameter and wall thickness; measure the hardness of the steel; and visually characterize external coatings. The report completed on February 27, 2007, by Stress Engineering Services described the fractured pipeline as follows: The rupture produced both a transverse fracture and a longitudinal fracture in the pipeline. The transverse fracture was located approximately 2.1 feet east of a field girth weld located in the section of pipe referred to as the “west portion.” The longitudinal fracture extended from the transverse fracture to the east for a distance of approximately 43.4 feet. The report identified a reversal in the direction of fracture surface markings and stated that the reversal was “consistent with a fracture origin area in the bend [in the longitudinal fracture surface].” The report noted that “internal and external corrosion were insignificant.” The Safety Board’s materials laboratory reviewed the report and found that “the origin area was associated with a large dent on the pipe exterior above the fracture.” The laboratory noted that the features of a bulge in the fracture surface were “consistent with the east portion moving downward relative to the west portion as would occur from contact at the location of the bulge with a spud moving downward.” The laboratory’s report stated that, according to the Stress Engineering Services document, “no evidence of preexisting cracks or significant corrosion was observed at the origin area.” The laboratory’s report stated further: “Results documented in the [Stress Engineering Services] report support the conclusion that the pipe ruptured in overstress due to contact with the spud.” 26  According to its serial number, the winch was built in the 1950s. The manufacturer is out of operation.

34 Marine Accident Report Analysis General The analysis first identifies factors that can be eliminated as causal or contributory to the accident. It then analyzes the cause of the accident and discusses the safety issues identified by the accident investigation: • Failure to use safety devices. • Limited oversight of vessels not subject to inspection. Exclusions The prevailing weather conditions near the accident site did not affect the ability of the three vessels to operate normally. The wind was slight, and the sea conditions would not have hindered the Miss Megan master from controlling the barges his vessel was towing. The recovered bodies of four crewmembers were tested for drugs and alcohol, with negative results. The two workers who survived were tested for drugs, with negative results. They were not tested for alcohol because of the lengthy postaccident rescue operations. However, an officer from the St. Mary Parish sheriff’s office who met the survivors at the dock did not detect evidence of alcohol use by either of them. The crews aboard the Athena 106 and the Miss Megan were working a normal, routine shift. The accident occurred at midday, and survivors indicated in interviews that they had not experienced any abnormal change in work habits or worked excessive hours in the days before the accident. Therefore, the Safety Board concludes that the following were not factors in the Athena 106 accident: weather, drug or alcohol use, and fatigue. The postaccident inspection of the Miss Megan revealed no obvious mechanical defects on the towboat. The engines of the Miss Megan suffered extensive damage in the fire. Investigators observed that the transmission shift levers indicated that both engines were in the neutral position at the time of the accident. The transmission could only have been changed by the master—that is, the shift levers could not have vibrated into the neutral position. Because the master’s remains were discovered outside the wheelhouse, it is likely that he put the towboat’s engines into neutral and left the wheelhouse for some reason before the fire. Thus, it is unlikely that the Miss Megan’s transmission malfunctioned and caused the towboat to suddenly accelerate, jar the barges, and cause the spud winch brake to dislodge the Athena 106’s aft spud. The Safety Board therefore concludes that the engine transmission of the Miss Megan was not a factor in the accident.

Analysis 35 Marine Accident Report Cause of Accident The timing of the rupture with the position of the barge above the gas sales pipeline, the loss of pressure recorded by Chevron’s SCADA system, the observation of the fire by witnesses, and the reports of postaccident divers who noted the spud’s proximity to the failed pipeline all indicate that the pipeline ruptured when the spud hit it. An estimated 973,000 cubic feet of natural gas escaped from the ruptured pipeline. A number of possible ignition sources existed on the accident vessels, such as generators and other motors, but the specific ignition source for the fire could not be determined. The Stress Engineering Services examination, which was reviewed by the Safety Board’s materials laboratory, identified the proximity of the pipe damage with the fracture origination area. According to the materials laboratory report, Stress Engineering Services found no evidence of preexisting cracks or significant corrosion in the fracture origin area. A cathodic protection survey on the pipeline in August 2005 produced readings that met NACE International criteria for acceptable cathodic protection against corrosion, and a February 2006 hydraulic pressure test of the pipeline for 4 hours at 1,000 psig pressure proved the pipeline’s structural integrity. Since the 2006 pressure test, the pipeline had not required repairs and had experienced no problems before it ruptured during the accident. Thus, no evidence suggests that the pipeline was in a weakened state before the accident. The aft spud, which weighed 5 tons, had penetrated an estimated 17 feet into the muddy bottom of the bay, according to markings and measurements made after the accident. (The forward spud remained raised after the accident until, according to an Athena Construction barge supervisor, it “just dropped” during the recovery effort. The forward spud had not been pinned.) In reviewing the Stress Engineering Services report, the Safety Board’s materials laboratory found that “the origin area was associated with a large dent on the pipe exterior above the fracture” and that “the pipe was deformed downward in the vicinity of the bulge, consistent with the spud moving downward.” Although the John Chance surveyors could not rule out the possibility that the pipeline had been ruptured when the Athena 106 dragged an object across it because the bottom of the bay around the accident site was significantly disturbed, the Board’s materials laboratory found: “Results documented in the [Stress Engineering Services] report support the conclusion that the pipe ruptured in overstress due to contact with the spud.” The tangled cable found after the accident on the winch drum for the aft spud shows that the cable paid out in a sudden, uncontrolled release and indicates that the spud fell rapidly (that is, was not dragged). The spud winch operator said that he looked at the winch after the spud fell and saw no one near it who might have accidentally released the brake. Given the witness statement and the postaccident condition of the pipeline and the aft spud’s cable, the Safety Board concludes that the pipeline was ruptured by the impact of the aft spud falling downward, and that the release of the spud was unintended, sudden, and uncontrolled. Safety Board investigators considered four possible explanations of why the spud had unintentionally released from the winch. One possibility was that the release resulted

Analysis 36 Marine Accident Report from a mechanical defect. The spud winch used on the Athena 106 and its associated lifting equipment were transported for examination to Athena Construction’s facility in Morgan City, Louisiana. Investigators searched for any mechanical conditions that might have allowed the aft spud to fall free from its lifted position and strike the high-pressure natural gas line. None of the driving components (chain, sprockets, gearing, transmission) showed any abnormalities or defects. All linkages associated with the spud winch operator’s drum controls were intact, and none were positioned at their endpoints of adjustment, an indication of excessively worn or improperly adjusted brakes or controls. The only mechanical abnormality was a small section of worn steel where the foot brake for the aft spud latched to the winch. Because the material wear was slight, the worn area would have had minimal effect on the holding ability of the pedal’s latching mechanism. Finally, the brake pad lining to the aft spud drum was found to have sufficient material thickness to control the braking action of the spud’s drum. During his interview, the Athena 106 spud winch operator said that he had conducted a routine check of the winch the morning of the accident and had found nothing abnormal. He also told investigators that the spud winch was working “fine” before the accident. He further stated that he had not needed to adjust the brakes that morning, as was periodically required to remove excessive free play from the control linkages. Thus, the evidence indicates that the winch on the Athena 106 was free of any mechanical defects or abnormalities. Investigators also examined the condition of the cable attaching the aft spud to the winch drum and the hardware used to run the cable between the winch and the spud. The cable was found free of damage or fraying along its entire length. Further, a company invoice indicated that the cable was nearly new, having been replaced about 2 months before the accident. The sheaves and other hardware between the spud and winch were in satisfactory operating condition. A second possible explanation for the spud’s sudden release is that the spud winch operator did not set the foot brake properly. The operator told investigators that the brakes were working properly the day of the accident and that he did not have to adjust them that morning. Since the brake released during the accident, it was impossible to determine its position beforehand. Therefore, the possibility that the brake released because it was improperly set cannot be ruled out. A third possible explanation for the spud release is that one or more of the vessels ran aground in the shallow bay and vibrated the spud’s foot brake loose. According to echo sounder data from the John Chance survey, the water in the area around the crater caused by the release of high-pressure gas was 6 to 7 feet deep (the crater was 3.5 to 4 feet lower than the surrounding area). Since the draft of the barges was between 4 and 4 1/2 feet, it is unlikely that either barge ran aground. The Miss Megan’s draft was about 5 feet. Although the John Chance survey found propeller marks on the bay floor, the marks could not be identified with the Miss Megan. The spud winch operator told investigators that he had felt the barge stop just before the spud dropped, “like the towboat stopped,” but that he had paid “no attention” because

Analysis 37 Marine Accident Report “that’s been known to happen out there . . . the water’s shallow.” If the towboat had stopped suddenly, the motion might have been sufficient to loosen the aft spud winch brake and cause the spud to fall. A fourth possibility, related to the possibility of a grounding, is that the vessels in the tow jostled each other enough to jar the foot brake loose and cause the aft spud to drop. The tow, which was traveling at about 6 knots, might have created enough motion to cause the vessels to hit each other with enough force to dislodge the foot brake. The investigation found evidence that the spud winch and its associated lifting hardware were free of mechanical damage or defect before the accident. There is, however, little or no evidence to establish which, if any, of the other possible scenarios accounted for the spud’s sudden fall—the spud winch operator failing to set the foot brake properly, one or more of the vessels grounding in the shallow bay, or the vessels in the tow jostling each other enough to loosen the foot brake on the Athena 106’s aft spud. The Safety Board therefore concludes that while it is unlikely that a mechanical defect in the spud winch or its associated apparatus caused the accident, the reason the foot brake for the aft spud released cannot be determined. Failure to Use Safety Devices The Athena 106 spud winch operator followed his usual and customary method of operating the spud winch on the day of the accident. His practice was to employ only the foot brakes at the operator’s station to secure both spuds once they were fully retracted. The spud winch operator had two additional means of locking the spuds in the retracted position, but he did not use either of them on either spud: • A steel pawl that, when engaged at the operator’s station, fit into a notched ring fastened to the outer periphery of the winch drum to stop it from turning backward if the brake failed. • A 36-inch-long, 2-inch-diameter steel securing pin that could be inserted directly through the spud slightly above deck level once it was fully retracted. The steel securing pin was a fail-safe device that would have kept the aft spud from falling even if the winch or the supporting cable failed. The Athena 106 spud winch operator told investigators that the securing pins were generally inserted only on long transits, not on the short trips the barges made between one work site and another. The operator stated in his interview, “I mean I’m sure it’s a lot safer to do it [use the pins], but we don’t. I don’t know why.” The Athena Construction barge supervisor confirmed that in day-to-day operations, crews used only the foot brakes to hold the retracted spuds. Further, after the accident, investigators witnessed company personnel moving another barge next to the Athena 106 so that its crane could pull the aft spud out of the mud. While moving the other barge, the spud winch operator used just the foot brake, neither of the other two safety devices, to hold the retracted spuds.

Analysis 38 Marine Accident Report Thus, after the Athena 106 spud winch operator raised the forward and aft spuds shortly before the accident, he failed to take two available and redundant safety actions. First, he did not position the lever that would have engaged the pawls into the notched ring on the drums’ outer edge and eliminate the chance of the winch “running away” in the event of brake failure. Second, he did not insert the steel securing pins through the retracted spuds to prevent the spuds from falling if the winch or a supporting cable failed. During the postaccident inspection of the Athena 106, the pins used for securing the spuds in place were found lying on the deck, one at the base of each spud. If the Athena 106 crew had used the steel pins to secure the retracted spuds in place during their transit, a pin would have prevented the aft spud from accidentally deploying. The spud would have remained locked in its lifted position regardless of whether the winch brake mechanism, the spud’s supporting cable, or a piece of connecting hardware had failed. Athena Construction’s health and safety manual contained no procedures mandating the use of the safety devices on the spud winch except during electrical work. OSHA cited Athena Construction for not providing a safe workplace and indicated that the securing pins were an important part of a safe operation. Therefore, the Safety Board concludes that the accident could have been prevented if Athena Construction had required the spuds on its barges to be securely pinned while the barges were in transit. In March 2007, Athena Construction reached a settlement agreement with OSHA according to which company employees will be instructed to pin each spud in the raised position before a barge is moved. The Safety Board agrees that the spud securing pins are an important safety element on barges such as the Athena 106 and believes that Athena Construction should develop procedures and provide initial and recurrent training to the employees on its barges to use the securing pins to hold spuds safely in place before transiting from one site to another. Investigators found no evidence that the Miss Megan master or deckhand checked whether the spuds had been properly secured before the tow began. A towboat crew occasionally moves barges that do not carry construction crews. The Miss Megan was operated by a licensed master who was responsible for the safe operation of his vessel. Before getting under way, a licensed mariner should ensure that the vessels under his control are safe to move. (A tow essentially operates as a single vessel because the towboat and the barges are lashed together.) In the case of the Athena 106, the Miss Megan master may have deferred to the construction crew. However, a master cannot delegate the responsibility for the safety of his crew and vessel to others. The deckhand left the towboat and could have quickly checked whether the spud securing pins were in place before the tow got under way. Central Boat Rentals had a health and safety manual and trained its crews. However, the written procedures did not specifically warn masters about the need to secure spuds or other barge equipment before navigating. Central Boat Rentals owned and operated a variety of vessels, including spud barges, and should have aware of this important safety requirement. The company’s crews should have been trained to identify potential safety hazards on vessels under their control. The Safety Board therefore concludes that the failure of Central Boat Rentals to require, and of the Miss Megan master to ensure, that the spuds on the Athena 106 were securely pinned before getting

Analysis 39 Marine Accident Report under way contributed to the accident. The Safety Board believes that Central Boat Rentals should develop procedures and provide initial and recurrent training to the employees on its barges to use the securing pins to hold spuds safely in place before transiting from one site to another. Limited Oversight of Vessels Not Subject to Inspection In this accident, the material condition of the towboat and the barges was not an issue. However, according to American Waterway Operators, more than 4,000 deck barges similar to the Athena 106 and IBR 234 operate across the country, using different types of winches and other equipment in a variety of operations. Coast Guard data show that 305 people were fatally injured on barge/tow combinations between 1997 and 2006 and that 379 explosions or fires occurred on barges or towboats during the same period, killing 14 people. No regulatory agency inspects operations—general working conditions, safety gear, equipment, and operating practices—on barges that are not subject to inspection. Coast Guard oversight is limited to examining the lifesaving and firefighting equipment on certain uninspected vessels such as the Miss Megan. OSHA investigates only after an accident, in the case of an employee complaint, or as part of a “special emphasis program” focusing on particular workplace safety hazards. In this accident, the condition of the Athena 106 barge and winch components was unlikely to have offered grounds for an OSHA action until after the fact. The Coast Guard acted under its authority to investigate the Athena 106 accident because it occurred on a navigable waterway. However, if a similar accident had occurred with no towboat present, OSHA would probably have investigated. After the accident, Athena Construction was found to be in violation of a general workplace safety provision of the Occupational Safety and Health Act of 1970. However, this accident illustrates that before an accident occurs, no agency currently inspects operations involving barges not subject to inspection, and that even if a material defect or unsafe work practice exists, in the absence of a complaint no preventive regulatory action will take place. The Coast Guard and Maritime Transportation Act of 2004 gives the Coast Guard the authority to require towing vessels such as the Miss Megan to have a towing safety management system.27 A safety management system would assist both the Coast Guard and the towing industry in providing for safe practices in vessel operation and a safe working environment on board towing vessels, establish and implement safeguards against identified risks, establish and implement actions to continuously improve the safety management skills of personnel on shore and on board towing vessels, and ensure compliance with rules and regulations. The Safety Board has previously addressed the need for safety management systems in the U.S. towing industry and concludes that the lack of a safety management system requirement for all U.S. towing industry companies 27  The Coast Guard has no plans to inspect barges that are not currently subject to inspection. The Coast Guard already inspects barges that carry hazardous materials, petroleum products, or other oils.

Analysis 40 Marine Accident Report poses a threat to waterway safety. The Safety Board therefore believes that the U.S. Coast Guard should finalize and implement the new towing vessel inspection regulations and require the establishment of safety management systems appropriate for the characteristics, methods of operation, and nature of service of towing vessels. This recommendation supersedes Safety Recommendation M-00-10, which is therefore classified as “Closed—Acceptable Action/Superseded.” When the new regulations supporting the Coast Guard and Maritime Transportation Act of 2004 are promulgated, they should restate the master’s responsibility for his vessel and for the safety of vessels in tow. The new regulations will add a layer of oversight for vessels under tow that are not subject to inspection. Although towboats will be inspected under the new rules, monitoring of workplace safety aboard barges such as the Athena 106 needs to be improved. The memorandum of understanding that the Coast Guard and OSHA signed in 1983 was “intended to eliminate confusion among members of the public with regard to the relative authorities of the two agencies.” The memorandum does not address uninspected vessels. Although OSHA has exercised its jurisdiction over workplace safety on barges after accidents, responsibility has been divided between the two agencies. With the advent of new regulations for towing vessels, the gap will shrink between vessels subject to inspection and uninspected barges such as the Athena 106. The Safety Board concludes that workplace safety on uninspected vessels should be more closely observed before accidents occur, and that the agreement between the Coast Guard and OSHA should reflect the new regulatory scheme, address all aspects of workplace and navigational safety, and encourage communication between the two agencies and industry. The Safety Board therefore believes that OSHA and the Coast Guard should review and update their memorandum of understanding to specifically address their respective oversight roles on vessels that are not subject to Coast Guard inspection. The Board further believes that OSHA should direct MACOSH to issue the following documents to the maritime industry: (1) a fact sheet regarding the accident, and (2) a guidance document regarding the need to secure the gear on barges, including spud pins, before the barges are moved, and detailing any changes to its memorandum of understanding with the Coast Guard. Response to Emergency Chevron’s SCADA system shut down the Vermilion Bay gas sales pipeline downstream of the rupture by about 1210. Pressure gauges associated with the SCADA system sensed a pressure decrease in the Vermilion Bay gas sales pipeline and automatically shut it down. As part of the automatic shutdown, a check valve on Chevron’s bay junction platform closed and prevented natural gas from backflowing into the ruptured pipeline from Chevron’s downstream pipeline system. The shutdown of the failed pipeline upstream of the failure was expedited by a workman on the Gulfport Sales Platform, who recognized the emergency and manually shut a valve feeding gas into the failed pipeline shortly after 1206. The Safety Board therefore concludes that the damaged natural gas pipeline was shut down in a prompt and timely fashion.

Analysis 41 Marine Accident Report Emergency response to the accident came from both traditional response assets and other vessels working in the West Cote Blanche Bay oil field. Because of the remote location of the accident, no traditional emergency response assets were in the immediate vicinity. The two closest fire departments were staffed by volunteers and had no waterborne firefighting equipment. Other vessels working in the field were closest and best prepared to deal with the fire emergency. Two towing vessels and one jack-up boat with firefighting capabilities quickly responded to the accident scene and used their firefighting equipment to extinguish the fires on the Miss Megan and the two barges. Crew transport boats and other small boats near the accident site were instrumental in the search-and-rescue efforts. The crew boat Captain Mitch arrived about 5 minutes after the accident. The crew pulled the Athena 106 spud winch operator from the water before traveling around the field to shut down wells. Workers from another Athena Construction barge arrived next on a small boat kept on the barge. They rescued the Miss Megan deckhand from the water and found the body of the Athena 106 barge foreman. Individuals on both the Captain Mitch and the small boat reported seeing other Athena 106 crew on or around the burning barge but could not move close enough to help because of the fire’s heat. Assets from the Coast Guard, the Louisiana Department of Wildlife and Fisheries, and St. Mary and Iberia parishes responded quickly on notification. The Coast Guard launched a jet aircraft and a helicopter within 20 minutes. Louisiana Department of Wildlife and Fisheries officers launched a vessel from Cypremort Point, about 2 miles from the accident site, and arrived within 20 minutes of receiving a 911 call. Marine units from Iberia and St. Mary parishes, which had to travel about 12 miles to reach West Cote Blanche Bay, arrived by 1300, an hour after the accident. A command center on nearby Cypremort Point was used to direct searches for missing crew from the towboat and barges. Marine units working together conducted grid searches of the accident site and surrounding areas. After the Coast Guard helicopter located one body, a boat from the St. Mary’s Parish sheriff’s office recovered it from the water. The boat also recovered the master’s body from the Miss Megan. Responding individuals and organizations worked effectively and cooperatively in the firefighting and search-and-rescue aspects of the emergency. Those closest to the accident responded immediately, while the Coast Guard and law enforcement groups sent assets as quickly as possible. There were no reports of issues or difficulties other than that of traveling to the remote accident location. Therefore, the Safety Board concludes that the actions by rescuers were timely and effective.

42 Marine Accident Report Conclusions Findings 1. The following were not factors in the Athena 106 accident: weather, drug or alcohol use, and fatigue. 2. The engine transmission of the Miss Megan was not a factor in the accident. 3. The pipeline was ruptured by the impact of the aft spud falling downward, and the release of the spud was unintended, sudden, and uncontrolled. 4. While it is unlikely that a mechanical defect in the spud winch or its associated apparatus caused the accident, the reason the foot brake for the aft spud released cannot be determined. 5. The accident could have been prevented if Athena Construction had required the spuds on its barges to be securely pinned while the barges were in transit. 6. The failure of Central Boat Rentals to require, and of the Miss Megan master to ensure, that the spuds on the Athena 106 were securely pinned before getting under way contributed to the accident. 7. The lack of a safety management system requirement for all U.S. towing industry companies poses a threat to waterway safety. 8. Workplace safety on uninspected vessels should be more closely observed before accidents occur, and the agreement between the Coast Guard and the Occupational Safety and Health Administration should reflect the new regulatory scheme, address all aspects of workplace and navigational safety, and encourage communication between the two agencies and industry. 9. The damaged natural gas pipeline was shut down in a prompt and timely fashion.

1. The actions by rescuers were timely and effective.

Probable Cause The National Transportation Safety Board determines that the probable cause of the accident was Athena Construction’s failure to require its crews to pin the spuds securely in place on its barges, which allowed the sudden, unintentional release of the Athena 106’s aft spud, rupturing a buried pipeline and causing natural gas to surface and ignite. Contributing to the accident was the failure of Central Boat Rentals to require, and of the Miss Megan master to ensure, that the barge spuds were securely pinned before getting under way.

43 Marine Accident Report Recommendations New Recommendations As a result of its investigation of the Athena 106 accident, the National Transportation Safety Board makes the following new safety recommendations: To the Occupational Safety and Health Administration: Review and update your memorandum of understanding with the Coast Guard to specifically address your respective oversight roles on vessels that are not subject to Coast Guard inspection. (M-07-4) Direct the Maritime Advisory Committee for Occupational Safety and Health (MACOSH) to issue the following documents to the maritime industry: (1) a fact sheet regarding the accident, and (2) a guidance document regarding the need to secure the gear on barges, including spud pins, before the barges are moved, and detailing any changes to your memorandum of understanding with the Coast Guard. (M-07-5) To the U. S. Coast Guard: Finalize and implement the new towing vessel inspection regulations and require the establishment of safety management systems appropriate for the characteristics, methods of operation, and nature of service of towing vessels. (M-07-6) (Supersedes M-00-10) Review and update your memorandum of understanding with the Occupational Safety and Health Administration to specifically address your respective oversight roles on vessels that are not subject to Coast Guard inspection. (M-07-7) To Athena Construction and Central Boat Rentals: Develop procedures and provide initial and recurrent training to the employees on your barges to use the securing pins to hold spuds safely in place before transiting from one site to another. (M-07-8)

Recommendations 44 Marine Accident Report Previously Issued Recommendations Classified in This Report To the U. S. Coast Guard: M-00-10 Seek authority to require domestic towing companies to develop and implement an effective safety management system to ensure adequate management oversight of the maintenance and operation of all towing vessels. Safety Recommendation M-00-10 (previously classified as “Open—Acceptable Response) is classified as “Closed—Acceptable Action/Superseded” in the “Limited Oversight of Vessels Not Subject to Inspection” section of this report. BY THE NATIONAL TRANSPORTATION SAFETY BOARD MARK V. ROSENKER

ROBERT L. SUMWALT Chairman

Vice Chairman DEBORAH A. P. HERSMAN

KATHRYN O’LEARY HIGGINS Member

Member

STEVEN R. CHEALANDER Member

Adopted: June 14, 2007

45 Marine Accident Report Appendix A Investigation The Safety Board was notified of the Athena 106 accident on October 12, 2006, through the National Response Center. The five-person investigative team sent to the scene arrived at 1400 on October 13. The following investigative groups and technical specialists were assigned to the investigation: deck operations, survival factors, engineering, pipeline, meteorology, and materials analysis. The on-scene investigation was completed on October 21. The Safety Board investigated the accident according to its rules under the authority of the Independent Safety Board Act of 1974. The designated parties to the investigation were the U.S. Coast Guard, the Occupational Safety and Health Administration, the Louisiana Department of Natural Resources, the National Oceanic and Atmospheric Administration, Athena Construction, Central Boat Rentals, Gulfport Energy Corporation, and Chevron U.S.A.

46 Marine Accident Report Appendix B Memorandum of Understanding Between Coast Guard and OSHA

50 Marine Accident Report Appendix C OSHA Guidance Document (CPL 2-1.20)

68 Marine Accident Report Appendix D OSHA Citation of Athena Construction

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FD07324 ｜ 2006_美国_NTSB_MAR0801_Heeling_Accident_on_MV_Crown_Princess.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2006 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

ACCIDENT REPORT NTSB/mAR-08/01 PB2008-916401 National Transportation Safety Board marine Heeling Accident on M/V Crown Princess Atlantic Ocean Off Port Canaveral, Florida July 18, 2006

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National Transportation Safety Board Marine Accident Report Heeling Accident on M/V Crown Princess Atlantic Ocean Off Port Canaveral, Florida July 18, 2006 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 NTSB/MAR-08/01 PB2008-916401 Notation 7963B Adopted January 30, 2008

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Web at http://www.ntsb.gov. Other information about available publications also may be obtained from the Web site or by contacting: National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (800) 877-6799 or (202) 314-6551 Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2008-916401 from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605-6000 The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. National Transportation Safety Board. 2008. Heeling Accident on M/V Crown Princess, Atlantic Ocean Off Port Canaveral, Florida, July 18, 2006. Marine Accident Report NTSB/MAR-08/01. Washington, DC. Abstract: This report discusses the July 18, 2006, accident on the cruise ship Crown Princess in which the vessel heeled at a maximum angle of about 24°, resulting in injuries to 298 passengers and crewmembers. The vessel’s second officer, the senior watch officer on the bridge, had disengaged the automatic steering mode of the vessel’s integrated navigation system and taken manual control of the steering in an effort to counteract a perceived high rate of turn to port. He turned the wheel first to port and then between port and starboard several times, causing the vessel to suddenly heel and people to be thrown about or struck by unsecured objects. The Crown Princess incurred no structural damage, although unsecured interior items were damaged. The Safety Board’s investigation of the accident identified the following safety issues: actions of the captain, staff captain, and second officer; training in the use of integrated navigation systems; reporting of heeling incidents and accidents; and emergency response following severe incidents. On the basis of its findings, the Safety Board made recommendations to the U.S. Coast Guard, to the Cruise Lines International Association, and to SAM Electronics and Sperry Marine (manufacturers of integrated navigation systems).

National Transportation Safety Board M A R I N E Accident Report iii Contents Acronyms and Abbreviations....................................................................................... v Executive Summary........................................................................................................vi Factual Information..........................................................................................................1 Accident Narrative...................................................................................................................1 Injuries.....................................................................................................................................10 Personnel Information ..........................................................................................................11 General................................................................................................................................11 Captain................................................................................................................................11 Staff Captain.......................................................................................................................11 Second Officer....................................................................................................................12 Vessel Information.................................................................................................................13 History and Construction................................................................................................13 Classification and Inspection...........................................................................................13 Propulsion and Steering...................................................................................................14 Voyage Data Recorder......................................................................................................14 Waterway Information..........................................................................................................16 Meteorological Information..................................................................................................16 Toxicological Testing.............................................................................................................16 Survival Factors......................................................................................................................17 Shipboard Response.........................................................................................................17 Shoreside Response...........................................................................................................18 Tests and Research.................................................................................................................19 Postaccident Steering Tests .............................................................................................19 Heel Angle Determination...............................................................................................20 Stability Considerations...................................................................................................22 Vessel Dynamics................................................................................................................23 Shallow Water Effects ......................................................................................................24 Operational and Management Information.......................................................................28 Corporate Organization...................................................................................................28 Princess Cruises Operations............................................................................................28 Additional Information.........................................................................................................31 Heeling Incidents on Cruise Vessels..............................................................................31 Integrated Navigation Systems ......................................................................................34 Analysis............................................................................................................................43 General.....................................................................................................................................43 Exclusions................................................................................................................................43 Accident...................................................................................................................................43 Actions of Captain and Staff Captain.............................................................................44 Second Officer’s Actions..................................................................................................45

Contents National Transportation Safety Board M A R I N E Accident Report iv Training in Use of Integrated Navigation Systems...........................................................47 Postaccident Crew Response ...............................................................................................50 Monitoring of Heeling Incidents.........................................................................................51 Conclusions.....................................................................................................................53 Findings...................................................................................................................................53 Probable Cause.......................................................................................................................54 Recommendations..........................................................................................................55 Appendixes A: Investigation..................................................................................................................59 B: Voyage Data Recorder Data Plots .............................................................................60 C: Voyage Data Recorder Audio Transcript.................................................................65 D: Pertinent Regulations and Guidelines.....................................................................79 E: Model Curriculum Proposed by International Maritime Organization.............82 F: International Maritime Organization Guidance on Integrated Navigation System Training............................................................................................................92 Contents

National Transportation Safety Board M A R I N E Accident Report v Acronyms and Abbreviations AIS automatic identification system ARPA automatic radar plotting aid CFR Code of Federal Regulations CLIA Cruise Lines International Association COTP Captain of the Port ECDIS electronic chart display and information system GPS global positioning system ICCL International Council of Cruise Lines IBS integrated bridge system IMAC integrated monitoring, alarm, and control INS integrated navigation system ISO International Organization for Standardization LORAN LOng RAnge Navigation MSC Maritime Safety Committee NACOS Navigation and Command System QE2 Queen Elizabeth 2 SOLAS International Convention for Safety of Life at Sea STCW Standards of Training, Certification, and Watchkeeping for Seafarers STW Standards on Training and Watchkeeping VDR voyage data recorder

National Transportation Safety Board M A R I N E Accident Report vi Executive Summary On July 18, 2006, the cruise ship Crown Princess, which had been in service about a month, departed Port Canaveral, Florida, for Brooklyn, New York, its last port on a 10‑day round-trip voyage to the Caribbean. Slightly more than an hour after departing, while on a heading to intersect its track to Brooklyn, the vessel’s automatic steering system began a turn to port. In an effort to counter the effects of a perceived high rate of turn, the second officer, the senior watch officer on the bridge, disengaged the automatic steering mode of the vessel’s integrated navigation system and took manual control of the steering. The second officer turned the wheel first to port and then from port to starboard several times, eventually causing the vessel to heel at a maximum angle of about 24° to starboard. The heeling caused people to be thrown about or struck by unsecured objects, resulting in 14 serious and 284 minor injuries to passengers and crewmembers. The vessel incurred no damage to its structure but sustained considerable damage to unsecured interior components and to cabinets and their contents. The National Transportation Safety Board determines that the probable cause of the Crown Princess accident was the second officer’s incorrect wheel commands, executed first to counter an unanticipated high rate of turn and then to counter the vessel’s heeling. Contributing to the cause of the accident were the captain’s and staff captain’s inappropriate inputs to the vessel’s integrated navigation system while the vessel was traveling at high speed in relatively shallow water, their failure to stabilize the vessel’s heading fluctuations before leaving the bridge, and the inadequate training of crewmembers in the use of integrated navigation systems. The Safety Board’s investigation of the accident identified the following safety issues: Actions of captain, staff captain, and second officer. • Training in use of integrated navigation systems. • Reporting of heeling incidents and accidents. • Emergency response following severe incidents. • As a result of its investigation, the Safety Board makes recommendations to the U.S. Coast Guard, to the Cruise Lines International Association, and to SAM Electronics and Sperry Marine (manufacturers of integrated navigation systems).

National Transportation Safety Board M A R I N E Accident Report 1 Factual Information Accident Narrative At 14061 on July 18, 2006, the Bermuda-registered cruise ship M/V Crown Princess (figure 1), operated by Princess Cruises, departed Port Canaveral, Florida, for Brooklyn, New York, on the last leg of a 10-day round-trip voyage to the Caribbean (figure 2). It was the vessel’s fourth voyage after being christened in Brooklyn on June 14. A total of 4,545 persons were on board—3,285 passengers and 1,260 crewmembers. A Florida state harbor pilot had the conn—that is, was in control of the ship’s movement.2 The ship’s captain, staff captain (second in command on Princess Cruises vessels), relief captain, second officer, two fourth officers, and two helmsmen were also on the bridge.3 According to the captain, the wind was light, the sky was clearing, visibility was good, and the sea state was “slight” as they left Port Canaveral. At 1437, according to the ship’s log, the pilot left the bridge, disembarking soon afterward, and the captain assumed the conn. The captain then began increasing the ship’s speed in increments of 10 propeller revolutions per minute. At 1456, as recorded on the vessel’s VDR,4 the captain told the chief engineer, “We want to go as fast as we can for the time being for the weather.” The staff captain told investigators that the captain was hoping to “get ahead of” a developing storm along the vessel’s route. Around the same time, the captain shifted control of the engines to the engineroom. The chief engineer, now in direct control of the vessel’s propulsion system, continued to increase the ship’s speed. 1  Times in this report are eastern daylight time according to the 24-hour clock. Times on the vessel’s various clocks, logs, and other recording devices (such as onboard cameras) differed. Investigators’ efforts went into determining the time a particular event occurred. The approach was to synchronize all times with those recorded by the vessel’s voyage data recorder (VDR) from a global positioning system (GPS) receiver. VDR time was then converted to local time (eastern daylight time) in the accident area. 2  A Florida-licensed state pilot is required for all foreign-registered vessels in foreign trade and for all vessels over 500 gross tons operating into or out of Port Canaveral, unless specifically exempted by the port director. 3  The Crown Princess was staffed with more than one second officer and more than one fourth officer. The report refers only to those on watch during the accident sequence. One of the fourth officers on the bridge was observing. The relief captain was on board because he was scheduled to relieve the captain at the ship’s next port of call (Brooklyn). See “Personnel Information” section for details about the watch officers. 4  The VDR continuously recorded audio data from the bridge, in addition to collecting data related to the ship’s operation. For more information, see “Voyage Data Recorder” section. VDR data from the Crown Princess are plotted in appendix B. A transcript of the vessel’s VDR audio recording is found in appendix C.

Factual Information National Transportation Safety Board M A R I N E Accident Report 2 From the dock to a point beyond where the pilot disembarked,5 the bridge crew controlled the vessel’s steering manually. At 1501, on orders from the captain, the crew engaged the trackpilot, the autopilot function of the vessel’s integrated navigation system (INS).6 The INS on the Crown Princess was a NACOS (Navigation and Command System) manufactured by SAM Electronics of Hamburg, Germany.7 The crew set the course to 100° in heading mode, one of three available steering modes in the trackpilot.8 According to the ship’s log, the seas were calm and there was a gentle breeze from the northeast. Shortly after the course was set, the captain noticed that the vessel’s heading was fluctuating, and he reviewed the trackpilot settings (table 1). According to the second officer, the course fluctuations were causing “quite an excessive rate of turn.” The second officer said that he asked the captain, “Would you like to go back into hand steering?” and the captain said, “No, I’ve got the conn.”9 5  Pilots ordinarily board and disembark about 1 mile southeast of whistle buoy 3 in Canaveral Harbor (National Oceanic and Atmospheric Administration, National Ocean Service, United States Coast Pilot, vol. 4 [Atlantic Coast: Cape Henry, VA, to Key West, FL], 2004, p. 419). 6  The International Maritime Organization, a specialized agency of the United Nations, defines an INS as follows: “A combination of systems which are interconnected in order to allow centralized access to sensor information or command/control from workstations, with the aim of increasing safe and efficient ship’s management by suitably qualified personnel.” (International Maritime Organization document STW 36/3/1 “Validation of Model Training Courses,” August 12, 2004, p. 27.) See “Integrated Navigation Systems” section for more information. 7  SAM Electronics, formerly STN Atlas Marine Electronics, is a wholly owned subsidiary of L3 Communications Corporation, New York. 8  The other steering modes were course mode and track mode. For details, see “Integrated Navigation Systems” section. 9  The second officer’s statement was made during an investigative interview. Investigators were unable to verify the exchange on the VDR audio recording from the bridge. See “Voyage Data Recorder” section for a discussion of the limitations of the VDR audio recording. The Figure  1.  Crown Princess sailing past the Statue of Liberty as it arrived in New York from the shipyard in Italy. The cruise ship was nearly 1,000 feet long, had 19 decks, and could carry more than 4,000 people. (Photo courtesy Princess Cruises)

Factual Information National Transportation Safety Board M A R I N E Accident Report 3 The Figure  2.  Crown Princess was returning to New York from a Caribbean cruise with ports of call at Grand Turk Island, Ocho Rios, Jamaica, and Grand Cayman Island when it heeled about 10 nautical miles east of Port Canaveral, Florida. Inset shows the ship’s track from Port Canaveral to the accident site. Water in the area was relatively shallow, about 26 feet below the vessel’s keel.

Factual Information National Transportation Safety Board M A R I N E Accident Report 4 Sequence of events while the trackpilot was engaged. Table 1.  Time Event 1501 Crew shifts steering from manual to trackpilot 1503 Captain notices heading fluctuations 1505:06 Trackpilot rudder limit alarm sounds 1505:38 Captain: “We’re wandering all over the place” 1506:09 Captain: “At the moment she is not responding other than 10 degrees at a time” 1506:27 Rudder limit alarm sounds 1507:07 Staff captain increases rudder limit to 10° 1508:00 Rudder limit alarm sounds 1512 Staff captain: “Is it okay now?” Captain: “No” 1513 Staff captain discusses trackpilot settings with captain 1513 New course input to trackpilot, vessel begins turn to port 1514:33 Captain: “Stay in that turn . . . OK, we’ll run like that” 1518:14 Captain to second officer: “Okay, you got the conn” 1522 Heading approaches ordered course of 040°, again begins to fluctuate 1522 Captain and staff captain leave bridge 1523 Relief captain leaves bridge At 1505:06, during the second heading fluctuation, when the rate of turn reached 9° per minute, the trackpilot’s rudder limit alarm sounded.10 According to the operating instructions for the NACOS,11 the rudder limit alarm indicates the following: The set rudder limit value has been reached; with this rudder limit, the maneuver cannot be performed without a deviation, or, the present rudder angle lies outside the rudder limit. Remedy: Increase the rudder limit, • Wait until the rudder angle becomes less than the rudder limit, or • Switch over to manual steering. • 10  The rudder limit was a trackpilot function that the crew could set to limit the extent of rudder movement. 11  SAM Electronics, Operating Instructions: Radarpilot 1100, Chartradar 1100, Conningpilot 1100, item ED 3051 G 032 (revision 2005-01), p. 268. International Electrotechnical Commission standard IEC 60945 requires manufacturers to provide crew operating and service manuals. The NACOS operating manual for crewmembers was 293 pages long, divided into sections for radar functions, automatic identification system, conning displays, trackpilot functions, VDR, alarms, and care and maintenance. Instructions related to the trackpilot covered operational and steering modes, definitions of terms, data displays, and adapting the trackpilot settings to actual states such as weather. A separate, later section included 35 trackpilot alarms in a listing of all alarms to the operator.

Factual Information National Transportation Safety Board M A R I N E Accident Report 5 After the alarm sounded, the captain called the staff captain over and said, “We’re wandering all over the place . . . we put her into NACOS-1.”12 At 1506:09, the captain said, “At the moment she is not responding other than 10 degrees at a time.” At 1506:27, the rudder limit alarm sounded again. The staff captain checked the INS settings. He told investigators that the rudder limit was set at 5°. VDR data show that the vessel’s speed was about 19 knots at the time. About 1507, the staff captain increased the rudder limit from 5° to 10°. The staff captain later explained to investigators: . . . you exceed this alarm of too much [rudder] and with basically 5 degrees [of rudder limit] set, the ship cannot go back on track within a certain time . . . so I intervened with the captain still having the conn and increased the rudder limit up to 10 and . . . we regained the intended heading that he wanted. The staff captain further explained: To increase the rudder limit, it doesn’t really mean . . . that the system will apply ten degrees of rudder. Normally, that gives us more allowance and a little bit more faster response . . . but, of course, it doesn’t mean that by setting the [rudder] limit that the limit is used constantly. The limit is only there if there is a need for using it by the system. . . . Since you are in heading mode, it doesn’t really make a difference because this applies only when you move from heading or course mode down to track mode.13 The staff captain added that he was not aware of guidance from the cruise line or the manufacturer on when to change the rudder limit.14 At 1508, the rudder limit alarm sounded again. At 1513, the vessel began a turn to port to intersect the first plotted track to New York. The course change, from a heading of 100° to a heading of 040°, was executed through several small adjustments to the autopilot’s set heading. The vessel’s speed had now reached 20 knots. The captain directed the second officer: “Stay in that turn . . . OK, we’ll run like that.” The captain then asked the second officer for the heading of the next navigation track. At 1518:14, the captain turned the conn over to the second officer. About 1519, the vessel’s heading again began to fluctuate around the set heading. The captain and staff captain left the bridge at 1522, and the relief captain left about a 12  NACOS-1 was the Princess Cruises term for trackpilot 1. The term is not consistent with the SAM Electronics designations. Its origin was not determined. 13  See “Integrated Navigation Systems” section. 14  General instructions for setting the rudder limit were given in the SAM Electronics Operating Instructions, “Trackpilot Functions,” section 26.2, “Adaptation to Suit the Weather and the Type of Waterway,” as follows: “The rudder limit value should be reduced if a constant course is to be steered for a long time on the open sea or if, for example because of the loading state or other reasons, large angles of the rudder are not permitted. In coastal approaches, the rudder limit value must be suitably increased so that the ship can turn with a small radius or can be controlled at low speed” (p. 208).

Factual Information National Transportation Safety Board M A R I N E Accident Report 6 minute later. The second officer, the two fourth officers, and the two helmsmen (as lookouts) remained on the bridge. About 1523, the vessel reached a turn rate of about 10° per minute to starboard. The turn then shifted to port, and the rate of turn reached nearly 20° per minute. The rate-of-turn indicator (figure 3) displayed red for turns to port, green for turns to starboard. The indicator did not show turn rates beyond 30° per minute in either direction, although a turn rate of any size was displayed digitally next to the indicator. The second officer told investigators that shortly after he took the conn, the rate-of-turn indicator “was a bright color red . . . my eyes were instantly drawn to it.” At 1524, the second officer disengaged the trackpilot and, because he was closer to the wheel than either of the helmsmen, took manual control of the steering.15 The second officer told investigators, “I just saw the rate of turn and instinct took over, I thought . . . we’re going to be swinging to port really fast here and I’ve got to get hand steering . . . [to] try to stop the swinging.” VDR data show that for about 15  The trackpilot was disengaged during the entire accident sequence. Disengaging the trackpilot also disengaged the rudder limit setting and the rudder economy setting (described later in the report). Trackpilot display on the Figure  3.  Crown Princess. The rate-of-turn indicator is at the top, abbreviated ROT. The highest rate of turn displayed in either direction on that indicator was 30° per minute. The digital display on the right above the indicator could show any rate of turn. The rate of turn displayed here is 18.7° to port.

Factual Information National Transportation Safety Board M A R I N E Accident Report 7 a minute after disengaging the trackpilot, the second officer repeatedly turned the wheel back and forth between port and starboard (table 2). VDR data also show that after the second officer disengaged the trackpilot, the speed at which he moved the wheel exceeded the rudders’ ability to respond to his commands.16 Thus, the rudders lagged the wheel inputs. The vessel’s response lagged the steering inputs even farther (see “Vessel Dynamics” section for details). Sequence of events after the second officer disengaged the trackpilot and began steering Table 2.  manually. Wheel commands indicate manual inputs to vessel steering, not the resulting rudder movement. Time Event 1524:05 Second officer disengages trackpilot, switches to manual steering mode 1524:11 Wheel command: port 10° 1524:18 Wheel command: starboard 10° 1524:20 Fourth officer: “Port ten” 1524:21 Second officer: “I know” 1524:22 Fourth officer: “Port ten . . . man you are port ten, you are port ten” 1524:23 Second officer: “Yeah, I am coming over to starboard” 1524:26 Wheel command: port 30° 1524:26 Warning sound (continues for 1 min 49 sec)a 1524:28 Fourth officer: “You are at port ten” 1524:29 Second officer: “Yeah, I am coming over . . .” 1524:36 Warning sounds (last less than 1 sec) 1524:42 Wheel command: starboard 10° ~1524:40-1525b Captain, staff captain, and relief captain return to bridge 1524:43 Relief captain: “Reduce the speed, reduce the speed” 1524:45 Wheel command: starboard 30° 1524:48 Warning sound (continues for 1 min 6 sec)a 1524:49 Wheel command: port 35° 1524:49 Second officer pulls back on throttle, orders 0 revolutions per minute 1524:50 Wheel command: port 45° 1524:59 Wheel command: starboard 5° 1525:00 Wheel command: 0° (midships) 1525:00 Captain: “Stop the engines, stop the engines, stop the engines” 1525:34 Wheel command: starboard 45° 1526:20 All audible warnings stop a Investigators could not determine which device sounded the warning. b The officers arrived back on the bridge over a period of several seconds. Time was estimated from the VDR audio record and interview statements. 16  The Crown Princess was equipped with two rudders. See “Vessel Information” section.

Factual Information National Transportation Safety Board M A R I N E Accident Report 8 The second officer first turned the wheel to port 10°. He told investigators that he had meant to turn to starboard, but instead went to port. He was unable to explain his action. Eight seconds after turning to port, he turned the wheel to starboard 10°. The fourth officer on watch immediately alerted the second officer that the rudders were at port 10°. (Although the second officer had already turned the wheel to starboard, the rudders required several seconds to respond.17) The second officer acknowledged the fourth officer’s statement, saying, “Yeah, I am coming over to starboard,” but he then turned the wheel to port 30°. Several seconds after being reminded, “You are at port ten,” and after again telling the fourth officer that he was “coming over,” the second officer turned the wheel to starboard 10°. The VDR recorded numerous audio alerts around this time, along with the sound of objects falling to the bridge deck. The second officer told investigators, “I’ve never seen a ship lean over that far before.” He further stated, I don’t remember just like moving the wheel around and I can’t say which way I was doing it and how much I was doing it because by then, the ship was leaning over so much that I was just basically trying to do anything that I thought was going to assist in getting the ship upright. The captain, staff captain, and relief captain ran to the bridge, arriving over a period of several seconds. The relief captain, who arrived first, ordered, “Reduce the speed, reduce the speed.” Two seconds later, the second officer turned the wheel to starboard 30°, followed 4 seconds later by a turn to port 35°. The second officer then pulled back on the throttle, ordered zero revolutions per minute,18 and turned the wheel to port 45°. Ten seconds later the captain ordered, “Stop the engines, stop the engines, stop the engines.” By that time, the wheel had been turned to midships and the staff captain had arrived. About 1525, the vessel reached a maximum angle of heel of about 24° to starboard (see “Heel Angle Determination” section). At the same time, the vessel’s rate of turn reached a maximum of 80° per minute. Immediately after the vessel reached its maximum heel, the staff captain turned the wheel hard to starboard. All audible warnings ceased at 1526:20, and the vessel returned to even keel about

1. By then, its speed had slowed to 12 knots.

17  As explained in the “Vessel Information” section, either 14 or 28 seconds were required for the steering gear to move a rudder from hard over in one direction to hard over in the opposite direction, depending on how many rudder pumps were operating. According to the International Convention for Safety of Life at Sea (SOLAS) 1974, as amended, chapter II-1, regulation 29, “Steering Gear,” section 3.2: “The main steering gear and rudder stock shall be capable of putting the rudder over from 35° on one side to 35° on the other side with the ship at its deepest seagoing draught and running ahead at maximum ahead service speed and, under the same conditions, from 35° on either side to 30° on the other side in not more than 28 s [seconds].” The rudders on the Crown Princess moved about 3° per second. 18  As noted earlier, the captain had passed engine control to the engineroom. Because the bridge did not have direct control of the engines when the second officer issued the engine order, the engine speed was not immediately reduced.

Factual Information National Transportation Safety Board M A R I N E Accident Report 9 Princess Cruises, like other cruise lines, employed dedicated observers on both bridge wings19 to monitor the balconies for fire. After the accident, the captain asked the observers whether they had noticed any passengers or crewmembers fall overboard. They told him that they had not. The captain decided against mustering the passengers because of the information from the observers and his sense that the passengers were “in shock” as a result of the accident. Responses to a Safety Board questionnaire, which was sent to most passengers who were evacuated to hospitals and 200 other passengers selected at random,20 describe the passengers’ reactions to the ship’s sudden heeling. Passengers in cabins saw televisions fall from their bases and tables and chairs move rapidly about the cabins, while those in public areas observed similar occurrences for both light and heavy objects. A 54-year-old man who was entering the buffet on the fifteenth deck wrote, They had reset the tables for dinner with wineglasses and china. The ship began to list to the starboard. The glasses and plates began to slide off the tables and I saw my sister-in-law fly off her chair. I fell off my chair, [I] tried [to] grab my wife and slid across the room. My sister-in-law seriously injured her hand and was taken off by ambulance. My son jumped off his bunk bed and hurt his knee. I was scraped and hurt my hamstring. During the accident, water, people, and objects spilled out of the ship’s swimming pools. A 44-year-old woman, who was near one of the pools at the time of the accident, reported: I first realized something was wrong when I felt the boat tilt and it was uncomfortable to stand upright. We (my husband and I) noticed the water slowly coming out of the pool and drinks on tables falling. A second tilt occurred and we moved quickly towards the railing for support, and watched [as] “a small wave” of water, people, and belongings moved out towards the starboard side. The tilting stopped for a few seconds and then a much greater tilt occurred with a “large wave” [spilling] out knocking over people, chairs, tables, and miscellaneous belongings. The captain made several announcements over the vessel’s public address system after the event. Following the first announcement, he asked the senior physician on the vessel about the condition of any injured passengers. She recommended, and he agreed, to return to port to enable those who needed more extensive medical treatment than available on the ship to be taken to hospitals. The Crown Princess returned to Port Canaveral and docked with gangways down at 1836. 19  The bridge wings were enclosed extensions of the bridge on either side. 20  Of the 278 questionnaires that were sent, 117 were completed and returned to the Safety Board.

Factual Information National Transportation Safety Board M A R I N E Accident Report 10 Injuries The type and number of recorded injuries to passengers and crewmembers in the accident are listed in table 3. Princess Cruises provided investigators with the names of 239 passengers who sought medical treatment, along with such information as cabin number, sex, age, date of birth, triage tag number, hospital, and injury description. Many names did not have entries for triage tag number or injury description. Princess Cruises also provided investigators with a list of 57 crewmembers who received injuries during the accident. The injuries were similar to those of the passengers. Injuries sustained in the Table 3.  Crown Princess accident. Injury Type Crew Passengers Total Fatal 0 0 0 Serious 0 14 14 Minor 57 227 284 None 1,203 3,044 4,247 Total 1,260 3,285 4,545

NOTE: Title 49 Code of Federal Regulations (CFR) section 830.2 defines a fatal injury as any injury that results in death within 30 days of an accident. It defines serious injury as that which requires hospitalization for more than 48 hours, commencing within 7 days from the date the injury was received; results in a fracture of any bone (except simple fractures of fingers, toes, or nose); causes severe hemorrhages, nerve, muscle, or tendon damage; involves any internal organ; or involves second- or third- degree burns, or any burns affecting more than 5 percent of the body surface. A 67- year old male passenger on the vessel died 37 days after the accident, according to his death certificate, as a result of sepsis and pneumonia, secondary to metastatic preexisting lung cancer. Listed injuries included sore extremities, minor bruising, scratches, lacerations needing stitches, broken bones, and chest pains. Minor injuries such as scratches and bruises were not recorded. A medically trained passenger who assisted vessel medical personnel in the dining facility, designated as a medical center in the event of a large-scale emergency, estimated that over 125 passengers were treated there. Investigators determined the number of injured passengers based on information provided by Princess Cruises and on records of shoreside hospitals and fire and rescue agencies. The Safety Board obtained 57 medical records of passengers treated at local hospitals, 10 describing injuries considered serious. They included a passenger with a dislocated shoulder, a passenger with muscle tissue lacerations, and passengers with fractures to the ribs, humerus, wrist, or foot. The remaining passengers sustained minor injuries such as contusions, lacerations, sprains, strains, or reported pain. Injuries resulted primarily from people striking objects on the vessel or objects on the vessel striking people. An additional four seriously injured passengers were identified from the passenger questionnaires; no medical records were received for those passengers.

Factual Information National Transportation Safety Board M A R I N E Accident Report 11 Personnel Information General The captain was in command of the Crown Princess. The staff captain reported to the captain, and the senior first officer and the other first officer reported to the staff captain. The senior second officer and other second officers reported to the first officers, and the third and fourth officers reported to the second officers. Captain The captain, a United Kingdom national aged 54 at the time of the accident, joined P&O Cruises21 as a third officer in 1973 after graduating from a British maritime academy, and served on both passenger and cargo vessels. From 1977, he worked exclusively on passenger vessels. The first vessel on which he served as captain was the Island Princess, in 1997. In 1999, he was captain of the Grand Princess, the first of the current generation of large vessels he commanded. He was the first captain of the Crown Princess, from its delivery voyage through the time of the accident. All performance appraisals in his personnel file were positive. According to Princess Cruises records, the captain completed courses in automatic radar plotting aids (ARPA) in September 1985, a 3-day computer chart systems class in July 1997, a 3-day course in the NACOS INS at the SAM Electronics facility in Germany, also in July 1997, and a course in electronic chart display and information systems (ECDIS)22 in November 2001. In addition, he completed a 5-day course in bridge resource management in December 1995. Three nights before the accident, the captain went to sleep at 2100 and arose at 0500. Two nights before the accident, he went to sleep at 2200 and arose at 0600. The night before the accident, he went to sleep at 2200, and he awoke at 0500 the day of the accident. Staff Captain The staff captain, an Italian national aged 43 at the time of the accident, graduated from an Italian maritime academy in 1981. He spent the next 10 years on various cargo vessels, including tankers, bulk carriers, refrigerated cargo vessels, container vessels, and general cargo vessels. He joined Princess Cruises

21  As explained in the “Operational and Management Information” section, P&O Cruises, like Princess Cruises, became a subsidiary of Carnival Corporation. 22  ECDIS is a navigation system that combines electronic navigation information, including vessel position, waterway information, and other critical parameters, into a single navigation display that can be used in lieu of paper navigation charts.

Factual Information National Transportation Safety Board M A R I N E Accident Report 12 in March 1991 as a second officer and had served as a deck officer exclusively on its vessels since. The performance appraisals in his Princess Cruises personnel file were positive. According to Princess Cruises records, the staff captain completed a 5-day course in bridge resource management in January 1995, a course in spoken English,23 and a 4‑day course on the NACOS system at the SAM Electronics facility in Germany in 2002. The staff captain told investigators that he regularly availed himself of opportunities to learn about the NACOS INS: I’ve done some personal training, including the various [INS] set ups on the new ships with . . . electronics technicians. Every time that . . . a new updated version of generation of [INS] systems [was installed], because I’m very keen with electronics, I always tend to have some more updates. So, continually I’ve done three new ships in a row, the Coral Princess, the Diamond Princess, and this is the other one. I think I received probably extra training from SAM Electronics. Three nights before the accident, the staff captain went to sleep at 2200 and awoke at 0600. Two nights before the accident, he went to sleep at 2200 and awoke at 0700. The night before the accident, he went to sleep at midnight and awoke at 0500. Second Officer The 27-year-old second officer, a United Kingdom national, was enrolled in a British maritime institute from 1996 through 2000. While a student, he served as a cadet on Cunard Lines vessels,24 receiving positive appraisals of his performance. In June 2000, on graduating from the institute, he joined Cunard Lines as a third officer and served on passenger vessels through the time of the accident. Performance appraisals in his personnel file were generally positive. After joining Cunard Lines, the second officer alternated between the Queen Elizabeth 2 (QE2), the Vistafjord (later rechristened the Caronia), and various Seabourn vessels.25 He served on the QE2 until April 2006 and then went on leave. On his return to duty in June, he served on the Diamond Princess for 2 ½ weeks, then reported to the Crown Princess on July 7, 2006. He spent 5 days familiarizing himself with the vessel, then assumed the responsibilities of second officer. 23  Princess Cruises required officers who were not native speakers to demonstrate proficiency in the English language. Students had to pass an examination in spoken English to earn a certificate of proficiency after taking this course. 24  The operations of Cunard Lines, which became a subsidiary of Carnival Corporation, were combined with those of Princess Cruises and P&O Cruises, also acquired by Carnival Corporation. See “Operational and Management Information” section. 25  Seabourn was part of the Princess/Cunard/P&O organization.

Factual Information National Transportation Safety Board M A R I N E Accident Report 13 Princess Cruises records indicate that the second officer completed a 5-day bridge resource management course in the United Kingdom in June 2001 and a 3-day course on the NACOS INS in July 2004, in Germany, conducted by SAM Electronics. The first vessel on which the second officer served that had a NACOS INS was the Diamond Princess. However, he told investigators that because the vessel operated almost entirely in Alaskan waters, where manual steering predominated, the INS “wasn’t really utilized” and he did not interact with an INS until joining the Crown Princess. He also said that the QE2 did not have a NACOS.26 In the 3 days before the accident, the second officer was on watch from midnight to 0400 and from noon to 1600. He then slept from 0430 to 1100, except on the day before the accident, when he slept from 0430 to 1000 and from 1730 to midnight. He slept again the morning of the accident from 0430 to 1100. Vessel Information History and Construction The Crown Princess was constructed in Monfalcone, Italy, by Fincantieri Cantieri. The manufacturer conducted sea trials of the vessel in March 2006. The trials included maneuvering tests, inclining (stability) tests, checks of mechanical and electrical systems, and checks of NACOS components. The vessel sailed to Brooklyn, New York, and entered service there in June. The gross tonnage of the Crown Princess was 113,561. The vessel had 19 decks and was 947 feet long, 195 feet high, and had a beam of 159 feet including the bridge wings (the beam was 118 feet without considering the bridge wings). The vessel’s maximum speed was 21.5 knots. Its forward draft on the day of the accident was 8.36 meters (27.4 feet), and its aft draft was 8.76 meters (28.7 feet). Classification and Inspection The Crown Princess was registered in Bermuda. The ship was dual-classed by Lloyd’s Register and Registro Italiano Navale. The Crown Princess was inspected by its flag-state authority, the Bermuda Maritime Administration. Under the control verification system, the U.S. Coast Guard examined the vessel and issued a passenger vessel certificate of compliance.27 26  According to SAM Electronics, the QE2 was retrofitted with a NACOS 35-4 INS in 2004. 27  The Coast Guard’s control verification program was established to monitor the safety of foreign- flag vessels that embark passengers from U.S. ports. Vessels are subjected to initial, annual, and quarterly examinations. A passenger ship control verification certificate is issued on satisfactory completion of the annual examination, which includes tests of emergency systems as well as observation and evaluation of crew actions and of communication dealing with emergency situations (U.S. Coast Guard Office of Marine Safety, Security and Environmental Protection, “Report of the Cruise Ship Safety Review Task Force,” October 31, 1995 ).

Factual Information National Transportation Safety Board M A R I N E Accident Report 14 Propulsion and Steering The Crown Princess was powered by four V-16 and two V-12 Wartsila ZA40S diesel engines that provided power through two 19-megawatt Siemens electric propulsion motors to two fixed-pitch, six-bladed propellers. The two rudders28 were capable of being turned a maximum angle of 45° but were limited to 35°.29 Each rudder had two pumps, only one of which operated while the ship was at sea. With one pump operating, 28 seconds were required for the steering gear to move a rudder from hard over in one direction to hard over in the opposite direction. Half that time, or 14 seconds, was needed with both pumps operating. The port and starboard rudders were synchronized, so that the same rudder order from the bridge control system went to each steering gear unit. The Crown Princess was equipped with a SAM Electronics NACOS 65-5. In the SAM Electronics numbering system, the first two digits refer to the configuration of components in the system, while the third refers to the particular NACOS generation.30 NACOS generation 5 was the most modern NACOS equipment at the time the Crown Princess was launched. The vessel’s steering gear units were controlled through one of two electronic steering control systems on the bridge. The first, a Sperry Marine Navipilot 4000, was a basic heading control system or autopilot. Sperry Marine also supplied the manual steering-control system. The second was the SAM Electronics trackpilot system. A steering mode selector switch was located on the bridge center control console. In general, the trackpilot was used mostly in open waters, with manual steering normally used when arriving to and departing from port or in pilotage waters. Princess Cruises allowed the officer on watch to select the steering mode (see “Operational and Management Information” section). Voyage Data Recorder As required by SOLAS 1974, as amended, the Crown Princess was equipped with a VDR.31 The ship’s VDR, model VER3000 manufactured by Broadgate Ltd., recorded inputs from 9 audio channels, 16 data channels, and a video source (ARPA radar). The recording period was 12 hours, after which the data were recorded over. The data were retained in a hard disk drive that was removed after the accident and taken to the Safety Board’s recorder laboratory in Washington, 28  The rudders were of the compensated spade type. Spade refers to the rudder shape. Compensated means that part of the blade area was forward of the stock or pivot point. 29  After the ship reached 5 knots, the rudders were limited to 35° of motion in either direction by a relay in the steering control. 30  See “Integrated Navigation Systems” section. 31  SOLAS chapter V, regulation 20, requires passenger ships constructed on or after July 1, 2002, to carry VDRs. The VDR on the Crown Princess met the requirements of International Maritime Organization resolution A.861 (20) and International Electrotechnical Commission performance standards for shipboard voyage data recorders, as listed in IEC 61996.

Factual Information National Transportation Safety Board M A R I N E Accident Report 15 DC. A simplified schematic of a representative VDR system architecture is shown in figure 4. The schematic is similar to, but does not match, the architecture of the VDR installed on the Crown Princess. VDR audio data were recorded by eight microphones on or near the ship’s bridge and from transmissions and receptions on channel 16 of the ship’s VHF transceiver.32 Safety Board investigators characterized the quality of the audio recording as “fair.”33 The size of the bridge made it possible for crewmembers to converse too far from any of the microphones for their voices to be recorded accurately. Princess Cruises personnel told investigators that they were researching options available to improve the quality of the recordings, which included seeking the advice of professional audio engineers. 32  Two microphones were in adjacent spaces, two on the bridge wings and four on the bridge itself, in addition to the one that recorded the ship’s VHF radio. 33  According to the Safety Board’s VDR audio data report: “The majority of the crew conversations were intelligible. The transcript that was developed may indicate passages where conversations were unintelligible or fragmented. This type of recording is usually caused by noise that obscures portions of the voice signals or by a minor electrical or mechanical failure of the VDR system that distorts or obscures the audio information.” Generic VDR system architecture Figure  4.  . Among the parameters recorded on the Crown Princess VDR were latitude and longitude, wind speed and direction, rate of turn, heading (magnetic and true), speed (ground and water), rudder (order and position), water depth below keel, engine (command and response), time (hour, minute, second), date (day, month, year), main alarm–hull opening (watertight and fire doors), and radar image. Data were sampled and recorded once per second. The recorded radar video was updated about every 9 seconds.

Factual Information National Transportation Safety Board M A R I N E Accident Report 16 Waterway Information Port Canaveral is located on the Atlantic coast of Florida, approximately 50 miles southeast of Orlando. A dredged entrance channel, 7 nautical miles long and 400 feet wide, runs into the port from the southeast (refer to figure 2). The channel is divided into outer, middle, and inner reaches; cruise ships dock in the inner reach.34 The accident occurred in the open ocean about 10 nautical miles east of Port Canaveral, in U.S. territorial waters. According to the navigation chart for the area,35 water depths near the accident site range from 45 to 62 feet (13.7 to 18.9 meters). The significance of water depth to vessel performance is discussed in the “Shallow Water Effects” section. Meteorological Information The National Weather Service marine forecast for Flagler Beach, Florida, to Cape Canaveral, issued at 0353 on July 18, 2006, read: “. . . variable winds 5 to 10 mph. Seas 2 feet. Intracoastal waters smooth. Scattered showers and thunderstorms.” At 1100 on July 18, the National Hurricane Center issued a tropical storm watch for eastern North Carolina. According to the Hurricane Center’s bulletin, a tropical depression had formed off the coast about 220 miles south-southeast of Cape Hatteras that “could become a tropical storm later today or tonight.” The depression developed into tropical storm Beryl. Toxicological Testing Princess Cruises, in accordance with the requirements of 46 CFR 4.06-1(b),36 directed deck and engineering crewmembers on duty at the time of the accident to provide samples for toxicological analysis. Samples were obtained from the captain, staff captain, relief captain, second officer, fourth officer on watch, relief fourth officer, two helmsmen, and five engineering crewmembers. All samples tested negative for the presence of alcohol and illegal drugs. 34  United States Coast Pilot, vol. 4, pp. 418-420. 35  Ponce de Leon Inlet to Cape Canaveral, chart 11484, Coast Survey, United States–East Coast, Florida (Washington, DC: U.S. Department of Commerce, National Oceanic and Atmospheric Administration, National Ocean Service, 1997). 36  The regulation, which applies to foreign-flag ships operating in U.S. territorial waters, states, in part, “The marine employer shall take all practicable steps to have each individual engaged or employed on board the vessel who is directly involved in the incident chemically tested for [illegal] drug and alcohol use.” Samples are tested for the presence of alcohol, marijuana, opiates, amphetamines, cocaine, and phencyclidine.

Factual Information National Transportation Safety Board M A R I N E Accident Report 17 Crewmember involvement in vessel operations and in the response to the accident precluded testing them for alcohol and drugs immediately afterward. That circumstance is provided for by Coast Guard regulations at 46 CFR 4.06, which require that alcohol tests be conducted within 2 hours of a serious marine incident37 and that drug tests be conducted within 32 hours “unless precluded by safety concerns directly related to the incident.”38 Alcohol testing is not required more than 8 hours after a serious marine incident.39 Officers and crewmembers were breath-tested for the presence of alcohol between 1918 and 1953 on July 18 (4 to 5 hours after the accident). Except for one sample that was collected the morning of July 19, urine samples for drug analysis were collected between 2100 and 2230 the evening of the accident. Thus, all samples were collected within the regulatory time limits. Survival Factors Shipboard Response As required by SOLAS chapter IX, the Crown Princess had written emergency response procedures and regulations in place before the accident. They included checklists and contingency plans for 17 different potential shipboard emergencies, among them collision, fire at sea, man overboard, medical emergency, and oil spill. Princess Cruises fleet regulations instructed that in an emergency, captains were “to maintain an overview of the entire situation” without becoming overly involved in the actual response to the emergency. Captains were to make “such announcements as are necessary to reassure and advise both passengers and ship’s company.”40 Immediately after confirming that the vessel was under control, the Crown Princess captain told passengers, over the vessel’s public address system, to sit down and stay in place. He explained that there had been a steering failure and that he would give them more information shortly. Subsequent announcements included calls to muster the stretcher party and the passenger-assistance party. The 37  A serious marine incident is defined at 46 CFR 4.03-2 as (a) a marine casualty or accident that results in any of the following: (1) one or more deaths, (2) injury that requires medical treatment beyond first aid and renders the individual unfit to perform routine duties, (3) property damage exceeding $100,000, (4) actual or constructive total loss of an inspected vessel, or (5) actual or constructive total loss of any uninspected vessel that exceeds 100 gross tons; (b) discharge of 10,000 or more gallons of oil into U.S. waters; or (c) the release of a reportable substance into the environment of the United States. 38  Title 46 CFR 4.06-3 (a) (1) (i-ii) and (b) (i-ii). 39  Title 46 CFR 4.06-3 (a) (iii). 40  Princess Cruises, Fleet Regulations, Fleet Instructions, Emergency Response, EME 1.2, “Emergency Duties—Captain and Senior Officers.”

Factual Information National Transportation Safety Board M A R I N E Accident Report 18 captain also announced to the passengers that they should return to their cabins. He did not sound the general emergency alarm after the incident, which would have signaled passengers to go to their muster stations. As noted earlier, he asked the observers on the bridge wings whether they had seen anyone fall overboard, and they replied that they had not. Medical facilities on the Crown Princess consisted of a primary medical center and a dining hall available for use as a secondary medical facility. The primary medical center was made up of five wards, or rooms, containing seven beds and various basic first aid supplies, as well as a pharmacy, cardiac equipment, and an x-ray machine. Two physicians and three nurses were on the staff. About 16 crewmembers were billeted to the stretcher party, which was divided into four teams. Both physicians reported that they were in their cabins when the ship began to heel. The senior physician indicated that she suspected that there would be injuries after items in her cabin began falling over. Because the other physician had experienced a similar heeling incident on another Princess Cruises vessel, the Grand Princess, 5 months before the accident,41 he quickly recognized the severity of the event and the potential for injuries. Both physicians went immediately to the medical center. They were joined by passengers with medical training, who provided medical assistance under the supervision of the ship’s physicians. The most seriously injured patients remained inside the vessel’s medical center to enable medical personnel to monitor them. Passengers with less serious injuries were asked to wait in the area outside the medical center, and chairs were brought for them. A third area was set up in a dining room for those with minor injuries such as scratches or bruises. Two emergency medical technicians were put in charge of injured passengers in the dining room. The ship’s nurses assisted in the medical center and also accompanied stretcher parties to assist injured passengers throughout the vessel. Several passengers with medical training offered to help, and they assisted in the shipboard response. Shoreside Response About 1600, the Brevard County, Florida, sheriff’s office learned of the accident from the ship’s agent. The sheriff’s office contacted the fire chief at Canaveral Fire Rescue to advise him of the situation and to inform him of the need to transport between 20 and 50 injured people to hospitals. The fire chief activated the rescue service’s mass casualty plan and departed for the cruise terminal.42 Triage and transport vehicles were in place before the Crown Princess arrived. 41  On February 4, 2006, the Grand Princess returned to the port of Galveston, Texas, after a passenger suffered a medical emergency. During the return, the vessel heeled an estimated 12° to 15°, injuring two crewmembers and one passenger. Neither the Coast Guard, the Safety Board, nor the flag state investigated the accident. Princess Cruises attributed the accident to poor communications and poor bridge resource management among the bridge crew. 42  Canaveral Fire Rescue participates in a mass casualty drill once a year in Melbourne, Florida.

Factual Information National Transportation Safety Board M A R I N E Accident Report 19 Coast Guard Station Port Canaveral received initial notification of the accident from a passenger on the Crown Princess at 1550. Coast Guard personnel in Port Canaveral established direct communication with the vessel, via VHF radio, around 1600. The master reported a steering casualty that caused the vessel to abruptly turn, resulting in injuries to several persons on board. Station Port Canaveral briefed Coast Guard Sector Jacksonville, which contacted Princess Cruises management. Company management informed Sector Jacksonville that the vessel planned to return to port. The Coast Guard Captain of the Port (COTP) later issued a verbal order denying entry to the vessel until a Coast Guard marine inspector could board and verify that the steering gear was functional. At 1710, a Coast Guard 47-foot patrol boat departed Station Port Canaveral with two Canaveral Fire Rescue officers and two Coast Guard marine inspectors on board to meet the Crown Princess while it was returning to Port Canaveral. They boarded the vessel at 1733. The marine inspectors observed a satisfactory basic steering gear test, which was completed at 1743, and conveyed the information to the COTP. About 1800, as the vessel continued its return to port, the COTP rescinded his order, and the vessel was allowed to enter the port. The vessel continued its return to Port Canaveral and lost no time en route as a result of these Coast Guard actions. After the vessel docked at 1836, helicopters airlifted two seriously injured people to hospitals. Ambulances then transported 101 people—93 passengers and 8 crewmembers—to local hospitals, four in the Cocoa Beach/Melbourne area, one in Orlando, and one in Daytona Beach. A total of 97 fire, rescue, and ambulance department personnel from 10 different agencies, with 9 fire engines, 21 ambulances, and 2 helicopters, responded to the accident, all under the command of the Cape Canaveral Volunteer Fire Department chief, who served as the incident commander. Tests and Research Postaccident Steering Tests On July 20, after the passengers had disembarked and the crew had inspected the vessel and its critical components, the Crown Princess departed Port Canaveral for New York. An authorized SAM Electronics technician boarded the vessel at Port Canaveral to test the vessel’s NACOS system, with Safety Board investigators, Coast Guard representatives, and a Lloyd’s Register surveyor on board to supervise the tests. A representative of Bermuda, the vessel’s flag state, joined the group on board. Before the vessel sailed, the technician performed a comprehensive steering gear test and found that it operated within acceptable limits. During the sailing,

Factual Information National Transportation Safety Board M A R I N E Accident Report 20 the crew activated the NACOS trackpilot, with course changes completed in both heading and course modes. At the captain’s direction, the vessel was kept below full speed until it reached the open ocean (July 21). Other vessel conditions during the test were similar to those at the time of the accident, except that no passengers or their baggage were on board and the swimming pools were empty. Data from the vessel’s trackpilot showed that the system performed as designed in all test phases. The Crown Princess reached New York on July 21. At the Safety Board’s request, SAM Electronics reviewed the short-term voyage recording in the NACOS for evidence of a system malfunction. After the review, company personnel stated, “No malfunction of the Trackpilot could be found in the recording.”43 The company concluded that an improper rudder economy setting44 and rudder limit setting “can lead to a nonproper function of steering in Heading mode for this ship’s speed of 18 to 20 knots together with the measured water depth.” The company further concluded, “It must be assumed that the squat effect influenced the steering ability of the ship. The rudder gain setting by the crew for the Trackpilot (Rudder Economy = 5 is a tolerant value) has been too low for [these] conditions.” (See “Shallow Water Effects” section for more information.) Heel Angle Determination As a result of limitations in the onboard Siemens integrated monitoring, alarm, and control (IMAC) system sensor, only heeling values from starboard 15° to port 15° were measured. The vessel’s VDR did not record heeling data, nor was it required to do so. The IMAC retained the heeling data, which were retrieved by Safety Board investigators after the accident. Because of the likelihood that the vessel’s maximum heel angle exceeded the limits of the IMAC data, Safety Board investigators sought other information for determining the maximum angle. Princess Cruises provided the Safety Board with images taken at regular intervals by videocameras positioned at various locations on the ship. One set of images was taken every 2 to 3 seconds by a camera on the vessel’s port side. The date and time were stamped on each image.45 Investigators determined that images recorded during and after the event, from July 18 at 1113:38 through July 19 at 0814:00, were of interest in determining maximum heel angles at specific times during and after the event. Safety Board investigators digitized part of the video to a computer-based video system so they could review and extract still images. The investigators then 43  The response from SAM Electronics was dated September 6, 2006. 44  The rudder economy setting allowed operators to enter one of 10 levels of weather/sea state conditions, with corresponding increases or decreases in rudder movement limits. See “Integrated Navigation Systems” section for details. 45  The basis of the time stamped on the images is unknown but is consistent with Central European time, offset by 1 hour for daylight saving time.

Factual Information National Transportation Safety Board M A R I N E Accident Report 21 used two methods to determine the maximum angle of vessel heel from the images taken by the shipboard camera. One method was to measure the angle formed by the apparent horizon in an image and the vertical axis of the vessel, taking into account the distortion created by the camera lens (figure 5). The other method was to measure the difference between the angle of the shadow created by the vessel on a reference point on the images and the angle that would have been created by the ship’s orientation to the sun at that time, given the sun’s angle over the horizon and the ship’s orientation. Investigators obtained the sun’s angle from U.S. Naval Observatory data and the ship’s orientation to the sun from VDR data. The maximum angle of heel calculated from the shadow images was 24.2° to starboard at 1524:57 (figure 6).46

46  The ship’s VDR clock time was different from the time stamped on the videocamera image. To synchronize the times, investigators assumed that the ship reached its peak heel angle at VDR time 1524:57, halfway between the first and last 15° angles recorded by the vessel’s heel sensor. Image of the Figure  5.  Crown Princess taken by a ship’s videocamera at the maximum angle of heel, with reference lines added by investigators. Stamped time corresponds to 1525:02 eastern daylight time. The apparent bending of the horizon is an artifact of the wide-angle camera lens, which causes straight lines to appear curved and bow outward from the image center.

Factual Information National Transportation Safety Board M A R I N E Accident Report 22 Stability Considerations At the Safety Board’s request, the Coast Guard reviewed the stability conditions of the vessel relative to applicable standards of the International Maritime Organization. The Coast Guard found that the ship complied with all International Maritime Organization intact stability47 requirements for passenger ships at the time of the accident.48 The Coast Guard’s report found that the maximum righting arm49 occurred around 32°.50 47  Intact stability is a naval architecture term referring to how an intact, or undamaged, vessel responds when heeled over. 48  Code on Intact Stability for All Types of Ships Covered by IMO Instruments (London: International Maritime Organization, 2002), chapter 3. 49  The concept of the “righting arm” relates to a vessel’s ability to restore itself to an upright position. When a vessel heels, both its center of gravity and its center of buoyancy shift to the side, but the center of buoyancy shifts faster. The horizontal difference, known as the righting arm, creates an imbalance that makes the vessel tend to right itself. The righting arm increases as the heel angle increases, but only to a point—the “angle of maximum righting arm.” When the heel angle increases beyond that point, the righting arm will decrease. When it reaches zero, the vessel will continue to heel until it capsizes. 50  Details of the Coast Guard stability review are found in Coast Guard Marine Safety Center Memorandum, Serial H2-0603148, November 24, 2006. Calculated and recorded heel angles of the Figure  6.  Crown Princess. The maximum heel angle calculated from shadow images was 24.2°; that calculated from the apparent horizon line was slightly less (23.4° to 23.5°).

Factual Information National Transportation Safety Board M A R I N E Accident Report 23 Vessel Dynamics Safety Board investigators studied the vessel dynamics both before and after the second officer took manual control of the steering. The investigators used VDR data from about 5 seconds before the trackpilot was disengaged until about 15 seconds after the commanded rudder oscillations ceased. Figure 7 plots the second officer’s wheel (rudder) commands against the rudder response and the heeling angle. The data show that after the second officer disengaged the trackpilot at 1524:05, the vessel’s rudder positions corresponded to the rudder commands for about 10 seconds. Then, at 1524:15, the rudder positions began to deviate from the wheel input as the rudders lagged the wheel commands.51 The deviation lasted until shortly after the rudders were commanded to midships (1525), after which the vessel gradually returned to even keel. The vessel’s response lagged both the rudder commands and the rudder positions. From 1524:30 to 1525:10, while the rudders remained at port, the vessel’s heading diverged from its direction of motion. That difference is known as the drift angle. The greater the drift angle and the greater the speed, the greater the resultant heel angle. The vessel’s maximum heel occurred about 1524:57, as shown by the red line in figure 7. 51  Lag results when the rate of wheel inputs exceeds the rudder response rate, which for the Crown Princess was 3° per second. After the second officer began steering the vessel manually, he turned the Figure  7.  wheel faster than the rudders could follow, as shown by the divergence between the rudder commands (light blue line) and the rudder responses (dark blue line). As the vessel attempted to respond to the commands, it heeled increasingly to starboard (red line).

Factual Information National Transportation Safety Board M A R I N E Accident Report 24 Shallow Water Effects As shown in figure 8, the water depth was about 5 meters (about 16 feet) below the keel of the Crown Princess during the first part of the trip, gradually increasing to 8.3 meters (27.2 feet) at 1524, when the second officer assumed the conn, and reaching 10.7 meters (35.1 feet) at the end of the accident sequence. When a vessel moves through shallow water, it experiences a complex hydrodynamic phenomenon that affects both its clearance above the waterway floor, known as squat, and its steering precision. As a vessel’s speed increases, the water level around the hull is lowered, because as water moves under the hull, the velocity and kinetic energy of the water increase. To compensate for the increase in kinetic energy, the potential energy (energy of a system derived from elevation rather than motion) must reduce, because the total energy of a system must remain constant. The reduction in potential energy is achieved through the lowering of the water level around the hull. Squat is approximately proportional to the ship’s speed squared; hence, halving the speed reduces the squat effect by a factor of four.52 52  Navigation and Vessel Inspection Circular No. 2-97, change 1, COMDTPUB P16700.4; Ch-1 (accessed May 3, 2007). Underkeel clearance of the Figure  8.  Crown Princess during the accident sequence, from data recorded by the vessel’s VDR.

Factual Information National Transportation Safety Board M A R I N E Accident Report 25 The greater a vessel’s speed in shallow water, the less predictable its steering.53 That holds true whether the vessel is steered automatically or manually. Test trials performed on model ships in tanks show that turning radius increases exponentially with a reduction in water depth under the keel. Some trials show that a ship’s turning diameter increases 60 to 100 percent at a water depth of 1.25 times ship’s draft.54 A ship’s draft of 8.5 meters (27.9 feet) and an underkeel clearance of 8 meters (26.3 feet) equals a water depth of 16.5 meters (54.1 feet), giving a ratio of water depth to ship’s draft of about 2:1 and meeting the general definition of shallow water.55 Princess Cruises informed its crewmembers about squat effects in its fleet regulations and deck standing orders:56 …The effects of squat can have an adverse affect on the ship’s handling characteristics, and these must be borne in mind when in confined waters: The vessel’s stopping distance and turning circle is increased. • The propellers and rudder become less effective. • The company also posted information about squat effects on the bridge of the Crown Princess (table 4). Information about squat effects posted on the Table 4.  Crown Princess bridge. Draft Increase (Loaded) Underkeel Clearance Ship’s Speed (knots) Estimated Maximum Squat (meters) 4 meters 24 3.48 14 1.18 4 0.01 8 meters 24 3.0 4 0.08 NOTE: The notice posted on the bridge also included other information. 53  A. J. Jurgens. and A. D. Jager, “Controllability at Too High Speeds in Too Shallow Water,” Proceedings of MARSIM 2006 (International Conference on Marine Simulation and Ship Manoeuvrability), Terschelling, The Netherlands, 2006. 54  Edward V. Lewis (ed.), Principles of Naval Architecture, vol. 3, Motions in Waves and Controllability (Jersey City, New Jersey: Society of Naval Architects and Marine Engineers, 1989), pp. 280-281. 55  Princess Cruises defined shallow water as “depths less than twice [vessel] draught” (NAV.7, Fleet Regulations and Standing Orders). Other sources define shallow water as either two or three times ship’s draft. Principles of Naval Architecture (vol. 3, p. 279) defines shallow water as a water-depth-to-ship’s-draft ratio of 3 or less. 56  Princess Cruises, Fleet Regulations, Deck Standing Orders, Navigation, NAV 7.10, “Squat.”

Factual Information National Transportation Safety Board M A R I N E Accident Report 26 After the Crown Princess accident, SAM Electronics commissioned a university to determine the effect of shallow water and high vessel speed on the maneuvering characteristics of a large vessel. The study found that in water depths of about 6.8 meters (22.3 feet) below the keel, the yaw-checking ability of a vessel the size of the Crown Princess will be “significantly reduced,” and the INS’s ability to control the vessel steering will be reduced as well. The author concluded:57 . . . Our analysis could show that due to the large beam of the vessel, a steady heel results in a large alteration of the hydrodynamic blockage which then results in a large impact on squat as such. A secondary yawing moment is generated due to the steady heel which forces the vessel into a turning circle exactly to the side of the heel. If the heel is initiated by an initial turning motion, then the secondary heeling moment will clearly amplify this turning motion, which can then only be compensated by more rudder action. . . . As the rudder action required to yaw check the first turning must result in a large rudder moment, all this results in a hunting where the amplitude of that hunting gradually increases. . . . According to our analysis, the only way to control the hunting is to keep the yawing instability of the ship under a certain limit, which must also reduce the squat effect. . . . As the auto pilot sees a completely different system compared to its deep water design characteristics, there is according to our results no possibility for the autopilot to cope with such kind of situation. After receiving information from its customers and the university study, SAM Electronics made several changes to its NACOS equipment (the updates are available as an option to vessel owners and only on generation 5 NACOS) as well as to its training material and operating manual: The NACOS autopilot will operate normally until the ratio of water • depth to ship’s speed reaches a theoretical threshold at which shallow water effects become apparent (based on the formula d < 0.085v2, where d = depth in meters, v = speed in knots). At that point, the operator hears a warning sound. If the water-depth-to-speed ratio goes lower (based on the formula d < 0.065v2), a second alarm alerts the operator that the ship has entered the critical squat range, below which limit, according to the university study, the ship’s maneuverability changes significantly.58 The alarm points are set based on vessel-specific information. Both alarms 57  S. Kruger, “Determination of the Squat Effect on the Course-Keeping Ability of a Large Cruise Liner” (Hamburg: Technische Universität Hamburg-Harburg, Institut für Entwerfen von Schiffen und Schiffssicherheit, 2007), p. 3. 58  The coefficients 0.085 and 0.065 are based on theoretical computations. For the value 0.085, the university study stated that it is well known that shallow water influence can be found if the wavelength of the ship’s own wave system is greater than two times the water depth. This results in a relation between water depth (d) and ship’s speed (v) of d = 0.085v2, when ship’s speed is in knots. The value 0.065 comes from theoretical computations for a hull form equivalent to that of the Crown Princess. The influence of shallow water was found to be significant for depths equal to or below 0.065v2.

Factual Information National Transportation Safety Board M A R I N E Accident Report 27 can be activated and deactivated independently. They are activated only if the trackpilot is engaged and the limit values persist for a defined period. A “low rudder limit” alarm sounds if the rudder limit is set so low that • the next turn in track mode cannot be executed with the preplanned turn radius. In addition, a “high rudder limit” alarm operates using a new parameter called “maximum allowed rate of turn,” which is used to calculate an upper limit for the rudder limit set by the operator. Its value is determined by the ship’s turning ability and its speed. Information on shallow water and high-speed effects (such as squat) on • vessel maneuverability was added to the NACOS training curriculum and the NACOS operating instructions. The following warning about the squat effect was added to the operating instructions:59 Shallow water may effect [sic] the dynamics and manoeuvrability of a vessel. Shallow water is considered to be a depth of less than 2.5 times the draught of the vessel. If sailing with high speed in shallow water the draught of the ship may increase considerably caused by the squat effect. The squat effect increases with higher speed and lower water depth. These effects may change the designated steering behavior of the ship in a material manner. Previously set parameters for the TRACKPILOT ability to steer the ship will no longer match with that ship behavior. After the accident, as noted earlier, an authorized SAM Electronics technician tested the vessel’s NACOS INS. He also prepared a one-page guidance document on the trackpilot for Princess Cruises bridge crews. The document listed the trackpilot parameters and summarized the control given by the various rudder economy settings, as well as the weather conditions under which they should be used. The rudder limit definition from the operating manual was also reproduced, with the following comments and recommendations: The rudder limit setting is a parameter that must be manually adjusted depending on the vessel’s speed and sea conditions. At high sea speeds a small rudder angle should be entered, i.e. 5 degrees. At slower speeds, when more rudder angle is required to perform a turn (required rate of turn not attainable with the smaller limit) a larger rudder limit should be utilized, i.e. 15 degrees. Acknowledgment of the [rudder limit] alarm silences the buzzer only, but continues the rudder limitation. 59  SAM Electronics, Operating Instructions, section 36.1.

Factual Information National Transportation Safety Board M A R I N E Accident Report 28 Operational and Management Information Corporate Organization Princess Cruises, founded in 1965, became a subsidiary of the Carnival Corporation in 2003.60 In fall 2004, after acquiring Cunard Cruise Lines, Carnival Corporation merged the fleet operations of Cunard Lines and P&O Cruises of Australia with those of Princess Cruises.61 At the time of the accident, Princess Cruises, Cunard, and P&O Cruises operated under a single management structure, while retaining separate brand identities. Princess Cruises considered deck officers to be interchangeable on the vessels of the three companies. Crewmembers on Princess Cruises, Cunard, and P&O ultimately reported to the vessel captains, while the captains reported to the Princess Cruises fleet captain, marine operations. The fleet captain and senior vice president, fleet operations, reported to the executive vice president, fleet operations. The executive vice president reported to the chief executive officer of Princess Cruises. The chief executive officer of the three cruise lines was a director of Carnival Corporation & PLC and reported to the vice chairman and chairman of the board of the corporation. Personnel at both Princess Cruises and Holland America Line, another Carnival Corporation subsidiary, indicated that the corporation allowed the individual cruise line subsidiaries latitude in overseeing vessel operations. That latitude extended to personnel selection, training, safety management systems, and vessel design and acquisition. Princess Cruises Operations Fleet Oversight. Princess Cruises management personnel told Safety Board investigators that they had known the fleet captains for many years and were familiar with both their strengths and their weaknesses. Management personnel regularly visited the vessels to observe vessel operations. All ship’s officers met with their superiors at the midpoints and ends of their assignments to review and discuss their performance. The performance appraisals were then sent to the senior vice president, marine operations, and finally to the fleet captain. 60  See Princess Cruises website (accessed December 10, 2007). 61  The corporate website states: “Carnival Corporation & plc is a global cruise company and one of the largest vacation companies in the world. Our portfolio of leading cruise brands includes Carnival Cruise Lines, Holland America Line, Princess Cruises and Seabourn Cruise Line in North America; P&O Cruises, Cunard Line and Ocean Village in the United Kingdom; AIDA in Germany; Costa Cruises in southern Europe; and P&O Cruises in Australia” http://phx.corporate-ir.net/phoenix.zhtml?c=200767&p=irol-prlanding (accessed October 10, 2007).

Factual Information National Transportation Safety Board M A R I N E Accident Report 29 The fleet captain, marine operations, oversaw a staff of two marine inspectors who visited each vessel at least once a year to observe operations and ensure compliance with procedures. The inspectors operated independently of the auditors that the company dispatched as part of its required internal safety management system audits. The inspectors reported their findings to the vessel captains, with suggestions for improvement, if necessary, as well as to Princess Cruises management. The company began the program because the demands of overseeing its growing fleet prevented senior management from visiting the vessels as often as they would have liked. Princess Cruises also read out VDR data and listened to VDR conversations after all incidents of concern to the company. Management personnel estimated that in the 3‑year period before the accident, they had read out and listened to about 12 VDRs. Watchkeeping Policies and Procedures. Princess Cruises watchkeepers had the discretion to steer using an automated INS mode or manually, within the standards that the vessel captains established in their standing orders. Deck standing order NAV.7.14 of the company’s fleet regulations62 advised crewmembers to use the INS because “it ensures [that the] maximum information is available to officers.” However, it advised crewmembers not to rely exclusively on the INS for navigation information but to verify the information against chart and other navigational information. As the order stated, “The Integrated Bridge System is not a substitute for maintaining a safe navigational watch.”63 Standing order NAV.7.14 attached the following provisos to the selection of the trackpilot’s operational mode: Operation in Heading Mode should be selected when a steady heading is required, particularly when in close proximity to other vessels. If a close- quarters situation is developing, then Heading Mode should be selected in preference to Course or Track Mode. Operation in Course Mode may be appropriate when necessary to deviate from the System Track when a set CMG [“course made good,” that is, course over the ground] is desirable. Operation in Track Mode may be used provided the System Track and/or Electronic Chart positioning has been confirmed as reliable and traffic conditions permit. Particular attention shall be paid to Position and Speed Sensor status, as well as the Horizontal Chart Datum in use prior to selection. 62  Princess Cruises, Fleet Regulations, Deck Standing Orders, Navigation NAV.7.14, “Integrated Bridge Systems (IBS),” reissued May 2002. 63  Princess Cruises referred to its INS as an integrated bridge system (IBS). Until recently, the terms IBS and INS were used interchangeably. However, International Maritime Organization regulations now distinguish between them. An INS is considered to be a component of an IBS, which includes other components such as communications, security, and cargo control.

Factual Information National Transportation Safety Board M A R I N E Accident Report 30 The standing order directed second officers and deck officers of higher rank on ships having integrated bridge systems to complete “an appropriate training course” before being permitted sole charge of the watch while at sea. In addition, Princess Cruises advised its watchkeeping officers to “be familiar with [the system’s] alarm messages, their meaning, and the action to take on their activation.” Postaccident Actions. Within days of the Crown Princess accident, Princess Cruises issued a letter to its deck officers instructing them not to use the NACOS trackpilot or speed pilot systems on their ships until they were satisfied that all watchkeeping officers fully understood the “correct and safe operation” of the equipment. Watchkeeping officers were also instructed to reread the NACOS instruction literature. Over the next several months, additional instructions were issued regarding the use of checklists for transferring the conn, for assuring deck officers’ familiarity with bridge procedures and emergency equipment, and for engaging or disengaging automated steering. The cruise line also cautioned officers about the effects of shallow water on steering, reminding them to be especially careful about using the trackpilot in shallow water “at higher speeds.” In a fleet regulation reissued in May 2007,64 captains were informed that “. . . good seamanship would require that following a departure from a port anchorage either they or their designee (staff captain) should remain on the Bridge until satisfied that the ship and the Bridge Watch are settled.” The cruise line informed the Safety Board that it had increased the complement of its bridge crew by adding a third officer. In addition, the company said that it was undertaking a trial period on nine of its vessels in which the first officers would divide the 0400-to-0800 and 1600-to-2000 watches, to create increased flexibility in the oversight by first officers of new officers during “demanding times on their watches.” In a fleet regulation reissued in September 2007,65 Princess Cruises required the reporting of marine casualties “wherever they occur” to the flag state. The regulation stated: “. . . if the casualty occurs outside U.S. territorial waters but the ship is bound directly to a U.S. port, then a report must be made to the [Coast Guard].” In a related regulation,66 the cruise line required the immediate notification of its corporate offices if any on a list of 13 incidents occurred, to include “any incident causing the vessel to heel more than 5 degrees.” Princess Cruises managers told the Safety Board that after the accident, they established a professional marine standards department to enhance the standards, protocols, and procedures of their operations, and to develop a program of human 64  Princess Cruises, Fleet Regulations, Deck Standing Orders, Bridge Procedures BRP.3.1, “Company Navigation Orders,” reissued May 2007. 65  Princess Cruises, Fleet Regulations, Fleet Instructions, Legal and Documentation LEG.7.2, “Marine Casualties,” reissued September 2007. 66  Princess Cruises, Fleet Regulations, Fleet Instructions, Communications COM.2.2, “Incident Reporting to Shore Management,” reissued September 2007.

Factual Information National Transportation Safety Board M A R I N E Accident Report 31 element understanding. No additional information was provided regarding the composition of the department, its location in the Princess Cruises management hierarchy, or the manner in which the department would carry out its duties. Princess Cruises also sent its SAM Electronics–certified NACOS trainer to its vessels to conduct 3-hour on-site training sessions in the use of the NACOS INS. The training was intended to serve as both refresher training for those who had previously completed a NACOS course and initial training for those who had not. In addition, the cruise line informed the Safety Board that it had employed an inhouse bridge team equipment trainer, approved by SAM Electronics to conduct NACOS training. The individual was to give bridge personnel one-to-one instruction on their NACOS equipment during 3-day visits to their vessels. Princess Cruises also required all captains to attend a 5-day bridge resource management course, irrespective of the year in which they had first completed such training. Princess Cruises managers indicated that they were revising a course for deck officers that would include practicing emergency scenarios in a full 360° bridge simulator, using a variety of scenarios. Princess Cruises also implemented the use of a new technological aid for accounting for passengers after a mishap, in addition to developing new procedures for responding to mishaps both on vessels and at its corporate offices and for reporting mass casualty incidents to authorities. The cruise line indicated that it recommended that user-friendly guidance from operations manuals specific to vessel bridge equipment be developed and placed in a readily accessible location on vessel bridges. Additional Information Heeling Incidents on Cruise Vessels Previous Occurrences. As part of the investigation of the Crown Princess accident, Safety Board investigators interviewed representatives of other cruise lines based in the United States67 regarding heeling incidents on their vessels in the 15 years before the accident. To focus on more severe episodes, investigators defined a heeling incident as an unexpected and unplanned heeling of a vessel during a turn, reaching an angle equal to or greater than 6°. Cruise lines that provided heeling incident data to the Safety Board maintained different record- keeping systems with varying definitions of heeling incidents and accidents, and employed different investigation procedures. 67  Norwegian Cruise Lines, Holland America Line, and Royal Caribbean/Celebrity cooperated with the Safety Board’s investigation, in addition to Princess Cruises, which, at the Safety Board’s request, voluntarily submitted internal information on heeling incidents and accidents that had not been investigated by government agencies.

Factual Information National Transportation Safety Board M A R I N E Accident Report 32 Most of the incidents were not required to be reported to a government agency because of their location or the scope of the event, and therefore most were not investigated by such agencies. The cruise lines themselves supplied most of the data on incidents. Because the intent of the Safety Board’s review was to determine whether commonalities were present among operator errors in the use of INSs, incidents not involving INS use, such as collision-avoidance maneuvers, were not considered. Safety Board investigators reviewed information on 13 accidents and incidents involving large passenger cruise vessels (those carrying more than 1,000 passengers) equipped with an INS. Five cases were found in which the incident arose exclusively from a technical malfunction in either the vessel’s steering system or its INS. In a 1994 incident, a vessel turned sharply to port after the second officer shifted vessel steering control from heading mode to track mode in the vessel’s INS. The cruise line investigated the incident, which occurred outside U.S. territorial waters. The bridge officer on watch was unaware of a requirement that, before making the shift between the two modes, the ship had to be within 5° of the proposed course heading. The proposed track heading diverged 24° from the proposed heading, and with the rudder limit having been increased from 5° to 10°, the vessel turned sharply to the proposed heading. Thirteen passengers and crew received minor injuries in the incident. The cruise line determined that the operating manual did not provide guidance on this type of situation, and that it had no policy to train deck officers in using the INS. It later revised its own INS operating procedures and training standards to address those issues. In a 1999 incident, a passenger vessel turned sharply to starboard when a watchkeeper engaged the INS after manually steering the vessel. The cruise line, which investigated the incident, determined that the watchkeeper had entered an incorrect rudder limit, one that was considerably beyond the maximum rudder limit that the vessel permitted. However, the INS accepted it and then attempted to turn the vessel sharply. Further examination revealed a fault in the system that was subsequently corrected. In 2001, a passenger vessel turned sharply and heeled, injuring 28 passengers and crew. The Coast Guard, which investigated the incident, found that a watchkeeper had entered a heading into the INS that was 180° different from the desired course. The vessel turned sharply to the “new” course. The Coast Guard initially restricted the vessel’s use of the INS until the reason for the failure could be determined. Subsequent investigation found no fault in the system and no reason for the erroneous entry. The cruise line revised its INS policies, reducing the maximum allowable rudder limit from 20° to 5°. In addition, the Coast Guard and the International Council of Cruise Lines (ICCL) prepared and distributed a safety alert on the importance of securing equipment for rough seas, and on the need to develop policies and training programs to ensure the proper use of autopilot systems.

Factual Information National Transportation Safety Board M A R I N E Accident Report 33 Seven months later, a different vessel of the same cruise line heeled to an estimated 6° to 7°, slightly injuring one passenger. The Coast Guard, which did not investigate the incident, worked with the cruise line to obtain and examine data from the event. Coast Guard correspondence indicates that it was satisfied that the changes regarding training and INS use that the cruise line had implemented in response to the heeling event 6 months earlier had addressed the deficiencies identified in both events. In 2005, a cruise vessel with a pilot on the bridge turned sharply after the helmsman implemented a pilot-requested course change through the INS, and the vessel turned beyond the selected heading. The vessel heeled to 6°, but no one on board was injured. The cruise line, which investigated the incident, attributed it to the deck officer’s incorrect method of entering the new course into the vessel’s INS, which allowed the autopilot to exceed the set rate of turn. Monitoring and Reporting. There is no Coast Guard or International Maritime Organization requirement for cruise lines to report heeling incidents that do not meet accident-reporting criteria to either INS manufacturers or government agencies, although steering and propulsion failures must be reported. Sperry Marine and SAM Electronics representatives told investigators that they learned about INS-related heeling incidents from the news media, local technical representatives, or directly from their customers. Both companies indicated that, when informed of a heeling incident or accident, their primary concern was to identify system malfunctions rather than operator errors. Sperry Marine indicated that the only formal investigation it conducted of an accident involving a vessel supplied with its system was the one involving the Exxon Valdez.68 SAM Electronics’s response to an incident or accident was dictated by a formal mechanism it had developed and implemented. The vessel, type of equipment on board, and the nature of the involvement of its product in the perceived cause of the incident determined the company’s response. If it was determined that its product was not causal to the incident, no further action was taken, other than reporting the information to its corporate parent. If it was determined that its product played a role in the cause of the incident, SAM Electronics would designate an individual to direct internal and external activities in response. SAM Electronics personnel were also assigned to analyze the data and propose product modifications, as needed. SAM Electronics maintained a record of steering-related incidents and accidents involving vessels equipped with NACOS equipment. Its record contained 12 incidents and accidents, from 1995 to the Crown Princess accident. One incident involved a 1995 grounding, one a 1996 incident of uncertain type, and one a heeling incident that resulted from an avoidance maneuver. Two involved cargo vessels 68  National Transportation Safety Board, Grounding of U.S. Tankship Exxon Valdez on Bligh Reef, Prince William Sound Near Valdez, Alaska, March 24, 1989, Marine Accident Report NTSB/MAR-90/04 (Washington, DC: NTSB, 1990).

Factual Information National Transportation Safety Board M A R I N E Accident Report 34 that experienced faults in NACOS components, and one involved a 2004 incident of uncertain type. The Safety Board obtained information on 13 steering-related incidents, as well as a list of 23 minor incidents provided by a cruise line. Nine of the incidents in the Board’s records were on SAM Electronics’s list. Integrated Navigation Systems Design. INS equipment is approved by government test and approval agencies on the basis of the standards and guidelines established by the International Maritime Organization and the performance and testing standards set forth by the International Electrotechnical Commission.69 Manufacturers design the systems to conform to classification society standards,70 requirements of the International Maritime Organization and International Electrotechnical Commission, and the standards and requirements of the flag state holding the vessel’s registration. Bermuda, the flag state of the Crown Princess, accepted the NACOS type-approval of the German government agency.71 According to Sperry Marine personnel, at the time of the accident, about 80 percent of cruise vessels were supplied with a NACOS INS, about 10 percent with a Sperry INS, and about 10 percent with equipment supplied by four other manufacturers. Princess Cruises vessels, like most large passenger vessels, were equipped with NACOS INS equipment. Early 1980s versions of the NACOS contained radar information with ARPA, display of navigation information, and automatic warning and alarms. Subsequent generations introduced predicted path displays, electronic charting (referred to as chartpilot), chartradar and multipilot, with VDR and automatic identification system (AIS).72 69  Regulations and guidelines pertaining to the NACOS at the time of the accident are discussed in appendix D. 70  Classification societies are private, independent organizations that establish and apply technical standards for the design, construction, and survey (inspection) of ships. Many countries delegate responsibility for some regulatory functions to classification societies, such as inspection for compliance with certain national and international regulations and issuance of some safety certificates, and may also adopt class society rules as their own national standards. 71  The International Electrotechnical Commission had not established INS test standards when the NACOS was installed on the Crown Princess. The German approval agency BSH (Bundesamt für Seeschifffahrt und Hydrographie) type-approved the NACOS as a track control and heading control system. Approval of the trackpilot system was according to International Electrotechnical Commission standard 62065, “Track Control Systems–Operational Performance Requirements, Methods of Testing and Required Test Results,” based in turn on International Maritime Organization Maritime Safety Committee resolution MSC.74(69), Annex 2, “Recommendations on Performance Standards for Track Control Systems.” Approval of the heading control system was according to Maritime Safety Committee resolution MSC A.342(IX), “Recommendation on Performance Standards for Heading Control Systems,” as well as International Organization for Standardization (ISO) standard 11674, “Ships and Marine Technology—Heading Control Systems.” 72  AIS is a shipboard broadcast system that provides identifying information on other vessels within 8 to 10 nautical miles of a ship, with such additional information as location, heading, speed, and rate of turn.

Factual Information National Transportation Safety Board M A R I N E Accident Report 35 NACOS generation 5 was introduced in 2005. (As noted earlier, the Crown Princess was equipped with model 65-5.) Generation 5 featured changes in the trackpilot that conformed to mandatory changes required by the International Maritime Organization. In addition, the latest version featured a fully integrated VDR that captured radar data.73 The NACOS model on the Crown Princess contained the following components: radarpilot, chartpilot, multipilot, conning pilot, and trackpilot. The radarpilot displayed radar information about the environment around the vessel as seen by the radar system. The trackpilot could be controlled and monitored from the radarpilot workstation, thus enhancing the vessel’s basic autopilot function with information on nearby vessels. The chartpilot combined nautical information, route planning, and geographical information with digital charts. It provided route-monitoring information including position, gyroscope heading, rate of turn, speed, course, date, time, distance to next way point or object, time to next way point or object, wind direction and velocity, engine power, propeller pitch, shaft revolutions per minute, rudder position, and thruster position, if available. The multipilot combined ECDIS with radar information to display planned and actual position, with location of nearby vessels, on an electronic chart. Among the information provided to the officer having the conn were heading, rate of turn, course, drift angle, extent off course, extent off track, estimated time of arrival to next way point or position, time to travel to next way point or position, water depth, wind velocity and direction, and engine and rudder information. Steering through the trackpilot could be set to one of three modes: heading mode, a mode comparable to a conventional autopilot in which the gyrocompass would determine the vessel heading; course mode, in which the true course would be maintained with compensation for drift and wind; and track mode, which would steer the vessel along a predetermined track using either specific navigation points entered by the operator or navigation points along a predetermined route, with compensation for drift and wind. Track mode steering could be fully automated, requiring crewmember confirmation only in the case of a course alteration. Trackpilot provided all the information included in the previous components with such additional information as GPS position, rudder economy setting, rudder limit, selected limit on course, distance from track (or drift), rhumb line (line of constant bearing) to track, time to next way point, course correction, and information on the track itself. Among the trackpilot parameters that could be selected at the option of the watchstanders were rudder economy, rudder limit, and course limit. The rudder economy setting allowed operators to enter one of 10 levels of weather/sea 73  The International Maritime Organization did not require VDR integration, an optional item in NACOS generation 5.

Factual Information National Transportation Safety Board M A R I N E Accident Report 36 state conditions, with resulting rudder movement limits increased or decreased, according to the setting. Level 1 was for calm seas and wind conditions, while levels over 6 were to be used when conditions were “very bad” (terms in quotes indicate terms from the NACOS operating manual). Level 5, the rudder economy setting that had been set into the vessel’s trackpilot at the time of the accident, was to be used when conditions were “bad.” With increases in rudder economy setting, designed to be used for increasingly rough seas, vessel heading was allowed to fluctuate increasingly. The NACOS manual described steering in level 1 as “precise” and, as the levels increased, steering became increasingly “tolerant.” Operators were expected to apply higher rudder movement restrictions during rough seas by inputting higher rudder economy settings. The NACOS operating manual stated:74 Economically advantageous optimisation between track-keeping and frequency of changing of the rudder angle, depending on sea state and wind, is achieved by means of the “rudder economy” parameter. This is comparable to a combination of the control variables “rudder,” “counter rudder” and “yaw” of a conventional autopilot. A common feature of the following [rudder] limits is that, when the set value is reached or exceeded, a corresponding alarm appears. The rudder angle setting which the trackpilot specifies as the maximum value for the rudder control system can be set under Limits in the Rudder Field. The rudder limit value should be reduced if a constant course is to be steered for a long time on the open sea or if, for example because of the loading state or for other reasons, large angles of the rudder are not permitted. When the rudder limit value is reached, the TP [trackpilot] Rudder Limit alarm appears [emphasis in original]. At higher vessel speeds, SAM Electronics recommended setting the rudder limit lower than at lower speeds to prevent excessive rates of turn and vessel heeling. The trackpilot manual specified: “The rudder limit value should be reduced if a constant course is to be steered for a long time on the open sea or large rudder angles are not permitted.” The INS recorded INS data independently of the VDR, which recorded data mandated by the International Maritime Organization.75 On the Crown Princess, INS data were registered on both a short-term and a long-term recording, stored in the chartpilot unit and capable of being replayed by specialized hardware and software (the chartpilot electronics unit). In addition, the system recorded errors in a log file that was stored on the multipilot radar unit. Training. Neither the International Maritime Organization, Bermuda (the state of registry of the Crown Princess), nor the Coast Guard required mariners to be trained in INS use. Ship owners or operators decided on the type of training, if 74  SAM Electronics, Operating Instructions, pp. 207-208. 75  No international requirements address VDR storage of inputs to vessel INS units. See “Voyage Data Recorder” section.

Factual Information National Transportation Safety Board M A R I N E Accident Report 37 any, to be provided. INS manufacturers were required only to provide customers with user manuals and system documentation. The International Maritime Organization developed an IBS/INS “model course” that presents a curriculum on system use (appendix E). Member nations are not required to adopt the model curriculum or to certify IBS/INS courses. There is no International Maritime Organization requirement that students completing IBS/INS courses demonstrate proficiency in using the systems, or that a maximum period be permitted to elapse before someone who has completed an IBS/INS course can work with a shipboard IBS/INS while serving as a watch officer. In addition to developing the model course, the International Maritime Organization’s subcommittee on Standards on Training and Watchkeeping (STW), at its session in 2006, considered the need for a comprehensive review of the International Convention on Standards of Training, Certification, and Watchkeeping for Seafarers (STCW) and the STCW code, and proposed a work item with a target completion date of 2008.76 At the 2007 meeting of the International Maritime Organization’s Maritime Safety Committee, revised performance standards for INS and guidelines on the application of SOLAS regulation V/15 related to INS, IBS, and bridge design were adopted.77 Included was guidance to equipment manufacturers for familiarizing mariners with INS use on board vessels (appendix F). Representatives of Sperry Marine told investigators that the company conducted a 40-hour class in the use of its ECDIS at its Charlottesville, Virginia, facility. A typical class consisted of 30 hours on a multiconsole INS installation that mimicked a typical ship’s bridge and about 10 hours on an ECDIS simulator. Within the 40-hour time frame, instructors generally tried to match class time with demonstrated student progress. Crewmembers were taught the relationship between sea state, rudder movement, and rudder hunting. That is, during rough seas, the Sperry system would limit rudder movement, and as a result vessel yaw fluctuations would become limited around a given heading. A crewmember could also select a particular sea state that would have the same effect on rudder movement. SAM Electronics conducted training in the NACOS system at its Bremen, Germany, training facility. Customers could order the training and take it in Bremen or at another site they selected. Carnival Corporation conducted NACOS training, using a SAM Electronics–certified instructor, at its training center in Southampton, England. Regular training began about March 2006. Classes could cover vessel- specific NACOS designs, but because a typical class contained students from different vessels, the classes usually dealt with generic systems. 76  The STCW code sets minimum international training standards for professional mariners. It was last amended in 1995. 77  Report of the International Maritime Organization Maritime Safety Committee, 83rd session, October

1. The performance standards for INS are found in resolution MSC.252(83), and the guidance to SOLAS

regulation V/5 is found in SN.1/Circ.265.

Factual Information National Transportation Safety Board M A R I N E Accident Report 38 The standard SAM Electronics NACOS training was conducted in a 4-day class. The first day included an overview of the company, the purpose of an INS, and a history of the NACOS. The design and system architecture of the current NACOS were outlined. The second day covered the operation of major NACOS components, including radar, ARPA, and ECDIS. The third day focused on the operation of the multipilot and trackpilot, including trackpilot modes, trackpilot accuracy and limitations, and track and speed control. On the last day, students completed exercises in voyage planning, execution, and monitoring using NACOS. The course material was then reviewed and new system elements discussed. If time allowed, students were presented with a system failure and asked to respond effectively. Exercises were conducted on computer-based simulators that displayed NACOS information matching actual vessel displays. SAM Electronics representatives told investigators that because the company considered the effects of shallow water and high vessel speed on vessel steering to be part of the basic knowledge of navigational officers, NACOS trainers did not discuss the issue before the Crown Princess accident (see “Shallow Water Effects” section). After the accident, SAM Electronics modified its NACOS software so that it will warn operators when vessel speed is excessive for water depth. A warning is given for decreasing water depth and an alarm is sounded for shallow water at high speed. The warnings are based on formulas developed in a postaccident study, as detailed in the “Shallow Water Effects” section. SAM Electronics modified its training material to instruct students about the warnings. Princess Cruises sent its watchkeeping deck officers to the Carnival Corporation training center in Southampton for NACOS training conducted by an employee that SAM Electronics certified to serve as a NACOS trainer. Deck officers on the Crown Princess were trained both at the SAM Electronics Bremen facility and at Southampton. Princess Cruises required captains to interview all deck officers assigned to a vessel for the first time in order to verify their understanding of and familiarity with the NACOS and other vessel systems. Princess Cruises personnel estimated that in the 2 years before the accident, as many as six crewmembers were directed to receive additional NACOS training. Either a vessel captain or a supervisor had recommended the additional training after reading the VDR in response to a concern about vessel operation. Company policy called for monitoring the VDR of a voyage after a concern about vessel operation was reported. In response to heeling incidents and other occurrences on its vessels, Holland America Line reviewed its operations and modified its bridge resource management class. The curriculum, while adhering to content requirements of the STCW code, featured simulator-based scenarios taken from actual incidents and accidents on the cruise line. Students in the class, all company deck officers, were presented with the scenarios and observed for the quality of their responses. Data on vessel position, speed, proximity to other vessels, weather and sea conditions, and the like were taken from actual events, with modifications to reduce the

Factual Information National Transportation Safety Board M A R I N E Accident Report 39 likelihood that students would recognize a specific event. Students were sent to the facility every 5 years, and the scenarios were scheduled to be modified on a 5-year cycle so that students would not be presented with the same scenarios in successive classes. Royal Caribbean International also reviewed its heeling incidents and created a lessons-learned exercise for deck officers based on selected incidents. The company described the incidents and highlighted crewmember errors leading to the incidents. The objective of the exercises was for deck officers to apply the lessons learned from the incidents to enable them to avoid similar errors. Previous Board Action. On August 7, 1992, the United Kingdom–registered vessel QE2 was outbound in Vineyard Sound, Massachusetts, when it grounded about 2 ½ miles south of Cuttyhunk Island. No injuries or deaths resulted from the accident, but the vessel sustained significant damage. The Safety Board determined that the probable cause of the grounding was the errors in communication made by the pilot, master, and watch officers regarding a navigation plan for departing Vineyard Sound and their failure to maintain situation awareness regarding vessel navigation after an unplanned course change. Contributing to the accident was “the lack of information available on the Queen Elizabeth 2 about how speed and water depth affect the ship’s underkeel clearance.”78 The Board’s investigation found that the vessel’s master and pilot, while generally aware of the phenomenon of squat on vessels operating at high speed in shallow water, had underestimated the effects of squat on the QE2. After the vessel cleared local marine traffic and headed toward the open ocean, the master, with the pilot’s agreement, directed the speed to be increased to 25 knots so the vessel would arrive in New York on schedule. The pilot asked for a course change to the right of the intended course. The second officer, who was on the bridge, observed that the projected path of the vessel would cross a shoal area and informed the captain (through the first officer). The captain expressed his concern to the pilot, who ordered a course change south of the projected track. The second officer noticed that the new trackline would pass over a 6-½-fathom (39-foot) sounding but did not express his concern. Both the pilot and the master considered the 39-foot sounding, with the tide of plus 1 ½ feet, to be sufficient for safe vessel passage. Neither recognized that the effects of the high vessel speed over the relatively shallow water would lead to the squat that caused the vessel to ground on the 39-foot shoal. Their lack of recognition may have been the result of the lack of widespread distribution of information regarding squat effects on vessel motion. As a result of its investigation of the QE2 accident, the Safety Board made the following recommendation to the Coast Guard: 78  National Transportation Safety Board, Grounding of the United Kingdom Passenger Vessel RMS Queen Elizabeth 2 Near Cuttyhunk Island, Vineyard Sound, Massachusetts, August 7, 1992, Marine Accident Report NTSB/MAR-93/01 (Washington, DC: NTSB, 1993).

Factual Information National Transportation Safety Board M A R I N E Accident Report 40 M-93-23 Widely publicize the particulars of this accident concerning the large squat for ships operating at high speeds in shallow waters. In response, the Coast Guard commandant, on September 27, 1993, wrote: I concur with this recommendation. Copies of the Coast Guard’s investigation report on this casualty are being provided to IMO [International Maritime Organization] to disseminate the research information regarding vessel squat. In addition, we will develop material for publication in a Notice to Mariners, Proceedings of the Marine Safety Council, or other maritime publications. I will provide copies of the articles to the Board when published. The Coast Guard disseminated information about the accident, specifically about the crew’s knowledge of squat effects, within the marine community. The accident was a cover story in a 1993 Coast Guard publication distributed to professional mariners. As a result of the Coast Guard’s action, on March 20, 1997, the Safety Board classified Safety Recommendation M-93-23 as “Closed— Acceptable Action.” Three years later, on June 10, 1995, the Panamanian-registered vessel Royal Majesty grounded approximately 10 miles east of Nantucket Island, Massachusetts, about 17 miles west of its intended track.79 None of the 1,509 persons on board was injured, but the vessel sustained several million dollars worth of damage. The Safety Board determined that the probable cause of the accident was the deck officers’ overreliance on the vessel’s INS,80 Majesty Cruises’s failure to ensure that its deck officers were adequately trained in the automated features of the INS and in the implications of this automation for the INS, deficiencies in the design and implementation of the INS and in its operational procedures, and errors the second officer committed in failing to detect cues that the vessel was off course. The Royal Majesty had been equipped with a NACOS 25 (the NACOS version STN Atlas was manufacturing at the time) that included an autopilot integrated with radar information, presented through an ARPA display that could steer the vessel along a track of selected navigation points (similar to the trackpilot, track mode, on the Crown Princess’s NACOS 65-5). The vessel, which obtained position data from both GPS and LORAN,81 began to deviate from its intended course after the cable connecting the GPS antenna to the receiver separated and the GPS automatically reverted to dead reckoning without bridge watchkeepers 79  National Transportation Safety Board, Grounding of the Panamanian Passenger Ship Royal Majesty on Rose and Crown Shoal Near Nantucket, Massachusetts, June 10, 1995, Marine Accident Report NTSB/ MAR-97/01 (Washington, DC: NTSB, 1997). 80  Note that in its report, the Safety Board used the term IBS rather than INS. 81  LORAN (LOng RAnge Navigation) is a ground-based navigation system using low-frequency radio transmitters for transoceanic navigation.

Factual Information National Transportation Safety Board M A R I N E Accident Report 41 recognizing the change. The GPS did not signal the INS that it had reverted to dead reckoning, nor was it required to. At the time of the accident, Majesty Cruises offered NACOS training to its deck officers through on-the-job training, under the supervision of the vessel’s navigator. The cruise line provided simulator sessions to deck officers to practice navigation using the INS, but it did not make training checklists available to the navigators who provided on-the-job training. STN Atlas had offered training in the use of NACOS to its customers, but Majesty Cruises did not order or receive such training. As a result of its investigation of the Royal Majesty accident, the Safety Board issued the following recommendation to the Coast Guard: M-97-5 Propose to the International Maritime Organization that it develop appropriate performance standards for the training of watch officers assigned to vessels equipped with integrated bridge systems and require this training. In response, on November 6, 1998, the Coast Guard wrote: We do not concur with this recommendation. The fact that the watch officers in this incident did not perform their watchkeeping duties properly does not establish a need for special international standards of training for watch officers on vessels equipped with integrated bridge systems. There is no indication that the existing international standards of qualification are inadequate. The 1995 amendments to the International Convention on Standards of Training, Certification, and Watchkeeping for Seafarers, 1978, (STCW) provide ample international standards and regulations which, if followed, would prevent incidents such as the grounding of the Royal Majesty. For example, regulation 1/14, STCW requires a company that owns or operates a ship to ensure that “seafarers, on being assigned to any of its ships, are familiarized with their specific duties and with all ship arrangements, installations, equipment, procedures, and ship characteristics that are relevant to their routine or emergency duties.” Officers in charge of a navigational watch are required to have the “ability to determine the ship’s position by use of electronic navigational aids,” and one criterion to evaluate the officer’s competence in navigation is that “the reliability of the information obtained from the primary method of position fixing is checked at appropriate intervals.” Watchkeeping requirements specify that “during the watch, the course steered, position and speed shall be checked at sufficiently frequent intervals, using any available navigational aids necessary, to ensure that the ship follows the planned route.” STCW also requires that masters and chief mates be proficient in effective bridge teamwork procedures. We anticipate that the 1995 STCW amendments, combined with the requirements of the International Safety Management code (ISM code),

Factual Information National Transportation Safety Board M A R I N E Accident Report 42 will improve watchkeeping practices. The Coast Guard plans no further action on this recommendation, and requests that it be closed. Because the Coast Guard planned no action on the recommendation, on April 20, 1999, the Safety Board classified Safety Recommendation M-97-5 as “Closed— Unacceptable Action.” Also as a result of the Royal Majesty accident, the Safety Board issued the following recommendation to the ICCL: M-97-21 Recommend that its members provide initial and recurrent formal training on essential technical information, equipment functions, and system operating procedures to all bridge watchstanding personnel on their ships that are equipped with integrated bridge systems. In its response of October 11, 1999, the ICCL wrote: ICCL member lines provide initial and recurrent formal training to their bridge personnel through “in-house” initial training/familiarization programs and recognized shoreside crew training facilities such as the Star Center in Dania, FL, and Marine Safety in Rotterdam. ICCL member vessels comply with the International Maritime Organization (IMO) requirements for crew training and certification. The International Convention, Standards of Training, Certification and Watchkeeping (STCW), sets the minimum standards for the training and certification of crew members onboard all vessels engaged in international voyages. Further, independent authorities, in accordance with the International Safety Management code (ISM) certify all ICCL member lines. This system ensures that the training, watch standing practices and procedures are in accordance with accepted international maritime practices. On March 21, 2000, the Safety Board responded to the ICCL, classifying Safety Recommendation M-97-21 as “Closed—Reconsidered”: While the ICCL did not provide information on how it recommended, encouraged, or advised its members as requested, the Safety Board understands that these recommendations were discussed and reviewed in detail at the ICCL’s technical committee meeting in July 1999. The Safety Board notes that member companies have implemented some of these recommendations. As stated in our February 19, 1999, letter, and as discussed at the Safety Board/ICCL meeting this past fall, the Safety Board understands that the ICCL does not make recommendations to its membership. Therefore, the Safety Board will address future recommendations to the individual cruise ship companies that are affected.

National Transportation Safety Board M A R I N E Accident Report 43 Analysis General The analysis first identifies factors that can be eliminated as causal or contributory to the accident. It then discusses the following safety issues identified in the accident investigation: Actions of captain, staff captain, and second officer. • Training in use of integrated navigation systems. • Reporting of heeling incidents and accidents. • Emergency response following severe incidents. • Exclusions The Crown Princess had been in service only a month at the time of the accident. The vessel’s steering and propulsion systems and NACOS were tested during sea trials before the accident, as well as in tests conducted after the accident. Both pre- and postaccident testing found that the systems performed as designed. The weather and sea state were mild and unlikely to have affected the vessel’s performance. Toxicological analysis of samples taken from the deck officers on duty during the accident were negative for the presence of alcohol and illegal drugs, and the officers had maintained regular sleep and work schedules in the days before the accident. Therefore, the Safety Board concludes that the following were not factors in the accident: vessel’s mechanical condition, weather, sea state, and behavioral or physiological impairment of the crew. Accident The Crown Princess’s departure from Port Canaveral was uneventful. The pilot had the conn at departure and the crew steered the vessel manually. After the pilot disembarked and the vessel entered the open ocean, the crew engaged the trackpilot and the captain ordered an increase in the vessel’s speed to stay ahead of forecast adverse weather. The captain and staff captain left the bridge, turning the navigation watch over to the second officer. The second officer, concerned by

Analysis National Transportation Safety Board M A R I N E Accident Report 44 indications of a high rate of turn to port, disengaged the trackpilot and began steering the vessel manually. His first turn was opposite to his intended direction. A minute later, the vessel heeled hard to starboard. The heeling caused passengers and crew to strike the vessel’s structure or objects on the vessel or to be struck by objects, resulting in almost 300 injuries. The Crown Princess was traveling at 20 knots, nearly full speed, when it heeled. The vessel was in relatively shallow water at the time of the accident, with 8.3 meters (about 26 feet) of water under the keel. Actions of Captain and Staff Captain According to information from both the VDR and interviews of the captain, staff captain, and second officer, about 1503 the vessel’s heading began to fluctuate around its designated 100° heading. Two minutes later, the trackpilot rudder limit alarm sounded. In response, the staff captain increased the rudder limit from 5° to 10°. At the time, the rudder economy was set to level 5, normally intended for rough seas. The captain and staff captain, both experienced mariners, should have realized that because the vessel was operating in relatively shallow water, its response to rudder movements would lessen and its maneuverability become unpredictable. The trackpilot, whose performance was predicated on deep-water vessel characteristics, would likewise perform unpredictably in shallow water at high speeds. These hydrodynamic effects were so obvious to SAM Electronics that its representatives told Safety Board investigators that they saw no need to address the topic in their NACOS training. They assumed that, irrespective of experience, all mariners would be aware that operating at high speed in shallow water would affect vessel performance. Both the captain and the staff captain, despite their experience, apparently failed to recognize that the INS would be unpredictable at a speed of 20 knots in waters 8 meters deep under the keel. The Safety Board therefore concludes that the captain and staff captain did not recognize that high speed and shallow water were adversely affecting the vessel’s course stability. In addition to the effects on vessel steering of high speed in shallow water, the staff captain further enabled the vessel’s course deviations by increasing the rudder limit while maintaining the trackpilot’s rudder economy setting at level

1. As described in the NACOS operating manual, the selection of the rudder

economy limit was to be based on the sea state and weather conditions. Level 5 was to be used when conditions were “bad,” according to the manual. Rudder economy settings allow increases in vessel heading fluctuations with increases in the rudder economy level. Such increases are desirable in rough seas but not in calm seas, where large rudder motion can increase passenger discomfort and wear and tear on the steering system. Neither the staff captain nor the captain appears to have recognized that the rudder economy setting was related to the rudder limit alarms that had led the officers to increase the rudder limit. They should have understood that the

Analysis National Transportation Safety Board M A R I N E Accident Report 45 rudder economy had been set to a level inappropriate to the operating conditions (sea state). When the captain said, “We’re wandering all over the place,” neither he nor the staff captain seemed to realize that the “wandering” was influenced by the vessel’s high speed in relatively shallow water and was exacerbated by the rudder economy setting. Increasing the rudder limit, particularly given the inappropriate rudder economy setting, was inappropriate as well because it allowed greater heading fluctuations. The proper response to the rudder limit alarm, given the sea state and operating conditions, would have been to assess the cause of the alarm, that is, the inappropriate rudder economy setting, and readjust the setting to the appropriate level. The Safety Board therefore concludes that the captain and staff captain inappropriately adjusted the trackpilot’s rudder limit in response to unintended deviations in the vessel’s set heading, and they failed to adjust the rudder economy setting, which was inappropriate for the sea state and was exacerbating the course deviations. The captain turned the conn over to the second officer at 1518, 6 minutes before the second officer disengaged the trackpilot. However, the fluctuations in the vessel’s heading that the captain and staff captain had attempted to address through the INS continued, leading the second officer to attempt to correct them by taking manual control of the steering. The captain transferred the conn without determining the cause of the heading fluctuations, and worse, left the bridge without verifying that they were lessening. The evidence of his previous experience as captain and his actions in turning over the conn suggest that the captain believed either that the INS would stabilize the heading or that the second officer would remedy the problem. However, neither outcome was realized. The Safety Board therefore concludes that the captain should not have transferred the conn to the second officer and left the bridge unless he could verify that the vessel’s heading fluctuations had diminished. Second Officer’s Actions The Crown Princess was operating at nearly full speed when the second officer took the conn. He immediately faced the problem of navigating a vessel that exhibited both increasing course deviations and high rates of turn. The second officer told investigators that his eyes “were instantly drawn to” the red color of the rate-of-turn indicator on the bridge, which indicated a high rate of turn to port. He responded immediately by disengaging the trackpilot82 and turning the wheel 10° to port, when he should have turned it to starboard to counteract the turn. After his initial turn to port, the second officer manually steered back and forth between port and starboard in increasingly wider turns. Rather than remedying the problem, the second officer’s actions exacerbated the course fluctuations and high turn rates, and caused larger and larger heel angles. The result was an increasing heel to starboard that eventually peaked at about 24°. 82  Disengaging the trackpilot disengaged the rudder limit and rudder economy settings.

Analysis National Transportation Safety Board M A R I N E Accident Report 46 As detailed in the “Vessel Dynamics” section, the second officer moved the wheel faster than the rudders could follow. Numerous cues were available to inform the second officer that the vessel was not responding as he commanded or expected. Visual cues came both from what he could see outside the window and from bridge instruments that indicated the vessel’s rate of turn and course. In addition, he would have received vestibular cues about angular acceleration. That is, he would have felt the speed with which the vessel was heeling and turning. The second officer’s three turns to port temporarily slowed the rate of heel. However, the overall effect was to increase the heel to starboard, because, as shown in figure 7, the rudders remained to port and the vessel’s drift angle (the difference between its heading and its track) continued to increase. Thus, after his initial command to port, each time the second officer commanded rudder movements, the heel rate temporarily slowed, giving the perception of correcting the starboard heel angle. However, this effect was at the overall expense of a greater starboard heel angle, a result that contradicted the desired outcome. That is, the second officer’s wheel inputs increased the starboard heel over the duration of the event rather than decreasing it. It could not be determined whether the second officer’s initial turn was due to a “slip”83 or to a misdiagnosis of the situation. Because the second officer was, as he stated, “instantly drawn to” the red color on the rate-of-turn indicator, and because the vessel did not respond as he expected, he reacted in a manner consistent with someone under stress. Stress would have limited the second officer’s ability to diagnose and respond effectively to the situation he faced. As has been observed: “Stress narrows people’s field of attention to a limited number of central aspects. Under perceived danger, a decrease in attention has been observed for peripheral information.”84 The second officer, according to what he told investigators, focused almost exclusively on the vessel’s rate of turn. The second officer’s repeated turns of the wheel thereafter were futile and inappropriate attempts to slow the turn rate and correct the heeling. His activity only made the situation he faced worse, his stress level higher, and his ability to comprehend and respond appropriately to the situation he faced more difficult. In such circumstances, a crewmember who was fully aware of the situation would most likely have taken two actions—held a steady course, and reduced speed. Because of the second officer’s inappropriate steering, the turn rate increased and the vessel heeled hard to starboard. The relief captain was the first person to return to the bridge when the vessel began heeling and immediately ordered, “Reduce the speed.” Slowing the vessel, in addition to disengaging the trackpilot, was a course of action that the second officer, as an experienced mariner, should have known to take in response to a possible steering failure. 83  The second officer’s initial turn to port, when he meant to turn to starboard, can be considered an error of execution. James Reason (Human Error [New York: Cambridge University Press, 1990]) refers to such an error as a “slip,” a relatively minor error that contrasts with a high-level cognitive error such as misdiagnosing a situation. In a slip, a person means to do one thing, but the execution differs from the person’s intention. 84  M. R. Endsley, “Toward a Theory of Situation Awareness,” Human Factors 37 (1995), p. 52.

Analysis National Transportation Safety Board M A R I N E Accident Report 47 The Safety Board concludes that the Crown Princess heeled because, after the second officer disengaged the trackpilot and turned the wheel to port rather than turning it to midships and slowing the vessel as he should have, his subsequent steering commands to both port and starboard, at angles ranging from 10° to 45°, led to vessel responses that he did not expect, did not understand, and was therefore unable to correct. The Safety Board examined the second officer’s training and experience to determine whether deficiencies in either might have played a role in his performance during the accident. His training in the British maritime academy was equivalent to that of the other British-trained deck officers that Princess Cruises employed, and his record indicates that he would have been exposed to the same training scenarios as other British students in maritime training at that time. His experience, which was entirely with Princess Cruises and a predecessor company, was consistent with that of a second officer who had been out of school for 6 years. In addition, the record indicates that he performed satisfactorily in his training and as a deck officer. Thus, there was no evidence of shortcomings in his training or background and no evidence that he performed less than satisfactorily in either. Therefore, the Safety Board concludes that no deficiencies in the second officer’s training or background could account for his inappropriate steering commands. Training in Use of Integrated Navigation Systems The captain and staff captain of the Crown Princess made several errors with regard to the INS trackpilot. Specifically, they failed to recognize the following: Effects of high vessel speed in shallow water on course stability. • Effects of rudder economy level 5 on rudder performance. • Effects on fluctuations around the heading of increasing the rudder limit • from 5° to 10°. In examining other heeling accidents and incidents, the Safety Board found common antecedents—crewmembers not fully understanding the INS they were using, not anticipating the effect of their actions on the INS, or both. Integrated navigation systems, whether manufactured by SAM Electronics, Sperry Marine, or another company, are sophisticated devices that monitor, display, and control considerable information about a vessel’s position, direction, and path, the sea state in which it operates, and related information about nearby vessels. The systems integrate previously developed individual components (such as AIS, ARPA, and ECDIS) with steering to allow the display of information and control of components at a single workstation. The systems also offer options as to the amount and type of information presented and the type of vessel navigation and control desired. As both hardware and software technology have advanced, designers have added

Analysis National Transportation Safety Board M A R I N E Accident Report 48 capabilities to the systems, further increasing an operator’s choices in information and vessel control. The Safety Board found shortcomings in training that may have contributed to the errors in INS use that played a role in some of the other heeling incidents reviewed in this investigation. For example, under the current system, completing INS training does not assure mastery of the system because students are not required to demonstrate mastery of an INS at the completion of many formal INS training programs. Given the amount of information an INS can present and its many control and display options, a crewmember who completes INS training and then does not use the system on a vessel for several years may not remember much of the class material or be able to apply it. Further, neither the Coast Guard nor the International Maritime Organization requires licensed mariners to complete formal INS instruction before using an INS. There is also no requirement that mariners who have completed INS instruction take courses thereafter. A system that allows users to interact with such sophisticated systems as an INS with the training shortcomings noted is deficient and increases the likelihood that crewmembers will commit INS-related errors. The Safety Board therefore concludes that the errors of the captain and staff captain in operating the INS resulted from inadequate training. The Safety Board identified deficiencies in INS training 10 years earlier in its investigation of the grounding of the Royal Majesty and issued Safety Recommendation M-97-5 to the Coast Guard. The Coast Guard disagreed with the recommendation, and the Safety Board classified it as “Closed—Unacceptable Action.” Since the Safety Board issued its recommendation, errors in INS use have continued. Although in recent years the International Maritime Organization has recognized the need for additional attention to INS training for bridge watch officers, the training is still not mandatory. The record of passenger vessel incidents and accidents related to deficiencies in INS training since the Royal Majesty accident contradicts the outcome foreseen by the Coast Guard when it responded to Safety Recommendation M‑97-5 that “there is no indication that the existing international standards of qualification are inadequate” and that “the 1995 amendments to the international convention on standards of training, certification, and watchkeeping for seafarers, 1978 (STCW) provide ample international standards and regulations” governing INS training. The International Maritime Organization has developed a model training curriculum for INS and IBS equipment (appendix E). The curriculum, which is advisory only, addresses many of the shortcomings in INS training requirements that the Safety Board noted in its investigation of the Crown Princess accident. For example, it details a 40-hour class, with instructional objectives related to INS/ IBS use, and devotes segments of class time to particular topics. In addition, it

Analysis National Transportation Safety Board M A R I N E Accident Report 49 suggests simulator exercises to allow students to apply the information addressed in class and offers guidance on testing or evaluating a student’s knowledge at course end. However, because there is no international requirement for INS training, the proposed model curriculum may not be effective in addressing the shortcomings in INS training noted in this investigation. Until crewmembers are required to demonstrate mastery of INSs and IBSs through formal, well-designed training programs, there can be no assurance that watchkeepers are proficient in the use of these sophisticated systems. The model International Maritime Organization curriculum, or other training endeavors that meet similar instructional objectives, if implemented and made mandatory with mariner participation in the training, would increase the likelihood that crewmembers will use INS or IBS equipment effectively in all operating conditions. Therefore, the Safety Board believes that the Coast Guard should propose to the International Maritime Organization that, in conjunction with the upcoming revisions to the STCW, it make training in INS and IBS mandatory for watchkeepers on vessels equipped with such systems. As a result of the Royal Majesty accident, the Safety Board issued recommendation M-97-21 to the ICCL, now the Cruise Lines International Association (CLIA). The ICCL did not agree with the Safety Board, citing the training its members received at shoreside training facilities and the adequacy of STCW requirements and ISO certification. The Safety Board accepted the ICCL’s stated inability to recommend particular courses of action to its members. In the Safety Board’s opinion, however, the Crown Princess accident indicates that passenger cruise lines should ensure that all deck officers are thoroughly versed in INS operations. The Board recognizes that it will take time for the International Maritime Organization to mandate INS training. Therefore, the Safety Board believes that, until the International Maritime Organization makes INS training mandatory, CLIA should recommend to its members that they voluntarily provide initial and recurrent training in INS operation to crewmembers having watchkeeping responsibilities on vessels equipped with such systems, and include in that training a requirement for a demonstrated level of proficiency. Further, the circumstances of this accident suggest that even experienced deck officers may not recognize how operating at high vessel speed in shallow water can affect rudder, vessel, and INS performance. In its investigation of the 1992 QE2 grounding, the Safety Board found that the crewmembers lacked knowledge of shallow water effects on their vessel. (They were operating off the coast of Massachusetts at a speed of 25 knots.) As a result, the Safety Board issued Safety Recommendation M-93-23 to the Coast Guard, which it classified as “Closed—Acceptable Action” after the Coast Guard publicized the circumstances of the accident. Partly because of this action, information on squat was prominently posted on the Crown Princess bridge. Nonetheless, the circumstances of the Crown Princess accident suggest that the officers, while familiar with squat, did not recognize that high vessel speed

Analysis National Transportation Safety Board M A R I N E Accident Report 50 in shallow water could also adversely affect the precision of vessel steering. In addition, the second officer’s actions indicate that he lacked the emergency ship- handling skills that would have allowed him to respond effectively to the vessel’s unexpected behavior. The Safety Board is concerned that other officers in charge of the navigational watch may also be unprepared for serious, unexpected incidents such as a vessel heeling. Therefore, the Safety Board believes that the CLIA should, through its website, publications, and conferences, inform its members about the circumstances of this accident and urge them to incorporate into their safety management systems and training programs for officers in charge of the navigational watch (1) information about the effects on vessel performance of high- speed vessel operations in shallow water, and (2) initial and recurrent training for emergency ship-handling scenarios based on the lessons learned from serious marine incidents and accidents. After the Crown Princess accident, SAM Electronics addressed shortcomings in its NACOS training by including in its material specific references to shallow- water effects on INS performance. Before the accident, the company had assumed that mariners did not need such instruction because they were already knowledgeable about shallow-water effects, but that assumption proved to be mistaken. The manufacturer’s action of adding an alarm to signal the bridge when a vessel is entering shallow water at high speed should help avoid situations that diminish vessel maneuverability and INS performance such as the Crown Princess experienced. After the accident, Princess Cruises required senior deck officers to repeat bridge resource management courses and provided all deck officers with additional NACOS training. Princess Cruises also urged its personnel to place user-friendly guidance from bridge operations manuals in readily accessible locations on vessel bridges. While there is no evidence that the complexity or inaccessibility of the NACOS manual or other operations manuals affected the crew’s actions in the Crown Princess accident, making equipment guidance easier to use and more accessible could enhance crew response in future unexpected or nonroutine situations. Holland America Line and Royal Caribbean have also taken steps to improve the training of their deck officers, such as developing lessons-learned programs based on previous heeling incidents. Postaccident Crew Response With almost 300 passengers and crew injured on the Crown Princess, the captain’s quick decision to return to port enabled injured passengers and crewmembers to be treated at shoreside medical facilities. The ship’s medical personnel helped those in need with transport to shoreside medical facilities. Before the vessel reached the dock, the medical team established a triage of the

Analysis National Transportation Safety Board M A R I N E Accident Report 51 injured, identified and treated the most seriously injured, and communicated to the captain the severity of the injuries. Therefore, the Safety Board concludes that the captain acted properly in returning to Port Canaveral after the accident, and that the crew responded effectively in administering medical care to the injured. The Safety Board examined the captain’s decision not to muster passengers after the accident. The captain told investigators that, shortly after the accident, he checked with the two bridge lookouts who were monitoring for balcony fires, and they informed him that they had not seen anyone fall overboard. Therefore, the captain decided not to ask the passengers to report to their muster stations but, rather, told them to report to their cabins. Directing passengers to report to their muster stations would certainly have enabled the crew to account for the passengers. However, although the captain did not say so, it is unlikely that anyone would have fallen overboard unnoticed because many passengers and crew were on the outside decks in the bright, mid-afternoon daylight conditions. Further, given the debris on the vessel after the accident, including water from the pools, broken glass, and displaced and overturned furniture, directing passengers to their muster stations could have exposed them to hazards of slips, falls, and blunt or lacerating injury. In addition, the number of injured passengers and crew and the severity of their injuries were uncertain. Having passengers report to muster stations could have delayed treatment of the injured. Therefore, the Safety Board concludes that the captain’s decision not to order passengers to their muster stations after the accident was appropriate. The captain’s decision, while appropriate under the circumstances of the Crown Princess accident, might be inappropriate under other circumstances. After the accident, Princess Cruises implemented the use of a new technological aid for the accounting of passengers after an emergency. The aid should reduce the burden on crewmembers of attempting to account for all passengers while they are busy responding to the aftereffects of an incident. Monitoring of Heeling Incidents The investigation found that there is no systematic way of providing information or feedback regarding INS- or IBS-related incidents to the system designers or trainers. The current system, by which companies learn of incidents through media reports or directly from a cruise line, is informal and unsystematic. Further, it does not provide manufacturers with complete data on how their systems are used or misused. Manufacturers focus primarily on data that inform them of hardware or software flaws. That information, while important, provides an incomplete account of actual operations. Worse, neither designers nor trainers may learn of

Analysis National Transportation Safety Board M A R I N E Accident Report 52 incidents that could lead to design or training changes because there is no system of reporting such incidents. Data on errors in INS or IBS use may point to flaws in the system interface or suggest areas of improvement in the system design or training. Without such information, manufacturers have no reliable method of learning whether their products are being used as intended and whether their products or training programs are meeting their objectives. The Safety Board therefore concludes that the systematic collection of data on mishaps related to INSs and IBSs will enhance the systems’ design, procedures, and training. Therefore, the Safety Board believes that SAM Electronics and Sperry Marine should work with cruise lines and other vessel operators to develop a system that provides them with critical information regarding errors or potential problems in the use of INSs or IBSs and apply the lessons learned to system design and crew training. Safety Board investigators determined the Crown Princess’s maximum angle of heel from images taken by videocameras installed on the vessel for purposes other than accident investigation. The VDR, which was designed to collect data for use in accident investigations, did not record heel angles. There is no requirement for VDRs to record heel angles. The vessel’s IMAC retained heeling data, but only measured angles of heel between starboard 15° and port 15°. Data that accurately record a vessel’s angle of heel can considerably assist those attempting to understand the nature of a heeling event. The Safety Board therefore concludes that the Crown Princess accident demonstrates the need for obtaining and archiving data on vessel angles of heel. Consequently, the Safety Board believes that the Coast Guard should propose to the International Maritime Organization that it mandate the recording on VDRs of heel angles through the complete range of possible values.

National Transportation Safety Board M A R I N E Accident Report 53 Conclusions Findings The following were not factors in the accident: vessel’s mechanical condition,

weather, sea state, and behavioral or physiological impairment of the crew. The captain and staff captain did not recognize that high speed and shallow

water were adversely affecting the vessel’s course stability. The captain and staff captain inappropriately adjusted the trackpilot’s rudder

limit in response to unintended deviations in the vessel’s set heading, and they failed to adjust the rudder economy setting, which was inappropriate for the sea state and was exacerbating the course deviations. The captain should not have transferred the conn to the second officer and left

the bridge unless he could verify that the vessel’s heading fluctuations had diminished. The

Crown Princess heeled because, after the second officer disengaged the trackpilot and turned the wheel to port rather than turning it to midships and slowing the vessel as he should have, his subsequent steering commands to both port and starboard, at angles ranging from 10° to 45°, led to vessel responses that he did not expect, did not understand, and was therefore unable to correct. No deficiencies in the second officer’s training or background could account

for his inappropriate steering commands. The errors of the captain and staff captain in operating the integrated navigation

system resulted from inadequate training. The captain acted properly in returning to Port Canaveral after the accident, and

the crew responded effectively in administering medical care to the injured. The captain’s decision not to order passengers to their muster stations after the

accident was appropriate. The systematic collection of data on mishaps related to integrated navigation

systems and integrated bridge systems will enhance the systems’ design, procedures, and training. The

Crown Princess accident demonstrates the need for obtaining and archiving data on vessel angles of heel.

Conclusions National Transportation Safety Board M A R I N E Accident Report 54 Probable Cause The National Transportation Safety Board determines that the probable cause of the Crown Princess accident was the second officer’s incorrect wheel commands, executed first to counter an unanticipated high rate of turn and then to counter the vessel’s heeling. Contributing to the cause of the accident were the captain’s and staff captain’s inappropriate inputs to the vessel’s integrated navigation system while the vessel was traveling at high speed in relatively shallow water, their failure to stabilize the vessel’s heading fluctuations before leaving the bridge, and the inadequate training of crewmembers in the use of integrated navigation systems.

National Transportation Safety Board M A R I N E Accident Report 55 Recommendations As a result of its investigation of this accident, the National Transportation Safety Board makes the following safety recommendations. To the U.S. Coast Guard: Propose to the International Maritime Organization that, in conjunction with the upcoming revisions to the Standards of Training, Certification, and Watchkeeping for Seafarers, it make training in integrated navigation systems and integrated bridge systems mandatory for watchkeepers on vessels equipped with such systems. (M-08-1) Propose to the International Maritime Organization that it mandate the recording on voyage data recorders of heel angles through the complete range of possible values. (M‑08‑2) To the Cruise Lines International Association: Until the International Maritime Organization makes training in integrated navigation systems mandatory, recommend to your members that they voluntarily provide initial and recurrent training in integrated navigation system operation to crewmembers having watchkeeping responsibilities on vessels equipped with such systems, and include in that training a requirement for a demonstrated level of proficiency. (M‑08-3) Through your website, publications, and conferences, inform your members about the circumstances of this accident and urge them to incorporate into their safety management systems and training programs for officers in charge of the navigational watch (1) information about the effects on vessel performance of high-speed vessel operations in shallow water, and (2) initial and recurrent training for emergency ship-handling scenarios based on the lessons learned from serious marine incidents and accidents. (M‑08-4) To SAM Electronics and Sperry Marine: Work with cruise lines and other vessel operators to develop a system that provides you with critical information regarding errors or potential problems in the use of integrated navigation systems or integrated bridge systems and apply the lessons learned to system design and crew training. (M‑08‑5)

Recommendations National Transportation Safety Board M A R I N E Accident Report 56 BY THE NATIONAL TRANSPORTATION SAFETY BOARD MARK V. ROSENKER

ROBERT L. SUMWALT Chairman

Vice Chairman DEBORAH A. P. HERSMAN

KathRYN O’LEARY Higgins Member

Member STEVEN R. CHEALANDER Member

Member Hersman filed the following dissenting statement on January 15, 2008. Notation 7963B Member Hersman, Dissenting: I voted against Recommendation #1 to the Coast Guard to propose that IMO make training in INS and IBS mandatory for watchkeepers on vessels equipped with such systems because I do not believe it addresses the shortcomings identified in this accident investigation. Our report very clearly states that the NTSB believes that mariners should be required to take INS training, yet at the same time, we acknowledge that such training may be ineffective if mariners cannot demonstrate mastery of the subject matter or currency. In this case, the crew had all received INS training at the manufacturer’s facility: the Captain completed a 3-day course in 1997; the Staff Captain completed a 4-day course in 2002; and the Second Officer completed a 3-day course in 2004. Nevertheless, our report concludes, “The errors of the captain and staff captain in operating the INS resulted from inadequate training.” Moreover, our investigators’ analysis found shortcomings in INS training that may have contributed to errors that played a role in other heeling incidents reviewed in this investigation. Under the current system, completing INS training does not assure mastery of the system because students are not required to demonstrate mastery of an INS at the completion of most formal INS training programs. Further, neither the Coast Guard nor the IMO require licensed mariners who have completed initial INS training take courses thereafter. Because this crew had received training, our recommendation to require training without addressing competency and currency does not fully address the concerns identified in the report and would not prevent a similar event from recurring. BY THE NATIONAL TRANSPORTATION SAFETY BOARD Mark V. Rosenker

Robert L. Sumwalt Chairman

Vice Chairman Deborah A. P. Hersman

Kathryn O’Leary Higgins Member

Member Steven R. Chealander Member Adopted: January 30, 2008

Recommendations National Transportation Safety Board M A R I N E Accident Report 57 At the Board meeting on January 10, my colleagues were reluctant to include competency and currency training in our recommendation to the Coast Guard because that would be asking for too much too soon. There was the argument that the IMO must first establish through delicate negotiations with many other countries a requirement for mandatory INS training before it can entertain a suggestion by the Coast Guard to also require a demonstration of proficiency or recurrent training. While I understand the sensitivity of the Coast Guard’s position with the IMO regarding any such recommendation, I also do not believe it is our role to determine what the negotiating posture of the Coast Guard should be. Our report seems to build an argument for a fuller, more inclusive, recommendation. I believe we should have put forth the more inclusive recommendation, leaving it up to the Coast Guard to determine what it will encourage the IMO to accomplish. I note that the IMO has already developed an INS/IBS “model course.” In addition, in 2006, the IMO’s Subcommittee on Standards on Training and Watchkeeping (STW) considered the need for a comprehensive review of the Seafarer’s Training, Certification, and Watchkeeping (STCW) Convention and the STCW code, and proposed INS/IBS training as a work item with a target completion of 2008. In an effort to not ask for too much, our new recommendation may be asking for something already underway, and perhaps it is asking for even less than what is already underway. The NTSB determines what happened in an accident and, as an independent voice of safety, recommends changes to prevent future accidents. It is up to others (industry, labor, regulators, government officials) to determine whether or not to adopt our recommendations. We are not the regulator bound by cost-benefit analysis, nor are we the international negotiator bound by political concerns. If we begin to anticipate how the recipients of our recommendations will respond, and modify our recommendations according to what can be accomplished in the near term, we are neglecting to promote broader safety initiatives that can be accomplished in the long term. As the sentinels of safety, we must issue candid and uncensored recommendations designed to encourage safety improvements for the immediate future as well as for many years to come.

Deborah A. P. Hersman

January 15, 2008

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National Transportation Safety Board M A R I N E Accident Report 59 Appendix A Investigation The Safety Board was notified of the Crown Princess accident by the Board’s communication center at 1725 on July 18, 2006. The Board launched a team of three investigators from Washington, DC, to Port Canaveral, Florida. The investigator- in-charge arrived the evening of July 18, boarded the ship, and retrieved the data from the vessel’s voyage data recorder. The next morning, the two other Board investigators (specialists in marine engineering and survival factors) arrived and joined investigators from the U.S. Coast Guard on board the ship. The team was later joined by a representative of Bermuda, the vessel’s flag state. No Board Member traveled to the scene. The investigative team interviewed witnesses, including the officers on the bridge watch at the time of the accident, and traveled with the crew and others on a postaccident test of the vessel’s navigation and steering equipment on July 20 and 21. The on-scene investigation concluded on July 22. The Safety Board investigated the accident under the authority of the Independent Safety Board Act of 1974, according to the Board’s rules. The parties to the investigation were the U.S. Coast Guard, Princess Cruises, and SAM Electronics.

National Transportation Safety Board M A R I N E Accident Report 60 Appendix B Voyage Data Recorder Data Plots

Appendix B National Transportation Safety Board M A R I N E Accident Report 61 PLOT 1

 National Transportation Safety Board M A R I N E Accident Report 62 PLOT 2 Appendix B

 National Transportation Safety Board M A R I N E Accident Report 63 Plot 3 Appendix B

 National Transportation Safety Board M A R I N E Accident Report 64 Plot 4 Appendix B

National Transportation Safety Board M A R I N E Accident Report 65 Appendix C Voyage Data Recorder Audio Transcript The reader of this report is cautioned that the transcription of a bridge voice recorder audio recording is not a precise science but is the best product possible from a Safety Board group investigative effort. The transcript or parts thereof, if taken out of context, could be misleading. The transcript should be viewed as an accident investigation tool to be used in conjunction with other evidence gathered during the investigation. Conclusions or interpretations should not be made using the transcript as the sole source of information. Transcript of a Broadgate voyage data recorder installed on cruise ship Crown Princess, which was involved in a heeling indicant that resulted in 298 injuries shortly after departing Port Carnival on July 18, 2006. BAM

Bridge area microphone voice or sound source CAPT

Voice identified as the captain 2/O

Voice identified as the second officer S/CAP

Voice identified as staff captain S/CAP(T) Voice identified as staff captain on telephone 4/O

Voice identified as 4th officer REL CAP Voice identified as relief captain AB/HELM-1 Voice identified as able body helmsman INTCOM Intercom communication INT COM (e) Intercom from engineroom Radar Video VDR radar video image

Unintelligible word

Expletive @

Nonpertinent word ( )

Questionable insertion [ ]

Editorial insertion Note 1: Times are expressed in eastern daylight time (EDT). Note 2: Words shown with excess vowels, letters, or drawn out syllables are a phonetic representation of the words as spoken. Note 3: A nonpertinent word, where noted, refers to a word not directly related to the operation, control, or condition of the vessel.

Appendix C National Transportation Safety Board M A R I N E Accident Report 66 Local Time VDR Time Source Content 14:44:31 18:49:08 2/O Forty-five 4/O Forty-five 14:44:34 18:49:11 S/CAP Did you ask the Captain? 14:44:36 18:49:13 REL CAP I think we should pass this… ???? I’m pretty sure... 14:44:39 18:49:16 S/CAP No No .So it is a CF buoy 2/O It is 14:44:43 18:49:20 S/CAP Ah Ok 14:44:44 18:49:21 S/CAP So forty-five, round number 2/O Um full away at forty-five 14:44:53 18:49:30 INT COM (e) Ok what’s that sorry S/CAP forty-five 2/O At forty-five 14:44:58 18:49:35 INT COM (e) forty-five Louie ???? Unintelligible 14:45:23 18:50:00 S/CAP Nostromo all flags CAPT definitely star... 4/O ninety RPM 2/O ninety RPM ???? Right it’s time to go ???? …so actually CAPT So what exactly is the weather? ???? me ah…do ah ... CAPT …web site… S/CAP (T) so is the bow…. cleared for sea? 14:47:03 18:51:40 S/CAP Ok

Appendix C National Transportation Safety Board M A R I N E Accident Report 67 Local Time VDR Time Source Content 14:47:05 18:51:42 S/CAP Anchors secured eh 2/O Anchors secured yea got that. 14:47:40 18:52:17 S/CAP …he is outside the… 14:47:42 18:52:19 CAPT ninety-five 2/O ninety-five 14:47:44 18:52:21 S/CAP It’s just ah - a depression they call it tropical. 14:48:32 18:53:09 CAPT one two nine 14:48:34 18:53:11 AB/HELM one two nine 14:51:13 18:55:50 ECR twenty two point two 14:51:15 18:55:52 2/O twenty two point two, yea the captain will speak to the chief. ECR Ok 14:51:19 18:55:56 2/O That was it, and… 14:51:23 18:56:00 BRIDGE Sound of Phone ring…. 14:51:28 18:56:05 CAPT Hello Captain… 14:51:35 18:56:12 CAPT Hay Carlo, we want to go as fast as we can for the time being for the weather. 14:52:00 18:56:37 CAPT Port three 14:52:02 18:56:39 AB/HELM Port three 14:52:32 18:57:09 CAPT five-degrees 14:52:34 18:57:11 AB/HELM five-degrees 14:56:01 19:00:38 CAPT one zero zero 14:56:03 19:00:40 AB/HELM one zero zero 14:57:24 19:02:01 AB/HELM Heading one zero zero sir. 14:57:27 19:02:04 CAPT Ok 15:00:51 19:05:28 CAPT three thirty NACOS-1 2/O right sir

Appendix C National Transportation Safety Board M A R I N E Accident Report 68 Local Time VDR Time Source Content 15:01:10 19:05:47 BAM Sound of switch 15:01:15 19:05:52 2/O NACOS-1 15:01:16 19:05:53 CAPT NACOS-1 15:01:17 19:05:54 2/O Engaged 15:01:18 19:05:55 AB/HELM …NACOS…. 15:01:19 19:05:56 2/O Wait there a second. 15:01:28 19:06:05 2/O ECR coming down to one set of steering motors now. 15:01:33 19:06:10 ECR OK one steering motor. 15:01:37 19O6:14 2/O Ok we will do one and three 15:01:41 19:06:18 ECR You need to keep the watertight doors closed CAPT Yes still… 15:01:45 19:06:22 2/O Yes please we will keep them closed for the time being. 15:02:47 19:07:24 CAPT Looks like a tour boat….fish watching. 15:02:54 19:07:31 ???? ….. turning 15:02:59 19:07:36 S/CAP Fish watching… 15:03:00 19:07:37 CAPT yea ok 15:03:01 19:07:38 ???? Right Adam 15:03:02 19:07:39 2/O Sir 15:03:03 19:07:40 CAPT You go ahead come around. Come around here. 15:03:07 19:07:44 2/O Alright. ???? unintelligible 15:03:13 19:07:50 CAPT Were over there because you won’t put it in 15:03:17 19:07:54 CAPT Otherwise …traffic see the buoy see the buoy 15:03:19 19:07:56 2/O Sir 15:03:20 19:07:57 S/CAP that’s the buoy 15:03:21 19:07:58 CAPT and it’s being able to access.

Appendix C National Transportation Safety Board M A R I N E Accident Report 69 Local Time VDR Time Source Content 15:03:22 19:07:59 2/O Speeding up to max on 6 15:03:49 19:08:26 S/CAP What’s the range to that vessel…. 15:03:51 19:08:28 CAPT I don’t know what….. 15:03:53 19:08:30 CAPT NACOS-one? 15:03:54 19:08:31 2/O NACOS-one 15:03:56 19:08:33 CAPT Reese????? 15:03:57 19:08:34 2/O parameters….set-up 15:04:01 19:08:38 CAPT Rudder group set up 15:04:03 19:08:40 CAPT set at ten….Yea 15:04:07 19:08:44 CAPT She’s applying port helm 15:04:12 19:08:49 CAPT and you can stop two pumps running… yes it’s always a start 15:04:17 19:08:54 CAPT Now she’s coming back 15:04:27 19:09:04 CAPT ….what are you set? 15:04:37 19:09:14 CAPT I think we’re better off with… 15:04:46 19:09:23 BAM beep beep 15:04:55 19:09:32 CAPT alright we’re in NACOS, heading mode 15:04:59 19:09:36 CAPT zero nine nine 15:05:01 19:09:38 CAPT now we’re going to port… 15:05:04 19:09:41 CAPT Steadying up 15:05:05 19:09:42 CAPT OK 15:05:06 19:09:43 BAM beep beep beep…. (TP rudder limit, identified from radar image) 15:05:08 19:09:45 2/O Rudder limit alarm. ???? unintelligible 15:05:19 19:09:56 CAPT Hopeless 15:05:22 19:09:59 2/O I don’t think we’re on…. 15:05:26 19:10:03 ???? alright

Appendix C National Transportation Safety Board M A R I N E Accident Report 70 Local Time VDR Time Source Content 15:05:31 19:10:08 BAM sound of click

???? unintelligible switches 15:05:32 19:10:09 BAM sound of click 15:05:33 19:10:10 2/O I don’t see why it is 15:05:36 19:10:13 CAPT Dominico 15:05:37 19:10:14 S/CAP yes sir 15:05:38 19:10:15 CAPT We’re wandering all over the place…, we put her into NACOS-1 15:05:43 19:10:20 CAPT There’s nothing wrong with the steering pumps, the helm is responding. 15:05:53 19:10:30 BAM sound of phone ring CAPT something 15:05:58 19:10:35 S/CAP lendis parma (phone answer)

15:06:00 19:10:37 S/CAP Ok… 15:06:05 19:10:42 S/CAP next course 15:06:06 19:10:43 BAM click 15:06:07 19:10:44 S/CAP you alright with that? 15:06:09 19:10:46 CAPT At the moment she is not responding other than10 degrees at a time 15:06:13 19:10:50 S/CAP we are out of its range…for sure. 15:06:16 19:10:53 CAPT Ah ha 15:06:20 19:10:57 CAPT take the helm Louie 15:06:22 19:10:59 ???? say again 15:06:24 19:11:01 ???? Ok 15:06:27 19:11:04 BAM Arr Arr (warning) followed by and simultaneous with beep beep beep…. 15:06:29 19:11:06 ???? You recommend it

Appendix C National Transportation Safety Board M A R I N E Accident Report 71 Local Time VDR Time Source Content 15:06:30 19:11:07 ???? well done… 15:06:47 19:11:24 BAM click 15:07:07 19:11:44 Radar Video Rudder limit changed from 5 to 10 degrees 15:07:20 19:11:57 CAPT ten degrees port ….; If we can’t steer a track (questionable text) 15:07:23 19:12:00 S/CAP Eddy, ????? 15:07:34 19:12:11 S/CAP I have just increased rudder and the course; gain; and now it is left. 15:07:42 19:12:19 S/CAP Unintelligible - approaching 15:07:48 19:12:25 S/CAP five 15:08:00 19:12:37 BAM beep beep beep…(rudder limit alarm) 15:08:03 19:12:40 Radar Video Alarm List – TP Rudder Limit 15:08:07 19:12:44 S/CAP 15:08:09 19:12:46 CAPT Yea 15:08:25 19:13:02 ???? unintelligible 15:08:37 19:13:14 BAM sound of alarm five-tones 15:09:28 19:14:05 ???? unintelligible 15:09:35 19:14:12 CAPT What 15:09:36 19:14:13 S/CAP … there is a party with ah course limit….. 15:10:32 19:15:09 2/O …Captain 15:10:34 19:15:11 S/CAP ..increase too much…, we’re at maximum 15:10:38 19:15:15 CAPT No idea but I don’t want her to (turn and drift). 15:10:43 19:15:20 BAM high pitch alarm 15:10:53 19:15:30 S/CAP unintelligible (laugh) 15:11:04 19:15:41 2/O alright hang on 15:11:08 19:15:45 BAM (sound of click) followed by high pitch tone 15:11:18 19:15:55 S/CAP unintelligible

Appendix C National Transportation Safety Board M A R I N E Accident Report 72 Local Time VDR Time Source Content 15:11:23 19:16:00 S/CAP wait turn around .. we are just in the middle don’t move it, so what am I management …. 15:11:46 19:16:23 CAPT master…according to our officers…

15:11:48 19:16:25 S/CAP (Italian) si,… to a one hundred-meters….OK. (consistent with phone conversation) 15:11:53 19:16:30 BAM sound of phone hung-up. 15:11:59 19:16:36 S/CAP Is it ok now? 15:12:00 19:16:37 CAPT No, ah no because, it was up to ten (meters )four miles, We’re bring it down to radius two. 15:12:23 19:17:00 CAPT Is it alright 15:12:26 19:17:03 S/CAP No no its better to do it by hand. 15:12:29 19:17:06 S/CAP it’s applies 15:12:33 19:17:10 CAPT you just applied it 15:12:34 19:17:11 S/CAP applied within this, every time you change it applied, where she is adapting at this point. 15:12:36 19:17:13 CAPT yea yea. 15:12:39 19:17:16 S/CAP ….so if you give it a change like oh (ten or fifteen) degrees you will adapt to that 4-mile range. But if you keep changing one by one then (it never or the number) stops it needs to… 15:13:03 19:17:40 2/O I can just look at it 15:13:06 19:17:43 S/CAP Yea, actually when you (hold or alter) this switch, it will show you continuous curve to the next track. And may be its when….applies…(unintelligible - ends at 15:13:20) 15:13:10 19:17:47 2/O unintelligible 15:13:12 19:17:49 BAM Phone ringing 15:13:23 19:18:00 CAPT Ok 15:13:39 19:18:16 CAPT Ok…put in nine nine nine 15:13:41 19:18:18 S/CAP (conversation in Italian – continues until 15:15:16) 15:14:33 19:19:10 CAPT stay in that turn,…..Ok we’ll run like that.

Appendix C National Transportation Safety Board M A R I N E Accident Report 73 Local Time VDR Time Source Content 15:14:42 19:19:19 CAPT unintelligible 15:15:05 19:19:42 CAPT Where is the track? 15:15:07 19:19:44 2/O unintelligible 15:15:15 19:19:52 CAPT the track 15:15:24 19:20:01 CAPT What’s the next track 15:15:30 19:20:07 4/O zero eight 15:15:35 19:20:12 CAPT How do you check it? CAPT Did you check it? 15:15:38 19:20:15 CAPT How do you check it? 15:15:41 19:20:18 CAPT Maybe the navigator put in the wrong number. 15:15:48 19:20:25 CAPT ….. we better check it. 15:15:50 19:20:27 S/CAP We can catch the liar 15:15:55 19:20:32 CAPT No, that’s only if you… 15:16:11 19:20:48 S/CAP That number can not be dialed, there is ah another one that can be I want him, I want him to dial another one, larger that I can see from here. CAPT Oh yea yea. 15:16:20 19:20:57 S/CAP logically I can see from here not that I could put that .. but that number is on the first leg on the track line so that’s come from.. 15:16:33 19:21:10 CAPT still good to check 15:16:36 19:21:13 S/CAP still good to check. Put the EBL on and ah. 15:16:38 19:21:15 CAPT That’s Ok; 15:16:39 19:21:16 S/CAP This is reversed. 15:16:40 19:21:17 CAPT I’ am going to leave on “O” 4, {then, check please check back.} are you happy? 15:16:44 19:21:21 2/O I am sir 15:16:45 19:21:22 CAPT Check each …zero four zero..{unidentified background conversation}

Appendix C National Transportation Safety Board M A R I N E Accident Report 74 Local Time VDR Time Source Content 15:16:55 19:21:32 2/O Can not. 15:16:56 19:21:33 CAPT Alright 15:16:57 19:21:34 S/CAP Had a job for the gadget.

15:16:59 19:21:36 CAPT I don’t know how long {he’s been with it} 15:17:01 19:21:38 2/O nine seven zero ..You guessed it… 15:17:03 19:21:40 S/CAP One hundred percent 15:17:04 19:21:41 CAPT Yes 15:17:05 19:21:42 2/O Check 15:17:06 19:21:43 REL/CAP We were we have some office books booklets which are in an envelope… we have some big big books so many books…[continued background conversation until 19:22:58] 15:17:13 19:21:50 CAPT Anchors secured for… 15:17:14 19:21:51 BAM Sound of two sharp bangs followed by two beeps. 15:17:15 19:21:52 CAPT the doors ….one hundred and thirty…. 15:17:18 19:21:55 2/O Sixtieth 15:17:20 19:21:57 S/CAP It is nine o’clock…quarter past eleven.. 15:17:23 19:22:00 2/O and the depth? 15:17:23 19:22:00 S/CAP [background conversation (lottery betting etc.) continues until19:22:59] 15:17:28 19:22:05 CAPT Ahm…just before they open…. you have the starboard side? 15:17:40 19:22:17 CAPT You happy with the books, the staff captain books?…… 15:17:41 19:22:18 2/O yes sir 15:17:43 19:22:20 ???? You know… 15:17:46 19:22:23 CAPT It’s only going to be a few minutes…and 2/O I know ???? Unintelligible 15:18:02 19:22:39 ???? It’s not that at all

Appendix C National Transportation Safety Board M A R I N E Accident Report 75 Local Time VDR Time Source Content 15:18:04 19:22:41 S/CAP You’ll have to check with your Bosun. ???? What’s the …? 15:18:08 19:22:45 ???? I’m trying to get near… 15:18:09 19:22:46 ???? Remember you can use that without bringing it up 15:18:12 19:22:49 2/O Yea 15:18:14 19:22:51 CAPT Ok you got the conn. 15:18:16 19:22:53 2/O I have the conn. 15:18:18 19:22:55 2/O Luigi…. 15:18:20 19:22:57 4/O Yes sir 15:18:32 19:23:09 S/CAP We have also got four charts from the area, so that ah we will also have paper charts for the gadget. 15:18:39 19:23:16 ???? For what? 15:18:39 19:23:16 CAPT The wind sensors slipped has it? 15:18:41 19:23:18 ???? Ah this…. 15:18:43 19:23:20 CAPT starboard wing 15:18:44 19:23:21 2/O …could be arriving in 15:18:45 19:23:22 S/CAP New York 15:18:46 19:23:23 S/CAP So that Luigi can check in the track on the chart; which one, check the track no put ah.. 15:18:51 19:23:28 REL/CAP Which one is the pilot..? 15:18:57 19:23:34 CAPT Yea we have the wind beside us. 15:18:58 19:23:35 ???? You said that.. 15:19:10 19:23:47 ???? Ah ______watch 15:19:14 19:23:51 CAPT I think I will go and put my feet up. 15:19:18 19:23:55 ???? Feet up Feet up 15:19:20 19:23:57 S/CAP Yeah…. I was thinking the same, but ah I can’t do it too late now, too late.

Appendix C National Transportation Safety Board M A R I N E Accident Report 76 Local Time VDR Time Source Content 15:19:28 19:24:05 S/CAP Ah, I’ll see you later minute second second ……. here. 15:19:34 19:24:11 S/CAP The chief is doing ah, oh ah he has to change a couple of things and one operator…. that’s fine. 15:19:42 19:24:19 S/CAP 15:19:47 19:24:24 CAPT …I would like to walk through another.. 15:19:50 19:24:27 S/CAP No No not for this ship no…. 15:19:54 19:24:31 S/CAP (unintelligible conversation) 15:20:17 19:24:54 ???? ….captain 15:20:23 19:25:00 CAPT Pick it up 15:20:24 19:25:01 CAPT Adam 15:20:28 19:25:05 CAPT It’s all happening Adam this is the Captains handing over 15:20:31 19:25:08 2/O And… 15:20:56 19:25:33 2/O I printed it out… (unintelligible conversation) 15:21:08 19:25:45 2/O …I just wanted to double check 15:21:10 19:25:47 S/CAP Ah you want to check mine against yours? 15:21:12 19:25:49 2/O yeah 15:21:24 19:26:01 CAPT …safety.. 15:21:26 19:26:03 S/CAP I am still available to go through that with you check. 15:22:02 19:26:39 S/CAP Ok Nico I’ll see you later I am going to …office. 15:22:09 19:26:46 REL/CAP ….chart. 15:22:11 19:26:48 2/O sorry 15:22:11 19:26:48 2/O No but from New York we’ll have the charts from New York 15:22:21 19:26:58 REL/CAP We don’t have any charts here, we don’t have any charts from here to New York 15:22:26 19:27:03 2/O We do but just for the cadets for training purposes, we’ve ordered a few extra charts so they can do some practicing, ah when we arrive in New York

Appendix C National Transportation Safety Board M A R I N E Accident Report 77 Local Time VDR Time Source Content 15:22:37 19:27:14 REL/CAP Anyway next time we use the parallel index, we go with the parallel indexing and you see how much ….. 15:22:44 19:27:21 ???? I use the (questionable text) one here…. 15:22:50 19:27:27 REL/CAP Ah the line 15:23:11 19:27:48 4/O You are still ah, you are still ah, turning 15:23:14 19:27:51 2/O Sorry 15:23:11 19:27:48 4/O You are still turning 15:23:17 19:27:54 2/O Na na, it’s a, well a few degrees at a time Luigi not much. 15:23:24 19:28:01 REL/CAP Anyway Adam …. 15:23:28 19:28:05 2/O Alright 15:23:31 19:28:08 REL/CAP I want this because I detected something…. 15:24:00 19:28:37 2/O ….on the wheel 15:24:02 19:28:39 Helm We got it, we got the wheel 15:24:05 19:28:42 BAM sound of click 15:24:13 19:28:50 4/O She She’s making me ill . 15:24:20 19:28:57 4/O port ten 15:24:21 19:28:58 2/O I know 15:24:22 19:28:59 4/O Port ten Adam, man you are port ten, you are port ten… 15:24:23 19:29:00 2/O Yah I am coming over to starboard 15:24:26 19:29:03 BAM Sound of warning (Beep, Beep continues until 19:30:52) 15:24:28 19:29:05 4/O Adam you are at port ten 15:24:29 19:29:06 2/O Yah I am coming over; get a fin out 15:24:32 19:29:09 4/O Yes 15:24:36 19:29:13 BAM Additional warning sounds for less than second. 15:24:38 19:29:15 4/O Adam 15:24:39 19:29:16 2/O OK 15:24:41 19:29:18 4/O Adam push on the button, push on the beep

Appendix C National Transportation Safety Board M A R I N E Accident Report 78 Local Time VDR Time Source Content 15:24:43 19:29:20 REL/CAP Reduce the speed, reduce the speed, reduce the speed 15:24:45 19:29:22 BAM Sound of objects falling to deck. (continues until 19:29: 39) 15:24:46 19:29:23 ???? unintelligible (sorry)?????….. 15:24:47 19:29:24 BAM Sound similar to door opening. 15:24:48 19:29:25 REL/CAP Reduce the speed. 15:24:48 19:29:25 BAM Sound of warning, ( continues until 19:30:31) 15:25:00 19:29:37 CAPT Stop the engines Stop the engines 15:25:02 19:29:39 REL/CAP Stop the…..operating again 15:25:04 19:29:41 2/O Stop the engines sir 15:25:11 19:29:48 CAPT Stop; stop the engines ask for op… ???? unintelligible 15:25:15 19:29:52 S/CAP …we need some engines now. 15:25:16 19:29:53 CAPT …we need to inspect the tanks… 15:25:21 19:29:58 S/CAP we need some engines now; we need some engines 15:25:26 19:30:03 BAM Sound of tones that precede Public Address System announcement. 15:25:33 19:30:10 CAPT ….sit-down where you are ……there is a problem with the steering gear and we are bring the ship back….

15:26:06 19:30:43 2/O …fuse boxes check on all the fuse buttons 15:26:11 19:30:48 ???? starboard. 15:26:12 19:30:49 S/CAP Keep her to starboard 15:26:15 19:30:52 BAM All audible warnings stop. 15:26:20 19:30:57 ???? What time is it? 15:26:21 19:30:58 CAPT Alright every body get round quickly, see what has happened, there must be some people hurt, call the ah surgery, …call the surgery.

National Transportation Safety Board M A R I N E Accident Report 79 Appendix D Pertinent Regulations and Guidelines When the Crown Princess entered service, the following regulations and guidelines pertained to the NACOS system: International Electrotechnical Commission standard 62065 (2002), • “Maritime navigation and radiocommunication equipment and systems—Track control systems—Operational and performance requirements, methods of testing and required test results.” International Maritime Organization Maritime Safety Committee • (MSC) resolution 74 (69), May 12, 1998. Adoption of new and amended performance standards [regarding GPS/GLONASS receivers, track control systems, AISs, and echo-sounding equipment]. International Electrotechnical Commission standard 61174 (2001). • “Maritime navigation and radiocommunication equipment and systems—electronic chart display and information system (ECDIS)— operational and performance requirements, methods of testing and required test results.” International Convention for Safety of Life at Sea (SOLAS) chapter • V, regulation 15, “Principles relating to bridge design, design and arrangement of navigational systems and equipment and bridge procedures.” International Maritime Organization MSC circular 1061, issued • January 6, 2003, “Guidance for the operational use of integrated bridge systems.” Since the vessel entered service, the International Maritime Organization has taken actions pertinent to the INS system on the Crown Princess. These include: International Maritime Organization MSC 82/WP.8, issued • December 8, 2006, “Draft report of the Maritime Safety Committee on its Eighty-second Session.” Standards of Training and Watchkeeping (STW) 38/17, issued • February 8, 2007, “Report to the Maritime Safety Committee.”

Appendix D National Transportation Safety Board M A R I N E Accident Report 80 International Electrotechnical Commission standard 62065 established performance standards for an autopilot system that steers a vessel along a predetermined track. At the time the NACOS 65 was developed, the International Electrotechnical Commission had not yet developed INS standards. As a result, the NACOS system on the Crown Princess met the trackpilot standards of International Electrotechnical Commission standard 62065, the pertinent standards of MSC 74(69), and classification society approval for an INS but not International Electrotechnical Commission standards for an INS. In 2006, the International Electrotechnical Commission adopted standard 6192, which established operational and performance standards for INSs. SAM Electronics told the Safety Board that the next NACOS generation INS will meet the operational and performance criteria of International Electrotechnical Commission standard 61924. SOLAS chapter V, regulation 15, provides the basic foundation for the design and arrangement of navigational systems, so that they enhance the performance of deck watchkeepers and bridge crewmembers. MSC circular 1061 calls for companies to incorporate their policies on the use of automation and the INS in their vessel operating manuals. The circular also addresses training in INS use, stating that companies, “in cooperation with the relevant manufacturers, should establish a training programme for all officers which have operational duties involving the INS.” MSC 82, the 82nd meeting of the MSC, produced several working papers and suggestions for action. Its human element working group recommended that the International Maritime Organization include ergonomic criteria in the application of SOLAS regulations to INSs and in training related to INS use. The report of the full MSC includes information regarding British research that had been “aimed at developing guidance for the mitigation of human error in automated shipborne maritime systems.” As the report noted: The research had identified a range of problems which could result from inappropriate or incorrect specification, design, selection, installation and use of automated systems, and suggested some methods of mitigation. In their opinion, the findings of this research should be considered by designers, shipbuilders, trainers, shore-based company management, ship- based management and seafarers themselves, to assist in the safe, effective and efficient use of automation aboard ships. (82/15.14) In addition, in 2006 the MSC instructed its STW subcommittee to review the International Convention on Standards of Training, Certification, and Watchkeeping for Seafarers (STCW code). In 2007, the MSC specified that such a review should include an issue involving the understanding of “automatic systems through familiarization training. . . .” Specifically, the subcommittee reported to the MSC that it:

Appendix D National Transportation Safety Board M A R I N E Accident Report 81 Identified that training recommendations given by performance management guidelines such as Integrated Navigation Systems, Integrated Bridge Systems and Bridge and Engine-room Resource Management, should be included within the STCW Convention with a view to seafarers understanding the limitations and weaknesses of automated systems and instructed STW 38 to consider this under its existing agenda item, “Compressive Review of the STCW Convention and the STCW Code.”1 1  STW 38/17, February 8, 2007, “Report to the Maritime Safety Committee,” p. 31.

National Transportation Safety Board M A R I N E Accident Report 82 Appendix E Model Curriculum Proposed by International Maritime Organization The suggested curriculum on IBS/INS system use developed by the International Maritime Organization assumes that the student has knowledge of deck operations and navigation but no IBS/INS experience. The model course is intended to serve as a guide for member states that are developing or certifying IBS/INS systems. States may use the curriculum, but the International Maritime Organization does not mandate such a course and does not specify when a mariner should take it, or the length of time that can elapse between when someone has completed the course and when that person uses an INS in actual vessel operations. The general objective of the course is noted in the Standards on Training and Watchkeeping (STW) circular, as follows: The safe and efficient use at sea of IBS and INS requires a level of knowledge beyond that normally given in the training of an officer in charge of a navigational watch. It is not just a matter of learning to use new controls, display techniques or how to switch on and off automatic functions. More importantly, it is learning the decision making process that must be applied in order [to] gain the full benefits of the integration in a safe manner and avoid the new problems that automatic controls and integrated systems can sometimes provide (p. 4). The STW circular includes a detailed instructor’s guide, a teaching syllabus, guidance on specific subject areas, recommendations both paper-and-pencil and simulator-based student exercises to demonstrate competence in the material, and guidance for evaluating a student’s knowledge of the material at the completion of the training. In addition to developing the model course, the International Maritime Organization’s STW subcommittee, at its 37th session (STW 37) in 2006, considered the need for a comprehensive review of the STCW convention and the STCW code, and proposed a work item with a target completion date of 2008. In May 2006, the Maritime Safety Committee (MSC 81)1 endorsed the proposal of STW 37 and included in the provisional agenda for STW 38 a high priority item on “Comprehensive Review of the STCW Convention and the STCW Code,” with a target completion date of 2008. At the subsequent meeting of the MSC, a resolution was passed instructing STW 38 to consider addressing the issue of human error in operator interactions with integrated bridge systems and the need for “basic 1  Report of the Maritime Safety Committee 81st session, MSC/81/25, paragraph 23.57.2.

Appendix E National Transportation Safety Board M A R I N E Accident Report 83 education and familiarization training of seafarers” as an agenda item in its “Comprehensive Review of the STCW Convention and the STCW Code”.2 The following pages reproduce the detailed teaching syllabus from the model IBS/INS course developed by the International Maritime Organization’s subcommittee on standards of training and watchkeeping. In addition to outlining the contents of the curriculum, the syllabus contains references to relevant publications and to teaching aids. 2  Report of the Maritime Safety Committee, MSC 82/24, paragraph 15.50

Appendix E National Transportation Safety Board M A R I N E Accident Report 84

Appendix E National Transportation Safety Board M A R I N E Accident Report 85

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Appendix E National Transportation Safety Board M A R I N E Accident Report 87

Appendix E National Transportation Safety Board M A R I N E Accident Report 88

Appendix E National Transportation Safety Board M A R I N E Accident Report 89

Appendix E National Transportation Safety Board M A R I N E Accident Report 90

Appendix E National Transportation Safety Board M A R I N E Accident Report 91

National Transportation Safety Board M A R I N E Accident Report 92 Appendix F International Maritime Organization Guidance on Integrated Navigation System Training

Appendix F National Transportation Safety Board M A R I N E Accident Report 93

Appendix F National Transportation Safety Board M A R I N E Accident Report 94

Appendix F National Transportation Safety Board M A R I N E Accident Report 95

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FD07325 ｜ 2006_美国_RAB0604.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2006 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

NTSB/RAB-06/04 E

P L U R IB US UN U M

N A T I O N A L

T R A S P O R T A T I O N

B O A R D S A FE T Y N

National Transportation Safety Board Washington, D.C. 20594

Railroad Accident Brief

Accident No.: DCA-06-FR-002 Location: Texarkana, Arkansas Date: October 15, 2005 Time: 4:56 a.m., central daylight time1 Railroad Union Pacific Railroad Damage: $2.4 million Injuries: 0 Fatalities: 1 Type of Accident: Collision

Synopsis At 4:56 a.m., central daylight time, on October 15, 2005, westbound Union Pacific Railroad (UP) train ZYCLD 132 collided with the rear of standing UP train MPBHG 15 in the UP rail yard in Texarkana, Arkansas. The collision resulted in the puncture of a railroad tank car containing propylene, a compressed flammable gas. The propylene was heavier than air and flowed near the ground into a nearby neighborhood. The flowing gas reached a house where an unknown ignition source ignited the gas, and the house exploded. The single occupant was killed. The fire moved quickly along the flowing gas back to the punctured tank car. A second, unoccupied, home was destroyed in the fire, and a wooden railroad trestle burned completely. Approximately 3,000 residents within a 1-mile radius of the punctured tank car were advised to evacuate the area. The two crews and the employees working at the Texarkana yard were not injured, and they evacuated the area safely. Between 5:00 a.m. and 7:00 a.m., the wind was calm, the visibility was 10 miles, and the temperature was approximately 59° F. Total damage was $2.4 million, including $325,975 in equipment damage and $2,053,198 in track damage. Accident Narrative The engineer and the conductor of train ZYCLD were scheduled to go on duty at 10:00 p.m. for a planned 260.9-mile trip from Pine Bluff, Arkansas, to Big Sandy, Texas.3 The crew was experienced over the territory. The engineer and the conductor arrived at the Pine Bluff yard office at 9:45 p.m. and 9:50 p.m., respectively. They gathered the

1 All times in this brief are central daylight time. 2 Each train will be identified by the letters in its identifier without the number. 3 The accident occurred 158.2 miles into the trip, at Texarkana, Arkansas.

NTSB/RAB-06/04 2 necessary paperwork for the trip, read the required notices, and conducted a safety briefing to discuss the trip. They were transported to their train at 11:00 p.m. The engineer performed an air test on the train, and the conductor checked the hand brakes. An employee from the mechanical department performed a successful air brake test on the train before the train departed at 11:34 p.m. The train consisted of 2 locomotive units and 57 loaded cars. The train was 5,598 feet long and weighed 3,961 tons. When train ZYCLD reached McNeil, Arkansas, 104.5 miles from Pine Bluff, the crew encountered a red signal, which was an indication that the train was following a train (MPBHG). The conductor told investigators that the trip was normal and the crew was not surprised to be following another train. The signal changed from red to yellow and then to flashing yellow. The train left McNeil on a flashing yellow signal, which meant that the train was at least two signal blocks behind the preceding train.4 At Stamps (two stations and 17.8 miles later), the crew encountered flashing yellow signals at both ends of the siding, meaning that they were still approximately two block signals behind the preceding train. At Lewisville (4.5 miles beyond Stamps) the crew observed a red signal that changed to yellow before the train had to stop. The signal at control point (CP)5 CB 414 (East Texarkana) remained red, and the crew said that they stopped the train and waited for a more favorable signal. According to the electronic signal records from the dispatching system, this signal (CP CB 414) went from red to yellow about 4:13 a.m. and from yellow to flashing yellow about 4:24 a.m. The event recorder on the lead locomotive indicated that train ZYCLD started moving at 4:45 a.m., 21 minutes after the signal had changed to flashing yellow. When investigators asked the crew why they did not proceed when the signal changed from yellow to flashing yellow, the crew could not provide a reason. The crew said that they did not call anyone on the radio while the train was stopped, but they did have a personal conversation. UP rules allow napping by one crewmember when the train is stopped if the other crewmember stays awake. The conductor and the engineer said that they did not nap during that time. The crew reported having extensive conversations during the trip. The next signal that train ZYCLD encountered was at CP CB 416. The signal had displayed a yellow aspect since 4:24 a.m., and the train passed this signal at 4:51 a.m. When the train passed the Texarkana rail yard limits at milepost (MP) 416.4, its speed was approximately 19 mph, according to the event recorder. The territory inside the yard limits was not controlled by the train dispatcher and did not have signals to indicate the presence of other trains. Within this territory, all trains were required to be operated at restricted speed.6 The engineer was controlling the train speed by using the power of the

4 The signal directly behind a train, which protects it from a following train, is red. The signal before the red is yellow, which tells the following train that it may proceed but must be prepared to stop at the next signal. In territories with higher speeds, a flashing yellow signal warns a following train of the upcoming yellow and red signals. Block signals are commonly spaced 1 to 2 miles apart. 5 Control points are locations where the signals are controlled by the train dispatcher. 6 Restricted speed was defined by operating rules, which required the train to be operated at a speed that would allow the train crew to stop the train in one-half the range of vision, but not exceeding 20 mph.

NTSB/RAB-06/04 3 locomotives against the braking force applied on the cars of the train.7 He applied more braking at MP 416.77, at 18 mph with the engine at throttle 4. The train slowed to 17 mph; and at MP 417.02, the engineer increased to throttle 5. Between MP 417.02 and MP 417.51, the engineer sounded the horn for a grade crossing and maintained the train speed at 17 mph. At MP 417.86, train ZYCLD collided with the rear car of train MPBHG. (See Figure 1.) After the collision, the event recorder showed the speed falling, a throttle reduction, a dynamic brake application, and an engineer-induced emergency brake application.

Figure 1. Aerial view of Texarkana accident. While the crew had worked all night, and their circadian rhythms were at a low point when the collision occurred, the engineer was actively operating the train shortly before the accident. He had blown the whistle at a grade crossing approximately 1/3 mile (70 seconds) before the collision and controlled the train’s speed by making brake and throttle adjustments only 1 mile before the collision. Further, during interviews, the crew told investigators that they had recognized a “dogleg” track configuration ahead of their train shortly before the point of impact. They both said that they had observed the standing train on their track with just enough time to brace themselves before impact.

7 This is referred to as power braking or stretch braking. It can be an effective method of controlling a train if it may have to be stopped quickly. Because brakes are already applied, the normal delay in the air brake system is avoided, and simply reducing the power decelerates the train almost immediately.

NTSB/RAB-06/04 4 When train ZYCLD struck the rear car of train MPBHG, neither the locomotives nor the cars on train ZYCLD derailed. The forces of the striking train derailed the rear three cars of train MPBHG, but the cars remained upright. Then the forces were transmitted through the next 12 cars without derailing them. As a result of the collision, the 18th car was forced out of train MPBHG completely, and the 17th car8 continued forward until it struck the end of the 19th car (tank car TIMX 33429) and punctured the head of the tank car with its uncoupled coupler. (See Figure 2.) The tank car was loaded with liquefied propylene gas,9 and immediately after it was punctured, about half of its propylene load was released. The propylene tank car was equipped with a tank-head puncture-resistance system and jacketed thermal insulation. Performance standards for tank-head puncture-resistance systems are contained in 49 Code of Federal Regulations 179.16. The regulations require that a tank-head puncture-resistance system on a standing tank car be capable of sustaining, without any loss of lading, the impact from a coupler on a single freight car that weighs at least 263,000 pounds and is moving 18 mph. Train ZYCLD weighed more than 8.7 million pounds.

Figure 2. Punctured tank car.

8 The UP numbers the cars in a train from the rear of the train; therefore, the 17th car was behind the 18th car. 9 Propylene is regulated under the U.S. Department of Transportation’s hazardous materials regulations, 49 Code of Federal Regulations 173.115, as a Division 2.1 flammable gas, which is defined as any material that is a gas at 68° F or less and 14.7 per square inch, gauge, of pressure and has a flammable range of at least 12 percent.

NTSB/RAB-06/04 5 The propylene did not ignite immediately. Eyewitnesses said that after the collision they saw fog-like conditions near the track in the ditches and low points of the surrounding area. A local law enforcement officer stated that he saw a fog-like substance reach a residence, which then exploded. He then saw a bluish flame follow the ground- level fog to the train, and then he saw another explosion near the derailed tank car. Emergency Response At the time of the accident, the yardmaster and eight other persons were on duty in the Texarkana yard during the evening work shift. In addition to these nine yard employees, there was a two-member crew in each of the arriving trains, MPBHG and ZYCLD. Shortly after the 4:56 a.m. collision of the two trains, the crew of standing train MPBHG notified the yardmaster that their train had been struck. About 5:00 a.m., the crew of the striking train advised the yardmaster that at least two cars at the rear of the train in front of them had derailed and were on the ground. The Texarkana, Arkansas, 911 communications center10 received several calls between 4:56 a.m. and 4:59 a.m. from residents complaining of a chemical odor adjacent to the Texarkana rail yard. The Texarkana 911 police dispatcher received the initial notification.11 The Texarkana fire and police departments then dispatched units, and the Texarkana Office of Emergency Management was notified about 5:00 a.m. Within the next several minutes, a police unit responding to the initial complaint (in the area of Hobo Jungle Park, across the street from the accident) reported to the 911 police dispatcher a chemical smell and a white cloud drifting south. During this time, the 911 police dispatcher received additional calls from residents in the Hobo Jungle Park area complaining of breathing difficulties. As the responding fire units established the initial command post within 1/4 mile of the yard, they encountered several residents with respiratory complaints. About 5:04 a.m., the 911 police dispatcher contacted the UP yardmaster. The yardmaster told the dispatcher that at least two cars at the rear of a train had derailed and that they might contain vinyl acetate residue. The dispatcher told the yardmaster about reports of a chemical odor at the scene. Reading through the train consist, the yardmaster told the dispatcher that the 19th car from the end of train MPBHG was a tank car containing propylene, a flammable gas. The yardmaster also told the dispatcher that he did not know whether the propylene tank car had derailed. He did not mention that the six cars ahead of the propylene tank car were also tank cars loaded with propylene.

10 The center had both police and fire dispatchers. 11 The incoming calls were taken initially by the police 911 dispatcher, who then coordinated on-line with the fire dispatcher to notify fire department personnel.

NTSB/RAB-06/04 6 About 5:05 a.m., the yardmaster contacted the manager of rail operations for the Texarkana yard—the senior management official for the yard—and reported the derailment.12 In a subsequent call to the 911 police dispatcher, the yardmaster recommended a 1-mile evacuation radius. The yardmaster told investigators that he had recommended the 1-mile evacuation radius because it would afford the “best and safest course of action because of the multiple numbers of cars involved” and because his consist showed a chlorine tank car in train MPBHG that was a potential poison inhalation hazard. About 5:08 a.m., emergency response units reported a large explosion and a massive fireball at a house adjacent to Hobo Jungle Park. Immediately afterward, a police officer reported that flames roughly 3 feet high with a blue-colored base ran back across the park to the train, where a second explosion and similar fireball ignited. The residential electricity in Hobo Jungle Park went out as the surrounding area was engulfed in extremely heavy black smoke. All police and fire units withdrew and established a new command post. Immediately following the explosions, the manager of rail operations, by telephone, directed the yardmaster to evacuate all yard employees and the four train crewmembers to Wadley Regional Hospital. The manager of rail operations later stated that he had ordered the evacuation because of the size of the event and his desire to have all railroad employees at one location. The manager of rail operations also said he had known that at the hospital the crew of the striking train would be tested in accordance with Federal Railroad Administration (FRA) postaccident toxicology procedures. By 5:15 a.m. the fire department chief arrived at the new command post and assumed incident command. The chief noted at that time that the only information the 911 fire dispatcher had provided to the command post was that a “residue vinyl acetate tank car had derailed.” The chief and other responders did not yet know that propylene tank cars were on the train. By 5:20 a.m., the immediate area around the accident site, including Hobo Jungle Park, was evacuated. At 5:30 a.m., the emergency operations center established a 1-mile evacuation radius around the accident site.13 About 5:25 a.m., the manager of rail operations arrived at the scene. Without checking in with the incident commander, he went directly to the yard office to obtain a copy of the train consist for train MPBHG.

12 During the emergency, the manager of rail operations and the yardmaster communicated only by telephone. Afterward, neither could remember precisely the number or times of conversations they had. 13 The evacuation concentrated on areas to the south and southeast of the rail yard. Police dispatchers had already started to assemble a reverse 911 notification list at 5:04 a.m. At 5:35 a.m., the incident command recommended that nearby jail facilities shelter in place and at 7:15 a.m. ordered the evacuation of a convalescent center. By 8:44 a.m., the incident command ended further evacuations but maintained the evacuations then in place.

NTSB/RAB-06/04 7 At 5:28 a.m., the fire department operations chief requested the train consist from on-scene UP personnel. Shortly afterward, the incident command directed the 911 dispatcher to contact the yard to obtain the train consist. However, with the yard tower evacuated, the dispatcher was unable to contact any of the UP personnel at the yard. Working with the consist for train MPBHG, the manager of rail operations began a damage assessment of the yard. By 6:00 a.m., he had worked his way along train MPBHG from the head end and marked the printed train consist with the locations of the derailed cars. He told investigators that he had seen the propylene cars and determined that only one of them, car 19, was leaking and burning at one end. Once he completed his preliminary assessment of the yard and damages, he reported this information to UP headquarters. At 7:15 a.m., the Texarkana emergency operations center coordinator, the incident commander, and the operations chief finally received the yard copy of the consist at the command post. No other information or assistance in interpreting the consist, such as the derailed car numbers or the manager of rail operations’ damage assessment, was provided by the UP, nor did the incident commander request additional information. When he received the consist, the fire department operations chief began to identify the tank cars containing hazardous materials that might be involved in the accident. Using binoculars and the train consist, he determined that the product in the burning tank car was propylene and that there were six additional loaded propylene tank cars. About 7:30 a.m., the fire department training chief and two firefighters (each using a self-contained breathing apparatus) entered the derailment site to assess the damage to all of the tank cars in the train, including the other six propylene tank cars. The training chief determined that there were no other leaks from any of the other cars. Upon completion of the fire department’s damage assessment, the incident commander ordered a water monitor (to cool the burning tank car without extinguishing the propylene flare on the end of the car) and a master stream (to cool a 6-inch natural gas line beside a burning trestle). Other fire suppression activities included extinguishing fires involving two houses and a nearby highway wooden bridge and putting out grass fires along the tracks. Fire department personnel also searched the two burning homes for additional victims. About 10:30 a.m., the UP’s contractor, the Center for Toxicology and Environmental Health, deployed air-monitoring equipment to evaluate the area surrounding the vinyl acetate tank cars. All readings later indicated that there were no leaks. Shortly afterward, additional UP contractors arrived, conducted a detailed assessment of the damaged tank cars, and developed a plan for removing those tank cars. At 1:30 p.m., the incident commander and all the parties agreed to dispose of the propylene in the punctured tank car by allowing it to burn in place. About 2:00 p.m., the incident commander reduced the evacuation zone to the immediate area at the site and allowed people to return to their homes. By 6:30 p.m., all fire suppression activities were completed; the propylene from the tank car was allowed to continue to burn. By

NTSB/RAB-06/04 8 10:30 p.m., wreck-clearing equipment raised one end of car 19 to drain the remaining propylene from the tank car. After the drained propylene was burned off and the tank car fire was extinguished, the emergency was concluded about 12:00 a.m. on October 16, 2005. Emergency Preparedness General guidance for hazardous material emergencies throughout the UP rail system was in the UP Hazardous Materials Emergency Plan dated October 15, 2000. The plan stipulated, in part, that local UP officials were to contact local emergency responders, meet emergency response personnel arriving at UP property, provide copies of shipping papers and emergency response information, and guide local emergency response personnel to an appropriate staging area. Under the UP Hazardous Materials Emergency Plan, the UP Texarkana yard was identified as a site requiring a specific hazardous materials emergency response plan. The manager of rail operations stated that copies of the UP Texarkana Yard Emergency Plan were in his office, in the yardmaster tower, and on all bulletin boards. The UP Texarkana Yard Emergency Plan lists the actions to take in a hazardous materials emergency, the telephone numbers of local and area public agencies including hospitals, the UP emergency response personnel at corporate headquarters and in the Texarkana area, and the hazardous materials equipment resources in the yard. The UP Texarkana Yard Emergency Plan requires a tabletop hazardous materials exercise every 5 years. The manager of rail operations stated that about 3 years ago, before he arrived in Texarkana, there was a simulated drill involving the fire department and the UP. Details of the scope of the exercises were not available, and no drills had been conducted since the manager of rail operations arrived. Before this accident, the UP had held some classes in Texarkana to familiarize first responders with the basics of rail tank cars. With several railroads, major highways, pipelines, and chemical facilities in the greater Texarkana area, the city’s hazardous materials response plan provides general guidance on policy and organizational responsibilities. In November 2005, Miller County, where Texarkana is located, conducted a multi-jurisdictional preparedness exercise that involved a simulated terrorist attack on a local rail yard; the training scenario also involved the release of chlorine from a tank car. Based on the lessons learned from the Texarkana accident and the training exercise, the city plans to have the entire fire department take technical hazardous materials responder training and to require hazardous materials awareness training for all the police and fire dispatchers in the communications center.

NTSB/RAB-06/04 9 Damage As a result of the collision, approximately 300 feet of track was disturbed. As a result of the fire, the railroad trestle was burned completely.14 Eight cars derailed on train MPBHG, one of which, a tank car, was destroyed. Four cars on the adjacent track maintenance train were also destroyed by the fire. Total equipment damage was $325,975, and track damage was $2,053,198. Two houses (one vacant), a shed, and a nearby highway bridge were also destroyed by explosion and fire. At least three highway vehicles that were parked near the tracks were burned completely. Fire destroyed the rear tires of a semitrailer parked near Hobo Jungle Park. The fire also burned approximately 4 acres of grass, brush, and trees. Personnel Information The Missouri Pacific Railroad hired the engineer of train ZYCLD as a switchman on April 17, 1978. In 1980, he was promoted to conductor. In 1986, he became a UP employee when the UP acquired the Missouri Pacific Railroad. In 1992, he was promoted to engineer. He passed his last operating rules examination in July 2004. The engineer had a total time on duty of 184 hours 24 minutes for the 28 days before the accident. In that period, he had worked approximately 17 days, with an average of 10 hours 51 minutes on duty per shift. He had been off duty for 44 hours 5 minutes before he went on duty on October 14, 2005. The conductor of train ZYCLD was hired by the Missouri Pacific Railroad as a brakeman on March 25, 1971, and he was promoted to conductor on September 1, 1975. Like the engineer, he became a UP employee in 1986. He passed his most recent operating rules examination in November 2004. The conductor had a total time on duty of 135 hours 35 minutes for the 28 days before the accident. He worked off the extra board15 and had worked 11 days during the first half of October. He was averaging 10 hours 26 minutes per day on duty and had been off duty for 17 hours before he went on duty on October 14, 2005. The train crew was experienced and qualified on the territory. After the accident, both crewmembers of the striking train were toxicologically tested as required by 49 Code of Federal Regulations Part 219. The test results showed no evidence of any impairing substances.

14 At the time of the accident, the wooden trestle, built in 1947, was scheduled for replacement. Within 3 days after the accident, the UP was preparing pilings for the replacement bridge. 15 The extra board is a pool of employees not assigned to regular runs who may be assigned to train crews to fill vacancies when regular employees take days off or are on vacation.

NTSB/RAB-06/04 10 Equipment Train ZYCLD originated in Chicago, Illinois, on October 13, 2005. The train received a Class I mechanical inspection and an initial terminal air brake test before departure. No mechanical defects were reported. The train received an additional Class I mechanical inspection and a Class IA 1,000-mile air brake inspection at Pine Bluff, Arkansas, on October 14, 2005. No mechanical defects were reported. Air brake leakage was recorded at 40 cubic feet per minute, which falls within the requirements of the FRA. No mechanical defects were reported during the trip from Pine Bluff to Texarkana. The locomotive engineer stated that the train had handled as anticipated during acceleration and deceleration. Operations Information At the time of the accident, the general written instructions covering these train movements were in the General Code of Operating Rules (GCOR), Fifth Edition, effective April 3, 2005. Supplementing the GCOR was the UP’s North Little Rock Area Timetable No. 2, effective June 3, 2001, and the revised Special Instructions, effective April 3, 2005. Train movements on the Pine Bluff Subdivision of the North Little Rock Area of the UP were authorized by a train dispatcher in Omaha, Nebraska, using a centralized traffic control system. However, just before trains reached Texarkana, at MP 416.4 they left the controlled territory and entered nonsignaled yard limits. Trains operating within rail yard limits, as in this accident, are required by the operating rules to be operated at restricted speed to prevent collisions. UP Oversight of Operating Rules Compliance One of the methods the UP used to monitor the effectiveness of and compliance with its operating rules was to conduct compliance field audits, called efficiency tests in the railroad industry. As required by Title 49 Code of Federal Regulations Part 217, this operational testing program and the results of the program were available for review by the FRA. In the 365 days before the accident, railroad supervisors had observed the engineer of train ZYCLD on 10 different occasions. The supervisors noted 30 individual operating or safety rules that the engineer followed. The tests indicated no failures. On two occasions the engineer was observed complying with the restricted speed rule. In the 365 days before the accident, railroad supervisors had observed the conductor of train ZYCLD on 24 separate occasions. The supervisors recorded only one failure, which was not related to operating at restricted speed. The conductor demonstrated proper rules compliance on the other 23 occasions, including 1 occurrence of complying with the restricted speed rule.

NTSB/RAB-06/04 11 Since the accident, the UP has provided the Safety Board with information about several measures that it has taken to reduce collisions at restricted speed. At Texarkana, the UP installed a signalized traffic control system on the main track through the yard. The UP removed yard limits at 28 locations by adding signalized control systems or track warrant controls and plans to eliminate yard limits at 121 additional locations. In addition, operational testing of train crews by supervisors has been improved, and the use of a red flag to stop trains while operating at restricted speed has been emphasized. As a result of these changes, there have been only three restricted speed collisions during the first 6 months of 2006. There were 12 restricted speed collisions in 2005. Sight-Distance Tests Investigators conducted sight-distance tests to investigate what the train ZYCLD crew would have been able to see at varying distances at the time of the accident. On October 17, 2005, investigators conducted reenactments between 4:45 a.m. and 5:45 a.m. with the same level of darkness before sunrise as on the day of the accident. The UP provided a locomotive similar to the locomotive on train ZYCLD and placed similar cars at the same locations as in the struck train. The first test was performed with the headlights on bright and the ditch lights turned off, as on the accident train. The end-of-train device on the parked train was illuminated. Visibility from the engineer’s seat was 3,272 feet, and from the conductor’s seat it was 3,228 feet. This test was performed a second time without the end-of-train device illuminated and with the flashing lights at the grade crossing activated. The visible distances were the same. The calculated stopping distance was approximately 1,500 feet at 20 mph. Postaccident Emergency Response Actions On October 25, 2005, the Texarkana Office of Emergency Management conducted a postaccident debriefing with all of the responding agencies, including the UP. Following this meeting, the Office of Emergency Management prepared a report containing recommendations addressing the lessons learned in this accident. The report identified specific problems that occurred during the incident in which communications broke down between the police and fire dispatchers and the UP tower. For example, initial observations of a vapor cloud and chemical odor by the responding police units were not passed by the dispatchers to the responding fire units, a dispatcher put the yardmaster on hold to answer other 911 calls, and the dispatchers were told to recall off- duty police department personnel during a time when the number of 911 calls was extremely high. In response to the findings in the report, the city of Texarkana has modified its communications center protocols for dispatcher assignments and hazardous materials training and has revised its communications center protocols for recalling off- duty personnel.

NTSB/RAB-06/04 12 In response to Texarkana’s requests following this accident, the UP provided in March 2006 the UP Hazardous Materials Emergency Plan, dated October 15, 2000. Furthermore, the UP has assured Texarkana that the UP Risk Management Communications Center in Omaha, Nebraska, will immediately provide on-line train consists in emergencies. Probable Cause The National Transportation Safety Board determines that the probable cause of the October 15, 2005, collision of Union Pacific Railroad train ZYCLD 13 with Union Pacific Railroad train MPBHG 15 in Texarkana, Arkansas, was the failure of the crew of train ZYCLD 13 to remain attentive and alert and thereby able to stop short of an observable standing train. Contributing to the severity of the accident was the puncture of a tank car during the collision, which resulted in the release of propylene and a fire.

NTSB/RAB-06/04 13 Recommendations As a result of its investigation of the Texarkana, Arkansas, railroad accident, the National Transportation Safety Board makes the safety recommendations listed below. For more information about these recommendations, see the safety recommendation letters16 to the recipients. To the city of Texarkana: Coordinate with all regional and local transporters of hazardous materials, such as railroads and trucking companies, to establish effective communications and response plans and conduct periodic joint emergency response drills and exercises. (I-06-01) To the Union Pacific Railroad: Implement measures to ensure that all of your field personnel understand and comply with your procedures for responding to hazardous materials incidents, with particular emphasis on timely notifications and appropriate coordination with local emergency responders. (R-06-23) To the International Association of Fire Chiefs: Notify your members about the circumstances of the accident in Texarkana, Arkansas, on October 15, 2005, and urge them to coordinate with all regional and local transporters of hazardous materials, such as railroads and trucking companies, to establish effective communications and coordination through joint emergency response drills and exercises. (I-06-02) To the Association of American Railroads and the American Short Line and Regional Railroad Association: Notify your members about the circumstances of the accident in Texarkana, Arkansas, on October 15, 2005, and urge them to coordinate with all communities adjacent to their railroad yards and along their hazardous materials routes to establish effective communications and coordination through joint emergency response drills and exercises. (R-06-18)

16 These letters are available on the National Transportation Safety Board’s web site.

NTSB/RAB-06/04 14

BY THE NATIONAL TRANSPORTATION SAFETY BOARD Mark V. Rosenker Chairman

Robert L. Sumwalt Vice Chairman Deborah A. P. Hersman Member Kathryn O’Leary Higgins Member

Adopted: October 17, 2006

FD07326 ｜ 2006_美国_RAR0601.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2006 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

Collision Between Two Washington Metropolitan Area Transit Authority Trains at the Woodley Park- Zoo/Adams Morgan Station in Washington, D.C. November 3, 2004 Railroad Accident Report NTSB/RAR-06/01 PB2006-916301 Notation 7680D National Transportation Safety Board Washington, D.C.

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Railroad Accident Report Collision Between Two Washington Metropolitan Area Transit Authority Trains at the Woodley Park- Zoo/Adams Morgan Station in Washington, D.C. November 3, 2004 NTSB/RAR-06/01 PB2006-916301 National Transportation Safety Board Notation 7680D 490 L’Enfant Plaza, S.W. Adopted March 23, 2006 Washington, D.C. 20594

National Transportation Safety Board. 2006. Collision Between Two Washington Metropolitan Area Transit Authority Trains at the Woodley Park-Zoo/Adams Morgan Station in Washington, D.C., November 3, 2004. Railroad Accident Report NTSB/RAR-06/01. Washington, DC. Abstract: On Wednesday, November 3, 2004, about 12:49 p.m., eastern standard time, Washington Metropolitan Area Transit Authority Metrorail train 703 collided with train 105 at the Woodley Park-Zoo/ Adams Morgan station in Washington, D.C. Train 703 was traveling outbound on the Red-Line segment of the Metrorail system and ascending the grade between the Woodley Park-Zoo/Adams Morgan and the Cleveland Park underground stations, when it rolled backwards about 2,246 feet and struck train 105 at a speed of about 36 mph. Train 703 was operating as a nonrevenue train; that is, it was not carrying passengers. Train 105, a revenue train, was in the process of discharging and loading passengers at the Woodley Park-Zoo/Adams Morgan station. There were about 70 passengers on board train 105. Some passengers had exited the train just before or during the collision. The District of Columbia Fire and Emergency Medical Service transported about 20 persons to local hospitals. Estimated property damages were $3,463,183. The safety issues discussed in this report are the lack of a rollback protection feature when trains are operated in the manual mode, operator performance, the lack of passenger emergency exit standards in the transit industry, and the crashworthiness of Metrorail 1000-series railcars. As a result of its investigation, the National Transportation Safety Board makes safety recommendations to the Washington Metropolitan Area Transit Authority and the Federal Transit Administration. On November 22, 2004, the Safety Board issued Urgent Safety Recommendation R-04-9 to the Washington Metropolitan Area Transit Authority. The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Web at http://www.ntsb.gov. Other information about available publications also may be obtained from the Web site or by contacting: National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (800) 877-6799 or (202) 314-6551 Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2006-916301 from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605-6000

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

iii Railroad Accident Report Contents Acronyms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Accident Synopsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Accident Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Preaccident Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 The Collision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Damages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Train Operator Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Operator of Train 703 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Operator of Train 105 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Train Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Train 703 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Train 105 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Wreckage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 General Description of Metrorail System, Tunnel/Station, and Track . . . . . . . . . . . . . . . . 11 Metrorail System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Tunnel/Station . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Track . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Operational Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Train Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Operations Control Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Method of Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Signal and Train Control Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Computerized Train Movement Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Mechanical Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Car Construction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Equipment Propulsion and Braking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Inspections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Rollback Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Toxicological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Survival Aspects and Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Station Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Passengers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Operations Control Center Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Metro Transit Police Department . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Disaster Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Passenger Car Side Windows . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Contents iv Railroad Accident Report Simulation Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Test of Rehabilitated Equipment With Rollback Protection . . . . . . . . . . . . . . . . . . . . . 25 WMATA’s Train Data Analysis Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Postaccident Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Other Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Transit Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Safety Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Internal Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Management and Organizational Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Crashworthiness of Passenger Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Operator Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Event Recorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 General Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 The Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Analysis Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Rollback Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Train 703 Operator’s Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Medical Fitness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Low Task Demands and Unremarkable Operating Environment . . . . . . . . . . . . . . . . . 42 Work Schedule and Sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Opportunity for Adequate Sleep During Off-Duty Hours . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Passenger Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Equipment Crashworthiness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 New Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Recommendation Reclassified in This Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Appendixes A: Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 B: Composition of Metrorail Passenger Railcar Fleet . . . . . . . . . . . . . . . . . . . . . . . 56 C: Summary of Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

v Railroad Accident Report Acronyms and Abbreviations AGM Assistant General Manager APTA American Public Transportation Association ATC automatic train control ATO Automatic Train Operation ATP Automatic Train Protection ATS Automatic Train Supervision B1/B5 braking positions CAF Construcciones Y Auxiliar de Ferrocarriles CEO Chief Executive Officer CFO Chief Financial Officer CFR Code of Federal Regulations DCFEMS District of Columbia Fire and Emergency Medical Service DGM Deputy General Manager FRA Federal Railroad Administration FTA Federal Transit Administration GERD Gastroesophageal Reflux Disease GM General Manager GMGR General Manager IOECCD Institute for Occupational Ergonomics and CCD Design and Ergonomics Ltd MSRPH Metrorail Safety Rules and Procedures Handbook MTPD Metro Transit Police Department OCC Operations Control Center P1/P5 propulsion positions TOC Tri-State Oversight Committee VDC Volts Direct Current VMS Vehicle Monitoring System WMATA Washington Metropolitan Area Transit Authority WSAD warning strobe and alarm device

vi Railroad Accident Report Executive Summary On Wednesday, November 3, 2004, about 12:49 p.m., eastern standard time, Washington Metropolitan Area Transit Authority Metrorail train 703 collided with train 105 at the Woodley Park-Zoo/Adams Morgan station in Washington, D.C. Train 703 was traveling outbound on the Red-Line segment of the Metrorail system and ascending the grade between the Woodley Park-Zoo/Adams Morgan and the Cleveland Park underground stations, when it rolled backwards about 2,246 feet and struck train 105 at a speed of about 36 mph. Train 703 was operating as a nonrevenue train; that is, it was not carrying passengers. Train 105, a revenue train, was in the process of discharging and loading passengers at the Woodley Park-Zoo/Adams Morgan station. There were about 70 passengers on board train 105. Some passengers had exited the train just before or during the collision. The District of Columbia Fire and Emergency Medical Service transported about 20 persons to local hospitals. Estimated property damages were $3,463,183. The National Transportation Safety Board determines that the probable cause of the November 3, 2004, collision between two Washington Metropolitan Area Transit Authority trains at the Woodley Park-Zoo/Adams Morgan station was the failure of the operator of train 703 to apply the brakes to stop the train, likely due to his reduced alertness. Contributing to the accident was the lack of a rollback protection feature to stop the train when operated in the manual mode. In its investigation of this accident, the Safety Board examined the following safety issues: • The lack of a rollback protection feature when trains are operated in the manual mode, • Operator performance, • The lack of passenger emergency exit standards in the transit industry, and • The crashworthiness of Metrorail 1000-series railcars. As a result of its investigation of this accident, the Safety Board makes recommendations to the Washington Metropolitan Area Transit Authority and the Federal Transit Administration. On November 22, 2004, the Board issued Urgent Safety Recommendation R-04-9 to the Washington Metropolitan Area Transit Authority.

1 Railroad Accident Report Factual Information Accident Synopsis On Wednesday, November 3, 2004, about 12:49 p.m.,1 Washington Metropolitan Area Transit Authority (WMATA)2 Metrorail train 703 collided with train 105 at the Woodley Park-Zoo/Adams Morgan (Woodley Park) station in Washington, D.C. Train 703 was traveling outbound on the Red-Line segment of the Metrorail system and ascending the grade between the Woodley Park and the Cleveland Park underground stations, when it rolled backwards about 2,246 feet3 and struck train 105 at a speed of about 36 mph. Train 703 was operating as a nonrevenue train; that is, it was not carrying passengers. Train 105, a revenue train, was in the process of discharging and loading passengers at the Woodley Park station. There were about 70 passengers on board train 105. Some passengers had exited the train just before or during the collision. The District of Columbia Fire and Emergency Medical Service (DCFEMS) transported about 20 persons to local hospitals. Estimated property damages were $3,463,183. Accident Narrative Preaccident Events On the day of the accident, the operator of train 703 started work about 8:00 a.m. at Shady Grove station. He stated that this was an overtime shift during which he was to work as assigned until about 1:00 p.m. and then start his regular work shift later that afternoon.4 His first assignment was train 156, a revenue train traveling from Shady Grove to Glenmont, which are stations located on opposite ends of the Red Line. The train was operated in the automatic mode for the morning trip. At the Dupont Circle station, a WMATA supervisor for the Red Line boarded the train and performed a quality check5 of the operator’s performance from Dupont Circle to the Gallery Place-Chinatown station. Upon completion of the quality check, the supervisor departed the train without comment. 1  All times in this report are eastern standard time. 2  WMATA is responsible for the Metrorail and Metrobus systems that serve Washington, D.C., and the surrounding suburbs in Maryland and Virginia. Although WMATA is responsible for rail and bus services, this report focuses exclusively on the Metrorail system. 3  This estimate is based on calculations provided by WMATA. 4  The operator normally worked the 2:00 p.m. to 11:00 p.m. shift, but on this day he had signed up for overtime to work the 8:00 a.m. to 1:00 p.m. shift prior to working his regular shift. 5  A quality check is an unannounced inspection by a line supervisor monitoring the performance of the train operator.

Factual Information 2 Railroad Accident Report Train 156 arrived at the Glenmont station, and the operator was informed that he would make a return trip with the same equipment to Shady Grove as train 103. When he arrived at the Friendship Heights station, a supervisor boarded his train and performed another quality check for the ride to the Shady Grove station. When he arrived at Shady Grove, the operator said that a supervisor told him to take a 6-car nonrevenue train to the maintenance facility at Brentwood. Specifically, he was told to leave four cars on track five and retrieve four cars from track three. He was expected to return to Shady Grove with train 703, a 6-car nonrevenue service train. After completing his work at Brentwood, the operator of train 703 received instructions from the Operations Control Center (OCC)6 to enter the mainline at Brentwood Yard and follow train 203, a revenue service train, back to Shady Grove. Train 105, another revenue service train, was to follow him. The operator of train 703 stated that he operated the train in manual mode,7 as required for a nonrevenue train move, on the trip back to Shady Grove. (See figure 1.) He stated that he was getting ringers8 frequently during the trip. Every time he received a ringer, he said that he had to brake his train by placing the master controller9 in either the B4 or B5 position. This slowed the train to the proper speed code (allowable track speed) and silenced the ringer. The Collision The operator of train 703 told investigators that he passed through the Woodley Park station at the required speed of 25 mph. In accordance with the operating rules, he sounded the horn but did not stop the train. He stated that he could see a train ahead at the Cleveland Park station platform, and he received an alarm as he ascended the grade approaching the station. He stated that he placed the master controller in the B4 position to slow his train and quiet the ringer. (See the report section entitled “Equipment Propulsion and Braking” for a description of braking designations.) About 12:49 p.m., train 703 rolled backwards about 2,246 feet downhill for about 78 seconds and collided with train 105, which was stopped at platform number 210 of the Woodley Park station, where passengers were boarding and deboarding the train. (See figure 2.) The operator was the only employee on board train 703 when the collision occurred.

6  The OCC controls and provides supervision for all train movements on the entire transit system. 7  In manual mode, the train is controlled by the train operator, which differs from the train being in the automatic mode under the computerized general control system. 8  Ringer is a slang term for the overspeed alarm, which is automatically activated when a train is following too close or going faster than speed codes allow. It is an element of the Automatic Train Protection (ATP) system. 9  The master controller is a lever with a spring-loaded handle that applies power (P1/P5) in the forward position and braking (B1/B5) when moved in the opposite position. The handle is spring loaded to function as a “deadman” control that applies the train brakes in an emergency if the operator releases the handle. 10  Platform number 2 is an outbound platform that services trains transporting passengers away from the metropolitan D.C. area.

Figure 1. WMATA Metrorail system map. Factual Information 3 Railroad Accident Report

Figure 2. Train 703 resting on top of train 105. Factual Information 4 Railroad Accident Report When questioned about the accident, the operator told investigators that after the train started to roll back: I would go to B-4, B-5, then back to a power load to pull the train up the hill, because it was going to drift between B-4 and B-5, so you have to come back to coast, in order to go to power load. So, I would come back to coast and usually it would catch but this time I drifted and once I drifted I went to power but the train didn’t catch it. So, then I went back, I said to myself, I will give it a second, you know, that is all I could do. I went to B-4, B-5 brake, and the train still did not catch. I tried once more, and I jerked it back as far as I could to B-5, to get the most brake possible but the train is not doing anything. So, at this point I hit the mushroom.[11] A short time later I felt it jerk and I thought the brakes had kicked in. If the mushroom did not work I was going to apply the handbrake that was my last option. When I felt it move I thought okay, the brakes kicked in. But when I looked at my console it was black, keyed down. He further stated that he was taught in the operator training class to troubleshoot the train by checking the circuit breakers to see why the console had gone dark. As he walked through the train, he stated that he saw smoke and that it looked like the train was buckled. He exited through the side emergency door and saw that his train had collided with another train. When the accident occurred, all revenue service trains were to be operated in manual Mode 2 Level 112 per protocol13 to enhance operator performance of manual train operations. (See the section entitled “Operational Information” for a description of train operating modes.) 11  Mushroom is a slang term for the activation button that applies the train’s emergency brakes on all cars. 12  Mode 2 level 1, as defined in the Metro Safety Rules and Procedures Handbook, is when the train is under operator control but protected by the ATP system. 13  WMATA protocol required all trains to operate in manual mode between 10:00 a.m. and 3:00 p.m.

Factual Information 5 Railroad Accident Report The operator of the struck train, train 105, stated that after he stopped at the station platform, he set his train brakes and the doors opened. As he got up from his console to close the doors, he looked up the tracks and saw train lights that appeared to be coming toward him. At first he was not sure whether the lights were coming toward his train because they were moving so slowly. He said that when he finally realized the other train was moving toward his train, he yelled to the passengers in the first car “get off the train, get off the train now,” and “everyone began screaming and running off the train.” The operator exited train 105 before the collision, and he went to the station manager’s booth on the mezzanine level to call the OCC and report the collision. He then returned to the train to help anyone needing assistance. After assisting one of the passengers retrieve papers left on the train, he applied the hand brakes in the last two cars of the train. He again contacted the OCC and described the actions he had taken. About 1:00 p.m., the Metro Transit Police Department (MTPD) and DCFEMS personnel began arriving at the Woodley Park station. Damages WMATA provided the following damage estimates: $3,102,000 for the replacement of rail transit vehicles; $337,031 for the repair of rail transit vehicles; and $24,152 for clean- up costs and related expenses. Total estimated damages were $3,463,183. Injuries See table 1 for a summary of injuries sustained in the accident. Table 1. Injuries14 sustained in accident. Type Train 105a a. The total in this column is an estimate based on witness statements. Train 703 Total Fatal 0 0 0 Serious 1 0 1 Minor 19 0 19 None 52 1 53 Total 72 1 73 14 Title 49 Code of Federal Regulations 830.2 defines fatal injury as “any injury which results in death within 30 days of the accident” and serious injury as “an injury which: (1) requires hospitalization for more than 48 hours, commencing within 7 days from the date the injury was received; (2) results in a fracture of any bone (except simple fractures of fingers, toes, or nose); (3) causes severe hemorrhages, nerve, or tendon damage; (4) involves any internal organ; or (5) involves second- or third-degree burns, or any burn affecting more than 5 percent of the body surface.”

Factual Information 6 Railroad Accident Report Train Operator Information Operator of Train 703 The operator of train 703 was a 32-year-old male hired by WMATA as a bus driver on December 4, 1997. After formal and on-the-job training, he was transferred and qualified as a train operator in April 2004. The train operator told investigators that he mostly had worked in the yard, performing such tasks as preparing trains for revenue service and moving them to and from the shop. In the yard, trains were operated only manually. He stated he had operated revenue service trains about once every 2 to 3 weeks. In the 1-month period preceding the accident, the train operator had 19 assigned workdays.15 On 10 of those days, he was assigned to a single shift, typically working from 2:00 p.m. to 11:00 p.m. On the 9 other days that he worked, he worked a double shift by adding a morning (overtime) shift to his regular shift. These overtime shifts, which began as early as 6:23 a.m., typically lasted 4 to 5 hours, and usually ended between 11:00 a.m. and 12:00 p.m. He was often off duty for 2 to 3 hours between shifts. The days on which his tour of duty included both an overtime shift and a regular shift generally lasted between 15 to 16 1/2 hours from start to finish. At the time of the accident, he was working an overtime shift (from about 8:00 a.m. to 1:00 p.m.), and he was also scheduled to work his regular shift. The train operator periodically worked consecutive days of overtime. On three occasions during the month before the accident, he had less than 8 hours (that is, 7 hours 45 minutes, 7 hours 33 minutes, and 7 hours 23 minutes) off duty between the end of his last (regular) assignment and the start of his next (overtime) shift. The train operator did not work on Sunday, October 31, or Monday, November 1,

1. Both days were his regular days off. He spent Monday at home doing chores. He

went to bed about 10:00 p.m., fell asleep at 10:30 p.m., and awoke at 6:30 a.m. on Tuesday, November 2. He went on duty about 8:00 a.m. and began working an extra shift, which concluded at 1:00 p.m. About 2:00 p.m., he began working his regular shift, which he completed at 11:00 p.m. After leaving work, he stated that he arrived at his house about 11:30 p.m. and went to sleep about 11:45 p.m. on the night of November 2. The train operator told investigators that he needs 8 hours of sleep to feel rested the next day. He indicated that he falls asleep “pretty quickly, maybe within 15, 20 minutes.” A review of the train operator’s cellular phone records for the night before and the morning of the accident showed he received three incoming calls and made one outgoing call. He received the first call, which lasted nearly 10 minutes, about 11:54 p.m. on November 2. The second call lasted about 1 minute and was received about 12:24 a.m. on November 3. The third call lasted 13 seconds and was received about 5:30 a.m. The operator then made a call at 5:31 a.m. That call lasted about 3 minutes. He reported that he awoke at 6:30 a.m. and arrived for work at Shady Grove station about 7:45 a.m. Cellular phone records indicate that the train operator did not use his personal cellular phone while operating train 703. 15  Sunday and Monday were his regularly assigned days off.

Factual Information 7 Railroad Accident Report The train operator stated that he was in good health. He had passed his last company physical examination prior to the accident on November 6, 2002. At that time, he had indicated that he did not have any medical problems on the health history portion of the medical examination report. He also indicated that he was not taking any prescription or non-prescription medications. The train operator’s medical records from his private physician indicated that since June 2001, he had visited a medical clinic eight times suffering from Gastroesophageal Reflux Disease (GERD) and once for stomach pain (diagnosed as gastritis). On two of those occasions (once for GERD and once for gastritis-related stomach pains), he had missed 2 days of work. About 4:30 a.m. on October 31, 2004, 3 days before the accident, the operator visited a medical clinic for stomach pain, which was determined to be related to epigastric pain and GERD.16 The clinic records for the operator’s October 31 visit indicated that the pain he was experiencing increased at night and had been a reoccurring problem during the previous month.17 Operator of Train 105 The operator of train 105 was a 58-year-old male hired by WMATA as a bus driver on October 24, 1978. After formal and on-the-job training, he was transferred and qualified as a train operator in June of 1996. He had spent his entire train career as an operator on the Red Line. On the day of the accident, he had made four trips on the Red Line and was completing his fifth trip when the collision occurred. The operator of train 105 reported for work about 7:45 a.m. on the Red Line at the Brentwood Yard. He traveled by train from Brentwood Yard to the Silver Spring station to pick up his first train. His initial assignment was from the Silver Spring station to the Grosvenor-Strathmore station and back to Silver Spring. He stated in interviews that the trip was uneventful, and he reported no anomalies. His next trip took him from Silver Spring to the Shady Grove station at the west end of the Red Line, where he arrived about 10:20 a.m. While at Shady Grove, he took a lunch break until 11:00 a.m. Then he began his third trip of the day, departing Shady Grove for the Glenmont station, located at the opposite end of the Red Line. After completing another normal trip, he departed Glenmont at 12:17 p.m. for his return trip to Shady Grove. This was to be his final trip of the day. 16  Investigators observed the train operator taking an over-the-counter antacid (that purports to relieve heartburn, acid indigestion, gas, and acid reflux) during interviews the day after the accident. It is unclear if any of his previous symptoms had persisted throughout the weekend, or if they reemerged following the accident. 17  During followup interviews conducted on March 16–17, 2005, the train operator told investigators that since the accident, he had visited another physician who did not believe he was suffering from acid reflux. The operator stated that his condition was more related to irritable bowl syndrome and he was told that he needed to change his diet.

Factual Information 8 Railroad Accident Report Train Information Metrorail utilizes a self-propelled, single-level, 175-passenger capacity,18 electrically powered,19 common-design passenger railroad car in its passenger transportation operations, as supplied by four manufacturers (Rohr,20 Breda,21 CAF,22 and ALSTOM23). (See appendix B.) Generally described, the cars measure 75 feet in length, 10.16 feet in width, and 10.83 feet in height. They have dual powered truck-assemblies, are constructed principally of aluminum alloy,24 and operate on 56.25-inch gauge track.25 A train operator’s compartment occupies one end of the car, which is referred to as the front end when the operator is operating the train. The passenger compartment occupies the balance of the carbody. A car-set consists of two railcars semi-permanently coupled together as a pair, commonly referred to as a married pair, with an operator compartment at each end. The two cars cannot operate separately because the married pair shares certain electronic control components, and the respective components are specific to each individual car. Passenger compartment seating is provided by a series of transverse mounted, paired seat- set assemblies, which are configured on both sides of a longitudinal oriented center aisle passageway. (See figure 3.) Numerous hand-hold stanchion posts and handrails are fitted throughout the car. Three passenger service doors are present on both sides of the car. That is, there are six passenger service doors available per car. There is also a body-end door at each end of the car.26 Passenger loading and unloading is performed only at Metrorail stations, all of which utilize a high-level passenger-loading platform.27 The cars involved in the accident were not fitted with event recorders.28 18  This passenger capacity is published by Metrorail Operations Department. 19  The cars are electrically powered by 700 Volts Direct Current/rail propulsion. 20  Built by Rohr Industries, which is no longer in business. 21  Breda Construzioni Ferroviarie S.p.A of Italy. 22  Construcciones Y Auxiliar de Ferrocarriles, Madrid, Spain, fabricates the carbody shell, and AAI Transportation Systems, in Hunt Valley, Maryland, provides the technical support (that is, the final carbody assembly). 23  ALSTOM Transport's, Saint Ouen Cedex, France, fabricates the carbody shell, and ALSTOM Transportation, Inc., in Hornell, New York, provides the technical support (that is, the final carbody assembly). None of the ALSTOM-built railcars were involved in the accident. They were scheduled for delivery commencing in 2005 through 2007. 24  Welded steel subassembly components are also used for certain structural load-bearing elements of the car. 25  Whereas, U.S. railroad standard gauge track is 56.5 inches. 26  Except for the extreme ends of the train, body-end doors remain unlocked during revenue operations. Body-end doors are provided for emergency use only, in order to access an adjacent car. 27  A high-level passenger-loading platform is located about 39 inches above the top-of-rail, the height of which matches the passenger service doors. 28  Metrorail indicated that the 5000-series and only the rehabilitated 2000/3000-series cars are fitted with event recorder equipment, and the 6000-series cars will have event recorder equipment. The accident cars were 1000 (train 703) and 4000 (train 105) series.

Factual Information 9 Railroad Accident Report Trains generally operate as 4- to 6-car trains, about 300 to 450 feet in length. Because the trains consist of car-sets, or married pairs, the shortest train that can be operated is a 2-car train. Train 703 Train 703 was a 6-car train consisting of 3 car-sets manufactured by Rohr. The operator was located in the first car, car 1128, followed by cars 1129, 1064, 1065, 1076, and 1077. The total train length was 450 feet. Train 105 Train 105 was a 6-car train consisting of 3 car-sets manufactured by Breda. The operator was located in the first car, car 4018, followed by cars 4019, 4017, 4016, 4093, and 4092. The total train length was 450 feet. Wreckage The rear end of the last car (1077) of northbound nonrevenue train 703 collided with the forward end of the first car (4018) of revenue train 105, which had stopped to service the Woodley Park station. The front end of car 4018 came to rest beneath, and substantially inside of, the breached rear carbody shell of 1077. Although almost all of the cars in both trains sustained damage, car 1077 bore the majority of the collision damage. Figure 3. Postaccident photo of car 1076 (mate to car 1077), showing typical interior view of an undamaged car.

Factual Information 10 Railroad Accident Report The collision wreckage was confined to about 100 feet of track immediately adjacent to the station platform. Small elements of collision debris were also found resting on the platform near the wreckage, having apparently separated from the wreckage during the collision.29 The two entangled carbodies came to rest upright and remained substantially aligned with the track, although elements of the two carbodies were wedged against the track-side of the platform and also on the opposite side, against the wall. There was no evidence of fire. The point of collision was determined to be about 75 feet south of the north end of the passenger platform. The impact shoved train 105 rearward about 16 feet, relative to where it had initially stopped. Car 1077, at the rear end of train 703, longitudinally overrode the leading end of the first car (4018) of the revenue train by about 20 feet. Car 1077 also sustained a loss of about 34 linear feet of the passenger occupant volume (survival space), which is almost half the length of the passenger compartment. The 34-foot loss of space (the collision intrusion) consisted of a tightly compressed mass of dislodged and displaced crushed seats, floor, ceiling, other interior elements, and the rear bulkhead panel structure. (See figure 4.) The rear end of car 1077 was lifted, and its roof came to rest about 18.8 feet above the top of rail with about a 10° upward incline and about a 4° cross level lean to the left toward the platform. (See figure 5.) Figure 4. Collision end of car 1077 showing debris field. 29  Emergency responders could have placed some of these items there during their search and rescue.

Figure 5. Accident site plan. Factual Information 11 Railroad Accident Report The first five cars of train 703 did not derail, and the fifth car (1076) sustained damage at the end adjacent to the sixth car (1077). The body-end doors between these cars were functional; however, the body-end doors between the fifth and sixth cars were wedged against each other and inoperable. The sixth car sustained the most damage when it telescoped and separated from its supporting wheel-set. A visual examination of the anti-climber element showed distinct indications of impact markings and striations on the upper face of the anti-climber flanges (teeth). The six cars of train 105 did not derail. The second through sixth cars had either a minimal amount of damage or no damage at all. The lead car (4018), although the forward carbody was intact and uncompromised, sustained damage to the front-end cab compartment. The left side window was pushed inward about 27 inches, and the forward body-end door was pushed inward about 20 inches at the top and about 6 inches at the bottom. The operator’s compartment, including the ceiling panels, was intact and undamaged. General Description of Metrorail System, Tunnel/Station, and Track Metrorail System WMATA’s Metrorail system comprises 106.3 miles with 86 stations. About one- half of the Metrorail system is below ground, and the other half is above ground. Five operating lines, designated by WMATA as Blue, Green, Orange, Yellow, and Red, make up the system that connects the Maryland and Virginia suburbs with the District of Columbia.

Factual Information 12 Railroad Accident Report The 30.38-mile Red Line serves passengers between the Glenmont station in Glenmont, Maryland, and the Shady Grove station near Gaithersburg, Maryland, by way of downtown Washington, D.C. There are 27 stations along the Red Line, 14 of which are above ground. Generally, it requires about 58 minutes for a train to completely traverse the Red Line and service all 27 stations. Rush hour headways30 are set for 3 minutes on all WMATA lines except for the Red Line, which allows a 2.5-minute rush hour headway. Headways during off-peak hours are about 12 minutes on all lines. Tunnel/Station The accident train was traveling on the Red Line in the single-track tunnel in the direction of Cleveland Park from the Woodley Park station. The tunnel is under Connecticut Avenue, and it is about 150 feet below ground at the Woodley Park station. The accident train collided with the standing train within the Woodley Park station. The station has two tracks (A-1 and A-2) at 37-foot centers separated by a 27-foot platform. Parallel to each track, along the tunnel wall, is a third rail electrified with approximately 750 volts, which supplies traction power to the trains. The interior cross-section of the station is symmetrical and approximates a semicircle with precast concrete sections that are about 52 feet wide by 29 feet high (its maximum height at its center) and about 24 feet above the top of rail of each track. WMATA designates the position and location of the track/tunnel within the system using engineering survey station numbering. For example, the Woodley Park station platform begins at station 128+0 and ends at station 134+0 (or is 600 feet in length), and the track/tunnel continues toward Cleveland Park, where the platform begins at station 165+40 and ends at station 171+40 (or is 600 feet in length). Trains travel through a 3,140-foot twin rock-lined, cast-in-place concrete tunnel between the two stations. Each tunnel approximates a semicircle that is 13 feet 6 inches above the top of rail and 16 feet 9 inches wide. Track The collision occurred on the A-2 outbound track at the north end of the Woodley Park station. A review and inspection of the A-2 single main track by investigators determined that the track met WMATA’s standards, which allow a maximum authorized speed of 59 mph on the Red Line. A visual examination by investigators did not show any evidence of wheel sliding on the top of the rail in the area of the accident. WMATA’s design criteria specify that the optimal maximum grade for attaining desired station elevation and for mainline running tracks is 4 percent. In exceptional circumstances, such as split level junctions and other isolated cases, the maximum grade may be increased to 5-percent downhill grades only (for normal direction of travel). The steepest grade on WMATA’s system is a 4.8-percent grade used to maintain the underground depth through parklands in an isolated area of the Green Line. A number of 3- and 4-percent grades are used to enter and exit underground tunnel portals and to ascend and descend aerial structures. 30  Headway is the time separation between two trains that are both traveling in the same direction on the same track. It is measured from the time the head end of the leading train passes a given reference point to the time the head end of the train immediately following passes the same reference point.

Factual Information 13 Railroad Accident Report Grade and Alignment. The A-2 track runs in a north-south direction, which is designated as outbound because trains operate away from the downtown area toward Shady Grove. Conversely, the A-1 track is designated as the inbound track. The track geometry approaching the Woodley Park station consists of a 9° 43’ 30” left-hand curve into the station. It then continues straight through the station on a 0.35 percent ascending grade. As it exits the Woodley Park station, the track remains straight and ascends on a 3.72 percent grade to the Cleveland Park station. Speed restrictions are determined by the conformance of the track to WMATA’s track standards. The maximum designed speed on WMATA’s system is 79 mph, and the maximum regulated speed is set at 59 mph. Maximum speed on WMATA’s system is determined by existing track geometry that includes track curvature, super elevation, length of spiral for curves, and other track conditions. During the most recent inspection prior to this accident, WMATA determined that the track was safe for normal speed. Operational Information Train Operations The Metrorail Safety Rules and Procedures Handbook (MSRPH), dated January 2004, governs the operation of trains on WMATA’s rail system. WMATA officials cited several rule violations applicable to this accident: MSRPH operating rules 3.1, 3.18, 3.57, 3.57.1, 3.69, 3.91, and 3.91.1; in addition to MSRPH general rule 1.1.1. The two most relevant operating rules are 3.57 and 3.91.1, which state in part: Rule 3.57 All propulsion problems regardless of severity are to be immediately reported to OCC, the Terminal Supervisor, or Interlocking Operator as appropriate. Rule 3.91.1 Train operators shall activate the emergency stop pushbutton (mushroom) any time a train must be stopped to prevent a collision with any object or, when the train fails to respond to a call for normal braking from the Master controller. Operations Control Center All train control and supervision for the entire transit system is conducted through the OCC, which is located in Washington, D.C. The OCC is equipped with monitoring, control, and communication facilities required to operate the transit system and to handle emergency situations. The OCC is staffed 24 hours a day, 7 days a week. OCC supervisors are responsible for all mainline train operations and the safe operation of revenue trains in accordance with approved timetables or modifications of them when necessary. When notified of an emergency, the OCC supervisor coordinates all activities to alleviate the situation. Ensuring the safety of passengers and employees and the protection of property and equipment are the OCC supervisor’s primary concerns.

Factual Information 14 Railroad Accident Report When this accident occurred, two supervisors were staffing the OCC desk for the Red Line. One of the supervisors was in charge of all communications with the trains. The other supervisor was in charge of routing the trains and expediting their movement across the system. Both supervisors stated that they would have expected the operator of train 703 to call the OCC for assistance the moment his train did not respond to the commands that he said he had applied. Method of Operations “Maximum authorized speed” is defined in the MSRPH as the most restrictive speed that includes the following: limiting speed, operating speeds specified in operating rules, safety rules, standard operating procedures and/or operating and restrictions notices; and speeds issued by verbal instructions of supervisory and OCC personnel. According to the MSRPH, this shall not preclude Mode 2 Level 2 operation of trains. Train operation is carried out via either automatic train control (ATC) or manual control by a train operator. The ATC system consists of three control subsystems and a computerized general control facility. The three control subsystems are Automatic Train Operation (ATO), Automatic Train Supervision (ATS), and Automatic Train Protection (ATP). Each subsystem performs its own particular functions independently of the other two (to a certain extent). The operation of the three subsystems is coordinated through the computer at the OCC to achieve an integrated control system: • ATO – The subsystem performing functions normally tasked to an operator. Those functions are acceleration, deceleration, speed regulation, programmed stopping, and door control (in conjunction with ATP and the Train-to-Wayside Communication System). • ATS – The subsystem that monitors the system status and provides the appropriate controls to direct the operation of trains in order to maintain traffic patterns and minimize the effect of train delays by controlling arrival and departure times, and by using OCC computer programs to accomplish minor schedule adjustments. • ATP – The subsystem that enforces safety operation. Speed limits are imposed both to maintain safe train separation and to operate trains in accordance with civil speed restrictions. At an interlocking it ensures that train movement is permitted only when a route is available through the interlocking, and the switches are safely locked in position. In all cases where two or more trains request the use of a single segment of track or interlocking, the ATP prevents occupancy by more than one train. The MSRPH defines various modes and levels of manual train operations with a train operator as follows:

Factual Information 15 Railroad Accident Report • Mode 2 Level 2 (Manual Operation with zero speed commands) – Train operation with train under train operator control with operation partially monitored and protected by the ATP system. The train is to be operated at restricted speed (15 mph or as directed by OCC) and an Absolute Block[31] or Permissive Block[32] must be established when operating on mainline. This is the normal operating mode in yards. • Mode 2 Level 1 (Manual Operation with Speed Commands) – Train operation with train under train operator control with operation monitored and protected by ATP. Train speed is not to exceed the more restrictive speed displayed on the console or as designated by OCC, whichever is less. • Mode 3 (Manual Operation with ATP cut out) – Train operation under train operator control without ATP monitoring and protection. This mode is not allowed unless passengers are off-loaded at the first available station and an Absolute Block or Permissive Block is established to allow train movement. Signal and Train Control Information Train operations on the Red Line are governed by a traffic control system that controls train movements in both directions on two main tracks. The system employs General Railway Signal light signals, located at interlocking locations only, and General Railway Signal Model 55E electric switch machines. Audio frequency track circuits control train speeds. All interlocking locations are operated remotely from a control panel in the OCC located in Washington, D.C. Each mainline route is divided into track blocks33 from one end of the terminal station to the other. Each block is checked for train occupancy by means of audio frequency track circuits. Tuned impedance devices provide block separation. These devices inject coded signals into the track that detect the presence of a train in the block and automatically transmit limiting and regulated speeds to passing trains. There is generally one track circuit per block with impedance bonds located at both ends of each track circuit. Computerized Train Movement Report At the OCC, WMATA has a computer system that uses track-bed detectors to record all train movement operations throughout the system. The system report shows the clock time that a track is occupied and when it is vacated by a train, as well as the minimum, maximum, and average speeds of the head end and rear end of the train. The report also lists the circuit number (block name), outbound and inbound locations, length 31  Absolute Block is a section of track between two specific locations into which no train is permitted to enter while it is occupied by another train. 32  Permissive Block is a section of clear track ahead of a train, in the established direction of traffic, up to a specific point into which no other train, track vehicle, or obstruction is permitted. 33  Track blocks through the accident section are designated with the prefix “A2” and the even station number of the inbound chainage mark. For example, A2-162 represents track number 2 starting at the inbound chainage location 162+27.

Factual Information 16 Railroad Accident Report of the track circuit, estimated pre- and post-shunt distance, clock time the train occupied and vacated the track circuit, maximum, minimum, and average speeds of the head end and rear end of the train at each track circuit, and the expected speed command. Each report is accompanied with a legend for interlocking and station platforms. (See the report section entitled “Tests and Research.”) Mechanical Information Car Construction The cars involved in the accident were from the 1000 and 4000 series built by Rohr and Breda, respectively. The carbody is composed principally of aluminum alloy extrusions and formed shapes with welded steel subassembly components for certain load- bearing structural elements. The front-end cowl assembly is fabricated of molded fiberglass incorporating a pair of collision and corner post elements. Aluminum sheeting makes up the exterior skin of the roof, sidewalls, and rear-end panels. The front end of each car contains a train operator’s compartment34 (fitted with operating controls). The rest of each car contains the passenger compartment. Although Federal Railroad Administration (FRA) regulations require anti-telescoping features on self-propelled multiple unit cars, the FRA does not have regulatory authority over WMATA’s equipment. However, WMATA specified to its car builders that collision post elements must be fitted to the cars and that they must consist of a pair of vertically mounted structural beams installed on both sides of the body-end doors at the front end of the railcar. WMATA further specified that they must be securely attached to both the end underframe assemblies and the carbody roof framing structure. The main underframe of the 1000- and 4000-series cars consists of transverse aluminum beams attached by blind-fastener bolts to the aluminum lower sidewall (U-channel shaped) extrusions. These beams extend the full length of the carbody and function as side-sill components. The cars do not have a conventional center-sill element (as found in some intercity passenger car designs), but incorporate longitudinally oriented intercostal elements fitted between some of the transverse beams. The end underframe assemblies (one fitted to each end of the car with the truck-assemblies attached to them) are fabricated of low-alloy/high-tensile steel and consist of a body bolster, a draft sill, and an angular end-sill fitted with a conventional anti-climber element, all welded together to form a single-unit assembly. (See figure 6.) 34  When a train is in service, only one operator compartment is occupied and all the others are locked.

Figure 6. a(A) Typical WMATA Metrorail carbody structure. (B) Underframe of Rohr a.This figure first appeared in the following report: National Transportation Safety Board, Collision of Washington Metropolitan Area Transit Authority Train T-111 With Standing Train At Shady Grove Passenger Station, Gaithersburg, Maryland, Railroad Accident Report NTSB/RAR-96/04 (Washington, DC: NTSB, 1996) 13. In that report, the figure was used to illustrate the underframe of a Breda Metrorail car. Here it represents the underframe of a typical Rohr Metrorail car in that the structural configuration is very similar. Metrorail car. (C) End underframe assembly. (D) Attachment of side sill to end of underframe. Factual Information 17 Railroad Accident Report

Factual Information 18 Railroad Accident Report The exterior carbody shell and the internal floor plan layout are virtually identical for the entire car fleet. However, many of the internal mechanical elements of each successive car delivery group35 are unique to that specific car group. That is, the Rohr- built cars differ from the Breda-built cars, which differ from the CAF-built cars. Also, cars built by a given manufacturer are required to be operationally compatible with cars built by any of the other manufacturers. WMATA prescribes the design and performance specifications of the cars to be built by the manufacturers, with each successive car delivery group having a separate specification from the previous car delivery group. Equipment Propulsion and Braking The operator of train 703 was operating the train from the lead car (1128) using the master controller handle. The master controller handle is equipped with a deadman function.36 When a master controller is in the “on” position, only that master controller will operate the train. The master controller handle has five propulsion positions (P1-P5), a coast position, and five braking positions (B1-B5). The positions P5 and B5 designate the maximum propulsion and braking efforts, respectively. The cars are equipped with both electric (dynamic37) and friction brakes. Both brake systems incorporate automatic slip/slide wheel protection designed to prevent wheel slips during acceleration and wheel slides when the train slows or stops.38 The car braking system is part of the overall ATC system. The design of the emergency brake causes direct electrical activation in three ways: release of the master controller handle, depressing the emergency stop button,39 or by an interruption of electrical power anywhere in the brake control circuit.40 Direct electrical activation engages a magnetic valve resulting in the application of brake cylinder pressure at the emergency rate and value. An emergency brake application also can be activated pneumatically. A pneumatically pressurized brake pipe is maintained through a train. In the event pneumatic pressure falls below a predetermined value, the magnetic valve deenergizes, initiating an emergency application of the friction brakes. 35  Because the cars were delivered in consecutive groups from different manufacturers, they are identified by an assigned number (for example, the 1000-, 2000-, etc. series cars), and they are referred to as successive delivery groups. 36  The deadman function applies the train brakes when the master controller handle is released. 37  Under propulsion, electric traction motors that receive electricity from an adjacent third rail drive WMATA trains. Under dynamic braking, the traction motors are converted to electric generators that supply electricity back to the third rail. This electrical load on the traction motor/generator acts to slow the motor shaft rotation, which results in a braking action being applied to the train wheels. 38  Slip/slide protection is not available when the emergency brake application is initiated. 39  The emergency stop button is also referred to as the mushroom. 40  Disengaging the friction brake switch has the same effect as a broken wire or other electrical malfunction and will serve to activate an emergency brake application.

Factual Information 19 Railroad Accident Report Inspections Investigators inspected the braking systems on trains 105 and 703, to the extent possible (as further described below), before the equipment was moved from the accident site. The friction brakes on train 105 were observed to be fully applied. Each brake pad was tightly pressed against its respective brake disk and did not rattle or move when struck. The working surface of each brake rotor was smooth and appeared polished. The friction brakes on five cars (1128, 1129, 1064, 1065, and 1076) from train 703 were in a condition similar to those on train 105. The sixth car, 1077, of train 703 had sustained major damage in the collision. The rear truck had derailed and lost hydraulic fluid from the braking system. Hydraulic fluid was evident on the truck components and track structure in the immediate area. The friction brakes on that truck were loose and not applying pressure to the rotors; however, the working surface of the rotors was smooth and polished. The friction brakes on the leading truck of 1077 were applied, and they did not rattle or move when struck. A second test, performed 24 hours after the first test on train 703, found that friction brakes on the trailing truck of cars 1128, 1129, and 1077 and on the lead truck of car 1076 rattled when struck. The electronic brake control units from each car of train 703 were removed and the data were downloaded before the cars were moved from the accident site. No faults were recorded on any of the electronic brake control units prior to the collision. After the cars were moved to the Brentwood Shops and the control units were reinstalled in cars 1128, 1129, 1064, and 1065, recordings of brake pressure readings indicated that the pressure levels were within tolerance for every brake application. Rollback Protection At the time of the accident, all WMATA passenger railcars were equipped with rollback protection when being operated in automatic mode. Some of the 2000- and 3000- series cars that had been recently rehabilitated were configured with rollback protection when operated in manual mode. However, none of the equipment on train 703 was equipped with the rollback protection feature in the manual mode. There was no documentation on board the WMATA equipment or issued to train operators that explained which cars had rollback protection in the manual mode and which cars did not. The operator of train 703 told investigators that after the train began to roll back, he applied power in an attempt to stop the rollback and resume forward movement. The Safety Board tested a similar set of six 1000-series cars operated in the manual mode. The Board found that in a rollback event on the grade exiting the Woodley Park station, the rollback could be stopped by applying forward power only if the rollback speed was 2 mph or less. If the rollback speed exceeded 2 mph, a brake application was required to stop the rollback or slow the train to 2 mph or less, at which time any application of power resulted in forward movement. In all cases, applying the train brakes stopped the train.

Factual Information 20 Railroad Accident Report Meteorological Information The collision occurred in a well-lit underground tunnel station. The temperature inside the underground tunnel station was about 65° F. The outside weather was clear, and the temperature was about 60° F. Medical and Pathological Information The DCFEMS transported 20 patients to five area hospitals. Medical records for these patients indicated that one passenger sustained a serious hip injury and was hospitalized for more than 48 hours. The other passengers were treated for various minor contusions, muscle pains, strains, and sprains and released. The operator of the struck train was treated for shortness of breath and released. Toxicological Information The Federal Transit Administration (FTA) regulations, 49 Code of Federal Regulations (CFR) 655.44, require transit owners to ensure that covered employees who have been directly involved in or who may have contributed to an accident provide specimens for toxicological testing. The accident train operator indicated that he was not taking any prescription or non-prescription medications. Both train operators provided postaccident toxicological urine specimens that were tested for the presence of drugs. Both operators also took a Breathalyzer test to detect any alcohol in their system. The test results for both operators were negative for drugs and alcohol. Survival Aspects and Emergency Response Station Access The Woodley Park station is located at 2622 Connecticut Avenue, NW, Washington, D.C. One entrance to the station is located at the intersection of Connecticut Avenue, NW, and 24th Street, NW. This entrance has escalators to an intermediate level, from the intermediate level to a mezzanine level, and from the mezzanine level to the platform level. The platform level is about 150 feet underground. The station manager is located in a station kiosk on the mezzanine level. A second station entrance is located at the intersection of Connecticut Avenue, NW, and Garfield Avenue, NW. This entrance has an elevator to the mezzanine level. There is also a second elevator between the mezzanine level and the platform level.

Factual Information 21 Railroad Accident Report Passengers After the accident, the MTPD obtained the names of 70 passengers. Investigators also reviewed WMATA’s security videos, recorded by cameras mounted inside of the station, in an attempt to determine the number of people exiting the train and the station. Due to the quality of the videos, an exact count was not possible. One video showed people on the escalators going from the platform level of the station to the mezzanine level. About 75 people were observed on the escalator. The second video showed people on the mezzanine level of the station moving toward the escalators that exit the station. About 150 people were observed exiting the station. These counts could include passengers on the train, other people in the station at the time of the accident, or people who entered and then exited the station after the accident. Following the collision, four trains traversed through the station on the adjacent track before all train traffic was stopped, about 1:14 p.m.,41 by WMATA officials at the request of emergency responders. The disembarking and embarking passengers from three trains (two inbound and one outbound) that stopped at the station42 complicated attempts to acquire an accurate count of passengers involved in the accident. From the MTPD’s statements, hospital records, and witnesses that came forward after the accident, it was estimated that 73 people, including the 2 train operators, were involved in the accident. Emergency Response About 12:49 p.m., the DC 911 communications center was notified of a train wreck at the Woodley Park station. Over the next several minutes, other notification calls were received. About 12:51 p.m., the DC 911 dispatcher contacted the MTPD and the DCFEMS. About 12:54 p.m., the DCFEMS began dispatching emergency units to the Woodley Park station. The first unit arrived on scene about 12:58 p.m. DCFEMS personnel entered the standing train about 1:01 p.m. and determined that everyone had exited the train. DCFEMS personnel began locating, assisting, and triaging the injured. Several of the injured passengers were located at the street level after they had left the station, and some had gathered in a hotel lobby above ground. About 1:14 p.m., the DCFEMS WMATA liaison officer reported that power to track A-2, where the accident trains were located, had been shut off and that other trains would be moving on track A-1, on the opposite platform side. The incident commander reported that at that time, two trains were waiting outside the station limits on track A-1 and they were going to travel through the station before all train traffic would be stopped. 41  About 1:14 p.m., the OCC removed power from track A-1 and began turning back trains on both sides of the Woodley Park station. 42  About 12:52 p.m., the first inbound train (110) serviced Woodley Park station a minute after the collision. About 12:59 p.m., the second train that serviced Woodley Park (204) was single tracked (outbound) with a supervisor on board to investigate the report of a collision. About 1:11 p.m., an inbound train (201) serviced Woodley Park. About 1:13 p.m., an inbound train (101) arrived in the station but did not service it.

Factual Information 22 Railroad Accident Report The DCFEMS was unsure if anyone was in the section of the last car of the striking train, train 703, which came to rest on top of the first car of the struck train, train

1. They used photo-imaging equipment to check for body heat readings, and they had

difficulty removing car windows to enter the car for a visual search. About 1:24 p.m., both train operators were located at the kiosk on the mezzanine level within the station. About 2:10 p.m., DCFEMS personnel advised that there was no one in the last car of train 703, and they recommended concluding the rescue operation. DCFEMS personnel transported the last of the injured passengers to the hospital about 2:22 p.m. About 3:05 p.m., the incident commander discontinued the operations. Operations Control Center Communications About 12:50 p.m., the operator of standing train 105 called the OCC and said: I saw another train coming down the track backwards. I opened up my door to get the passengers off. I told everybody to get off. I ran off the train. The other train ran into my train…. The other train ran into my train. It is on top of my train now. About 12:53 p.m., the operator of the striking train, train 703, called the OCC and said: “I was on the train. It got away. It rolled backwards. I couldn't stop it.” Metro Transit Police Department The MTPD is the law enforcement agency for the metro system. The first responding officers arrived on scene about 1:01 p.m. Another MTPD responder advised the MTPD dispatcher that he had a warning strobe and alarm device (WSAD43) and would go to the scene. Two additional units responded with WSADs, and a device was placed on the track at each end of the train. Additional units responded to provide security at Woodley Park and the surrounding stations (Van Ness, Cleveland Park, and DuPont Circle). A MTPD officer coordinated operations with the DC Fire Department incident commander at the command post outside the station, and another officer coordinated with the fire department forward commander inside the station. A liaison was assigned to coordinate with the OCC. Disaster Preparedness Emergency Services Manual. WMATA and the Metropolitan Council of Governments Passenger Rail Safety Subcommittee developed the Emergency Services Manual. The purpose of the manual is to “serve as a training manual and a reference source for information the Fire and Rescue service will need to handle emergencies in and around the Metrorail system.” The manual was first published in November 2000 and last revised in June 2001.44 The manual includes information about WMATA’s Metrorail 43  A WSAD is a warning unit that can be attached to the third rail when power is down. The WSAD provides a visual and audible alert if third rail power is restored. 44  The precursor to the Emergency Services Manual was the Emergency Services Training Manual, which was first published in 1987.

Factual Information 23 Railroad Accident Report system, stations, elevators, escalators, the right-of-way, railcars, electrical systems, communications, ventilations systems, fire detection and alarm systems, fire suppression systems, and rescue equipment. The manual also contains the “Metrorail and Fire/Rescue Services Emergency Procedures Policy Agreement,” dated May 13, 1997. WMATA and the region’s fire chiefs developed the agreement. The agreement includes specific standard operating procedures for emergency operations.45 Emergency Responder Training. WMATA provides training for emergency responders at its training facility in Landover, Maryland. The training facility has a mock tunnel designed to replicate the features found in tunnels on the rail system. The mock tunnel has track with a simulated third rail, an emergency access catwalk, standpipes, an emergency trip station phone, an emergency tunnel evacuation cart, and two railcars that were damaged in a previous accident.46 The training includes classroom instruction and a disaster exercise. The classroom instruction provides general information about the Metrorail system and specific information about responding to a rail emergency. Disaster drills simulate an emergency situation that could occur on the system, such as smoke in a tunnel. These drills are specifically designed to incorporate use of the response maps, the standpipes, the ventilation system, the emergency trip station phone, and WSAD. According to WMATA’s records for the class, about 575 DCFEMS firefighters and recruits were listed on sign-in sheets for the training in 2004.47 Prior to the accident, the most recent disaster response and readiness exercise in which DCFEMS personnel participated was conducted on October 16, 2004, at the Largo Town Center station. Passenger Car Side Windows The center door (the emergency exit door) of car 1077 of train 703 was damaged, and debris in the car end did not permit access to search that area. Emergency responders stated that when they tried to place imaging equipment in car 1077, they had difficulty removing a window in the damaged portion of the car. Responders stated that the rubber zip strip48 surrounding the outside of the window was brittle and kept tearing. The window was stuck in its frame, and only after significant effort was it removed. According to WMATA, the windows on the 1000-series railcars are an assembly consisting of a safety glass exterior and a polycarbonate interior. The windows on the 2000-, 3000-, and 5000-series cars are single-sheet safety glass. The windows on the 45  These procedures are also published in WMATA’s Metrorail Safety Rules and Procedures Handbook. 46  National Transportation Safety Board, Collision of Washington Metropolitan Area Transit Authority Train T-111 with Standing Train at Shady Grove Passenger Station, Gaithersburg, Maryland, January 6, 1996, Railroad Accident Report NTSB/RAR-96/04 (Washington, DC: NTSB, 1996). 47  Some persons attended the class more than once during that time. 48  Although emergency responders referred to the window sealant as a zip strip, it was actually a rubber grommet that was not intended for manual removal.

Factual Information 24 Railroad Accident Report 4000-series cars are single-sheet polycarbonate, which is being replaced with single-sheet safety glass. WMATA’s Emergency Services Manual provides emergency responders with general window specifications, stating in part: Rail car side windows are a combination of safety glass on the exterior and polycarbonate on the interior. These windows are designed not to open. Each window is held in place with a rubber zip strip that can be removed from the inside of the passenger compartment. For the 1000-series car side windows, the Emergency Services Manual further explains that: The side windows in the Rohr cars are set in a metal frame. If it is necessary to remove a side window you will remove the zip strip gasket that holds the metal frame in the opening. Then push the window and frame outward from the inside to remove it. It will require considerable force to remove the window and frame; the design of the opening causes an extremely tight fit of the window and frame in the opening. Tests and Research Simulation Tests Investigators reviewed security videotapes from WMATA of the Woodley Park station to determine the time it took for train 703 to depart Woodley Park and then reenter the station and strike train 105. Investigators determined that train 703 struck train 105 about 2 minutes 30 seconds after train 703 had departed from Woodley Park. Based on this information, investigators calculated the time it would have taken a train to roll back from the farthest point train 703 reached after leaving Woodley Park. This point was calculated using the total time (30 seconds) train 703 occupied the last signal block. Simulation tests were conducted at the accident site on the section of track that train 703 traversed before the collision. Testing began on the evening of November 6, 2004, and continued into the morning of November 7. More tests were conducted on November 15. During these tests, investigators attempted to replicate the train operator’s reported actions prior to the collision. Two series of tests were performed using 6-car trains. The first series of tests used an exemplar train consisting of six Rohr train cars operated in the manual and automatic mode. None of these cars were involved in the accident. The second series of tests used four of the six cars that had made up the train consist of striking train 703, plus two other exemplar cars. In the first series of tests, the train was allowed to drift backwards, and its speed was allowed to increase to 3 mph or greater before the master controller was placed in a power position, at which point the train continued in a backward direction and gained speed as it moved down the grade. After it was determined that a power application would

Factual Information 25 Railroad Accident Report not stop the train, a B3 brake application was used to bring the train to a smooth stop. The first series of tests showed that in manual operation, the train took 1 minute 18 seconds to roll back to the point of the collision (reaching a speed of 34 mph). In ATO tests, the train drifted back and then moved forward, demonstrating the designed rollback protection feature in the automatic mode. WMATA reported that some train operators had experienced a situation prior to the accident where a power application to a car that was drifting backwards had increased the speed of the backward motion, rather than stopping the car and moving it forward as intended. Following a complete diagnostic evaluation prior to the accident, WMATA had discovered a flaw in the software associated with the braking system on the 2000-series cars. Investigators conducted additional testing to determine whether a similar situation could occur on the 1000-series cars. The test train was allowed to drift backwards toward Woodley Park, and in a series of test speeds of 3 mph, 5 mph, and 8 mph, the master controller was placed in the P4 and P5 positions. Train speed did not increase above the gravitational acceleration that had been observed in the first series of tests to replicate the train operator’s actions. The second series of tests used four cars from train 703 (cars 1128, 1129, 1064, and 1065) and two exemplar Rohr cars. Accident damage to cars 1077 and 1076 precluded meaningful testing with them. Minor repairs were made to the four cars from train 703 in order to make them safe to operate during the tests, but nothing was done to the braking system. The tests were performed at the accident site using the same procedures as in the first series of tests. Again, as in the first series of tests, the train speed was allowed to increase to 3 mph or greater before the master controller was placed in a power position as the train continued in a backward direction and gained speed as it moved down the grade. After it was determined that a power application would not stop the train, a B3 brake application was used to bring the train to a smooth stop. The second series of tests showed that in manual operation, the train took 1 minute 17 seconds to roll back to the point of the collision (reaching a speed of 36 mph). Test of Rehabilitated Equipment With Rollback Protection Safety Board investigators conducted several tests of the recently rehabilitated 2000- and 3000-series cars’ rollback protection system, using a 6-car train operated in the manual mode. The tests were performed on the same track segment where the accident occurred. In each test, the train was allowed to roll back freely in the manual mode. The rollback protection system stopped the train within 6 to 8 seconds. WMATA’s Train Data Analysis Report WMATA provided a report generated by its computerized train monitoring system that listed the train movements between the Woodley Park and Cleveland Park stations as time-stamped events. (See appendix C.) The data included information on the striking train (703), the train immediately ahead of 703 (train 203), and the struck train (105) at Woodley Park station.

Factual Information 26 Railroad Accident Report The data indicated that train 203 had entered track circuit A2-165 at Cleveland Park station about 12:45:28 p.m. (See figure 7 for block layout between Woodley Park and Cleveland Park stations.) At the same time, train 703 was entering track circuit A2-124 (moving at 34.1 mph), which was about 3,827 feet from the beginning of track circuit A2-165. About 12:46:38 p.m., train 203 left track circuit A2-165. At that time, train 703 was transiting circuit A2-146, about 1,097 feet from the beginning of track circuit A2-165. The data then indicated that about 12:46:41 p.m., train 703 would have received a 50 mph ATP regulated speed authority when it entered track circuit A2-154. About 12:46:47 p.m., train 703 was in track circuit A2-157. At this time, train 203 was still occupying track circuit A2-171. According to interpretations by WMATA officials, train 703 received a “reduced 28 mph ATP speed with Train 203 occupying A2-171 circuit,” and “train 703 would have received an over speed alarm.” In addition, about 12:46:51 p.m., as train 203 left track circuit A2-171, train 703 would have received a 55 mph ATP regulated speed authority. Train 703 traveled into track circuit A2-162 about 12:47:03 p.m. This was the farthest point train 703 traveled on November 3. Because train 203 had left track circuit A2-181, train 703 would have received a 50 mph ATP regulated speed authority. Figure 7. Block identification and length for A2 track outbound on Red Line. The data then indicated that at least part of train 703 had occupied track circuit A2- 162 for about 30 seconds. About 12:47:33 p.m., train 703 was recorded as leaving track circuit A2-162 moving in the reverse direction (negative speed recorded). Train 703 was recorded as exiting track circuit A2-140 with a train speed of 36 mph. This is the last recorded data before train 703 collided with train 105. The estimated total distance train 703 traveled backwards to the collision with train 105 at Woodley Park station was about 2,246 feet. Postaccident Information Initially, WMATA officials told Safety Board investigators that all of their cars were equipped with an automatic rollback protection feature, which would automatically apply train brakes, if necessary, to prevent a rollback. WMATA officials later told investigators that at the time of the accident, the only cars in the fleet that had rollback protection in the manual mode were the 70 rehabilitated cars in the 2000 and 3000 series,

Factual Information 27 Railroad Accident Report which had undergone a software upgrade as part of an ongoing rehabilitation program. The remaining 324 cars in the 2000 and 3000 series, as well as the cars in the 1000, 4000, and 5000 series, did not have rollback protection when operated in the manual mode. During the investigation, it was determined that because of the presence of the rollback protection feature on the cars, WMATA officials did not anticipate a situation in which an uncontrolled rollback could occur. Investigators interviewed several train operators, the training instructor for train operators, and the OCC supervisors. All of the interviewees said they believed that the rollback protection feature would automatically prevent excessive rollback. All were apparently unaware that this feature was not available for all trains being operated manually. Consequently, no specific information had been provided to train operators regarding the proper management of a rollback. On November 7, 2004, WMATA issued a memorandum to all train operators and Metrorail supervisors concerning the lack of a rollback protection feature on the 1000- series cars. The memorandum advised operators and supervisors that: there is [sic] no roll back features on the Rohr series 1000 cars when operating in a manual mode . . . . Therefore, each operator is advised to be aware of any and all operating conditions, related to grade positive or negative, that will affect train handling. Any changes in operating conditions of the train shall be reported to the Operations Control Center (OCC) immediately. On November 9, 2004, WMATA issued a supplement to the November 7 memorandum. The November 9 supplement, also directed to all train operators and rail supervisors, stated: This reminder covers the balance of the fleet [cars other than the Rohr cars addressed in the previous memorandum] for your clarity and for your governance. Operators are reminded that ‘roll-back’ protection exists in Automatic Mode, but not in Manual. However, in Manual, your brake systems (B1 through Emergency/Mushroom) are available and are to be used in accordance with operating conditions and consistent with your training and the provisions of the MSRPH. The Safety Board was concerned that the guidance provided in the two memorandums may have been too broad to properly prepare train operators for this type of emergency. WMATA officials and train operators acknowledged that small rollbacks (1 or 2 feet) were normal. A train stopped on a grade routinely experiences a rollback during the brief interval between the release of the brake and the reapplication of power. In automatic mode, these small rollbacks are stopped by the automatic application of power and, if the rollback continues beyond certain limits, by the rollback protection system. In the manual mode, applying power to the train is an appropriate response to a small rollback. However, the results of the Board’s tests revealed that once a train’s rollback speed exceeded about 2 mph, the rollback could not be stopped by a power application alone. In this situation, either the service or emergency brakes must be used.

Factual Information 28 Railroad Accident Report On November 22, 2004, the Safety Board made the following urgent safety recommendation to WMATA: R-04-9 Immediately revise the directions to train operators contained in your memorandums of November 7 and 9, 2004, to include specific written instructions for identifying and responding to an emergency rollback situation, and provide training to operators on the procedures to follow if such a rollback event occurs. (Urgent) On November 23, 2004, WMATA responded to the Board’s urgent safety recommendation, advising that new bulletins were issued on November 22 and 23, 2004,49 which revised the November 7 and 9, 2004, memorandums concerning rollback protection on Rohr 1000- series cars. The revised bulletins of November 22 and 23 again reminded operators that in manual mode there is no rollback protection except in the rehabilitated Breda cars. WMATA also advised the Safety Board that according to the most recent guidance issued by WMATA, operators were to take the following actions in the event of a rollback: • In manual mode, a rollback is to be stopped by application of the train brakes. • Should a rollback of greater than 5 seconds occur, the operator shall apply maximum service brakes by pulling the brake handle to the B4 position. • Should the train not stop within another 4 seconds, the operator shall apply the emergency brakes by releasing the safety handle or by depressing the emergency stop button. • Operations Control Center shall be notified immediately. Because the train’s speed—and not the elapsed time of the rollback, as included in the revised bulletins—was the relevant variable in stopping the train, the Safety Board asked WMATA to include a discussion of speed in its written instructions for identifying and responding to a rollback situation. The Board also asked that these instructions be incorporated in WMATA’s Initial Train Operator’s Course and in its operator recertification training procedures. Pending these additions, the safety recommendation was classified “Open—Acceptable Response” on May 31, 2005. In a letter dated February 15, 2006, WMATA stated that it did not agree with the Safety Board’s position. WMATA stated that “basing a decision to stop a train on the constant, time, is more effective because speed is a variable and is a function of time and distance.” WMATA provided information about how time and distance are used to control rollback during automatic train operation, explaining that if a rollback continues for 10 seconds, the operator is to push the “ATO stop.” Similarly, WMATA explained that the 49  WMATA issued a bulletin on November 22, 2004, outlining the procedures for responding to emergency rollback situations. The WMATA Safety Department provided the Safety Board a revised bulletin dated November 23, 2004, that was issued because the braking rate between automatic and manual modes was transposed on the November 22 bulletin.

Factual Information 29 Railroad Accident Report rollback detection feature in the manual mode is adjustable from 7 to 15 seconds before automatic braking is applied in the cars equipped with this feature. Overall, WMATA believes that the time-based criterion is better because it is simple and easily explained to and understood by the operators. Other Information WMATA was formed in 1967. Responsibility was assigned to Maryland, Virginia, and the District of Columbia to plan, finance, construct, and operate a comprehensive mass transit system for the Washington, D.C., metropolitan area. A board of directors comprised of two members from each of the three jurisdictions governs the transit authority. The board of directors does not play a direct role in day-to-day operations of the Metrorail or Metrobus systems, although it may promulgate safety requirements. Transit Oversight The Safety Board’s interest in the oversight of rail rapid transit safety dates back more than 30 years, beginning with the Board’s special study50 that explored the role of the Urban Mass Transportation Administration, now the FTA, in developing safe transit systems. The Board also investigated a number of rapid rail accidents during the 1970s and 1980s and issued several relevant safety recommendations over the years. Further, the Board conducted a safety study in 1991 that addressed oversight of rail rapid transit safety.51 On December 18, 1991, considering the Board’s safety recommendations and studies, Congress enacted the Intermodal Surface Transportation Efficiency Act of 1991 (P.L. 102-240), which added Section 289 to the Federal Transit Act. This section directed the FTA to require those States that have a rail fixed-guideway system (such as WMATA’s Metrorail), which is not regulated by the FRA, to designate a State agency to oversee the safety of the guideway system. It also authorized the FTA to withhold some transit funding should a State fail to implement a safety program. Safety Oversight There are no Federal or State regulations specific to train operations; the maintenance, inspection, and the testing of the equipment; the structures; or the track on WMATA’s rail transit system. Rather, the FTA in 49 CFR 659 requires each State with a rail transit system to designate an oversight agency to conduct safety and security oversight. The State agency in turn requires the transit system to write a system safety program that includes elements identified by the FTA. In addition, the State agency is responsible for reviewing the transit system’s compliance with the system safety program and implementing corrective action when needed. 50  National Transportation Safety Board, Special Study of Rail Rapid Transit Safety, Railroad Special Study NTSB/RSS-71/01 (Washington, DC: NTSB, 1971). 51  National Transportation Safety Board, Oversight of Rail Rapid Transit Safety, Railroad Safety Study NTSB/SS-91/02 (Washington, DC: NTSB, 1991).

Factual Information 30 Railroad Accident Report According to 49 CFR 659.21(b), if a transit agency operates a system in more than one State, then those States may designate a single entity, other than the transit agency, to implement the requirements of the regulations. The District of Columbia, Virginia, and Maryland formed the Tri-State Oversight Committee (TOC) to carry out the oversight responsibilities for the WMATA system. The TOC then hired a consultant to develop a system safety program standard, conduct safety reviews, establish procedures and conduct investigations, review corrective action plans, and prepare required audit reports. The most recent audit of WMATA was conducted in January 2004. The audit did not identify any anomalies within WMATA’s organization that involved issues related to the November 3, 2004, accident. WMATA is also a member of the American Public Transportation Association (APTA), and it requests periodic APTA safety audits. These audits, which are provided as a service to APTA members, cover all elements of the safety program. Prior to the November 3, 2004, accident, the most recent APTA audit of WMATA was conducted from May 23 through June 4, 2002. The audit did not reveal any issues directly related to the 2004 accident at the Woodley Park station. However, APTA did recommend that WMATA review its hours-of-service guidelines for operating personnel, evaluate industry practices, and initiate appropriate changes as required. Internal Oversight WMATA’s safety department performs annual internal audits of WMATA’s operations. Each audit is reviewed by the TOC, and recommendations are made based upon the findings. The results of the most recent audit, which occurred on August 18, 2004, indicated that WMATA’s safety department’s system safety program plan complied with the requirements set forth in APTA’s guidelines. Management and Organizational Factors Title 49 CFR 659.19(c) states that a system safety plan shall include an overview of the management structure of the rail transit agency, including the following: (1) An organization chart; (2) A description of how the safety function is integrated into the rest of the rail transit organization; and (3) Clear identification of the lines of authority used by the rail transit agency to manage safety issues. The Safety Board investigated the January 6, 1996, collision between two WMATA trains at the Shady Grove station in Gaithersburg, Maryland.52 During the course of the Board’s investigation, several WMATA employees reported that there was a lack of communication within the organization. The employees further noted that information isolation was a common issue stemming from that lack of communication. As an example, they explained that the general manager (GM), the director of the safety department, and 52  NTSB/RAR-96/04.

Factual Information 31 Railroad Accident Report the instructor responsible for operator training were not aware, before the fact, of the policy change regarding full-time automatic train operation. After the 1996 accident and while the Safety Board’s investigation was ongoing, a WMATA safety review committee submitted a report to WMATA’s board of directors recommending that the safety department report directly to the GM. This recommendation was subsequently adopted and implemented, and the safety department began reporting directly to the GM. An organization chart provided by WMATA in 2004 showed that the safety department was still reporting directly to the GM when the November 3, 2004, accident occurred. (See figure 8.) However, after the accident, WMATA instituted a reorganization effective March 17, 2005, that rescinded the direct reporting link between the safety department and the GM. (See figure 9.) Figure 8. WMATA’s organizational chart in effect on November 3, 2004.

Figure 9. WMATA’s organizational chart reflecting the reorganization of its management structure after the November 3, 2004, accident. Factual Information 32 Railroad Accident Report

Factual Information 33 Railroad Accident Report In a letter to WMATA, dated March 31, 2005, the TOC expressed concern about the transit authority’s reorganization, which eliminated the safety department’s direct access to the GM. The GM responded to the TOC and explained that the postaccident change to WMATA’s reporting structure would provide for: swift resolution of issues and recommendations identified by WMATA Safety and Audit organizations and provide them with a mandate to ensure compliance in the event that necessary corrective actions are not being taken by other parts of the WMATA organization in a prompt fashion. Crashworthiness of Passenger Equipment The Safety Board investigated two accidents on WMATA’s Metrorail system prior to this accident: the January 13, 1982, accident at the Smithsonian interlocking53 and the January 6, 1996, collision at the Shady Grove station in Gaithersburg, Maryland.54 In the 1982 accident, one car of a 6-car train derailed as it negotiated a track- crossover (interlocking). The center section of the derailed car crashed into a concrete barrier wall, resulting in a breach of the carbody sidewall structure and a loss of survival space in the middle of the passenger compartment. Of the approximately 220 passengers in the car, 25 passengers were injured, and 3 sustained fatal injuries. There were no relevant crashworthiness-related safety recommendations issued by the Safety Board. In the 1996 accident, a 4-car train failed to stop at a station platform and continued moving for about 470 feet. Moving at an estimated 22 to 29 mph, the train struck a standing, unoccupied 6-car train. The operator of the 4-car train was fatally injured; the train’s two passengers, who were riding in the last car, were not injured. The front end of the lead car of the striking train overrode the front end of the standing train. The lead car of the striking train experienced a catastrophic failure of the forward end bulkhead structure, resulting in an inward displacement of that structure and a telescoping of the carbody, effectively causing a loss of about 21 feet of survival space. The front end of the lead car of the standing train sustained a uniform crush of approximately 10 inches across the front of the car at frame level, and it telescoped approximately 21 feet into the striking train. The Safety Board issued the following safety recommendation to WMATA on November 14, 1996: R-96-37 Undertake, with the assistance of qualified engineering support, a comprehensive evaluation of the design and design specifications of all series of Metrorail cars with respect to resisting carbody telescoping and providing better passenger protection, and make the necessary modifications, such as incorporating underframe bracing or similar features, to improve the crashworthiness of cars in the current and/or future Metrorail fleet. 53  National Transportation Safety Board, Derailment of Washington Metropolitan Area Transit Authority Train No. 410 at Smithsonian Interlocking, January 13, 1982, Railroad Accident Report NTSB/RAR-82/06 (Washington, DC: NTSB, 1982). 54  NTSB/RAR-96/04.

Factual Information 34 Railroad Accident Report In a March 22, 2002, letter to the Safety Board, WMATA stated that its consultant had determined that adding underframe reinforcement was neither desirable nor practical and that such modification could result in higher longitudinal accelerations and possibly more injuries. In addition, WMATA stated that the mid-life overhaul of the Rohr (1000- series) cars had been completed and that it would be impractical to modify the cars before they were scrapped. WMATA also contended that the cost and downtime that would be involved in modifying the balance of the fleet when the Breda cars are refurbished was prohibitive. Considering WMATA’s position on its existing fleet to be reasonable, the Board responded to WMATA on May 28, 2002, stating that the intent of Safety Recommendation R-96-37 had been met. The recommendation was then classified “Closed—Acceptable Action.” The original contract specifications for the 2000-, 3000-, and 4000-series cars show that the car collision posts have the same section modulus and yield stress material as the 1000-series cars, but the ultimate shear value was increased by 50 percent. No crashworthiness improvements were required in the recent rehabilitation of the 2000- and 3000-series cars. The Safety Board’s investigation of the November 3, 2004, WMATA accident shows that the 1000-series, Rohr-built, passenger railcars experienced telescoping damage and complete loss of occupant survival space in a longitudinal end-structure collision. In reviewing the crashworthiness collision protection of the Metrorail passenger railcar fleet, the Board found that the fleet will be comprised of four successive delivery series generations of carbody structural designs. Investigative data further revealed that each of WMATA’s successive delivery series railcars (Rohr, Breda, CAF, and ALSTOM) will have a higher degree of carbody end-structure resiliency (that is, resistance to catastrophic carbody telescoping) than its immediate predecessor. Therefore, WMATA's successive introduction of progressively more robust carbody designs is consistent with an ensuing increase in carbody end-structure crashworthiness protection. Transit passenger railroad systems, such as WMATA’s Metrorail, operate railcars that are comparable to those used in commuter train operations in many regards: physical size, passenger capacity, and frequency of stops. However, unlike commuter train operations, transit passenger railroad systems are not subject to FRA crashworthiness requirements as described under 49 CFR 238, Passenger Equipment Safety Standards. That is, there is no Federal regulatory requirement that addresses structural crashworthiness provisions for passenger cars operating in transit service. The FTA addresses only flammability resistance for the elements of passenger cars operating in transit service in a 1986 publication, “Recommended Fire Safety Practices for Rail Transit Materials Selection.” Operator Training WMATA requires that all prospective train operators have 65 days of formal training prior to becoming certified on WMATA’s system. The training schedule includes about 3 weeks of classroom instruction, and the remaining time is divided between classroom and on-the-job training in the yard. The on-the-job training familiarizes the

Factual Information 35 Railroad Accident Report trainee with equipment, yards, tracks, tower operations, terminals, communications, and operating rules. A trainee is required to score 75 percent or higher on the exam to pass the class. If a trainee scores less, the trainee is given one-on-one instruction and another opportunity to take the exam. However, if the trainee scores less than 80 percent on the second attempt, the trainee will be dropped from consideration for a train operator position. A review of WMATA’s training instructions showed that during their on-the-job training, students were taught on a daily basis how to use the emergency brake. However, rollback protection was not part of the curriculum for operator training. The operator of train 703 stated that he had never experienced having a train “drift” (rollback) as it did during the moments before the collision. He stated he had experienced minor drifting while operating in the automatic mode, but when the train drifted back, the brakes would “kick in” relatively quickly. He said that he had never received formal training in managing a rollback; although he understood that hitting the emergency brakes (by depressing the mushroom) was an acceptable option if braking and propulsion were not adequate to stop the train. A WMATA rail instructor told investigators that train operators are instructed to use the emergency brake (mushroom) immediately if normal braking fails to stop the train. He indicated that operator trainees practice applying emergency brakes during their formal training. Specifically, they practice hitting the mushroom in the yard, and they also simulate hitting the mushroom while operating on the mainline. The instructor indicated that during a rollback situation, if train operators could not stop the train through “initial (normal) braking,” they should not make more than one attempt to apply the brakes. Although the instructor indicated that an operator should press the mushroom during any problematic situation, which would include a rollback, this was not part of WMATA’s formal training. Event Recorders Neither train 703 nor train 105, consisting of 1000-series Rohr equipment and 4000-series Breda equipment, respectively, were equipped with event recorders to record specific train operation events. Therefore, no information was available for investigators to confirm the statements made by the operator of train 703 regarding his application of the train brakes. Following its investigation of the accident at the Shady Grove station on January 6, 1996, the Safety Board issued the following recommendation to WMATA55 regarding event recorders: 55  NTSB/RAR-96/04.

Factual Information 36 Railroad Accident Report R-96-39 Finalize the specifications for a new advanced-technology carborne monitoring system and, once that is complete, retrofit existing Metrorail cars with monitors/recorders during rehabilitation and require that all new Metrorail cars be equipped with the devices. On March 22, 2002, WMATA responded that the new 5000-series cars would be equipped with monitors on each car. In its response, WMATA further stated that the 2000- and 3000-series cars would be retrofitted during mid-life rehabilitation, with a completion date of 2005. Starting in 2012, the 4000-series cars would begin their mid-life rehabilitation and would also be retrofitted with monitors on each car. After the 4000-series rehabilitation, WMATA stated that it would reevaluate the 1000-series to determine whether the monitors on each car could be made compatible. WMATA noted that the 1000-series cars are scheduled for retirement between 2012 and 2015. On May 28, 2002, the Board classified Safety Recommendation R-96-39 “Closed—Acceptable Action.” During the investigation of this accident, Safety Board investigators examined the installation and status of event recorders on WMATA’s operating fleet. According to WMATA, about 292 1000-series cars are currently available for service. These cars are nearing their 35-year life expectancy, at which time WMATA plans to retire or rehabilitate them. The 2000- and 3000-series cars are currently going through a mid-life rehabilitation. During the rehabilitation, the cars will be retrofitted with an on-board event recorder system. About 100 4000-series cars are currently available for service, but they have not reached their mid-life rehabilitation schedule checkpoint. The 5000-series cars that have been delivered are equipped with an on-board event recorder system. The 6000-series cars, which are currently being manufactured, will also be equipped with an on-board event recorder system. (See appendix B.)

37 Railroad Accident Report Analysis General Factors Safety Board investigators inspected the Washington Metropolitan Area Transit Authority (WMATA) track and reviewed its recorded train movement records. No anomalies were found in the track, signal, or communications systems, including the wayside communications devices and the electronic command systems related to Automatic Train Control (ATC). Therefore, the Safety Board concludes that the track, signal, and communications systems were not factors in this accident. WMATA’s postaccident toxicological test results showed no drug or alcohol use by the operator of train 703. Therefore, the Safety Board concludes that the use of drugs or alcohol was not a factor in this accident. The DC 911 communications center received its first call at 12:49 p.m. Emergency response units began arriving on scene within 8 minutes. A battalion chief assumed incident command and established a command post outside the station for transportation, treatment, and staging groups to manage the medical operations. A second battalion chief managed the search and rescue operations on the platform inside the station. Therefore, the Safety Board concludes that the emergency response to the accident was well coordinated and effectively managed. The Accident Train 703 departed Brentwood Yard traveling in the direction of the Shady Grove station, closely following revenue train 203. The train 703 operator received overspeed alarms, alerting him that his train was getting too close to train 203. The train operator applied braking to slow the train, thereby silencing the alarm and creating more distance between the two trains. Overall, the trip to Woodley Park station was uneventful. The accident sequence began after train 703 left the Woodley Park station, ascending upgrade toward the Cleveland Park station. Because there was no train movement event recorder on train 703, the Safety Board considered several other sources of information to reconstruct the events leading up to the accident, including interviews with the train operators, training instructors, and managers; physical evidence at the scene (security video); data collected and analyzed from the track circuits pertaining to the movement of the trains; and accepted transit standard operating practices and procedures.

Analysis 38 Railroad Accident Report WMATA’s computerized train movement record showed that train 703 left the Woodley Park track circuit about 12:46 p.m., traveling about 24.1 mph56 as it ascended the grade toward the Cleveland Park station. About 17 seconds later, train 703 received an Automatic Train Protection (ATP) regulated speed authority of 45 mph. (The record showed an actual average train speed of about 30 mph.) Eighteen seconds after that, the train received an ATP regulated speed authority of 50 mph. (The record showed an actual average train speed of about 32 mph.) About 6 seconds later, train 703 received an ATP regulated speed authority of 28 mph because it was getting closer to train 203. As a result, the operator of train 703 received an overspeed alarm. Knowing that train 203 was servicing the next station,57 the operator of train 703 likely made a brake application to silence the alarm and likely placed the master controller in the coast setting, slowing the train speed from about 31 mph to 19 mph in 15 seconds. However, about 1 second after train 703 received the ATP regulated speed authority of 28 mph, it received an ATP regulated speed authority of 50 mph. During this interval, train 703 reached its farthest point from the Woodley Park station and began to roll back. About 78 seconds passed before train 703 collided with train 105, which was servicing the Woodley Park station. The operator of train 703 stated that he tried to brake the train and apply power in succession during the rollback. However, he said he did not receive power to the train before applying the emergency brakes.58 Postaccident testing of the train equipment did not support the train operator’s claim that he applied normal braking. Had train 703 been equipped with an event recorder, the operator’s statements could have been verified. Examination and testing of the accident train’s four undamaged cars showed no evidence of mechanical or brake failure. Consequently, any brake application should have at least slowed or stopped the train. There is no indication, however, that the train slowed as it rolled backwards toward the Woodley Park station. On the contrary, data retrieved and analyzed indicate that the train’s speed progressively increased during the rollback, from 7 mph to about 36 mph, up to or near the point of collision.59 Moreover, the speed and acceleration of the accident train closely correlated with that of two similar test trains that were rolled back from the same location with no brake application. Also, investigators could not find any evidence of flat spots on the wheels or markings on the track, which would have suggested that emergency brakes had been applied before the collision. The emergency brake mushroom, which apparently had been pushed, may have been applied 56  See appendix C. 57  After departing Woodley Park station, train 703 ascended the grade, and the train operator was eventually able to see train 203 servicing Cleveland Park. 58  The train operator had several options to slow or stop the train, including releasing the master controller, which would have automatically resulted in a brake application; moving the master controller to a brake setting; or applying the emergency brake mushroom. WMATA’s operating rules require train operators to radio the OCC for assistance when they experience a braking problem. The operator of train 703 did not contact the OCC. 59  The available data from the track circuits were collected and calculated for the accident train until it entered the circuit, where the accident occurred. No speed calculations are possible for a train that has entered, but not exited, a track circuit. Consequently, it could not be determined if any braking occurred in the track circuit occupied by the struck train. (It was estimated that train 703 entered the last track circuit 3 to 5 seconds before the collision.) Therefore, if any normal braking did occur, it would have likely occurred only seconds before impact.

Analysis 39 Railroad Accident Report at the time of the impact or shortly afterwards. Therefore, the Safety Board concludes that the braking systems of train 703 were operable on the day of the accident and, if applied, could have stopped the train. Analysis Overview The accident investigation identified several areas that needed to be examined to determine the probable cause and contributing factors of the accident: (1) the lack of rollback protection when trains are operated in the manual mode, (2) the failure of the operator of train 703 to take appropriate action to stop the train from rolling backwards, (3) the adequacy of the safety oversight of WMATA’s operations, (4) the adequacy of the accessibility to passengers in WMATA’s train cars during an emergency response, and (5) the crashworthiness of WMATA’s equipment. Rollback Protection WMATA officials had initially informed Safety Board investigators that they believed that all of their cars were equipped with a rollback protection feature. Later, it was determined that the rollback protection feature was available in the automatic mode for all equipment but only for the rehabilitated 2000- and 3000-series cars in the manual mode. Therefore, the Board issued an urgent safety recommendation to WMATA on November 22, 2004, because rollback protection was not available in the manual mode for all equipment: R-04-9 Immediately revise the directions to train operators contained in your memorandums of November 7 and 9, 2004, to include specific written instructions for identifying and responding to an emergency rollback situation, and provide training to operators on the procedures to follow if such a rollback event occurs. (Urgent) WMATA has sent the Safety Board two letters, dated November 23, 2004, and February 15, 2006, explaining the actions it has taken to address the rollback protection safety issues and the Board’s related concerns raised by the November 3, 2004, accident. WMATA’s guidance prescribes that a rollback is to be stopped by application of the train brake, but also allows for a rollback of 5 seconds before the operator must make a maximum brake application. If the train does not stop in another 4 seconds, the emergency brake is to be applied. The Board finds WMATA’s 2004 and 2006 responses to be lacking in that WMATA has not addressed train speed during a rollback event. Also, WMATA has not provided a discussion in its written instructions and training that explains that once rollback speed exceeds 2 mph, the train cannot be stopped by applying forward power, and brakes must be applied.

Analysis 40 Railroad Accident Report The Safety Board’s simulation testing found that trains that did not have the rollback protection feature could be controlled only by applying the train brakes when the train speed exceeded 2 mph in a rollback situation. The Board is disappointed that WMATA’s response noted that it will not address train speed factors in its written instructions for identifying and responding to a rollback situation. Therefore, Urgent Safety Recommendation R-04-9, previously classified “Open—Acceptable Response,” is reclassified “Open—Unacceptable Response.” Rollback protection is an engineered safety redundancy. The train operator is primarily responsible for safety in accordance with all established procedures. In the event a train operator fails to take appropriate action to prevent a train from rolling backwards within predetermined limits, the rollback protection feature is designed to safely stop the train. WMATA obviously saw value in this feature because its entire fleet was equipped with it in the automatic mode. WMATA also assumed its fleet was equipped with the rollback protection feature in the manual mode, but was unaware of the fact that it was not. Therefore, the Safety Board concludes that WMATA was unaware, at the time of the accident, that the rollback protection feature was generally not available when a train was operated in the manual mode, and consequently no specific training was provided to operators about the lack of this feature on all cars. The Board could not determine why WMATA neglected to equip its fleet with the rollback protection feature in the manual mode or why WMATA was unaware of the lack of this safety redundancy feature within its entire fleet. The rollback protection feature was readily available in the transit industry for the type of cars WMATA operated. One of WMATA’s primary car building and refurbishing contractors had been installing and maintaining the rollback protection feature in manual mode on similar equipment for another transit agency for many years. Therefore, the Safety Board concludes that if the equipment on train 703 had been equipped with a rollback protection feature in the manual mode, the train could have been safely stopped, regardless of the train operator’s action or inaction, and the accident could have been prevented. The Safety Board believes that WMATA should equip, as soon as possible, all existing and future train equipment with rollback protection for trains operated in the manual mode. Train 703 Operator’s Performance The Safety Board examined the performance of the operator of train 703, specifically his failure to stop the train while it rolled back, ultimately striking train 105 as it was servicing Woodley Park station. Although he had been operating trains for only 6 months, the operator of train 703 was adequately trained and experienced in both automatic and manual train operating modes.60 He was experienced in slowing and 60  The train operator never received formal training about how to manage a rollback. Nevertheless, he understood that applying the emergency brakes (by depressing the mushroom) was an acceptable option if braking and propulsion were not adequate to stop the train. A WMATA rail instructor also told investigators that train operators are instructed to use the emergency brakes (the mushroom) immediately if normal braking fails to stop the train.

Analysis 41 Railroad Accident Report stopping trains through normal braking, and he understood that using the emergency brake (mushroom) was a reasonable and expected response if normal braking was inadequate. During the accident trip, train operations were routine. The Safety Board explored other explanations for the train operator’s failure to respond to the train’s 78-second rollback and prevent the collision. Specifically, the Board examined three other factors that may have reduced his alertness and impaired his performance: his medical fitness, the low operating demands on the accident trip, and the adequacy of his sleep. Medical Fitness On October 31, 2004, at 4:30 a.m., the train operator’s Gastroesophageal Reflux Disease (GERD)61 and epigastric pain,62 which had persisted for a month and increased at night, forced him to seek treatment at a medical clinic. Although this episode occurred 3 days before the collision, the train operator’s symptoms may have affected his fitness for duty on the day of the accident. Beyond general discomfort, GERD has been shown to affect sleep. Moreover, the majority of those suffering from heartburn experience it at night, and nighttime GERD is a significant contributor to sleep problems.63 In addition, because the pain increased at night during the month preceding the accident, the operator’s nighttime sleep may have been further disrupted during this period. Thus, as a result of his condition, he may have experienced a cumulative sleep debt.64 Further, since the operator received little or no sleep between late Saturday night and Sunday morning (when he normally would have been asleep), he also would have experienced an acute sleep debt.65 Even if his treatment relieved his pain and discomfort, his sleep routine was disrupted by his visit to the clinic, making it even more difficult for him to get the necessary sleep to recover from his sleep debt before the start of his next work assignment. Although it is not clear if the train operator’s performance on the day of the accident might have been impaired by his medical condition, his condition could have 61  Gastroesophageal reflux is a physical condition in which acid from the stomach flows backward up into the esophagus. Some will experience heartburn symptoms when excessive amounts of acid flow back up into the esophagus. Others describe heartburn as a feeling of burning discomfort, localized behind the breastbone, which moves up toward the neck and throat. (Source: American College of Gastroenterology.) 62  Pain in the upper middle region of the abdomen. 63  Source: National Sleep Foundation. 64  Cumulative sleep debt refers to the chronic build up of sleep deprivation, which occurs when successive periods of inadequate sleep are experienced. This can produce a cumulative increase in lapses, even during the daytime. Recovery from a sleep debt typically involves more deep sleep and not an hour-for- hour payback of lost sleep that requires extended sleep. Generally, 2 nights of usual sleep, at a person’s regular bedtime, can reduce the cumulative sleep debt. See National Transportation Safety Board, Uncontrolled Collision with Terrain American International Airways Flight 808, Douglas DC-8-61, N814CK U.S. Naval Air Station Guantanamo Bay, Cuba August 18, 1993, Aviation Accident Report NTSB/AAR-94/04 (Washington, DC: NTSB, 1994) 136. 65  An acute sleep debt is the difference between the amount of sleep needed and the amount one slept in a 24-hour period.

Analysis 42 Railroad Accident Report affected the quantity and quality of sleep he received on the days leading up to the accident. Therefore, the train operator’s medical condition might have affected his sleep, alertness, and ultimately, his performance on the day of the accident. Low Task Demands and Unremarkable Operating Environment During the accident trip, the train operator’s task demands were relatively low. He was operating during off-peak hours, a time when WMATA’s system moves fewer trains and time between revenue trains is greater. Further, he was operating a nonrevenue train, that is, a train that was not carrying passengers. Therefore, the operator did not have the usual responsibilities associated with attending to passengers, such as making public address announcements, stopping at stations, and opening and closing doors.66 In the absence of station stops, his primary requirements were operating his train in accordance with track speed, slowing to 25 mph, and sounding his horn at each station. When he operated too close to the train ahead of him, the overspeed alarm was activated, and subsequently silenced by the operator making a regular brake application. The train operator also believed that his train was equipped with rollback protection that would prevent it from rolling backwards. Thus, in contrast to operating a revenue train during peak hours, the workload on the accident trip was comparatively low.67 During test rides in the control cab of an exemplar train, investigators noted that the operating compartment of the train, even while the train was moving, was generally comfortable and quiet, particularly when the master controller was in the coast setting. As previously discussed, train 703, after the train operator received the overspeed alarms and eventually placed the train into coast, slowed to a stop and then began to roll back. Safety Board investigators further noted during their test rides that a train rolling back remains relatively quiet and free of unusual sounds, creating minimal rocking or vibration, and only a subtle physical sensation of movement. Under these conditions, there were no obvious external cues that would have been a deterrent to an operator’s reduced alertness. Investigators found that focusing on the position of the tunnel lights relative to the position of the train was the most salient cue to determining the movement of the train. However, an operator experiencing reduced alertness, or one who is particularly inattentive to train operations or activity inside and outside the operating compartment, could remain unaware of conspicuous external cues for the duration of the rollback. Therefore, the Safety Board concludes that the low task demands and unremarkable operating environment during the accident trip were conducive to the train operator becoming disengaged from some critical train operations. 66  At Woodley Park station, a train operator in revenue service making a station stop would have to leave his seat, move to the other side of the operating compartment, open the window, and stick his head out to visually confirm that the doors had fully closed. The operator then would have to close the window and return to his seat before departing the station. 67  The Safety Board is mindful that prolonged periods of low activity may be fatiguing and may inhibit immediate attention to operations. See “Train Driver Mental Workload: The Train Driver Workload Principles Guidance Note,” produced by the Institute for Occupational Ergonomics and CCD Design and Ergonomics Ltd as part of the project 20-T147-IOECCD Investigation into Train Driver Mental Workload on behalf of the Rail Safety and Standards Board (2005).

Analysis 43 Railroad Accident Report Work Schedule and Sleep From Monday night to the time of the accident on Wednesday, about 38 hours, the train operator had very limited opportunity to recover any needed sleep, and he did not get much sleep. Because of his late arrival home Tuesday night (following his 13-hour workday) and his interrupted sleep that night due to calls to and from his cellular phone, his opportunity for uninterrupted sleep was limited to about 5 hours. The train operator reported a usual sleep requirement of 8 hours. Therefore, his 3-hour acute sleep loss the night before the accident might have affected his ability to remain alert and to safely operate his train. Research has shown that acute sleep loss may affect subsequent alertness and performance.68 Generally, obtaining 2 hours less sleep than a person needs results in a significant alertness and performance decrement, and more acute sleep loss results in a greater corresponding deficit in alertness.69 Moreover, laboratory research has clearly established the relationship between sleep loss, both acute and cumulative, and decreased performance and alertness.70 The train operator’s lack of any measured action to stop the train’s rollback for about 78 seconds before the collision, when several options were available to him, suggests that he was unaware of the movement of the train or of any impending danger. Therefore, the Safety Board concludes that the train operator’s alertness was likely reduced due to inadequate sleep. Opportunity for Adequate Sleep During Off-Duty Hours The FTA does not have hours-of-service regulations for train operations. By contrast, the Federal Aviation Administration, the Federal Railroad Administration (FRA), and the Federal Motor Carrier Safety Administration all have hours-of-service regulations. Consequently, rail transit companies are under no constraint regarding the number of hours an employee may work or the number of hours an employee is required to have off duty. WMATA told the Safety Board that its practice (established with the union representing train operators and bus drivers) limits train operators’ on-duty time to 16 hours. WMATA’s practice also requires train operators to have at least 8 hours of continuous off-duty time between the completion of their last shift and the start of their next shift within a 24-hour period. 68  M.A. Carskadon and T. Roth, “Sleep restriction,” ed. T.H. Monk, Sleep, Sleepiness and Performance (Chichester, U.K.: John Wiley, 1991) 155-167. 69  M.R. Rosekind, "Managing Safety, Alertness and Performance through Federal Hours of Service Regulations: Opportunities and Challenges." Document created and produced independently by Alertness Solutions, 2005. 70  Varying amounts of acute sleep loss (2, 4, 6, and 8 hours) were found to increase sleepiness more than ethanol and had comparable effects to ethanol on degrading psychomotor performance. In this study, 2 hours of sleep loss equated to a breath-alcohol concentration (BrEC percent) of .045 percent or the equivalent of ingesting 2 to 3 12-ounce beers. Four hours of sleep loss equated to a .095 percent BrEC percent or the equivalent of ingesting 5 to 6 12-ounce beers. T. Roehrs, E. Burduvali, A. Bonahoom, and others, “Ethanol and Sleep Loss: A ‘Dose’ Comparison of Impairing Effects,” Sleep 26 (2003) 981-985.

Analysis 44 Railroad Accident Report The night before the accident, the train operator went off duty about 11:00 p.m., and 9 hours later (about 8:00 a.m.) began his next shift. It took him about 30 minutes to commute each way to work and home; the 60-minute round trip provided him with 8 hours at home. The train operator informed investigators that he needs 8 hours of sleep to wake up feeling rested. However, realistically, there was inadequate opportunity for him to receive 8 hours of sleep after his last shift and before the start of his first shift on the day of the accident. Specifically, during his 9 hours off-duty time, he stated that he took about 30 minutes commuting from work to home, about 15 minutes to fall asleep after he arrived home, and a combined 75 minutes in the morning to get ready and commute to work in order to arrive 15 minutes before the start of his shift. Therefore, since the train operator arrived home at 11:30 p.m. on Tuesday night and woke up Wednesday at 6:30 a.m., he had no more than 7 hours available for him to sleep. This assumes that he fell asleep immediately after arriving home and spent little or no time eating meals and tending to family matters. The Safety Board is thus concerned that because a person, on average, needs 8 hours of sleep, allowing an operator as little as 8 hours off duty between shifts does not provide a realistic opportunity for adequate sleep. The available time train operators have for sleep is limited by various necessities, including commuting, as well as the usual time it takes to prepare for bed, fall asleep, shower, and prepare for work the next day. Other typical needs, such as eating meals or tending to family or personal matters, further impinge on their available rest (sleep) time. In actuality, in order to have an opportunity to sleep for 8 hours, a train operator’s off-duty time must be appreciably greater than 8 hours. Further, the Safety Board notes that WMATA’s practice of allowing train operators to start a shift after having only 8 hours off duty conflicts with its own scientifically-based fatigue-educational material,71 which indicates that, on average, adults physiologically require 8 hours of sleep for optimal waking performance and alertness. The Safety Board concludes that WMATA’s practice of allowing train operators to return to work after having as few as 8 hours off between shifts following prolonged tours of duty does not give train operators the opportunity to receive adequate sleep to be fully alert and to operate safely. The Safety Board is also concerned that train operators working an extended tour of duty may not be able to obtain adequate rest before the start of their next assignment. While working an extended day may in itself be demanding,72 it also reduces the available time off before the start of their next shift. For instance, the operator of the accident train worked an additional (overtime) shift on 9 of the 19 days in the month preceding the 71  WMATA provides fatigue awareness training, which is presented to train operator trainees during formal train operator training classes. The fatigue program, developed by the FTA, encompasses a wide range of fatigue-related issues, such as fatigue signs and symptoms (that is, lack of alertness, nodding off, slow reaction time, and micro sleeps). The material also discusses the need for train operators to achieve adequate sleep and to report to work rested before the start of their shift. Specifically, the information (accurately) details that people, on average, require about 8 hours of sleep (per day). 72  Continuous hours of wakefulness is another factor that can affect performance and alertness. Data suggest that 16 or 17 hours of continuous wakefulness can be associated with significantly reduced performance and alertness. See NTSB/AAR-94/04.

Analysis 45 Railroad Accident Report accident. Often, his overtime assignments occurred on several consecutive days. These extended days, typically lasting between 15 and 16 1/2 hours, began with an overtime shift starting as early as 6:23 a.m., followed by his regular shift ending at 11:00 p.m. As a result, the time off between the end of one day’s tour and the start of the next day’s shift was as little as 7 hours 23 minutes. So, rather than having 14 hours off between regular assignments, the extra assignment reduced the time off to 8 hours or less. Thus, prolonged tours of work on successive days reduce the opportunity for train operators to get adequate sleep. The Safety Board recognizes that assigning overtime shifts is not necessarily an unsafe practice. That is, the operator on the accident train could have worked the same number of assignments over the last month without jeopardizing his sleep. For instance, working an extra assignment on alternate days would provide ample opportunity for adequate rest before returning to work. Thus, train operators can safely work extra assignments if their work time is not exceedingly long and if their time off is adequate for them to receive sufficient rest before the start of their next shift. Other transit agencies contacted by the Safety Board have a maximum time on duty and minimum time off practice that is similar to WMATA’s.73 Therefore, the Safety Board believes that the FTA should require transit agencies, through the system safety program and hazard management process if necessary, to ensure that the time off between daily tours of duty, including regular and overtime assignments, allows train operators to obtain at least 8 hours of uninterrupted sleep. Oversight During the investigation of the January 6, 1996, accident at the Shady Grove station, the Safety Board identified employee concerns about WMATA’s organizational structure, specifically, a perceived lack of communication and a sense of information isolation. These concerns were addressed by a WMATA safety review committee, which recommended that WMATA change its organizational structure to have the safety department report directly to the GM. This recommendation was subsequently adopted and implemented, and WMATA’s safety department began reporting directly to the GM. WMATA’s organizational structure was not an issue in the November 3, 2004, accident at the Woodley Park station. However, following the 2004 accident, WMATA restructured its organization again, reverting back to the safety department having a disconnected responsibility and accountability reporting chain. In effect, this restructuring maneuver rescinded the direct reporting link between the safety department and the GM that had been established as result of the Shady Grove accident. This postaccident reorganization could recreate the systemic information isolation that existed within 73  For instance, New York City Transit, Metro Transit (Minneapolis, Minnesota), and Metropolitan Atlanta Rapid Transit Authority allow as little as 8 hours off between shifts. The Southeastern Pennsylvania Transportation Authority permits scheduling operators for as many as 18 hours in 1 day.

Analysis 46 Railroad Accident Report WMATA prior to the Shady Grove accident, which in turn could inhibit serious safety problems from being identified or adequately addressed. The FTA apparently believes that an effective management structure is important, and it has established that a transit system must include an organizational chart in its system safety plan along with a description of how the safety function is integrated into the rest of the transit organization. Still, the Safety Board is concerned that the more distant reporting relationship between WMATA’s safety department and the GM could inhibit serious safety problems from being identified or adequately addressed. Therefore, the Safety Board believes that the FTA should assess the adequacy of WMATA’s current organizational structure and ensure that it effectively identifies and addresses safety issues. Passenger Safety In a life-threatening situation, emergency responders must be able to enter the passenger cars quickly. Passengers must also be able to evacuate the cars rapidly and safely. The Safety Board is concerned about the limited number of emergency access/egress points on Metrorail passenger cars. The windows on Metrorail cars are not designed to open easily. WMATA’s Emergency Services Manual provides emergency responders with general window specifications, stating that the windows are not designed to be removed, but can be removed from the inside by taking off the inside zip strip. However, according to the General Superintendent of Rail Car Maintenance, the rubber grommet surrounding the window inside the car must be pried off with a tool, and it is not easily removed by hand. As reported during the emergency response activities, the emergency responders had extreme difficulty removing the Metrorail car windows because the rubber grommet surrounding the outside of the window was brittle and kept tearing; and the window was stuck in its frame and could not be removed easily. They had to remove a window in the damaged portion of a car to insert imaging equipment because they did not know whether the car was still occupied by any incapacitated passengers. Fortunately, the visual and thermal imaging searches confirmed that no one was trapped in the car. The conditions surrounding the search and rescue operations after this accident were optimal. The collision occurred within a lighted rail station while the passenger load was light. One train had no passengers, the occupied train was disembarking passengers, and the last car of the striking train was next to the platform. In addition, both the incident commander and the forward commander reported that they had attended WMATA’s training for emergency responders. Despite these conditions, the limited access into the cars delayed the search of the last car. As previously stated, the center door (the emergency exit door) of car 1077 of train 703 was damaged, and debris in the car end did not permit access to search that area. Further, two other door panels that can be opened from the outside the car were in a section that was severely damaged by the collision.

Analysis 47 Railroad Accident Report The Safety Board investigated WMATA’s January 13, 1982, accident at the Smithsonian interlocking in which a Metrorail train car derailed, struck the end of a reinforced concrete wall, and was severed, resulting in three fatalities. Following the investigation, the Board issued Safety Recommendation R-82-70 to WMATA.74 R-82-70 Require the installation of an adequate number of marked emergency escape windows on all new Metrorail cars and implement a program to similarly retrofit existing cars. In a letter dated October 18, 1984, WMATA expressed concern that emergency windows would create new hazards, such as an uncontrolled evacuation in tunnels or vandals opening the windows. Instead of emergency windows, WMATA installed passenger-initiated evacuation devices that allow passengers to open center doors of cars. On January 14, 1986, the Safety Board classified Safety Recommendation R-82-70 “Closed—Acceptable Alternate Action.” Although there is an emergency exit on each side of a car, passengers are instructed to exit the train from only one side during an emergency evacuation. The emergency exits are located at the center doors on each side of the car. These center doors have two panels. However, only one panel can be opened using a mechanical emergency pull located next to the door. Passengers can slide the door open only if it is undamaged, and there is no debris or obstruction in the doorway path. However, passengers can also use the end bulkhead doors to exit from one car into another if the side doors are inoperative and the end doors are not damaged. In this accident, the side door panels and the end doors in the last car of train 703 could not have been used. Emergency responders’ access to the Metrorail cars is substantially limited to doors. Electrical power and a special key are required to open the door panels. In the event that third-rail power is down, an on-board battery can be used to furnish power to open the doors. The Safety Board is concerned that the only means for emergency responders to quickly enter the cars relies on electrical power and key-controlled access. In an accident, third-rail power may be turned off and the back-up battery in the passenger car could be damaged, which would prevent the doors from operating properly. Further, although WMATA distributes access keys to fire departments in WMATA’s territory, bystanders who may be on scene and willing to help cannot open doors. Therefore, the Safety Board concludes that emergency access/egress points for WMATA’s equipment do not provide adequate means for emergency responder entry or passenger evacuation. Passenger railroads regulated by the FRA, per 49 Code of Federal Regulations (CFR) 238.113, are required to have a minimum of four emergency window exits on their passenger cars. However, there is no requirement for rail transit equipment to have 74  NTSB/RAR-82/06.

Analysis 48 Railroad Accident Report emergency window exits. The Safety Board believes the FTA should develop transit railcar design standards to provide adequate means for safe and rapid emergency responder entry and passenger evacuation. Equipment Crashworthiness The last car of train 703 sustained damage that was vastly disproportionate to that sustained by the lead car of train 105. The carbody structure of car 1077 inboard of the collision posts failed, which demonstrates a fundamental flaw in the crashworthiness structural design of the 1000-series carbody. Even though the anti-climber showed indications of engagement,75 the last railcar of train 703 telescoped and overrode the leading end of the first railcar of train 105, sustaining a catastrophic loss of approximately 34 feet of survival space in the passenger compartment. However, the collision post elements of the lead car of train 105 remained intact, and the operator’s cab was not compromised. The Woodley Park station collision scenario was not much different from that of the January 1996 collision at the Shady Grove station.76 In that accident, the collision speed was calculated between 22 and 29 mph occurring on a 0.35-percent descending grade of straight track with the moving train telescoping 21 feet over the stopped equipment, severely compromising the occupant volume of the striking car. In the November 3, 2004, accident, the calculated speed of train 703 was 36 mph as it rolled backwards down a 3.72-percent descending grade of straight track and collided with stopped train 105 and telescoped 20 feet over it. Almost half of the passenger occupant volume of the striking car of train 703 was also severely compromised. In WMATA’s March 2002 response to the Safety Board’s recommendation (R-96-37) to conduct a comprehensive evaluation of Metrorail cars and make modifications to improve their crashworthiness, WMATA stated that its consultant determined that it was neither practical nor desirable to add underframe reinforcement and that such modification possibly could result in more injuries. WMATA also stated that it would have been impractical to modify the 1000-series Metrorail cars before they are scrapped and it would be prohibitive to modify the 2000, 3000, and 4000 series when they are refurbished. As a result of this response, the Board classified Safety Recommendation R-96-37 “Closed— Acceptable Action” based on the information that WMATA’s position on the existing fleet was reasonable and that the intent of the recommendation had been met. The Safety Board concludes that the failure of the carbody (underframe) end structure of the 1000-series Metrorail cars may make them susceptible to telescoping and potentially subject to a catastrophic compromise of the occupant survival space. WMATA’s evaluation, which determined that it was impractical to modify the 1000-series 75  Engagement was indicated by the shear damage to the anti-climber flanges (teeth), which suggested that there was positive engagement with the anti-climber of the adjacent railcar (4018). 76  NTSB/RAR-96/04.

Analysis 49 Railroad Accident Report cars and their crashworthiness performance in collisions, in effect validates the scheduled retirement of the cars.77 Any replacement car should be designed with crashworthiness components for absorbing maximum energy in a collision and to transmit minimum acceleration to passengers without override or telescoping, as found in the current 5000- series railcars and specified for the 6000-series cars. Railroad and commuter passenger railcars are subject to FRA regulations and are required to have carbody structural provisions to reduce the propensity of carbody telescoping during severe end-structure collisions.78 Conversely, the FTA has not established requirements to address structural crashworthiness provisions for passenger cars operating in transit service. Because transit passenger railroad systems operate railcars of a similar size and passenger capacity to that used by commuter train operations, which are subject to FRA crashworthiness requirements as described under 49 CFR 238, the Safety Board concludes that the failure to have minimum crashworthiness standards for preventing telescoping of rail transit cars in collisions places an unnecessary risk on passengers and crew. The Safety Board believes that the FTA should develop minimum crashworthiness standards to prevent the telescoping of transit railcars in collisions and establish a timetable for removing equipment that cannot be modified to meet the new standards. Because the 1000-series, Rohr-built, passenger railcars, which will comprise 26 percent of the Metrorail passenger railcar fleet when all the cars are delivered, are vulnerable to catastrophic telescoping damage and complete loss of occupant survival space in a longitudinal end-structure collision (as occurred at the Woodley Park station), the Safety Board believes that WMATA should either accelerate retirement of Rohr-built railcars, or if those railcars are not retired but instead rehabilitated, then the Rohr-built passenger railcars should incorporate a retrofit of crashworthiness collision protection that is comparable to the 6000-series railcars. 77  The 1000-series cars (292 cars) are currently scheduled for retirement between 2012 and 2015. The 4000-series cars (100 cars) will begin their mid-life rehabilitation in 2012.WMATA plans to have in service during 2006 its 5000- (192 cars) and 6000- (184 cars) series Metrorail cars and have completed the rehabilitation of the 2000- (76 cars) and 3000- (288 cars) series cars. 78  A feature as described in 49 CFR 238.211.

50 Railroad Accident Report Conclusions Findings 1. The track, signal, and communications systems were not factors in this accident. 2. The use of drugs or alcohol was not a factor in this accident. 3. The emergency response to the accident was well coordinated and effectively managed. 4. The braking systems of train 703 were operable on the day of the accident and, if applied, could have stopped the train. 5. If the equipment on train 703 had been equipped with a rollback protection feature in the manual mode, the train could have been safely stopped, regardless of the train operator’s action or inaction, and the accident could have been prevented. 6. The Washington Metropolitan Area Transit Authority was unaware, at the time of the accident, that the rollback protection feature was generally not available when a train was operated in the manual mode, and consequently no specific training was provided to operators about the lack of this feature on all cars. 7. The low task demands and unremarkable operating environment during the accident trip were conducive to the train operator becoming disengaged from some critical train operations. 8. The train operator’s alertness was likely reduced due to inadequate sleep. 9. The Washington Metropolitan Area Transit Authority’s practice of allowing train operators to return to work after having as few as 8 hours off between shifts following prolonged tours of duty does not give train operators the opportunity to receive adequate sleep to be fully alert and to operate safely.

1. Emergency access/egress points for the Washington Metropolitan Area Transit

Authority’s equipment do not provide adequate means for emergency responder entry or passenger evacuation.

1. The failure of the carbody (underframe) end structure of the 1000-series Metrorail

cars may make them susceptible to telescoping and potentially subject to a catastrophic compromise of the occupant survival space.

1. The failure to have minimum crashworthiness standards for preventing telescoping of

rail transit cars in collisions places an unnecessary risk on passengers and crew.

Conclusions 51 Railroad Accident Report Probable Cause The National Transportation Safety Board determines that the probable cause of the November 3, 2004, collision between two Washington Metropolitan Area Transit Authority trains at the Woodley Park-Zoo/Adams Morgan station was the failure of the operator of train 703 to apply the brakes to stop the train, likely due to his reduced alertness. Contributing to the accident was the lack of a rollback protection feature to stop the train when operated in the manual mode.

52 Railroad Accident Report Recommendations As a result of its investigation of the November 3, 2004, collision between two Washington Metropolitan Area Transit Authority trains at the Woodley Park-Zoo/Adams Morgan station, the National Transportation Safety Board makes the following safety recommendations: New Recommendations To the Washington Metropolitan Area Transit Authority: Equip, as soon as possible, all existing and future train equipment with rollback protection for trains operated in the manual mode. (R-06-1) Either accelerate retirement of Rohr-built railcars, or if those railcars are not retired but instead rehabilitated, then the Rohr-built passenger railcars should incorporate a retrofit of crashworthiness collision protection that is comparable to the 6000-series railcars. (R-06-2) To the Federal Transit Administration: Require transit agencies, through the system safety program and hazard management process if necessary, to ensure that the time off between daily tours of duty, including regular and overtime assignments, allows train operators to obtain at least 8 hours of uninterrupted sleep. (R-06-3) Assess the adequacy of the Washington Metropolitan Area Transit Authority’s current organizational structure and ensure that it effectively identifies and addresses safety issues. (R-06-4) Develop transit railcar design standards to provide adequate means for safe and rapid emergency responder entry and passenger evacuation. (R-06-5) Develop minimum crashworthiness standards to prevent the telescoping of transit railcars in collisions and establish a timetable for removing equipment that cannot be modified to meet the new standards. (R-06-6)

Recommendations 53 Railroad Accident Report Recommendation Reclassified in This Report To the Washington Metropolitan Area Transit Authority: R-04-9 Immediately revise the directions to train operators contained in your memorandums of November 7 and 9, 2004, to include specific written instructions for identifying and responding to an emergency rollback situation, and provide training to operators on the procedures to follow if such a rollback event occurs. (Urgent) Urgent Safety Recommendation R-04-9, previously classified “Open—Acceptable Response,” is reclassified “Open—Unacceptable Response” in the “Rollback Protection” section of this report. BY THE NATIONAL TRANSPORTATION SAFETY BOARD MARK V. ROSENKER Acting Chairman DEBORAH A. P. HERSMAN Member ELLEN ENGLEMAN CONNERS Member KATHRYN O’LEARY HIGGINS Member Adopted: March 23, 2006

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55 Railroad Accident Report Appendix A Investigation The National Transportation Safety Board was notified of the collision between two Washington Area Metropolitan Transit Authority trains about 2:18 p.m., eastern standard time, on November 3, 2004. An investigative team was dispatched with members from the Safety Board’s Washington, D.C., headquarters and its Los Angeles, California, regional office. The team included Member Deborah A. P. Hersman and investigative groups for transit operations, track, and oversight; mechanical; human performance; survival factors and emergency response; event recorders; and crashworthiness. The Office of Public Affairs assisted with the on-scene public/media relations. Parties to the on-scene investigation included the Washington Area Metropolitan Transit Authority, the District of Columbia Fire Department, and the Tri-State Oversight Committee.

56 Railroad Accident Report Appendix B Composition of Metrorail Passenger Railcar Fleet The composition of the Metrorail passenger railcar fleet is provided below. This information was received from the Washington Metropolitan Area Transportation Authority’s Office of Rail Systems Engineering on December 7, 2004. Railcar Manufacturer Assigned Car Numbers Production Dates Event Recorder Equipped Car Count Notes Original Current Rohr 1000-1299 8000-8003 1974 - 1978 NO 300 292 4 4 damaged (retired from service): 1028/29, 1076/77. Mid-life rehabilitation completed on all cars mid-1990s. Revenue collection cars: (formerly 1010/11, 1044/45). Breda 2000-2075 1983 YES* 76 76 Mid-life rehabilitation completed December 2004. Breda 3000-3291 1984 - 1988 YES* 290 288 2 damaged (retired from service): 3191, 3252. Cars 3190 and 3253 married as: 3290/91. Mid-life rehabilitation of this Series in process; scheduled completion October 2005. Breda 4000-4099 1992 - 1994 NO 100 100 CAF 5000-5191 2001 - 2004 YES 192 192 ALSTOM 6000-6183 2005 - 2007 YES 0 0 This series (184 railcars) currently in production; anticipated delivery (to commence) August 2005. Total 958 952 Current count includes 4 revenue collection cars

• The 2000- and 3000-series cars will be equipped with the Vehicle Monitoring System (VMS) during rehabilitation and they

will have the same type recorder as the 5000- and 6000-series cars. Each married pair unit will be equipped with a VMS. Power supply and sensor components will be distributed between the married pair, with the central unit located in the A car of each pair.

57 Railroad Accident Report Appendix C Summary of Events The following is a summary of events derived from the Washington Metropolitan Area Transit Authority Train Data Analysis Report. Time Train Number Event 12:45:22 #203 Entered track circuit A2-162 approaching the Cleveland Park station track circuit, A2-165. 12:45:28 #203 Entered track circuit A2-165.

#703 Entered track circuit A2-124 (moving at 34.1 mph), A2-124 was about 3,827 feet from the beginning of track circuit A2-165. 12:46:06 #703 Maintained a speed of 24.1 mph as it traveled through the underground Woodley Park station, leaving the track circuit A2-128 moving in the direction of the Cleveland Park station. 12:46:23 #703 Would have received a 45 mph ATP regulated speed authority when it entered track circuit A2-146. 12:46:38 #203 Left track circuit A2-165

#703 Transiting circuit A2-146, about 1,097 feet from the beginning of track circuit A2-165. 12:46:41 #703 Would have received a 50 mph ATP regulated speed authority when it entered track circuit A2-154. 12:46:47 #703 Is in track circuit A2-157. According to WMATA, “…receive(d) reduced 28 mph ATP speed with Train 203 occupying A2-171 circuit.”

#203 Still occupying track circuit A2-171. 12:46:51 #203 Left track circuit A2-271.

#703 Would have received a 55 mph ATP regulated speed authority. 12:47:02 #703 Exiting track circuit A2-154 at a speed of 31.9 mph (head end) and at a speed of 19.2 mph (rear end). 12:47:03 #703 Entered track circuit A2-162 and would have received a 50 mph ATP regulated speed authority. 12:47:33 #105 Entered A2-128 at Woodley Park station.

#703 Recorded as leaving track circuit A2-162 moving in the reverse direction (negative speed recorded). 12:46:47 #703 Rear of train entered track circuit A2-157 at a speed of 7 mph. 12:47:35 #703 Speed had increased to 16 mph entering track circuit A2-154. 12:47:47 #703 Speed had increased to 26 mph entering track circuit A2-146. 12:48:08 #703 Speed had increased to 29 mph entering track circuit A2- 140; 12:48:23 #703 Speed had increased to 32 mph entering track circuit A2-134.

#105 Train stopped at Woodley Park station. 12:48:32 #703 The data recorded the trailing end of train as it exited track circuit A2- 140 as 36 mph. 12:48:38

Electrical DC Feeder Tie Breakers tripped at time of collision.

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FD07327 ｜ 2006_美国_RAR0602.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2006 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

Collision Between Two BNSF Railway Company Freight Trains Near Gunter, Texas May 19, 2004 Railroad Accident Report NTSB/RAR-06/02 PB2006-916302 Notation 7793A National Transportation Safety Board Washington, D.C.

RAILROAD ACCIDENT REPORT NTSB/RAR-06/02 (PB2006-916302)

COLLISION BETWEEN TWO BNSF RAILWAY COMPANY FREIGHT TRAINS NEAR GUNTER, TEXAS MAY 19, 2004

• Page 26, table 2 first row has been updated to include column head text (Fort Worth Conductor Extra Board*). The text did not print in the original version. (10 OCT 2006)

THE CORRECTIONS BELOW ARE INCLUDED IN THIS VERSION OF THE PUBLISHED REPORT

Railroad Accident Report Collision Between Two BNSF Railway Company Freight Trains Near Gunter, Texas May 19, 2004 NTSB/RAR-06/02 PB2006-916302 National Transportation Safety Board Notation 7793A 490 L’Enfant Plaza, S.W. Adopted June 13, 2006 Washington, D.C. 20594

National Transportation Safety Board. 2006. Collision Between Two BNSF Railway Company Freight Trains Near Gunter, Texas, May 19, 2004. Railroad Accident Report NTSB/RAR-06/02. Washington, DC. Abstract: About 5:46 p.m., central daylight time, on May 19, 2004, two BNSF Railway Company freight trains collided head on near Gunter, Texas. The southbound train, BNSF 6789 South, was traveling about 37 mph, and the northbound train, BNSF 6351 North, was traveling about 40 mph when the collision occurred. The trains were being operated under track warrant control rules on non-signaled single track. The collision resulted in the derailment of 5 locomotives and 28 cars. About 3,000 gallons of diesel fuel were released from the locomotives and resulted in a fire. The southbound train engineer was killed, and the southbound train conductor was airlifted to a hospital in Dallas with serious burns. The crewmembers on the northbound train were transported to a local hospital, where they were admitted. Estimated property damages exceeded $2 million. The safety issues discussed in this report are the issuance of track warrant authority that contains an after-arrival stipulation and the informal communication of proposed meeting locations for trains in non-signaled territory. As a result of its investigation, the National Transportation Safety Board makes safety recommendations to the Federal Railroad Administration, the BNSF Railway Company, the Association of American Railroads, and the American Short Line and Regional Railroad Association. The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Web at http://www.ntsb.gov. Other information about available publications also may be obtained from the Web site or by contacting: National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (800) 877-6799 or (202) 314-6551 Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2006-916302 from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605-6000

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

iii Railroad Accident Report Contents Acronyms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Accident Synopsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Accident Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Preaccident Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 First Northbound Train/BNSF 2917 North . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Second Northbound Train/BNSF 6351 North . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Southbound Train/BNSF 6789 South . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 The Collision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Damages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 BNSF 6351 North Engineer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 BNSF 6351 North Conductor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 BNSF 6351 North Brakeman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 BNSF 6789 South Engineer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 BNSF 6789 South Conductor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Train Dispatcher . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Train Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Track and Site Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Method of Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Movement of Trains . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Track Warrants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 After-Arrival Track Warrants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Postaccident Changes in After-Arrival Track Warrant Volumes . . . . . . . . . . . . . . . . . 18 Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Medical and Toxicological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Track and Mechanical Tests and Inspections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Recovered Track Warrants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Event Recorder Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Sight-Distance Observations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Use of Cellular Phones by Operating Crews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Management Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Operational Testing Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 BNSF Operational Testing of Personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Testing on After-Arrival Track Warrant Rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Train Crew Qualification and Familiarization Training Trips . . . . . . . . . . . . . . . . . . . 25 Additional Data/Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Use of After-Arrival Track Warrants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Contents iv Railroad Accident Report Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 First Northbound Train/BNSF 2917 North . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Second Northbound Train/BNSF 6351 North . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Southbound Train/BNSF 6789 South . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Dispatcher Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 After-Arrival Track Warrants in Non-Signaled Territory . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 BNSF 6789 South Engineer’s Fitness for Duty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Use of Cellular Phones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Positive Train Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 New Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Recommendation Reclassified in This Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Appendixes A: Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45 B: Time Line of Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46 C: Train Identifications Used in Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . .48 D: Recovered Track Warrants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49

v Railroad Accident Report Acronyms and Abbreviations BNSF BNSF Railway Company CFR Code of Federal Regulations CPAP continuous positive airway pressure EAP Employee Assistance Program FRA Federal Railroad Administration GCOR General Code of Operating Rules MP milepost NORAC Northeast Operating Rules Advisory Committee PTC positive train control

vi Railroad Accident Report Executive Summary About 5:46 p.m., central daylight time, on May 19, 2004, two BNSF Railway Company freight trains collided head on near Gunter, Texas. The southbound train, BNSF 6789 South, was traveling about 37 mph, and the northbound train, BNSF 6351 North, was traveling about 40 mph when the collision occurred. The trains were being operated under track warrant control rules on non-signaled single track. The collision resulted in the derailment of 5 locomotives and 28 cars. About 3,000 gallons of diesel fuel were released from the locomotives and resulted in a fire. The southbound train engineer was killed, and the southbound train conductor was airlifted to a hospital in Dallas with serious burns. The crewmembers on the northbound train were transported to a local hospital, where they were admitted. Estimated property damages exceeded $2 million. The National Transportation Safety Board determines that the probable cause of the May 19, 2004, collision near Gunter, Texas, was the southbound train (BNSF 6789 South) crew’s failure to adhere to an after-arrival track warrant requiring them to stay at Dorchester until the northbound train (BNSF 6351 North) arrived. Contributing to the accident was the BNSF Railway Company’s use of after-arrival track warrant authority in non-signaled territory, and the Federal Railroad Administration’s failure to prohibit the use of such authority. Also contributing to the accident was the train dispatcher’s informal communications regarding planned train meeting locations. In its investigation of this accident, the Safety Board examined the following safety issues: • The issuance of track warrant authority that contains an after-arrival stipulation and • The informal communication of proposed meeting locations for trains in non-signaled territory. As a result of its investigation of this accident, the National Transportation Safety Board makes safety recommendations to the Federal Railroad Administration, the BNSF Railway Company, the Association of American Railroads, and the American Short Line and Regional Railroad Association.

1 Railroad Accident Report Factual Information Accident Synopsis About 5:46 p.m.1 on May 19, 2004, two BNSF Railway Company (BNSF) freight trains collided head on near Gunter, Texas. (See figure 1.) The southbound train, BNSF 6789 South, was traveling about 37 mph, and the northbound train, BNSF 6351 North, was traveling about 40 mph when the collision occurred. The trains were being operated under track warrant control rules on non-signaled single track. The collision resulted in the derailment of 5 locomotives and 28 cars. About 3,000 gallons of diesel fuel were released from the locomotives and resulted in a fire. The southbound train engineer was killed, and the southbound train conductor was airlifted to a hospital in Dallas with serious burns. The crewmembers on the northbound train were transported to a local hospital, where they were admitted. Estimated property damages exceeded $2 million. Figure 1. Map showing accident site. Tulsa Dallas Oklahoma City Gunter Accident Site Madill 1  Unless otherwise noted, all times in this report are central daylight time.

Factual Information 2 Railroad Accident Report The accident occurred at milepost (MP) 661.9 on the Madill Subdivision. (See figure 2.) BNSF 6351 North had 4 locomotives and 65 empty cars. BNSF 6789 South had 3 locomotives and 65 cars loaded with rock. The dispatching plan called for the two trains to meet at Dorchester siding, about 3 1/2 miles north of the collision site, with BNSF 6789 South holding the main track and BNSF 6351 North entering the siding. BNSF 6789 South left Dorchester before BNSF 6351 North arrived. The data for both trains show an emergency brake application initiated from the control stand at, or just before, impact. The collision took place on straight track, just south of a 1 1/2°-curve with a 0.50-percent grade descending to the south. Figure 2. Madill Subdivision map. Madill Lakeside Barry Sherman CTC Denison Hebron Dorchester Gunter Celina Prosper Irving T E X A S O K L A H O M A Accident Site N BNSF Madill Subdivision NOT TO SCALE To Dallas To Tulsa Accident Narrative Preaccident Events Prior to the collision, three BNSF trains were operating on the Madill Subdivision between Irving and Sherman, Texas: two northbound trains and one southbound train. The first northbound train, BNSF 2917 North, was not involved in the collision. The second northbound train, BNSF 6351 North, was struck by the third train, BNSF 6789 South. In the time leading up to the accident,2 each train crew received track warrants and discussed train movements with the train dispatcher concerning potential meeting locations with the 2  See appendix B for a complete time line of accident events.

Factual Information 3 Railroad Accident Report other trains. According to radio transcripts and voice recordings,3 each of the three train crews used the radio while taking track warrants and talking with the train dispatcher. There were no indications that the communications systems were not working properly. As the trains approached each other, they were in different radio tower ranges, which can affect a train crew’s ability to hear all of the dispatcher’s conversations with or instructions to other crews. The only information available to the train crews about the dispatcher’s communications was either overheard on the radio or issued via track warrants. First Northbound Train/BNSF 2917 North4 The crew of the first northbound train, BNSF 2917 North, reported for duty about 7:00 a.m. in Sherman, Texas. BNSF 2917 North had two locomotives and nine freight cars. This train was also sometimes referred to in transcripts as the Sherman Switcher, the R TEX 641, the 641 Job, the 641, or the Switcher.5 On the day of the accident, the BNSF 2917 North crew departed from and worked in and around Sherman Yard before traveling south to Celina, Texas. About 4:37 p.m., after the BNSF 2917 North crew had completed its work at Celina, it was issued a track warrant authorizing movement from Celina6 to the north siding switch at Dorchester. About 4:40 p.m., the train dispatcher had a discussion with the BNSF 2917 North crew concerning possible meeting points. The train dispatcher advised the BNSF 2917 North crew that he might hold BNSF 6789 South at Dorchester for two trains. He said the meeting locations depended on how the Sherman Rock Train, BNSF 6351 North, was running. Although it was authorized to proceed on the main track to the north switch at Dorchester, BNSF 2917 North had only a few cars, and the crew offered to head in at the south siding switch and release its main track authority. The dispatcher said he appreciated the offer because BNSF 6789 South had indicated some engine trouble and it was approaching the north switch on an upgrade. About 5:12 p.m., the BNSF 2917 North crew reported that it was clear of the main track in Dorchester siding. The crew aligned the south siding switch behind it for the main track. The dispatcher then issued a track warrant to the BNSF 6789 South crew authorizing further movement on the main track to the south siding switch at Dorchester. Because BNSF 2917 North was in the siding and had released its track warrant authority, 3  The dispatching office’s radio and phone communications are recorded. The Safety Board obtained all relevant transcripts pertaining to this accident. At the time of the accident, radio communications between trains were not being recorded. 4  The BNSF designates timetable directions on the Madill Subdivision as north and south. Timetable direction may vary from actual compass direction. 5  See appendix C for more information regarding the identification of the three trains discussed in this report. 6  Between CTC Denison and Irving, train movements are authorized through a computerized track warrant control system.

Factual Information 4 Railroad Accident Report the dispatcher did not need to issue a track warrant to BNSF 6789 South to meet BNSF 2917 North at Dorchester. BNSF 2917 North and BNSF 6789 South passed each other at Dorchester. BNSF 2917 North crewmembers said that both trains radioed each other that their respective rear markers7 were in place. The BNSF 2917 North engineer told Safety Board investigators that he also advised the BNSF 6789 South crew when the southbound train was clear of the north siding switch. During the investigation, the BNSF 2917 North engineer stated the following regarding the communication of engine numbers: Investigator: In the normal process of communication, you identified yourself by locomotive number, BNSF 2917? BNSF 2917 North Engineer: I don’t think so. Investigator: Did, did he [BNSF 6789 South] ever contact you and ask specifically your engine number? BNSF 2917 North Engineer: No. About 5:18 p.m., the BNSF 2917 North crew was authorized to depart for Sherman, after the arrival of BNSF 6789 South. BNSF 2917 North was not involved in the collision. It was in Sherman when the accident occurred. Second Northbound Train/BNSF 6351 North The crew of the second northbound train, BNSF 6351 North, reported for duty about 7:00 a.m. in Sherman Yard, Texas. The three-person crew departed Sherman about 8:50 a.m. Their assignment, also referred to in transcripts as the Sherman Rock Train, the Sherman Clark Rock Train, and the Am Rock, involved taking a loaded rock train south to an unloading facility near Irving, Texas, and then returning with empty cars to Sherman. They arrived in Irving about 11:32 a.m. The BNSF 6351 North crew began its northbound return trip about 4:27 p.m. with track warrant authority to the north siding switch at Prosper. About 5:06 p.m., the train dispatcher radioed the BNSF 6351 North crew and discussed issuing a track warrant to meet BNSF 6789 South at Prosper. The dispatcher advised BNSF 6351 North that BNSF 6789 South was experiencing power problems at Dorchester and he was afraid the train might stall out. The dispatcher said: So, if I can make this meet at Prosper it will probably make it easier on him [BNSF 6789 South], over. Ya’ll go ahead and copy another one, put you in the hole[8] at Prosper, over. 7  Rear marker refers to a device placed on the last car indicating the end of the train. The marker displays a reflector during the day and a light illuminated during darkness. 8  In the hole means to clear the main track by entering a siding.

Factual Information 5 Railroad Accident Report The BNSF 6351 North conductor advised the dispatcher that if they were held at Prosper, they might not have time9 to return to Sherman by 7:00 p.m. At this point, the dispatcher said to “hang on,” and he contacted the BNSF 6789 South crew. He asked: “Hey engineer on BNSF 6789 South, can you hold between the switches there at Dorchester, over?” The BNSF 6789 South engineer responded: “That’s correct, over.” The dispatcher then repeated this question, and the BNSF 6789 South engineer again responded: “That is correct.” The train dispatcher then issued the BNSF 6351 North crew a track warrant authorizing it to proceed as far as MP 659, which was between Dorchester and Prosper. About 5:21 p.m., the BNSF 6351 North crew was issued another track warrant authorizing it to proceed to the south siding switch at Dorchester and to enter the siding to meet BNSF 6789 South. BNSF 6351 North continued north, passing through the town of Gunter, 4 miles south of the accident site about 5:40 p.m. Southbound Train/BNSF 6789 South The crew of the southbound train, BNSF 6789 South, reported for duty about 10:15 a.m. in Alliance Yard near Fort Worth, Texas. The crew traveled by taxi to Madill, Oklahoma, where they boarded their locomotives and departed Madill about 1:15 p.m. They proceeded south to the siding at Lakeside, Oklahoma, where they picked up their train of 65 cars loaded with rock. In transcripts, BNSF 6789 South is also referred to as the Doni Rock, the Doni Madill, and the Doni Train. About 2:36 p.m., BNSF 6789 South departed Lakeside headed to Irving. Between Lakeside and CTC Denison, the dispatcher authorized train movements through the wayside signals of a centralized traffic control system. Beyond CTC Denison, train movements were authorized through a track warrant control system. About 3:17 p.m., the train dispatcher issued the BNSF 6789 South crew a track warrant authorizing movement from CTC Denison (the end of centralized traffic control and the beginning of track warrant control) to the south siding switch at Sherman. The conductor had difficulty correctly repeating the track warrant information back to the train dispatcher. According to radio transcripts, the conductor made multiple attempts to copy and read back the track warrant to the train dispatcher. The dispatcher slowed the pace of his communications, and the track warrant was OK’d10 at 3:17 p.m. At that time, the dispatcher requested that the engineer call him on the phone. 9  Railroad operating crews are limited to 12 hours on duty by regulations at 49 Code of Federal Regulations Part 228. 10  The dispatcher uses the term OK as a formal confirmation that the crewmember has read back the track warrant instructions correctly. A track warrant is not considered in effect until the OK time is recorded.

Factual Information 6 Railroad Accident Report About 4:02 p.m., the BNSF 6789 South engineer contacted the train dispatcher by cellular phone. The dispatcher said: Hey, do me a favor; I want you to work close with your conductor. Make sure he is using proper radio procedures, especially when it comes to spelling out words and his directions. It’s not a criticism. I can tell he’s new and I’ll certainly go slowly. Make sure he gets it right, if you could. Back him up, and make sure he’s doing it right. I sure would appreciate it. During this cellular phone conversation, the BNSF 6789 South engineer asked the dispatcher if he was going to hold them at Sherman. The dispatcher replied: “No, what I’m going to do is roll up[11] the . . . 641 Job [641 Job was one of the names used for the BNSF 2917 North] and have you meet them at Dorchester.” The engineer said: “Sounds good.” About 4:47 p.m., the dispatcher again advised the BNSF 6789 South crew that they would meet the 641 at Dorchester. About 4:51 p.m., a second track warrant was issued to the BNSF 6789 South crew authorizing movement from the south siding switch at Sherman to the north siding switch at Dorchester. Following the OK on this track warrant, the dispatcher advised the BNSF 6789 South crew that the dispatching plan was to meet one train at Dorchester and then proceed to Prosper to meet a second northbound train: Dispatcher: Yes sir, that’s correct on that repeat, and ah, Sherman Switcher is going to clear up for you, and we’ll just take you to Prosper to meet the Sherman Clark Rock Train, OK, over. BNSF 6789 South: Copy, ah, meet one at Dorchester. About 5:05 p.m., the BNSF 6789 South engineer called the dispatcher and asked: “Were we going in the hole there [north siding switch at Dorchester] or what?” The dispatcher answered: No, no, no, you’re going to hold there till the Sherman Rock, excuse me, until the Sherman Switcher[12] clears up at Dorchester. Then I’ll take you guys on south to Prosper to meet the Sherman Rock Train. The BNSF 6789 South engineer responded: “OK, we don’t have the best power, that north switch is right on the hill there. Anyway, we can go to the south switch?” The dispatcher advised the BNSF 6789 South engineer to “hang on a second.” About 5:06 p.m., the BNSF 2917 North crew advised the dispatcher that it was entering the siding at the south end of Dorchester. The dispatcher in turn advised the BNSF 6789 South crew to “slow up a little bit,” and he said, “they’re dragging in the siding right now.” Just after this, the train dispatcher gathered additional information that resulted in a decision to change the meeting locations from what he had just radioed the BNSF 6789 South crew. The dispatcher radioed the BNSF 6351 North crew to determine their location and what time they had to be off duty. About 5:10 p.m., after being told that 11  As trains release portions of their authority, it is referred to as rolling up their authority. 12  The Sherman Switcher was BNSF 2917 North. The Sherman Rock was BNSF 6351 North.

Factual Information 7 Railroad Accident Report the BNSF 6351 North crew might exceed their maximum hours-of-service times before getting to Sherman if they were held at Prosper, the dispatcher issued the BNSF 6351 North crew a track warrant authorizing movement to MP 659, which is north of Prosper. About 5:16 p.m., after BNSF 2917 North (the first northbound train) entered Dorchester siding and released its track warrant authority on the main track at Dorchester, the BNSF 6789 South crew was issued a track warrant authorizing movement on the main track to the south end of Dorchester. (See figure 3.) About 5:21 p.m., the dispatcher issued a track warrant to the BNSF 6351 North (the second northbound train) crew, authorizing it to proceed to the south siding switch at Dorchester with an instruction to clear the main track (enter the siding). BNSF 6789 South was stopped at the south end of Dorchester on the main track about 5:39 p.m., when the dispatcher issued a track warrant (No. 3598) authorizing its movement from the south siding switch at Dorchester to the south siding switch at Hebron, after the arrival of BNSF 6351 North (the second northbound train). (See appendix D for a copy of the track warrant.) Prior to issuing the track warrant, the dispatcher checked twice with the BNSF 6789 South crew to ensure that they could “hold between switches at Dorchester.” The last series of communications between the BNSF 6789 South engineer13 and the train dispatcher was as follows: BNSF 6789 South Engineer: Track Warrant No. 3598, with the box 7 not in effect till after the arrival of BNSF 6351 at south, s-o-u-t-h, siding switch Dorchester is OK’d at seventeen thirty-nine, 1-7-3-9. WHM,[14] over. Dispatcher: OK, that’s correct, hey ah, what time should I have you guys a taxi at, at ah, Irving back to Fort Worth for, over? BNSF 6789 South Engineer: Ah, probably about 7:30. Dispatcher: Nineteen thirty, OK. I’ll call you back to confirm, OK, over. BNSF 6789 South Engineer: All right. I’ll report, ah, south siding switch Dorchester restored to normal. Dispatcher: OK, ah, I can’t, I can’t, ah, normal it, ah, because ah, I can’t show it normal because the ah, that Rock Train,[15] the Sherman Switcher’s[16] got a box 7 on you, OK, over. BNSF 6789 South Engineer: OK. After we get by, we’ll let you know. Dispatcher: Here we go, dispatcher out. 13  The dispatcher said that he recognized the engineer’s voice after listening to the recorded communications. 14  WHM are the dispatcher’s initials. 15  The Rock Train was BNSF 6351 North. 16  The Sherman Switcher was BNSF 2917 North.

Figure 3. Train operations schematic. North South To Madill MP 602.6 Sherman MP 645.5 Dorchester MP 657.7 Prosper MP 679.7 Hebron MP 692.5 To Irving MP 709.2 Collision Location MP 661.9 BNSF 6789 South BNSF 6351 North Schematic view only-Not to scale 1 1 2 2 3 3 4 4 5 5 Approximate Time of Events BNSF 2917 North 5:12 p.m. BNSF 2917 North clears main track in Dorchester siding and releases track warrant authority. 5:16 p.m. BNSF 6789 South receives track warrant authority on main track to south siding switch Dorchester. 5:20 p.m. BNSF 2917 North and BNSF 6789 South pass at Dorchester. BNSF 6789 South crew does not verify engine number of train passing in siding using radio. 5:21 p.m. BNSF 6351 North receives track warrant authority on main track to south siding switch Dorchester. 5:39 p.m. BNSF 6789 South receives track warrant authority on main track to Hebron with stipulation "after-arrival of BNSF 6351 North" and immediately departs Dorchester. Factual Information 8 Railroad Accident Report

Factual Information 9 Railroad Accident Report This last radio exchange was made about 5:40 p.m., following the completion of the track warrant that required BNSF 6789 South to wait for BNSF 6351 North to enter the siding at the south siding switch at Dorchester before departing. However, as soon as this track warrant was OK’d, BNSF 6789 South departed Dorchester and accelerated to 40 mph. The Collision About 5:46 p.m., 7 minutes after the track warrant requiring BNSF 6789 South to wait at Dorchester until after the arrival of BNSF 6351 North was issued, the two trains collided head on about 3 1/2 miles south of the Dorchester siding. The point of collision occurred at MP 661.9 near the intersection of Fallon Road and State Highway 289, north of the town of Gunter. Most of this area was undulating agricultural land. The track was relatively straight with occasional curves, one of which was the 1 1/2° curve17 at the accident site. (See figure 4.) Trees restrict the view as trains round this curve, and the BNSF 6351 North conductor and engineer said that they first noticed the southbound train through the trees as they approached the curve. The conductor and engineer, who were on the leading locomotive, exited the cab and jumped off the train. A brakeman was riding in a trailing locomotive, where he remained until after the collision. According to a BNSF official, who arrived at the accident site shortly after the collision, the BNSF 6351 North brakeman told him that the BNSF 6789 South engineer had jumped out the window before the collision. However, the brakeman said that he could not remember this account when later interviewed by Safety Board investigators. The BNSF 6789 South conductor told the BNSF official that he had jumped out the window and that he thought the engineer had attempted to get out, but he was not sure how the engineer had exited the train. Event recorder data indicate that both trains were placed into emergency braking just before the collision. BNSF 6351 North was placed into emergency braking at about 40 mph with the throttle in position 4 (of 8). BNSF 6789 South was placed into emergency braking as it was moving about 37 mph with the throttle in the idle, 1, or 2 position.18 17  This was a right-hand curve as viewed from the northbound train, BNSF 6351 North. 18  The event recorder does not distinguish between these three throttle positions. Also, the southbound train was descending a 0.50-percent grade. Throttle and braking actions just prior to the collision were consistent with maintaining the allowed speed of 40 mph.

Figure 4. Aerial photo of accident scene. Factual Information 10 Railroad Accident Report

Factual Information 11 Railroad Accident Report Emergency Response Records indicate that about 5:49 p.m., the Grayson County Communications Center began receiving multiple phone calls about the accident. One of the calls was placed from the BNSF 6351 North brakeman’s cellular phone. The Grayson County Communications Center in turn notified the Gunter Volunteer Fire Department by pager. The Gunter Volunteer Fire Department chief told the Safety Board that he was the first responder to arrive on scene, about 6 minutes after receiving the page. En route to the scene, he said that he activated mutual aid from surrounding jurisdictions and requested that two medical helicopters be put on standby. As he approached the accident site, he observed some of the injured crewmembers and radioed a request to dispatch the helicopter from Sherman. The BNSF 6789 South conductor received serious burns and was transported by helicopter to a hospital burn center in Dallas. The other surviving crewmembers were transported to a local hospital in Sherman, Texas, a short time later. A BNSF official arrived on scene about 6:00 p.m. and assisted rescue workers as they accounted for the crewmembers. He advised them that the BNSF 6789 South engineer had not been located. After searching the wreckage site, responders found the engineer’s body on the west side of the tracks. Two locomotive fuel tanks ruptured, resulting in a fire immediately following the collision. Fire department personnel extinguished the fire. Later in the evening during clean up efforts, a foam truck arrived from the Grayson Airport Fire Department, located in Grayson, Texas, about 20 miles north of Gunter. The foam truck was placed on standby as a precaution. In all, seven other jurisdictions assisted the Gunter Volunteer Fire Department during the accident. At the time of the accident, the Gunter Volunteer Fire Department consisted of 21 volunteer firefighters and 7 fire explorer scouts. The chief stated that during the year prior to the accident, the department had participated in training on chemical response and railroad operations and also had taken part in a tabletop exercise with BNSF. The chief stated that this previous training proved helpful when responding to the Gunter accident. Injuries The BNSF 6789 South engineer was killed. The BNSF 6789 South conductor was seriously burned. All three of the BNSF 6351 North crewmembers were injured and taken by ambulance to a hospital in Sherman. Damages During the collision, both trains were extensively damaged. A total of 28 cars were derailed. BNSF 6789 South had three locomotives, all of which were derailed and

Factual Information 12 Railroad Accident Report destroyed. BNSF 6351 North had four locomotives. The lead locomotive and the second locomotive were derailed and destroyed. The third and fourth locomotives also sustained extensive damage; however, they were not derailed. BNSF provided the following damage estimates: $2,039,791 for equipment (locomotives and cars); $50,000 for track; $52,867 for lading and environmental clean up; and $18,800 for wreck clearing. Total estimated property damages were $2,161,458. Personnel Information BNSF 6351 North Engineer The BNSF 6351 North engineer was hired in August 1979. Prior to the accident, the engineer’s last annual checkride took place in April 2004. He had completed a rules examination in March 2003, and his engineer’s certification was current. He had regularly worked on the Madill and Creek Subdivisions as an engineer during the 12 months before the accident. When the accident occurred, he had been on duty for about 10 hours 50 minutes. The engineer had worked the previous day, going off duty about 8:00 p.m. He had been off duty for 11 hours when he reported for work on May 19. BNSF 6351 North Conductor The BNSF 6351 North conductor was hired in April 1998. He had completed a rules examination in April 2003. He had regularly worked on the Madill and Fort Worth Subdivisions as a conductor during the 12 months prior to the accident. The conductor had been on duty for about 10 hours 50 minutes when the accident occurred. He had worked the previous day, going off duty about 8:00 p.m. He had been off duty for 11 hours before reporting for work on May 19. BNSF 6351 North Brakeman The BNSF 6351 North brakeman was hired in July 2001. He had completed a rules examination in October 2003. He had regularly worked on the Madill and Fort Worth Subdivisions as a trainman during the 12 months before the accident. He had been on duty for about 10 hours 50 minutes when the accident occurred. The brakeman had worked the previous day, going off duty about 8:00 p.m. Prior to reporting for work on May 19, he had been off duty for 11 hours. BNSF 6789 South Engineer The BNSF 6789 South engineer was hired as a conductor in October 1994. He was promoted to engineer in May 1997. Prior to the accident, the engineer’s last annual checkride took place in July 2003. He had completed a rules examination in April 2004, and his engineer’s certification was current. He had regularly worked on the Madill Subdivision as an engineer during the 12 months before the accident. He had been on duty for about 7 hours 35 minutes when the accident occurred. The engineer had last worked on May 17. He had been off duty for 50 hours 30 minutes before reporting for work on May 19.

Factual Information 13 Railroad Accident Report The engineer’s records show he was dismissed on March 24, 2000, for being absent from duty without proper authority. He was reinstated on October 29, 2001, after an arbitrator determined that the charges against him were valid and that he had violated carrier rules. The ruling required him to consult with BNSF’s Employee Assistance Program (EAP) and follow a program on attendance devised by the EAP. BNSF 6789 South Conductor The BNSF 6789 South conductor was hired in August 2001. Prior to the accident, he had completed a biennial rules examination in June 2003 and an annual train ride in September 2003. The conductor had been on duty for about 7 hours 35 minutes at the time of the accident. He had last worked on May 17, and he had been off duty for 50 hours 30 minutes when he reported for work on May 19. The conductor had recently transferred to a road service pool19 assignment covering the Madill Subdivision. This was his second trip. He had worked a yard assignment for several months before taking the pool assignment. On the yard assignment, he had not been required to work with a train dispatcher copying track warrants over the radio. The BNSF official in charge of field operations on the Madill Subdivision stated that the conductor was qualified to work as a conductor on the day of the accident based on normal qualification procedures. Train Dispatcher The train dispatcher was hired in July 1999. He had completed biennial rules training in December 2003. He had regularly dispatched the Madill Subdivision during the 12 months prior to the accident. The dispatcher was working a regular 3:00 p.m. to 11:00 p.m. shift and had been on duty for about 2 hours 45 minutes at the time of the accident. He had gone off duty the previous evening about 11:00 p.m. He had been off duty about 16 hours when he reported for work on May 19. Train Information BNSF 6789 South consisted of 3 locomotives and 65 rock cars. The train weighed 9,044 tons and was 2,871 feet in length (3,066 feet with locomotives). It was a unit train20 identified by BNSF with the symbol U MADDON1 19A. BNSF 6351 North consisted of 4 locomotives and 65 empty rock cars. The train weighed 1,996 tons and was 2,847 feet in length (3,119 feet with locomotives). It was a unit train identified by BNSF with the symbol U SHTIRB1 19A. 19  A road service pool consists of personnel working on-call assignments in rotation. 20  A unit train is a set of dedicated equipment that is operated between a loading and unloading facility.

Factual Information 14 Railroad Accident Report Track and Site Information The collision occurred about 3 miles north of Gunter, a town about 45 miles north of Dallas. Track structure in the area of the collision consisted of a single main track. The rail was composed of 115-pound21 continuous welded rail fixed to treated timber crossties in crushed stone ballast. The track was designated Class 4 track22 that had a maximum allowable speed of 49 mph. There was a temporary speed restriction of 40 mph from MP 656.2 to MP 680.1 due to crosstie conditions. Method of Operation Movement of Trains Train operations on the Madill Subdivision were governed by the General Code of Operating Rules (GCOR) dated April 2, 2002; BNSF “Texas Division Timetable Number 5” issued on January 20, 2002; BNSF “System Special Instructions Number 8” issued on July 13, 2003; the BNSF Train Dispatcher, Operator, Control Operator Manual dated July 13, 2003; and various other bulletins and notices issued periodically. A train dispatcher at the BNSF Network Operations Center managed and directed train movements on the Madill Subdivision. During a typical 24-hour period around the date of the accident, there were about 26 train movements on the Madill Subdivision and 7 or 8 train movements on other territories that the Madill train dispatcher handled. The Madill Subdivision consisted of both centralized traffic control and track warrant control territory. Between Sherman and Irving, the Madill Subdivision was non-signaled single track with designated passing tracks (sidings). Within this dark territory,23 the dispatcher issued mandatory directives for trains to proceed from point to point and to make meets and passes of other trains via track warrants. The BNSF official in charge of this territory described typical train movements between Sherman and Irving as unit rock trains and a turn-around local freight assignment. Loaded rock trains moved south, and empty trains moved north. He described train movements as “pretty much a scheduled thing,” and he stated that crews that regularly work the Madill Subdivision usually know which trains are running. 21  Rail is measured in weight per linear yard. 22  Railroads determine how they will classify various segments of their track. As the class designation increases, the track must meet increasingly higher Federal standards for construction, maintenance, and inspection. Federal regulation also establishes maximum train speeds for each class of track. Class 4 track has a maximum allowable speed of 60 mph for freight trains and 80 mph for passenger trains. The railroad may restrict the speed further (as was the case near Gunter). 23  Non-signaled track is often referred to as dark territory in the railroad industry.

Factual Information 15 Railroad Accident Report Track Warrants Track warrants are mandatory directives that convey authority for trains to occupy and operate on the main track between specific locations. When a track warrant is issued, the dispatcher also enters it into the computerized track warrant control system. The track warrant control system is designed to assist the train dispatcher and to identify potential conflicting movements. As the train dispatcher issues a track warrant by radio to the train crew, a crewmember writes the information on a preprinted track warrant form. The BNSF track warrant form has 19 items (1–17 and 21–22) that are checked off as needed by the train dispatcher to regulate the movement of trains. (See figure 5.) As the dispatcher issues the track warrant instructions, a crewmember checks off the boxes and enters other information as directed. Box 7 is the item that must be checked by the train dispatcher and the train crew when an after-arrival track warrant is issued. The train crew reads the track warrant back to the train dispatcher, and providing the read back is correct, the dispatcher advises that it is OK and issues a time. Track-warrant rules require that personnel identify trains by railroad initials, engine number, and direction in a track warrant (for example, BNSF 6789 South or BNSF 6351 North). The BNSF made a distinction between how trains are identified in formal track warrant directives (railroad initials, engine number, and direction) and how they are referred to in less formal information exchanges (the 641 Job, the Sherman Rock, etc.). A senior BNSF manager explained the distinction: Investigator: OK. Another thing is, whenever the train dispatcher is talking to a job, I know that when you issue a track warrant, you do it by initial, number, and direction, like BNSF 6125 northbound. But you also have train symbols that the train dispatchers are using a lot. In this Gunter case, we see where the train dispatcher has talked about the same train and used at least four different identifications in it. Is that a concern that we need to look at? BNSF Manager: I don’t believe so. From a traffic planning standpoint, when meets and passes occur that have strict operational requirements regarding main track authority moves, I think that certainly there’s a level of communications and expectations that we have for those communications. I think that outside of those, that some short identifications are actually more telling, I guess, for a train crew as far as who they’re meeting, such as you’re going to meet a Road Switcher or Rock Train or some of those type of things versus actually getting into alpha-numeric symbol abbreviations that the train crews will do a translation themselves anyway. BNSF procedures required that employees copying track warrants state their name before instructions were transmitted. Before the transmittal of the last track warrant to BNSF 6789 South, the engineer stated that the conductor was copying the track warrant. After listening to the tapes, the train dispatcher recognized the engineer’s voice as the person who had read the instructions back and OK’d the track warrant for BNSF 6789 South to wait at Dorchester. BNSF officials stated that they took no exception to one crewmember copying and a different crewmember repeating the instructions back to the dispatcher.

Figure 5. BNSF track warrant form. Factual Information 16 Railroad Accident Report

Factual Information 17 Railroad Accident Report After-Arrival Track Warrants To comply with an after-arrival track warrant, the train crew that receives the box 7 track warrant must wait until the train listed has arrived at the designated location before any movement is made. The conductor and engineer on BNSF 6789 South were jointly responsible for complying with these requirements.24 BNSF track warrant instructions required that the train to be met be identified by railroad initials, engine number, and direction. The instructions further required that the meeting crew know that the opposing train passed the point of restriction. Additionally, in non-signaled territory, the meeting train was required to make positive radio contact with the train to be met in order to confirm the identity of the passing train. If the crew that was restricted by the box 7 track warrant could not reach the train identified in box 7, then the train dispatcher was to be contacted to confirm the identity of the train that they met. BNSF procedures also included a requirement that both the engineer and the conductor of the train restricted by the box 7 track warrant record the time and location on their track warrant form, indicating that they had identified the train listed in box 7 of their track warrant. When the track warrant was issued requiring that the trains meet at the Dorchester siding (see figure 6), it was a formal directive issued by the dispatcher with a read-back by the crew, which provided confirmation of communication and understanding. Earlier informal discussions between the dispatcher and crews regarding potential meeting points were informational rather than directive. The BNSF viewed these informal information exchanges as important for operational planning to address issues, such as fuel conservation, and to avoid extended blocking of road crossings. A BNSF senior manager explained: I think there’s balance in providing that information and that think aloud, you know, think out loud taking place may be good, and there’s other cases that it may set an expectation that when the plan change (sic). You know, it gets back to what is an obligation to go back and to what I’ll call correct that information that was originally transmitted because operation plans do change. As a result of this accident, on May 28, 2004, the BNSF issued “System General Order Number 45,” amending the after-arrival track warrant procedures. The changes, which took effect on June 1, 2004, established a three-step process in non-signaled territory: 1.  Dispatcher advises the train that will receive the box 7 track warrant of the identification of train(s) that will be listed in box 7 (by railroad initials, engine number, and direction); 2.  The train that will receive the box 7 track warrant establishes the location of the train(s) that will be listed in box 7 (by railroad initials, engine number, and direction), advising the dispatcher that direct communication has been made and the location of the train(s) contacted; and 3.  The train crew to receive the box 7 track warrant has stopped at the meeting point and has notified the dispatcher that they are stopped. 24  GCOR Rule 1.47, “Duties of Trainmen and Enginemen.”

Factual Information 18 Railroad Accident Report An additional condition was implemented requiring that crews turn in their track warrants at the completion of each trip. On May 28, 2004, the BNSF also issued “Job Briefing Number 24” to all dispatchers and chief dispatchers, further explaining the revised communication requirements and expectations regarding the after-arrival track warrant process. The briefing also stated that the BNSF was attempting to minimize the number of trains listed in track warrant box 7. Figure 6. South siding switch at Dorchester Postaccident Changes in After-Arrival Track Warrant Volumes The BNSF monitored track warrant volumes, comparing the period from January 1 to May 20, 2004, with the period from June 6 to July 14, 2004. The comparison showed that the number of after-arrival track warrants issued decreased on a systemwide basis from a monthly average of 2,559.2 (5.88 percent of total track warrants) to 649 (1.13 percent of total track warrants) after the accident and after the revisions to the after-arrival track warrant procedures. On the Madill Subdivision, the number of after-arrival track warrants decreased from a monthly average of 90.9 (5.03 percent of total track warrants issued) to 14 (0.67 percent). The BNSF has continued to monitor after-arrival track warrant volumes and has told the Safety Board that the monthly average remains about the same. During calendar year 2005, an average of about 13 after-arrival track warrants were issued per day in non-signaled territory on the BNSF system. BNSF representatives advised the Board that a number of these after-arrival track warrants were issued solely to monitor compliance with BNSF procedures in non-signaled territory.

Factual Information 19 Railroad Accident Report Meteorological Information The report from the Collin County Regional Airport (about 20 miles south of Gunter) at the time of the accident indicated that the weather was dry and clear, and the temperature was 86° F. There were no weather-related impediments to visibility. Medical and Toxicological Information Toxicological specimens were obtained from the surviving BNSF 6789 South conductor, the three BNSF 6351 North crewmembers, and the BNSF dispatcher on duty at the time of the accident. The coroner provided specimens taken from the deceased BNSF 6789 South engineer. All of the specimens were screened for the following substances: cannabinoids, cocaine, opiates, amphetamines, methamphetamines, phencyclidine, barbiturates, benzodiazepines, and ethyl alcohol. All of the test results were negative for the presence of alcohol and drugs. Information obtained from the medical records maintained by the personal physician of the deceased BNSF 6789 South engineer indicated that he had been diagnosed with severe obstructive sleep apnea in 1999 and he had been prescribed a continuous positive airway pressure (CPAP) device. The diagnosis was based on a sleep study that indicated the engineer had a sleep latency25 period of 2 minutes. According to notes in the physician’s records, the engineer began using the CPAP and reported: “More energy! Less fatigued/feels well.” A physician’s note from January 2002 stated that the engineer had discontinued using the CPAP and that he was sleeping well and had “no daytime somnolence.” Further notes from 2003 and 2004 exams stated that the engineer had not resumed use of his CPAP device. Medical records maintained by the BNSF from July 2001 indicated that the deceased BNSF 6789 South engineer had been diagnosed with diabetes and hypertension and his condition was described as “stable.” Medications prescribed were listed in the records as follows: Glucophage [metformin], 1000 mg twice a day; felodipine, 10 mg a day; Amaryl [glimepiride], 4 mg a day; Avandia [rosiglitazone], 4 mg a day; Accupril [quinapril]; and Zocor [simvastatin]. His recommended work status was described as “Full Duty.” The engineer’s personal physician’s name and signature appeared on the form. No additional details were provided regarding the engineer’s diabetes and hypertension, and there was no mention in the BNSF’s records of a diagnosis of, or treatment for, obstructive sleep apnea. There is no Federal regulation that requires locomotive engineers or their personal physicians to report an obstructive sleep apnea diagnosis to employers. 25  Sleep latency is the amount of time it takes a person to fall asleep. The sleepier someone is, the shorter the person’s sleep latency will be. A person with a sleep disorder such as obstructive sleep apnea often has a very short sleep latency.

Factual Information 20 Railroad Accident Report No additional requests for information regarding the engineer’s diabetes or hypertension had been made by the BNSF, and no other medical examinations were documented in the BNSF’s records. The BNSF’s records did reflect that the engineer’s last required vision evaluation indicated that he had normal color vision. The evaluation also indicated distant vision of 20/30 in the left eye and 20/20 in the right eye. His near vision was recorded as 20/30 in each eye. Medical records for the BNSF 6789 South conductor did not contain information about any potentially performance impairing medical conditions. Tests and Research Track and Mechanical Tests and Inspections Track in the area of the collision was inspected, and no defects were noted. Undamaged cars on both trains were inspected. All brakes had applied on BNSF 6789 South. One car (FURX 911139) on BNSF 6351 North had inoperative airbrakes. The engineer on BNSF 6351 North told investigators that the train handled as expected, and he took no exception to the train’s performance or braking. Both trains were given airbrake tests prior to departing their originating locations. No exceptions were noted. Each locomotive from both trains was within all inspection parameters required by the Federal Railroad Administration (FRA). Recovered Track Warrants Track warrants were recovered from the locomotives involved in the accident. The track warrants documenting the meet between BNSF 6789 South and BNSF 6351 North are provided in appendix D. There is no indication on Track Warrant No. 3598, the after-arrival track warrant issued to BNSF 6789 South, showing that either the engineer or the conductor recorded the identifying information (time and location) for the train that was listed in box 7. Event Recorder Data Event recorder data were produced using the Safety Board’s data analysis software in Washington, D.C.26 The data were verified for accuracy by examining operating characteristics of the locomotives that had been previously recorded. The data were consistent and within the operating range and limitations of the locomotives. 26  Locomotive event recorders typically record information that includes time, speed, distance, and throttle and brake settings.

Factual Information 21 Railroad Accident Report Sight-Distance Observations Sight-distance observations were conducted on May 21, 2004, to approximate the conditions that the crews experienced prior to the collision. The observations were conducted using similar locomotives to those involved in the accident. The weather at the time of the sight-distance observation testing was dry and cloudy, and the temperature was 87° F, which was similar to the accident conditions. During the testing, both locomotives stopped at the point of collision at MP 661.9 and backed away from each other in 100-foot increments until they were 1,700 feet apart. Both locomotives were then moved 25 feet farther apart until the southbound locomotive was backed into the curve and lost sight of the northbound locomotive. At 875 feet from the point of collision, personnel on each locomotive lost sight of the other locomotive. The distance between the two locomotives measured 1,750 feet. (See figure 7.) The sight-distance observations and the event recorder speed data indicate that the crewmembers in the control cabs had about 15 seconds to recognize the impending collision, apply the emergency brakes, and jump from the moving trains before impact. Figure 7. Collision site as viewed from southbound train (BNSF 6789 South). Use of Cellular Phones by Operating Crews The GCOR and the BNSF “System General Order Number 37” dated March 7, 2004, restricted the use of cellular phones and other electronic devices. Cellular phones were not to be used by crewmembers while the train or engine was moving. However,

Factual Information 22 Railroad Accident Report cellular phone use was allowed while the train or engine was stopped, providing that such use did not interfere with required duties. Safety Board investigators obtained records that showed the number and duration of cellular phone calls made by crewmembers on both trains between 1:50 p.m. and the time of the accident. (See table 1.) During this time, a total of 25 cellular phone calls were made and/or received by the 5 crewmembers on both trains while the trains were in motion. Three of these calls were railroad business related. The BNSF 6789 South engineer made two of the business related calls, and the BNSF 6351 North conductor made the third. Table 1. Summary of crew cellular phone activity between 1:50 p.m. and collision. The BNSF 6789 South engineer’s cellular phone record showed activity between 3:12 p.m. and 3:16 p.m. This time period coincides with the time that track warrant authority was being received by the BNSF 6789 South conductor. (Track Warrant No. 3583 was OK’d at 3:17 p.m.) BNSF track warrant procedures required the receiver (the BNSF 6789 South conductor in this case) to repeat back verbatim certain critical portions of the track warrant. In this instance, the track warrant had to be repeated back to the dispatcher several times before it was considered correct. Crewmember Number of Calls Duration of Calls Calls While Train in Motion Calls While Track Warrant Authority Was Being Issued BNSF Business Related Calls BNSF 6789 South Engineer 16 36 minutes 7 1 2 BNSF 6789 South Conductor 7 16 minutes 1 0 0 BNSF 6789 South Total 23 52 minutes 8 1 2 BNSF 6351 North Engineer 20 37 minutes 12 0 0 BNSF 6351 North Conductor 6 22 minutes 3 0 1 BNSF 6351 North Brakeman 12 91 minutes 2 0 0 BNSF 6351 North Total 38 150 minutes 17 0 1 Combined Total 61 202 minutes 25 1 3

Factual Information 23 Railroad Accident Report Following the 3:17 p.m. OK on Track Warrant No. 3583, the dispatcher asked the BNSF 6789 South engineer to use his cellular phone to call him at the Network Operations Center. The engineer had to call the dispatcher twice because of poor transmission/reception during the first call. The first call to the dispatcher was made at 3:22 p.m., and the second call was made at 4:02 p.m. Both calls were recorded. The dispatcher asked the engineer to provide additional assistance to the conductor in future track warrant communications. Event recorder data indicate that both calls were made while the train was in motion. The BNSF 6351 North conductor’s cellular phone records showed a call to the BNSF work order reporting line27 at 5:04 p.m. Event recorder data indicate that the train was in motion at that time. No cellular phone activity was recorded for either train crew during the time the BNSF 6789 South crew was receiving the after-arrival track warrant authority at Dorchester, which required them to wait for the arrival of BNSF 6351 North (OK time 5:39 p.m.). The last cellular phone activity for the BNSF 6789 South crew was recorded at 5:31 p.m. The call lasted about 2 minutes while the train was stopped. The last cellular phone activity for the BNSF 6351 North crew before the collision was recorded at 5:24 p.m. The call lasted about 3 minutes while the train was moving. A 911 call originated from the BNSF 6351 North brakeman’s cellular phone at 5:48 p.m. Management Oversight Operational Testing Program Operational testing28 is one of the methods used to monitor the effectiveness of, and compliance with, the operating rules. The Federal Railroad Safety Act of 1970 requires that railroads have a program of operational tests and inspections. Regulations at 49 Code of Federal Regulations (CFR) Part 217. 9 (a) require that a railroad: Conduct operational tests and inspections to determine the extent of compliance with its code of operating rules, timetables, and timetable special instructions in accordance with a written program retained at its system headquarters and at the division headquarters for each division where the tests are conducted. The BNSF described the program as providing “an opportunity to verify that employees are working safely and in compliance with all company rules, policies, instructions and procedures.” According to managers interviewed, the BNSF established a goal of conducting at least 80 tests per month per manager. Operational testing statistics are maintained and provided to the division general manager. 27  The BNSF has a system where crewmembers can call in information to a centralized database concerning work performed en route, such as railroad cars removed from or added to a train. 28  Operational testing involves management observations of employees, as well as structured scenarios, to verify that rules and procedures are followed.

Factual Information 24 Railroad Accident Report Several of the tests in the BNSF program are related to track warrants, although the BNSF official assigned to the Madill Subdivision stated that box 7 requirements were difficult to test: I have never had a violation with a box 7 track warrant, and in fact, again, they are difficult to catch because, I mean, you just have to be in the right spot at the right time. BNSF operational testing records for the 12 months prior to the accident showed that about 1,119 operational tests were performed on the Madill Subdivision. Of that number, 167 were specific29 to track warrant control operations, and 5 of those were recorded as failures. The five failures were recorded for test 612, which covers the requirement that crews operating in non-signaled territory make a radio transmission 2 miles in advance of a siding or junction, stating the engine number, direction, speed, and location. Train dispatchers in the Network Operations Center also monitor the safe operations of trains. If dispatchers become aware of an operating rule violation, they are expected to notify the chief dispatcher. Such a notification would result in followup action. If the rule violation were serious (for example, a “de-certifiable”30 event, such as a train exceeding its movement authority), the dispatcher would typically stop the train and notify a supervisor to contact the crew. BNSF Operational Testing of Personnel Records indicate that the BNSF conducted 184 operational tests of the five crewmembers involved in the collision during the 12 months prior to the accident. The BNSF 6789 South engineer was tested eight times. None of the tests was related to track warrant authority. The engineer failed one test related to derail position, and he was verbally counseled. The BNSF 6789 South conductor was tested 69 times. He passed all of the tests; however, none of them were related to track warrant authority. The BNSF 6351 North engineer was tested 41 times. Two of the tests were related to track warrant authority. The engineer failed three tests, all of which were related to fuel conservation procedures. The BNSF 6351 North conductor was tested 46 times. Three of the tests were related to track warrant authority. He failed two tests pertaining to the use of personal protective equipment. The BNSF 6351 North brakeman was tested 20 times. One test was related to track warrant authority. He passed all of the tests. 29  These tests included 209, 608, 612, 613, and 614 in the BNSF Operations Testing Guide dated December 15, 2003. 30  The FRA requires railroads to certify locomotive engineers. Certain serious rule infractions can result in de-certification under 49 CFR 240.

Factual Information 25 Railroad Accident Report In the 12 months prior to the accident, the BNSF tested the train dispatcher 43 times. He failed two tests because he did not follow proper procedures when authorizing a train to pass a stop signal. Testing on After-Arrival Track Warrant Rules Prior to the Gunter collision, the BNSF did not have a specific line item test for compliance with box 7 track warrant requirements. However, there were line item tests for other aspects of track warrant control compliance, and testing officials could enter test results for box 7 compliance. As a result of this accident, the BNSF established a line item test specifically for box 7 after-arrival authorities, which required the tester to ensure communication and documentation requirements were being met. On May 28, 2004, the BNSF issued “Operations Management Instruction Number 19” to its operations managers, detailing changes to the Operations Testing Reference Guide. These changes added a specific test on after-arrival track warrant compliance. The test procedure addressed each of the three steps required to issue a box 7 track warrant in non-signaled territory, as well as the requirement for crews to turn in their track warrants at the completion of each trip. Train Crew Qualification and Familiarization Training Trips The BNSF official responsible for the Madill Subdivision described the familiarization process for a conductor transferring to the subdivision as making a minimum of one round trip.31 There were also provisions for additional training trips. He explained: If the person says, yes, I made my qualifying trip, but, I don’t have a clue where I am at, and I don’t understand the track warrant stuff and what have you, we will, yeah, we will get them with somebody. And in fact, we will put them on a road switcher, a local out there every day so they get plenty practice at it, I will. But, but, as far as standard qualification trips, that is just one trip. As a result of this accident, the BNSF increased the number of conductor familiarization trips required. On June 21, 2004, the BNSF issued a general notice to Texas Division employees regarding changes to the policy on familiarization trips. On the Madill Subdivision, the policy required an increased numbered of minimum familiarization trips for conductors, as described in table 2. These additional trips provide new employees, or employees new to track warrant control territory, more practice with track warrants before they are qualified to work in this territory. 31  Prior to the Gunter accident, a conductor made this single trip as a working conductor. After the accident, the BNSF established a policy requiring that familiarization trips be made with another qualified conductor present.

Factual Information 26 Railroad Accident Report Table 2. BNSF minimum number of familiarization trips for conductors working on the Madill Subdivision.

• These familiarization trips are also required for pool freight conductors.

Also as a result of this accident and the BNSF 6789 South conductor’s difficulties with reading back a track warrant, the BNSF implemented a new policy limiting the number of read-back attempts allowed before management intervention. On June 1, 2004, the BNSF issued “System General Notice Number 515” to all operating employees and managers explaining a new policy on repeating authorities. The notice stressed the importance of repeating authorities precisely as transmitted and advised that if an authority was not repeated correctly after three attempts, the dispatcher would stop the authority and a supervisor would be contacted for followup. On June 3, 2004, the BNSF issued “Operations Management Instruction Number 20” to managers explaining their responsibilities under the three-strikes policy. Additionally, the BNSF created a presentation on the policy to be used during dispatcher training. The presentation offered the following guidance to train dispatchers: • Use Consistency in Delivery • Discuss Conditions and Restrictions BEFORE issuing • Require a FULL repeat to verify clear understanding • Issue at a SPEED at which it can be copied • Issue in a professional manner • Stop and START OVER any authorities in which conversation occurs • Do not use CONFIRMATION of limits at beginning as a reason to STOP listening to repeat of limits later • If necessary, STOP train and have engineer copy authority • After 3 attempts, END issuance Fort Worth Conductor Extra Board* 1 round trip Fort Worth to Oklahoma City 1 round trip Irving to Madill on local freight assignments 3 trips Fort Worth to Irving on Trinity Railway Express passenger trains 1 trip on U-SHTIRB (same train symbol as BNSF 6351 North) 1 trip on U-SHTCAK (Sherman, Texas, to Clark, Oklahoma) Madill Conductor Extra Board* 1 round trip Madill to Tulsa 1 round trip Madill to Irving 1 trip on U-SHTCAK (Sherman, Texas, to Clark, Oklahoma) 1 trip on Madill Road Switcher

Factual Information 27 Railroad Accident Report Additional Data/Information Various aspects of BNSF operations fall under the regulatory authority of the FRA, as outlined in 49 CFR Parts 200-299. Texas Railroad Commission personnel also enforce FRA regulations in a state participation program, as outlined under 49 CFR Part 212. The FRA was designated as a party to this investigation, and Texas Railroad Commission personnel assisted the FRA. Use of After-Arrival Track Warrants Over a period of time, some railroads have discontinued the use of after-arrival movement authorities. Rules promulgated by the Northeast Operating Rules Advisory Committee32 (NORAC) have not allowed the use of after-arrival movement authorities for at least 17 years. CSX Transportation uses a proprietary rulebook that does not allow after- arrival authorities. However, rules promulgated by the GCOR Committee33 do allow the use of after-arrival movement authorities. Norfolk Southern Railroad uses a proprietary rulebook on the majority of its system, which also allows after-arrival authorities. After the Safety Board investigated a head-on collision of two Union Pacific Railroad trains at Devine, Texas, in June 1997,34 the Board recommended that the Union Pacific Railroad: R-98-25 Discontinue permanently the use of after-arrival orders in dark (nonsignalized) territory. This recommendation was classified “Closed—Acceptable Action” on July 23, 2001, after Union Pacific Railroad stated that it would stop using after-arrival track warrants in non- signaled track warrant control territory. In May 2002, Union Pacific Railroad issued instructions to its operating employees that again allowed the use of after-arrival track warrants, providing the train that was issued such instructions had already stopped to wait for the arrival of the opposing train. After the Safety Board investigated a head-on collision of two BNSF trains at Clarendon, Texas, in May 2002,35 the Board recommended that the FRA: 32  More than 50 railroads operate under NORAC rules, including Amtrak (North-East Corridor), Conrail, and portions of the Norfolk Southern. 33  More than 150 railroads operate under the GCOR, including Amtrak (Western locations); BNSF; Canadian National; Kansas City Southern; and Union Pacific. 34  National Transportation Safety Board, Collision and Derailment of Union Pacific Railroad Freight Trains 5981 North and 9186 South in Devine, Texas, June 22, 1997, Railroad Accident Report NTSB/RAR- 98/02 (Washington, DC: NTSB, 1998). 35  National Transportation Safety Board, Collision of Two Burlington Northern Santa Fe Freight Trains Near Clarendon, Texas, May 28, 2002, Railroad Accident Report NTSB/RAR-03/01 (Washington, DC: NTSB, 2003).

Factual Information 28 Railroad Accident Report R-03-2 In territory not equipped with a positive train control system, restrict the issuance of track warrant authority that contains an after-arrival requirement to trains that have stopped at the location at which they will meet the opposing train. The FRA declined to implement Safety Recommendation R-03-2, responding in a letter dated October 3, 2003, that: Most railroads in the Nation do have sufficient operating rules and instructions already in place to address the Safety Board’s concern regarding restrictions placed on the issuance of “after-arrival” orders without the intrusiveness of regulatory intervention by FRA. Based on this response, Safety Recommendation R-03-2 was classified “Closed— Unacceptable Action” on August 6, 2004. After the Clarendon accident, the BNSF changed its operating rules to allow the use of after-arrival track warrants in non-signaled territory only after the train that was issued these instructions had stopped at the point at which it was to wait for the arrival of the opposing train. The BNSF instructions for train dispatchers36 in effect at the time of the Gunter collision read: For movement in nonsignaled territory, issue track warrant containing Box 7 (Not in Effect Until After the Arrival of______ at ______) only after the train to receive the track warrant containing Box 7 is stopped at the meeting point where opposing train will be met. After the Gunter accident, the BNSF modified its track warrant procedures by adding more communication requirements in non-signaled territory. The new requirements went into effect on June 1, 2004, and read: In non-signaled territory, a train may only be granted a Box 7 “Not in Effect Until After the Arrival of _________” track warrant, after the following requirements have been completed: 1. Dispatcher advises the train that will receive the Box 7 track warrant of the identification of train(s) that will be listed in Box 7 (by initials, engine number and direction). 2. The train that will receive the Box 7 track warrant establishes the location of the train(s) that will be listed in Box 7 (by initials, engine number and direction), advising the dispatcher that direct communication has been made and the location of the train(s) contacted. 3. The train to receive the Box 7 track warrant has stopped at the meeting point and has notified the dispatcher that they are stopped. 36  BNSF Train Dispatcher’s and Control Operator’s Manual issued July 13, 2003.

Factual Information 29 Railroad Accident Report 4. In nonsignaled territory after the meet has occurred, the train with Box 7 must establish positive radio contact with the train listed in Box 7 to confirm the identity of the passing train. If radio communication cannot be established, the train dispatcher must be contacted to provide the required confirmation. The train identification, time passed, location passed, or current time and location must be written on the track warrant form by both the conductor and engineer of the train being so restricted. As a result of the Devine, Texas,37 collision, the Safety Board made two recommendations to the FRA: R-98-26 Revise 49 Code of Federal Regulations 220 to address track warrants and other current railroad operating practices. R-98-27 Require railroads to discontinue permanently the use of after-arrival orders in dark (nonsignalized) territory. In a February 4, 1999, letter in response to Safety Recommendation R-98-26, the FRA notified the Safety Board that it had issued a final rule, effective January 4, 1999, modifying 49 CFR 220 as requested. Accordingly, the Board classified Safety Recommendation R-98-26 “Closed—Acceptable Action” on June 29, 1999. In the same February 1999 letter, the FRA also stated that it had issued a safety directive addressing safety practices in direct train control territory. The directive recommended that in those instances in which a train movement instruction includes a train meet, the dispatcher specifically state in the movement authority, “this track warrant includes a requirement to meet another train.” The second recommendation in the directive required that railroads review their operating rules and practices pertaining to operations in non-signaled territory to determine what further enhancements were warranted to improve safety. These considerations included possibly eliminating the use of after-arrival orders. The letter further stated that FRA audits had determined that the “overwhelming majority” of railroads had eliminated the use of these orders in non- signaled direct train control territory. Although the letter stated that the FRA would continue to review these safety critical procedures during future dispatcher audits, the FRA stopped short of prohibiting the use of after-arrival orders in non-signaled territory. Based on this response, the Safety Board classified Recommendation R-98-27 “Closed— Unacceptable Action” on June 29, 1999. 37  NTSB/RAR-98/02.

30 Railroad Accident Report Analysis Exclusions The track, the locomotives, and the railcars were inspected and tested to the extent possible after the accident. No defects were identified. Further, both trains had received initial terminal airbrake inspections on the day of the accident, and no discrepancies were noted. Neither crew reported any problems with their respective trains. On the day of the accident, the weather was dry, the temperature was 86° F, and visibility was clear. The train dispatcher and the surviving crewmembers on both trains provided toxicological specimens that were screened for drugs and alcohol. The coroner provided specimens taken from the deceased engineer. All of the test results were negative for drugs and alcohol. The BNSF 6789 South crewmembers had been on duty for about 7 hours 35 minutes at the time of the accident. They had been off duty for more than 50 hours before beginning the trip. The train dispatcher had been on duty for about 2 hours 45 minutes, and he had been off duty for 16 hours before beginning his shift. The Safety Board concludes that the following were not factors in this accident: the condition of the track, locomotives, or railcars; the weather; drug or alcohol use; and work schedules. First Northbound Train/BNSF 2917 North BNSF 2917 North originally had main track authority to the north siding switch at Dorchester. Because BNSF 2917 North entered the Dorchester siding at the south switch and reported clear of its main track authority, it was not necessary for the dispatcher to issue a track warrant for BNSF 6789 South to meet BNSF 2917 North at Dorchester. BNSF 2917 North and BNSF 6789 South passed each other at Dorchester, and the BNSF 2917 North subsequently was authorized to continue north. Because the BNSF 6789 South crew did not verbally confirm the train identification of BNSF 2917 North by radio when the trains passed, they most likely assumed that BNSF 2917 North was the single train that the dispatcher had told them they would meet at Dorchester. After the trains passed, BNSF 6789 South was issued the track warrant authorizing it to proceed south from Dorchester after the arrival of BNSF 6351 North. The BNSF 6789 South crew likely assumed that this was the train they had just passed at Dorchester.

Analysis 31 Railroad Accident Report The Safety Board concludes that the BNSF 6789 South crewmembers’ failure to verify the engine number listed on their track warrant against the engine number of the train in the siding, combined with the expectation that they would proceed south after meeting a single train at Dorchester, resulted in the BNSF 6789 South crewmembers likely assuming that they had met BNSF 6351 North at Dorchester. Second Northbound Train/BNSF 6351 North At the time of the collision, BNSF 6351 North was proceeding at the allowed track speed with valid track warrant authority to travel north on the main track from milepost (MP) 678 to the south siding switch at Dorchester. Southbound Train/BNSF 6789 South The BNSF Railway Company (BNSF) had a number of procedures in place to address the circumstances of this accident. The BNSF 6789 South crew was required to note on their track warrant form the engine number, the time, and the location when they met BNSF 6351 North. There was also a procedure requiring them to make positive radio contact with the train listed in the after-arrival track warrant and to verify the engine number. According to the BNSF 2917 North engineer, there was no radio request for engine number verification when the two trains passed or afterwards. Had either of the BNSF 6789 South crewmembers made such a call, they would have learned that they had not yet met BNSF 6351 North and the accident might have been averted. The BNSF 6789 South crew departed Dorchester immediately after receiving Track Warrant No. 3598 requiring them to wait for BNSF 6351 North, which had yet to arrive. The Safety Board concludes that had the BNSF 6789 South crew complied with their track warrant, they would not have left Dorchester and the accident would not have occurred. Both crewmembers were responsible for the safe operation of the train, and they were required to hold a job briefing to discuss the track warrant they received. The conductor had limited experience with track warrants and had demonstrated difficulty copying and repeating track warrant authorities earlier in the day. The dispatcher had asked the engineer to help the conductor and “make sure he’s doing it right.” Helping the conductor complete this task added to the engineer’s responsibilities. Although the engineer was experienced with track warrants on this territory, it is possible that helping the conductor distracted his attention from verifying which train they were to meet at Dorchester, particularly given the expectation that likely was established by earlier informal communications with the dispatcher that indicated they would meet a single train at Dorchester and a second train farther south.

Analysis 32 Railroad Accident Report Dispatcher Communications In the hours leading up to the accident, there were two types of communication between the dispatcher and the BNSF 6789 South crew. Communications transmitting mandatory directives (track warrant authorities) consisted of a formal process in which trains were referred to by their operational identification (for example, BNSF 6789 South), and an accurate read back was required to confirm the directives. Other communications between the dispatcher and the BNSF 6789 South crew were more informal as the dispatcher discussed future train movements and meeting points. Trains were referred to by various nicknames; sometimes several different nicknames were used for the same train. (See appendix C.) Safety Board investigators listened to audio recordings of the radio transmissions between the dispatcher and the BNSF 6789 South crew when the after-arrival track warrant was issued. The dispatcher transmitted the track warrant word for word as entered into the dispatch center computer. The BNSF 6789 South engineer38 repeated the track warrant incorrectly, adding a box 139 entry that the dispatcher had not stated. The dispatcher caught the error, and the engineer acknowledged that there was no box 1 instruction on the track warrant. The rest of the text read back by the BNSF 6789 South crew was correct, including the repetition of the after-arrival stipulation. The track warrant form recovered from the BNSF 6789 South wreckage had a number of incorrect entries. Box 1 was checked, then blacked out, and “3593” was entered on the box 1 line, reflecting the error that was made and corrected during the read back. Boxes 2, 7, and 20 were marked with an “X.” The box 2 line had several words crossed out in the “Proceed from” space, and the entry was not legible. The entry in the box 7 line read, “B6351 North South SS Dorchester.” The line 20 box was marked with an “X,” and no switch was listed. Box 21 (permission to leave a switch in reverse) was checked, and “SSS DOR” was entered on that line. (See appendix D.) The BNSF 6789 South crew was informed on four separate occasions that they would meet a single train at Dorchester. During the last two occasions, they were also informed that they would be traveling beyond Dorchester to meet a second train. When the plan changed, the dispatcher asked the BNSF 6789 South crew if they could fit between siding switches at Dorchester. He asked this question to ensure that BNSF 6789 South could clear the switches without blocking a road crossing. However, the dispatcher did not explain that he was changing the original plan and that BNSF 6789 South would then meet a second train at Dorchester. The Safety Board recognizes that some informal communication may be useful (for example, to avoid blocked crossings, to keep trains moving on heavy grades, or to 38  The dispatcher said that he recognized the engineer’s voice after listening to the recorded communications. 39  Box 1 is used when a previously issued track warrant is made void. See figure 5 for an example of the BNSF track warrant form.

Analysis 33 Railroad Accident Report pace trains for fuel conservation). However, such informal communication can establish expectations that may not be resolved when plans change and a mandatory directive is issued, as likely occurred in this accident. The use of train nicknames can add further confusion. On two occasions, the dispatcher first referred to BNSF 2917 North as the Sherman Rock Train or the Rock Train before correcting himself. (BNSF 6351 North—the train overlooked by the BNSF 6789 South crew—was the Sherman Rock Train, and the majority of trains on the Madill Subdivision carried rock cars.) Therefore, the Safety Board concludes that had the dispatcher consistently referred to all of the trains by their engine numbers—the identification mechanism required in mandatory directives—it would have reinforced the need to verify engine numbers when the trains met. In the very last radio communication that followed the dispatcher’s OK on the after-arrival track warrant issued to BNSF 6789 South at Dorchester, the BNSF 6789 South crew reported the south siding switch at Dorchester as restored to normal.40 The dispatcher replied: “I can’t show it normal because that Rock Train, the Sherman Switcher’s got a box 7 on you.” This was potentially confusing because the dispatcher used two names to describe the northbound train; and while the Sherman Switcher (BNSF 2917 North) did have a box 7 track warrant naming BNSF 6789 South, that track warrant authorized movement from the Dorchester north siding switch, not the south siding switch. The other train name the dispatcher used, the Rock Train (BNSF 6351 North, the train that never reached Dorchester), did not have a box 7 marked on its track warrant. However, BNSF 6351 North did have a box 21 marked, allowing it to leave the south siding switch at Dorchester in reverse position when it entered the siding. The BNSF 6789 South crew had been issued a track warrant with box 20 checked, advising them to be prepared to stop at that switch if it was aligned for the siding after they met BNSF 6351 North. If the BNSF 6789 South crew believed that they had met BNSF 6351 North at Dorchester, it was appropriate for them to report the switch as normal. Another factor that may have resulted in confusion involved BNSF 2917 North reporting clear of its track warrant authority and, therefore, not being listed on any of the track warrants issued to BNSF 6789 South. BNSF 6789 South crewmembers were told (on four occasions) that they would meet one train at Dorchester. They received an after-arrival track warrant requiring them to meet one train at Dorchester, and they did pass one train at Dorchester. However, it was not the train listed on the after-arrival track warrant they were issued. The after-arrival portion of the track warrant was transmitted and read back correctly, and the BNSF 6789 South crew should have waited at Dorchester. However, the BNSF 6789 South crewmembers were never specifically advised of the dispatcher’s change in plans. Train dispatchers should be acutely aware of how informal communications can create expectations that do not always correspond with the dispatchers’ intentions. The dispatcher involved in this accident might have 40  Normal is aligned for movement on the main track, as opposed to reverse, which is aligned for a movement into or out of the siding.

Analysis 34 Railroad Accident Report further reinforced incorrect expectations by frequently using the phrase “here we go”41 as a closing salutation, when after his last communication it was necessary for BNSF 6789 South to remain in place. Therefore, the Safety Board concludes that informal communications between the dispatcher and train crews regarding authority limits, train names, and meeting or stopping points may lead to misunderstandings and errors. The Safety Board believes that the BNSF should use the Gunter collision as a case study in train crew and dispatcher training and retraining to illustrate how informal communications can lead to misunderstandings and errors. The Safety Board is also concerned about the use of informal communications on other railroads. Therefore, the Board will inform the railroad industry about the circumstances of this accident and will advise the industry of the importance of training and retraining employees to recognize how informal communications regarding authority limits, train names, and meeting or stopping points can lead to misunderstandings and errors. After-Arrival Track Warrants in Non-Signaled Territory Non-signaled (dark) territory presents a unique problem for rail safety. In dark territory there are no signals to warn trains as they approach each other, and the avoidance of collisions relies solely on dispatchers and train crews adhering to operating procedures. Issuing after-arrival track warrants under these conditions only exacerbates an already potentially tenuous and contingent work situation. While the railroad industry contends that after-arrival track warrants facilitate the expedient and efficient movement of trains and reduce the amount of wasted resources, and the Federal Railroad Administration (FRA) sees merit in the industry’s logic,42 ultimately, the role of human error and the cost of human casualties also must be considered in this equation. The FRA acknowledges that “until positive train control can be fully achieved, we need to take those steps that will decrease the risk of collisions that may occur as a result of employee error.”43 Yet, the FRA has not taken the proactive steps to address this issue as the Safety Board has recommended. The Safety Board has investigated a number of accidents involving track warrants in non-signaled territory. In 1996, in Smithfield, West Virginia,44 the Board investigated a head-on collision between two CSX Transportation freight trains. CSX Transportation subsequently discontinued the use of after-arrival authorities in non-signaled territory. In 41  A review of dispatcher communication transcripts between 3:11 p.m. and the time of the collision showed that the dispatcher ended his conversations with BNSF 6789 South with “here we go” on six occasions. 42  FRA letter to the Safety Board dated October 3, 2003. 43  FRA letter to the Safety Board dated October 3, 2003. 44  National Transportation Safety Board, Head-On Collision, Trains Q317-19 and Q316-18, CSXT Railroad, Smithfield, West Virginia, August 20, 1996, Railroad Accident Brief NTSB/RAB-98/13 (Washington, DC: NTSB, 1998).

Analysis 35 Railroad Accident Report 1997, the Board investigated a collision between two Union Pacific Railroad freight trains in Devine, Texas.45 As a result of the Devine investigation, the Board issued Safety Recommendation R-98-27, which advised the FRA to permanently discontinue the use of after-arrival orders in non-signaled territory. Safety Recommendation R-98-27 was classified “Closed—Unacceptable Action” on June 29, 1999. In 2002, the Safety Board investigated a collision between two BNSF trains in Clarendon, Texas.46 In its accident report, the Board issued Safety Recommendation R-03-2, which advised the FRA to limit the use of after-arrival orders in non-signaled territory to trains that have stopped at the location at which they will meet the opposing train. Safety Recommendation R-03-2 was classified “Closed—Unacceptable Action” on August 6, 2004. In Safety Recommendation R-03-3, the Board also recommended that the General Code of Operating Rules (GCOR) Committee add language to its track warrant rules to ensure the same. In response to the Clarendon investigation, the BNSF established procedures requiring a train to stop before receiving an after-arrival track warrant and to make positive radio contact with the train to be met in non-signaled territory. After the Gunter collision, the BNSF further strengthened these procedures by requiring more communication between the restricted train, the train(s) to be met, and the dispatcher. The FRA has declined to implement either of the Safety Board’s recommendations (R-98-27 and R-03-2) regarding after-arrival track warrants that were developed in response to the Devine and Clarendon, Texas, accidents. The FRA’s final written response to Safety Recommendation R-03-2, dated October 3, 2003, indicated that disallowing after-arrival orders in non-signaled territory would reduce flexibility and hinder the efficient movement of trains. The FRA also stated that like the industry, it expects that railroad employees will adhere to all applicable operating rules. Unfortunately, expecting employees to always adhere to all applicable rules is more often an ideal than a reality. The Board has investigated too many railroad accidents in which the avoidance of a collision depended on the use of an operating rule or standard practice that proved to be insufficient to prevent accidents caused by human error. Even though the BNSF strengthened its procedures for after-arrival track warrants after the Clarendon accident, the BNSF 6789 South crew still did not make positive radio contact to verify that the train they were passing was the train listed on their track warrant. In the Gunter accident, the BNSF 6789 South crew had already stopped at the location where they were to meet the opposing train, BNSF 6351 North. Therefore, the circumstances of this accident also raise concerns regarding the effectiveness of limiting the issuance of after-arrival orders to trains that have already stopped at the location at which they will meet the opposing train. Regardless of how the after-arrival order is implemented, this practice places full responsibility for ensuring a proper meet on the crew involved. When a crew does not follow procedures in non-signaled territory, as occurred in the Gunter accident, there are no additional warnings to either train. By contrast, when after-arrival track warrants are used in territory with automatic block 45  NTSB/RAR-98/02. 46  NTSB/RAR-03/01.

Analysis 36 Railroad Accident Report signals, both trains receive restrictive signals requiring the trains to slow and eventually stop short of a collision point. Although there may be some circumstances where the use of after-arrival orders in non-signaled territory is beneficial, the accident record has demonstrated that any use of these procedures increases the risk of train collisions. The Safety Board recognizes that unless an automated collision avoidance system is in place, there is no assurance that a collision will not occur. The Board remains convinced that the ultimate safety goal is positive train control (PTC). However, even if PTC becomes more widely adopted, the current non-signaled areas of the U.S. railroad network will probably be among the last to be outfitted with PTC for the same reasons they remain non-signaled now—train volume and type of traffic. Consequently, non-signaled territories will remain higher risk areas for collisions. The incremental steps taken to date by the BNSF and other railroads have not been sufficient. The Safety Board concludes that the use of after-arrival track warrants for train movements in dark (non-signaled) territory creates an unacceptable risk of collision. The Safety Board is also concerned about the FRA’s failure to prohibit or limit the use of after-arrival track warrants in non-signaled territories as previously recommended by the Board. Staff from the Board and the FRA met on March 17, 2004, to discuss open recommendations related to railroad safety. Safety Recommendation R-03-2 was specifically addressed at the meeting, and FRA staff stated that although it shared the Board’s concerns about the problems with after-arrival orders, it was reluctant to prohibit their use at that time. However, the FRA staff did state that if another accident occurred because of an after-arrival order, it would issue an emergency order. The Gunter accident occurred on May 19, 2004, and the FRA has yet to take action to address this continuing problem. The Safety Board concludes that had the FRA required railroads to permanently discontinue the use of after-arrival orders in dark territory as advised in Safety Recommendation R-98-27, this accident would not have happened. The Safety Board has investigated several accidents involving after-arrival orders in non-signaled territory and believes that the FRA has delayed action too long. The Safety Board believes that the FRA should prohibit the use of after-arrival track warrants for train movements in dark (non-signaled) territory not equipped with a PTC system. The Safety Board also believes that the BNSF should discontinue the use of after-arrival track warrants for train movements in dark (non-signaled) territory not equipped with a PTC system. Further, the Safety Board believes that the Association of American Railroads and the American Short Line and Regional Railroad Association should encourage their members to discontinue the use of after-arrival track warrants for train movements in dark (non-signaled) territory not equipped with a PTC system. As noted above, the Safety Board issued Safety Recommendation R-03-3 to the GCOR Committee as a result of the Clarendon, Texas, accident investigation.47 Specifically, the Board recommended that the committee: 47  NTSB/RAR-03/01.

Analysis 37 Railroad Accident Report R-03-3 Add language to the track warrant rules to ensure that in territory not equipped with a positive train control system, track warrant authority that contains an after-arrival requirement is issued only to trains that have stopped at the location at which they will meet the opposing train. However, as a result of its investigations, the Board now believes that the use of after- arrival track warrants in non-signaled territory not equipped with a PTC system should be prohibited. The Board also recognizes that the GCOR Committee was not the appropriate recipient for this recommendation because its rules are not mandatory. Accordingly, Safety Recommendation R-03-3, which was previously classified “Open—Unacceptable Response,” is now reclassified “Closed—Reconsidered.” BNSF 6789 South Engineer’s Fitness for Duty The BNSF 6789 South engineer had been diagnosed with severe obstructive sleep apnea through a formal sleep study almost 5 years before the accident. Obstructive sleep apnea is a chronic medical condition that prevents those affected by it from obtaining restful, uninterrupted sleep. The engineer had been prescribed and had successfully used a continuous positive airway pressure (CPAP) device with excellent results to treat the obstructive sleep apnea, but apparently he had discontinued use of the CPAP more than 2 years before the accident. The BNSF was unaware of his obstructive sleep apnea or his noncompliance with treatment. The Safety Board obtained this latter information from the records of his personal physician and the results of the sleep study he underwent. The engineer can be heard communicating with the dispatcher about 5:39 p.m., 10 minutes before the collision. Event recorder data suggest that the engineer was actively involved in operating the train and that his manipulations of the locomotive controls were appropriate. Therefore, it seems likely that he, and the conductor, mistook BNSF 2917 North for BNSF 6351 North as the train they were supposed to meet according to the after-arrival track warrant. Neither the engineer nor his personal physician informed the BNSF of the sleep apnea diagnosis. They were not required to inform the railroad company. FRA guidance pertaining to medical certification is limited to regulations concerning medications and minimum vision and hearing standards. In its investigation of the collision between Union Pacific Railroad and BNSF freight trains in Kelso, Washington,48 the Safety Board found that crew medical conditions, of which the railroad was unaware, were contributing factors in the accident. As a result of its earlier investigation into a collision between two

48  National Transportation Safety Board, Side Collision of Burlington Northern Santa Fe Railway Train and Union Pacific Railroad Train near Kelso, Washington, November 15, 2003, Railroad Accident Brief NTSB/RAB-05/03 (Washington, DC: NTSB, 2005).

Analysis 38 Railroad Accident Report Canadian National Railroad freight trains near Clarkston, Michigan,49 the Board recommended that the FRA develop a standard medical examination form, requiring that certain conditions, including sleep apnea, be reported to the railroad and prohibiting safety-sensitive work until those conditions could be appropriately evaluated (R-02-24, -25, and -26). As a result of these previous recommendations, the FRA is currently reviewing the findings of a study commissioned to evaluate possible medical certification protocols. The status of these recommendations remains classified as “Open—Acceptable Response.” Emergency Response Emergency responders arrived on scene within 6 minutes of initial notification. While en route, the first responder placed two air ambulance services on standby and activated mutual aid from surrounding jurisdictions. It is noteworthy that the accident occurred in a rural area and that the Gunter Volunteer Fire Department is an all volunteer operation, as are most of the surrounding fire departments. The Safety Board concludes that the emergency response was prompt and appropriate to the accident. Use of Cellular Phones As a result of its investigation into the Clarendon, Texas, collision, the Safety Board found that the accident was caused in part by the “engineer’s use of a cell phone during the time he should have been attending to the requirements of the track warrant his train was operating under….” Consequently, the Board made the following recommendation to the FRA regarding the use of cellular telephones by operating crews: R-03-1 Promulgate new or amended regulations that will control the use of cellular telephones and similar wireless communication devices by railroad operating employees while on duty so that such use does not affect operational safety. On October 3, 2003, the FRA advised the Safety Board that it believed that railroad operating and safety rules were adequate to address cell phone use by operating crews. Further, during a meeting on March 17, 2004, the FRA informed the Board that its inspectors would watch for unauthorized use of cell phones but that a regulation would be almost impossible to enforce. On August 19, 2004, the Board advised the FRA that it remained concerned that the risks of complacency and attention deficiencies associated 49  National Transportation Safety Board, Collision of Two Canadian National/Illinois Central Railway Trains Near Clarkston, Michigan, November 15, 2001, Railroad Accident Report NTSB/RAR-02/04 (Washington, DC: NTSB, 2002).

Analysis 39 Railroad Accident Report with cell phone use are not sufficiently understood or recognized and that cell phone use has the potential to distract crewmembers for a considerable length of time, and is avoidable. Pending the FRA’s assessment of additional information to determine the proper direction the FRA should take, Safety Recommendation R-03-1 was classified “Open—Acceptable Response.” BNSF 6789 South crewmembers were not using cellular phones at the time the last track warrant requiring them to wait at Dorchester was issued or at the time they departed Dorchester without authority. However, the BNSF 6789 South engineer received a call on his personal cellular phone while the conductor was having difficulty reading back Track Warrant No. 3583, which was only OK’d after he had made multiple read-back attempts. The Safety Board notes that inappropriate use of cellular phones has been a factor in other accidents. The frequent use by all crewmembers on the two accident trains while the trains were in motion indicates that BNSF rules prohibiting such use are ineffective. The Board remains concerned that the inappropriate use of cellular phones by crewmembers may pose a risk to the safety of railroad operations. Positive Train Control For more than 30 years, the Safety Board has investigated train collisions that could have been prevented through the deployment of a PTC system. Over the years, the Board has issued a series of relevant recommendations, and PTC has remained on the Board’s Most Wanted Transportation Safety Improvements list since 1990. The most recent safety recommendation relating to PTC, Safety Recommendation R-01-6, was issued to the FRA as a result of the Board’s investigation of a fatal train collision in Bryan, Ohio.50 Since its adoption by the Board, Safety Recommendation R-01-6 has been reiterated in two other reports about railroad accidents that took place in Placentia, California, in 200251 and Chicago, Illinois, in 2003:52 R-01-6 Facilitate actions necessary for the development and implementation of positive train control systems that include collision avoidance, and require implementation of positive train control systems on main line tracks, establishing priority requirements for high-risk corridors such as those where commuter and intercity passenger railroads operate. 50  National Transportation Safety Board, Collision Involving Three Consolidated Rail Corporation Freight Trains Operating in Fog at Bryan, Ohio, January 17, 1999, Railroad Accident Report NTSB/RAR- 01/01 (Washington, DC: NTSB, 2001). 51  National Transportation Safety Board, Collision of Burlington Northern Santa Fe Freight Train With Metrolink Passenger Train, Placentia, California, April 23, 2002, Railroad Accident Report NTSB/RAR- 03/04 (Washington, DC: NTSB, 2003). 52  National Transportation Safety Board, Derailment of Northeast Illinois Regional Commuter Railroad Train 519 in Chicago, Illinois, October 12, 2003, Railroad Accident Report NTSB/RAR-05/03 (Washington, DC: NTSB, 2005).

Analysis 40 Railroad Accident Report Based on a March 27, 2002, letter in which the FRA outlined steps that it had taken toward “achieving the proper atmosphere in the rail industry to allow for the development and implementation of PTC,” the Safety Board classified Safety Recommendation R-01-6 “Open—Acceptable Response.” In answer to an April 17, 2003, letter from the Safety Board asking for an update on actions regarding this safety recommendation, the FRA responded, in a May 5, 2003, letter, that it was “moving forward across a broad front to create the conditions under which PTC systems can be more widely deployed on the national rail system.” In the letter, the FRA detailed some of the steps the agency was taking in the following areas: • Providing a radio-navigation infrastructure and ensuring adequate spectrum; • Facilitating positive train control through regulatory change; • Supporting the demonstration and deployment of candidate technologies; and • Analyzing costs and benefits. The FRA stated that the agency was “doing everything within its power to prepare the way for PTC and encourage its rapid deployment.” In the meantime, the majority of railroad operations occur in territory without any automatic means of preventing train collisions. The Safety Board hosted a seminar on PTC at the NTSB Academy in March 2005, and the Board is aware of several initiatives in the railroad industry to test PTC installations. The BNSF has a pilot installation on its 135-mile Beardstown Subdivision. The BNSF electronic train management system is described as a “safety overlay” working in conjunction with existing train control and signal systems to enforce speed and authority limits. The BNSF has applied to the FRA for an expansion of the electronic train management system to its line from Fort Worth, Texas, to Arkansas City, Kansas. (The Madill Subdivision is not on this line.) The BNSF also has submitted a product safety plan to the FRA that, if approved, would authorize installation of the electronic train management system on the entire BNSF network. On March 7, 2005, the FRA issued a performance standard for processor-based signal and train control systems, which became effective on June 6, 2005. While it is encouraging that the FRA has moved forward on these performance standards and that other PTC pilot projects are underway, the Safety Board remains concerned that it has taken so long for the FRA to require, and for the railroad industry to develop and implement, such systems. The Safety Board concludes that had a PTC system with collision avoidance capabilities been in place and operational on the Madill Subdivision at the time of the accident, the collision would not have occurred.

41 Railroad Accident Report Conclusions Findings 1. The following were not factors in this accident: the condition of the track, locomotives, or railcars; the weather; drug or alcohol use; and work schedules. 2. The BNSF 6789 South crewmembers’ failure to verify the engine number listed on their track warrant against the engine number of the train in the siding, combined with the expectation that they would proceed south after meeting a single train at Dorchester, resulted in the BNSF 6789 South crewmembers likely assuming that they had met BNSF 6351 North at Dorchester. 3. Had the BNSF 6789 South crew complied with their track warrant, they would not have left Dorchester and the accident would not have occurred. 4. Had the dispatcher consistently referred to all of the trains by their engine numbers— the identification mechanism required in mandatory directives—it would have reinforced the need to verify engine numbers when the trains met. 5. Informal communications between the dispatcher and train crews regarding authority limits, train names, and meeting or stopping points may lead to misunderstandings and errors. 6. The use of after-arrival track warrants for train movements in dark (non-signaled) territory creates an unacceptable risk of collision. 7. Had the Federal Railroad Administration required railroads to permanently discontinue the use of after-arrival orders in dark territory as advised in Safety Recommendation R-98-27, this accident would not have happened. 8. The emergency response was prompt and appropriate to the accident. 9. Had a positive train control system with collision avoidance capabilities been in place and operational on the Madill Subdivision at the time of the accident, the collision would not have occurred.

Conclusions 42 Railroad Accident Report Probable Cause The National Transportation Safety Board determines that the probable cause of the May 19, 2004, collision near Gunter, Texas, was the southbound train (BNSF 6789 South) crew’s failure to adhere to an after-arrival track warrant requiring them to stay at Dorchester until the northbound train (BNSF 6351 North) arrived. Contributing to the accident was the BNSF Railway Company’s use of after-arrival track warrant authority in non-signaled territory, and the Federal Railroad Administration’s failure to prohibit the use of such authority. Also contributing to the accident was the train dispatcher’s informal communications regarding planned train meeting locations.

43 Railroad Accident Report Recommendations As a result of its investigation of the May 19, 2004, collision between two BNSF Railway Company freight trains near Gunter, Texas, the National Transportation Safety Board makes the following safety recommendations: New Recommendations To the Federal Railroad Administration: Prohibit the use of after-arrival track warrants for train movements in dark (non-signaled) territory not equipped with a positive train control system. (R-06-10) To the BNSF Railway Company: Use the Gunter collision as a case study in train crew and dispatcher training and retraining to illustrate how informal communications can lead to misunderstandings and errors. (R-06-11) Discontinue the use of after-arrival track warrants for train movements in dark (non-signaled) territory not equipped with a positive train control system. (R-06-12) To the Association of American Railroads and the American Short Line and Regional Railroad Association: Encourage your members to discontinue the use of after-arrival track warrants for train movements in dark (non-signaled) territory not equipped with a positive train control system. (R-06-13) Recommendation Reclassified in This Report To the General Code of Operating Rules Committee: R-03-3 Add language to the track warrant rules to ensure that in territory not equipped with a positive train control system, track warrant authority that contains an after-arrival requirement is issued only to trains that have stopped at the location at which they will meet the opposing train.

Recommendations 44 Railroad Accident Report Safety Recommendation R-03-3, previously classified “Open—Unacceptable Response,” is reclassified “Closed—Reconsidered” in the “After-Arrival Track Warrants in Non-Signaled Territory” section of this report. BY THE NATIONAL TRANSPORTATION SAFETY BOARD Mark V. Rosenker Acting Chairman Deborah A. P. Hersman Member Kathryn O’Leary Higgins Member Adopted: June 13, 2006

45 Railroad Accident Report Appendix A Investigation The National Transportation Safety Board was notified about 7:47 p.m., eastern daylight time, on May 19, 2004, of the collision between two BNSF Railway Company freight trains near Gunter, Texas. The Safety Board launched an investigator-in-charge and other investigative team members from the Board’s Washington, D.C., headquarters and the Los Angeles and Atlanta regional offices. Investigative groups were formed to study operations, mechanical equipment, track, and human performance. No Safety Board Member went to the accident site. Follow-up interviews were conducted at the BNSF Network Operations Center in Fort Worth, Texas, on June 29, 2004. The Federal Railroad Administration, the BNSF Railway Company, the Brotherhood of Locomotive Engineers and Trainmen, and the United Transportation Union assisted the Safety Board in this investigation.

46 Railroad Accident Report Appendix B Time Line of Events 7:00 a.m. Crews of BNSF 6351 North and BNSF 2917 North report on duty at Sherman for southbound trips. 10:15 a.m. Crew of BNSF 6789 South reports on duty at Alliance Yard, then travels by taxi to Madill, Oklahoma. 1:15 p.m. BNSF 6789 South begins southbound trip from Madill, Oklahoma. 3:17 p.m. BNSF 6789 South Track Warrant No. 3583 in effect to proceed on main track from CTC Denison to south siding switch at Sherman. Conductor has difficulty repeating order correctly. Dispatcher asks engineer to telephone him. 3:51 p.m. BNSF 6351 North begins northbound trip. Track Warrant No. 3586 in effect from north restricted limits Irving to north siding switch at Prosper. 4:02 p.m. BNSF 6789 South engineer contacts dispatcher by cellular phone and is asked to help conductor with future track warrants. Dispatcher advises they will meet the 641 Job (BNSF 2917 North) at Dorchester. 4:37 p.m. BNSF 2917 North begins northbound trip. Track Warrant No. 3587 in effect from milepost (MP) 675 to north siding switch at Dorchester. 4:47 p.m. BNSF 6789 South engineer is again told they will meet the 641 at Dorchester. 4:51 p.m. BNSF 6789 South Track Warrant No. 3589 in effect to proceed from north siding switch at Sherman to north siding switch at Dorchester. After track warrant is OK’d, dispatcher advises that BNSF 6789 South will meet the Sherman Switcher at Dorchester and the Sherman Clark Rock Train at Prosper. 5:05 p.m. BNSF 6789 South is again advised by dispatcher that they will meet the Sherman Switcher at Dorchester and the Sherman Rock Train at Prosper.

Appendix B 47 Railroad Accident Report 5:10 p.m. After checking with BNSF 6789 South that they can fit between switches at Dorchester, dispatcher issues BNSF 6351 North Track Warrant No. 3591 to proceed from MP 685 to MP 659. 5:12 p.m. BNSF 2917 North reports clear of main track in Dorchester siding and releases Track Warrant No. 3587. 5:16 p.m. BNSF 6789 South Track Warrant No. 3593 in effect to proceed from MP 652 to south siding switch at Dorchester. 5:18 p.m. BNSF 2917 Track Warrant No. 3594 in effect to proceed from north siding switch at Dorchester to south siding switch at Sherman, after arrival of BNSF 6789 South. 5:21 p.m. BNSF 6351 North Track Warrant No. 3593 in effect to proceed from MP 678 to south siding switch at Dorchester and take siding. 5:22 p.m. Lead locomotives on BNSF 6789 South and BNSF 2917 North pass each other at Dorchester. 5:39 p.m. BNSF 6789 South Track Warrant No. 3598 in effect to proceed from south siding switch at Dorchester to Hebron, after arrival of BNSF 6351 North. 5:40 p.m. BNSF 6789 South departs south siding switch at Dorchester, accelerates to 40 mph. 5:46 p.m. BNSF 6789 South and BNSF 6351 North collide head on at MP 661.9. 5:49 p.m. Grayson County Communications Center receives first of many calls reporting collision. 5:55 p.m. First emergency responder on scene.

48 Railroad Accident Report Appendix C Train Identifications Used in Communications Southbound Train/BNSF 6789 South BNSF 6789 South Operational Identification U MAODON1 19 BNSF Train Symbol Doni Rock Nickname Doni Madill Nickname Doni Train Nickname First Northbound Train/BNSF 2917 North BNSF 2917 North Operational Identification R TEX 6411 19 BNSF Train Symbol 641 Nickname 641 Job Nickname Sherman Switcher Nickname Road Switcher Nickname Second Northbound Train/BNSF 6351 North BNSF 6351 North Operational Identification U SHTIRB1 19 BNSF Train Symbol Sherman Rock Nickname Sherman Rock Train Nickname Sherman Clark Rock Train Nickname Am Rock Nickname Rock Train Nickname

49 Railroad Accident Report Appendix D Recovered Track Warrants

Appendix D 50 Railroad Accident Report

FD07328 ｜ 2007_美国_AAR0701.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2007 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

aviation Crash of Pinnacle Airlines Flight 3701 Bombardier CL-600-2B19, N8396A Jefferson City, Missouri October 14, 2004 ACCIDENT REPORT NTSB/AAR-07/01 PB2007-910402

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Aircraft Accident Report Crash of Pinnacle Airlines Flight 3701 Bombardier CL-600-2B19, N8396A Jefferson City, Missouri October 14, 2004 NTSB/AAR-07/01 PB2007-910402 National Transportation Safety Board Notation 7695E 490 L’Enfant Plaza, S.W. Adopted January 9, 2007 Washington, D.C. 20594 E

P L U R IB US UN U M

N A T I O N A L

T R A S P O R T A T I O N

B O A R D S A FE T Y N

National Transportation Safety Board. 2007. Crash of Pinnacle Airlines Flight 3701, Bombardier CL-600-2B19, N8396A, Jefferson City, Missouri, October 14, 2004. Aircraft Accident Report NTSB/AAR-07/01. Washington, DC. Abstract: This report explains the accident involving a Bombardier CL-600-2B19, N8396A, which crashed into a residential area about 2.5 miles south of Jefferson City Memorial Airport, Jefferson City, Missouri. During the flight, both engines flamed out after a pilot-induced aerodynamic stall and were unable to be restarted. Safety issues discussed in this report focus on flight crew training in the areas of high altitude climbs, stall recognition and recovery, and double engine failures; flight crew professionalism; and the quality of some parameters recorded by flight data recorders on regional jet airplanes. The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Web at http://www.ntsb.gov. Other information about available publications also may be obtained from the Web site or by contacting: National Transportation Safety Board Public Inquiries Section, RE-51 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (800) 877-6799 or (202) 314-6551 Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2007-910402 from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605-6000 The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

iii Aircraft Accident Report Contents Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x

1. Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2. 1

History of Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.2 Injuries to Persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 1.3 Damage to Airplane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 1.4 Other Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 1.5 Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 1.5.1 The Captain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 1.5.1.1 Pilot and Simulator Instructor Interviews Regarding the Captain . . . . . . . . . . . . 8 1.5.2 The First Officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 1.5.2.1 Pilot and Simulator Instructor Interviews Regarding the First Officer . . . . . . . . 10 1.6 Airplane Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 1.6.1 Powerplants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 1.6.2 Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 1.6.3 Maintenance Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 1.7 Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 1.8 Aids to Navigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 1.9 Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 1.10 Airport Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 1.10.1 Air Traffic Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 1.11 Flight Recorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 1.11.1 Cockpit Voice Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 1.11.2 Flight Data Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 1.12 Wreckage and Impact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 1.12.1 Powerplants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 1.12.2 Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 1.13 Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 1.14 Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 1.15 Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 1.16 Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 1.16.1 Aircraft Performance Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 1.16.1.1 Climb to 41,000 Feet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 1.16.1.2 Aerodynamic Stall and Upset Event . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 1.16.1.3 Descent and Glide Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 1.16.2 Cockpit Voice Recorder Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 1.16.3 Engine Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 1.16.4 Load Control Valve Simulation Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 1.17 Organizational and Management Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 1.17.1 Ground School and Simulator Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

iv Aircraft Accident Report 1.17.1.1 Upset Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 1.17.1.2 High Altitude Climbs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 1.17.1.3 Double Engine Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 1.17.1.4 Stall Recognition and Recovery Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 1.17.1.5 Crew Resource Management Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 1.17.1.6 Leadership Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 1.17.2 Flight Manuals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 1.17.2.1 High Altitude Climbs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 1.17.2.2 Double Engine Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 1.17.2.3 Stall Protection System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 1.17.2.4 Flight Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 1.17.3 Federal Aviation Administration Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 1.18 Additional Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 1.18.1 Oxygen Mask Use During the Accident Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 1.18.2 Core Lock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 1.18.3 Previous Related Safety Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 1.18.3.1 Core Lock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 1.18.3.2 Crew Professionalism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 1.18.3.3 Flight Data Recorder Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 1.18.4 Federal Aviation Administration Notice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 1.18.5 Bombardier All Operator Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

1. Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
2. 1

General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 2.2 Accident Sequence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 2.2.1 Climb to 41,000 Feet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 2.2.2 Aerodynamic Stall and Upset Event . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 2.2.3 Double Engine Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 2.2.3.1 Performance of the Double Engine Failure Checklist . . . . . . . . . . . . . . . . . . . . 50 2.2.4 Communications With Air Traffic Controllers and Management of Forced Landing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 2.2.5 Accident Sequence Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 2.3 Flight Crew Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 2.3.1 High Altitude Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 2.3.2 Stall Recognition and Recovery Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 2.3.3 Double Engine Failure Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 2.4 Flight Crew Professionalism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 2.4.1 Part 91 Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 2.4.2 Industrywide Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 2.4.2.1 Pilot Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 2.4.2.2 Operator Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 2.5 Quality of Flight Data Recorder Data for Regional Jet Airplanes . . . . . . . . . . . . . . . . . 68

1. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
2. 1

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 3.2 Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Contents

v Aircraft Accident Report

1. Safety Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
2. 1

New Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 4.2 Previously Issued Recommendation Reiterated and Classified in This Report . . . . . . . 75 4.3 Previously Issued Recommendations Resulting From This Accident Investigation . . . 76

1. Appendixes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

A: Investigation and Hearing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 B: Cockpit Voice Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 C: Pinnacle Airlines’ Double Engine Failure Checklist at the Time of the Accident. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 D: Pinnacle Airlines’ Revised Double Engine Failure Checklist . . . . . . . . . . . . . . . . . . . 149 E: Core Lock Safety Recommendation Letter. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 Contents

vi Aircraft Accident Report Figures

1. Components in the CRJ Pneumatic Supply and Start Systems . . . . . . . . . . . . . . . . . . . . . . 12
2. Glide Distances for the Accident Airplane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

vii Aircraft Accident Report Abbreviations a.c. alternating current AC advisory circular AD airworthiness directive ADG air-driven generator AIRMET airman’s meteorological information AIZ Lee C. Fine Memorial Airport, Kaiser Lake Ozark, Missouri ALPA Air Line Pilots Association AND airplane nose down ANU airplane nose up AOA angle of attack APU auxiliary power unit ARTCC air route traffic control center ASAP Aviation Safety Action Program ASOS automated surface observing system ATC air traffic control ATOS Air Transportation Oversight System ATS air turbine starter CFR Code of Federal Regulations cg center of gravity CRJ Canadair regional jet CRM crew resource management CVR cockpit voice recorder DTW Detroit Metropolitan Wayne County Airport, Detroit, Michigan EICAS engine indicating and crew alerting system FAA Federal Aviation Administration FCOM flight crew operating manual

Abbreviations viii Aircraft Accident Report FDR flight data recorder FMS flight management system FOQA flight operational quality assurance fpm feet per minute FSDO flight standards district office GAO Government Accountability Office GE General Electric GPWS ground proximity warning system Hg mercury ICAO International Civil Aviation Organization ILS instrument landing system ISA International Standard Atmosphere JEF Jefferson City Memorial Airport, Jefferson City, Missouri KIAS knots indicated airspeed LBO Floyd W. Jones Lebanon Airport, Lebanon, Missouri LCV load control valve LIT Little Rock National Airport, Little Rock, Arkansas LOSA Line Operations Safety Audit METAR meteorological aerodrome report msl mean sea level MSP Minneapolis-St. Paul International Airport, Minneapolis, Minnesota N1 engine fan speed N2 engine core speed NWS National Weather Service POI principal operations inspector SB service bulletin SGF Springfield-Branson Regional Airport, Springfield, Missouri SMS safety management system S/N serial number

Abbreviations ix Aircraft Accident Report SPS stall protection system TBN Waynesville Regional Airport, Fort Leonard Wood, Missouri VIH Rolla National Airport, Rolla/Vichy, Missouri

x Aircraft Accident Report Executive Summary On October 14, 2004, about 2215:06 central daylight time, Pinnacle Airlines flight 3701 (doing business as Northwest Airlink), a Bombardier CL-600-2B19, N8396A, crashed into a residential area about 2.5 miles south of Jefferson City Memorial Airport, Jefferson City, Missouri. The airplane was on a repositioning flight from Little Rock National Airport, Little Rock, Arkansas, to Minneapolis-St. Paul International Airport, Minneapolis, Minnesota. During the flight, both engines flamed out after a pilot-induced aerodynamic stall and were unable to be restarted. The captain and the first officer were killed, and the airplane was destroyed. No one on the ground was injured. The flight was operating under the provisions of 14 Code of Federal Regulations Part 91 on an instrument flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident. The National Transportation Safety Board determines that the probable causes of this accident were (1) the pilots’ unprofessional behavior, deviation from standard operating procedures, and poor airmanship, which resulted in an in-flight emergency from which they were unable to recover, in part because of the pilots’ inadequate training; (2) the pilots’ failure to prepare for an emergency landing in a timely manner, including communicating with air traffic controllers immediately after the emergency about the loss of both engines and the availability of landing sites; and (3) the pilots’ improper management of the double engine failure checklist, which allowed the engine cores to stop rotating and resulted in the core lock engine condition. Contributing to this accident were (1) the core lock engine condition, which prevented at least one engine from being restarted, and (2) the airplane flight manuals that did not communicate to pilots the importance of maintaining a minimum airspeed to keep the engine cores rotating. The safety issues discussed in this report focus on flight crew training in the areas of high altitude climbs, stall recognition and recovery, and double engine failures; flight crew professionalism; and the quality of some parameters recorded by flight data recorders on regional jet airplanes. Safety recommendations concerning these issues are addressed to the Federal Aviation Administration.

1 Aircraft Accident Report 1. Factual Information 1.1 History of Flight On October 14, 2004, about 2215:06 central daylight time,1 Pinnacle Airlines flight 3701 (doing business as Northwest Airlink), a Bombardier CL-600-2B19,2 N8396A, crashed into a residential area about 2.5 miles south of Jefferson City Memorial Airport (JEF), Jefferson City, Missouri. The airplane was on a repositioning flight3 from Little Rock National Airport (LIT), Little Rock, Arkansas, to Minneapolis-St. Paul International Airport (MSP), Minneapolis, Minnesota. During the flight, both engines flamed out4 after a pilot-induced aerodynamic stall and were unable to be restarted. The captain and the first officer were killed, and the airplane was destroyed. No one on the ground was injured. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 91 on an instrument flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident. Flight 3701 departed LIT about 2121. The flight plan indicated that the company-planned cruise altitude was 33,000 feet. About 5 seconds after takeoff, when the airplane was at an altitude of about 450 feet mean sea level (msl)5 (about 190 feet above ground level), the first of three separate pitch-up maneuvers during the ascent occurred when the flight crew moved the control column to 8º airplane nose up (ANU), causing the airplane’s pitch angle to increase to 22º and resulting in a vertical load of 1.8 Gs.6 The rate of climb during this pitch-up maneuver was 3,000 feet per minute (fpm). Immediately afterward, the flight data recorder (FDR) recorded stickshaker and stickpusher activations,7 a full airplane-nose-down (AND) control column deflection, a decrease in pitch angle, and a drop in vertical load to 0.6 G. About 2125:55, when the airplane was at an altitude of about 14,000 feet, the flight crew engaged the autopilot. The air traffic control (ATC) transcript and FDR data showed 1 All times in this report are central daylight time based on a 24-hour clock. 2 The accident airplane was a Canadair regional jet (CRJ) -200 model, which is one of three models in the CL-600-2B19 series. (The other two models are the CRJ-100 and CRJ-440.) Bombardier acquired Canadair in December 1986. 3 A repositioning flight relocates an airplane to the airport where the airplane’s next flight is scheduled. Repositioning flights do not carry revenue passengers or cargo but can carry nonrevenue passengers. 4 A flameout is an interruption of a turbine engine’s combustion process that results in an uncommanded engine shutdown. 5 All altitudes and elevations in this report are msl unless otherwise noted. 6 G is a unit of measurement that is equivalent to the acceleration caused by the earth’s gravity (32.174 feet/second2). 7 The stickshaker produces vibrations in the control columns to warn pilots of an impending stall. If the angle of attack (AOA) continues to increase, the stickpusher moves the control columns forward (nose down) automatically to prevent an aerodynamic stall, which can occur afterward.

Factual Information 2 Aircraft Accident Report that the flight crewmembers changed seats in the cockpit during this time,8 but the ATC transcript did not indicate the reason for the seat change. About 2127:15, when the airplane was at an altitude of about 15,000 feet, the flight crew disengaged the autopilot. About 2127:17, when the airplane was in level flight at an altitude of 15,000 feet, the second pitch-up maneuver began when the flight crew moved the control column to 3.8º ANU, causing the airplane’s pitch angle to increase to 17º and resulting in a vertical load of 2.3 Gs. The rate of climb during this pitch-up maneuver reached 10,000 fpm briefly. Between about 2128:40 and about 2128:43, the flight crew made a left rudder input of 4.2º, a right rudder input of 6.0º, and a left rudder input of 0.4º, resulting in lateral loads of -0.16 G, 0.34 G, and -0.18 G, respectively. About 17 seconds later, the flight crew made a right rudder input of 7.7º. About 2132:40, when the airplane was in level flight at an altitude of 24,600 feet, the third pitch-up maneuver began when the flight crew moved the control column to 4º ANU, which increased the airplane’s pitch angle to more than 10º and resulted in a vertical load of 1.87 Gs.9 The rate of climb during this pitch-up maneuver reached 9,000 fpm briefly. The ATC transcript showed that the captain requested a climb to 41,000 feet, which is the Canadair regional jet (CRJ) maximum operating altitude,10 about 2135:3611 and received clearance to climb to that altitude about 2136:13.12 The cockpit voice recorder (CVR) recording began about 2144:44 with the captain and the first officer discussing the climb to 41,000 feet. About 2148:44, the first officer stated, “man we can do it. Forty one it.” About 2151:51, the first officer stated, “there’s four one oh my man.” About 2152:04, the CVR recorded the first officer laughing as he stated, “this is … great.” FDR data showed that, about 2152:08, the airplane was in level flight at 41,000 feet. FDR data also showed that the airplane climbed from 37,000 to 41,000 feet at an airspeed that decreased from 203 knots/0.63 Mach13 at the start of the climb to 163 knots/0.57 Mach as the airplane leveled off.14 The FDR data further showed that the autopilot vertical speed 8 The cockpit voice recorder (CVR) did not preserve any information or sounds associated with the seat change because the CVR had the capability to record only the final 30 minutes of the flight. For information about the seat change, see section 1.16.2. 9 According to the ATC transcript, the controllers made no transmissions to the pilots that required them to perform the three pitch-up maneuvers during the ascent. For more information about the three pitch-up maneuvers, see section 1.16.1.1. 10 The maximum operating altitude of the CRJ-200 is the maximum density altitude at which the airplane is certified to operate. For the CRJ-200, the maximum operating altitude of 41,000 feet represents the maximum capability of the airplane; the actual altitude capability will primarily depend on airspeed, weight, and ambient temperature. 11 The airplane was at an altitude of about 32,000 feet at the time. 12 During postaccident interviews, Pinnacle Airlines pilots stated that some pilots had expressed curiosity about operating the airplane at 41,000 feet and that an informal “[flight level] 410 club” existed at the airline. Managers at Pinnacle Airlines, including the chief pilot, the CRJ program manager, and the vice president of safety and regulatory compliance, were not aware of the club’s existence. 13 Mach is a number that expresses the ratio of the speed of an object to the speed of sound in the surrounding medium. The Safety Board calculated Mach number using the computed airspeed and total air temperature recorded on the FDR. 14 All airspeeds cited in this report are knots indicated airspeed unless noted otherwise.

Factual Information 3 Aircraft Accident Report mode was engaged during the climb with a commanded vertical speed of 500 fpm and that the airplane’s angle of attack (AOA) at 41,000 feet was initially 5.7º. About 2152:22, the CVR recorded the captain asking the first officer whether he wanted something to drink and then the first officer responding that he wanted a soda. CVR evidence indicated that the captain left his seat shortly afterward to get the drink. About 2153:28, the CVR recorded the captain stating, “look how high we are.” About 2153:42, a controller at the Kansas City Air Route Traffic Control Center (ARTCC) asked the pilots whether they were flying a CRJ-200. The captain confirmed this information, and the controller stated, “I’ve never seen you guys up at forty one there.” About 2153:51, the captain replied, “we don’t have any passengers on board so we decided to have a little fun and come on up here.” About 2153:59, the captain added, “this is actually our service ceiling.”15 About 2154:07, the captain told the first officer, “we’re losing here. We’re gonna be … coming down in a second here.” About 3 seconds later, the captain stated, “this thing ain’t gonna … hold altitude. Is it?” The first officer responded, “it can’t man. We … (cruised/greased) up here but it won’t stay.” About 2154:19, the captain stated, “yeah that’s funny we got up here it won’t stay up here.” About 2154:32, the captain contacted the controller and stated, “it looks like we’re not even going to be able to stay up here … look for maybe … three nine oh or three seven.”16 About 2154:36, the FDR recorded the activation of the stickshaker.17 FDR data showed that, at that point, the airplane’s airspeed had decreased to 150 knots, and its AOA was about 7.5º. The FDR recorded activations of the stickshaker and the stickpusher18 three times between 2154:45 and 2154:54.19 FDR data showed that, after the second activation of the stickshaker and stickpusher, the No. 1 (left) and No. 2 (right) engines’ N1 (fan speed) and fuel flow indications began decreasing. FDR data also showed that, at the time of the second stickpusher activation, the airplane’s AOA had increased to 12º and that, after the stickpusher activated for the third time, the pitch angle decreased from 7º to -20º. 15 The service ceiling is the altitude at which the best rate of climb airspeed will produce a 100-fpm climb. The service ceiling varies depending on airspeed, weight, and ambient temperature. The accident airplane was not at maximum weight and was capable of climbing at a rate greater than 100 fpm while at an altitude of 41,000 feet if the airspeed had been maintained at Mach 0.7. 16 The ATC transcript showed that, after this request, the controller began coordinating the descent. 17 For the Mach number at this time, the CRJ-200 stickshaker AOA is about 7.8º at the time of shaker activation. The stickshaker activates at an airspeed of about 150 knots. 18 For the Mach number at this time, the CRJ-200 stickpusher AOA is about 10.5º at the time of pusher activation. The stickpusher activates at an airspeed of about 142 knots. 19 For more information about the stickshaker and stickpusher activations, see section 1.16.1.2.

Factual Information 4 Aircraft Accident Report About 2154:57, the FDR recorded the fifth activation of the stickshaker and the fourth activation of the stickpusher. Even with the stickpusher’s activation, the motion of the airplane continued to increase its AOA to the maximum measurable value of 27º.20 The pitch angle increased to 29º, and the airplane entered an aerodynamic stall. Afterward, a left rolling motion began, which eventually reached 82º left wing down, the airplane’s pitch angle decreased to -32º, and both engines flamed out. About 2155:06, the captain stated to the controller, “declaring emergency. Stand by.” FDR data showed that, during the next 14 seconds, the flight crew made several control column, control wheel, and rudder inputs and recovered the airplane from the upset at an altitude of 34,000 feet. During the recovery, the CVR recorded a sound similar to decreasing engine rpm, and FDR data showed that the No. 1 and No. 2 engines’ N1 indications continued to decrease and that the engines’ fuel flow indications were at zero.21 About 2155:14, the controller told the pilots to descend and maintain an altitude of 24,000 feet; about 5 seconds later, the captain acknowledged the assigned altitude. About 2155:20, the FDR stopped recording because normal a.c. power to the airplane was lost. (The CVR had a different source of power and continued to record.) The last reliable N2 (core speed) recorded by the FDR before it stopped operating was 46 percent for the No. 1 engine and 51 percent for the No. 2 engine. About 2155:23, one pilot stated to the other, “we don’t have any engines,” and, about 10 seconds later, the captain stated, “double engine failure.” About 2156:42, the flight crew began performing the double engine failure checklist,22 which required pilots to maintain 240 knots until they were ready to initiate the double engine failure procedure.23 The checklist indicated that, if the airplane were at or below 21,000 feet and above 13,000 feet, pilots should relight the engines using the windmill restart procedure,24 which required an airspeed of at least 300 knots. The procedure indicated that an altitude loss of 5,000 feet could be expected when accelerating from 240 to 300 knots. The FDR resumed operation about 2159:16.25 FDR data showed that the auxiliary power unit (APU) was supplying electrical power to the airplane, both engines’ N1 indications continued to decrease, and both engines’ N2 indications were at zero. FDR data also showed that the airplane’s altitude was 29,200 feet and that its airspeed was 178 knots. 20 The 27º AOA value is the physical limit of the sensor that measures this parameter. AOAs that are physically higher were recorded as this limit. 21 FDR data and the CVR recording indicated that the engines were operating normally before the upset. 22 For information about this checklist, see section 1.17.2.2. 23 This requirement was a checklist memory item. 24 A windmill restart is an emergency in-flight procedure in which the effect of ram airflow passing through the engine provides rotational energy to turn the engine’s core. 25 At that time, the cabin altitude warning signal was being recorded by the FDR. The FDR did not record the cabin altitude warning signal any time before the loss of engine power or the beginning of the gap in FDR data. The CVR recorded the first activation of the cabin pressure warning about 2157:04. For information about the cabin pressurization system and oxygen mask use during the flight, see sections 1.6.2 and 1.18.1, respectively.

Factual Information 5 Aircraft Accident Report About 2200:38, the captain told the first officer to increase the airspeed to above 300 knots, and the first officer acknowledged this instruction. FDR data showed that the airplane pitched down to -4.4º and accelerated to an airspeed of 200 knots but that, during the next 25 seconds, the airplane pitched up to 0º while its airspeed remained at 200 knots. About 1 minute later, the captain again told the first officer to increase the airspeed to 300 knots. FDR data showed that the airplane pitched down to -7.5º and accelerated to an airspeed of 236 knots (the maximum airspeed achieved during the windmill restart attempt) but that, during the next 22 seconds, the airspeed decreased to 200 knots.26 About 2201:51, the captain stated, “we’re not getting any N two at all. So we’re gonna have … to go to … thirteen thousand feet. We’re going to use the APU bleed air [restart] procedure.”27 Shortly afterward, the captain resumed the double engine failure checklist, which indicated that pilots were to maintain between 170 and 190 knots until they were ready to initiate the APU bleed air restart procedure. About 2203:09, the controller asked the flight crew about the nature of the emergency. The captain responded, “we had an engine failure up there … so we’re gonna descend down now to start our other engine.” About 2203:30, the captain stated, “we’re descending down to thirteen thousand to start this other engine,” and the controller replied, “understand controlled flight on a single engine right now.” FDR data showed that, during the next several minutes, four APU-assisted engine restarts were attempted, but the N2 speed for both engines remained at zero throughout the restarts. About 2206:40, the controller asked the flight crewmembers whether they wanted to land; the captain replied, “just stand by right now we’re gonna start this other engine and see … if everything’s okay.” About 2206:54, the controller informed the flight crew that JEF was up ahead, and the captain acknowledged this information. About 2208:17, the CVR recorded the captain stating, “switch.” About 2209:02, the captain instructed the first officer to tell the controller that they needed “to get direct to [an] airport neither engine’s started right now.” The first officer informed the controller for the first time of the double engine failure,28 and the controller then asked the pilots if they wanted to go direct to JEF. The captain stated, “any airport and closest airport,” and the first officer told the controller, “closest … airport. We’re descending fifteen hundred feet per minute we have … nine thousand five hundred feet left.” Between about 2210:21 and about 2211:20, the controller provided information about the winds, the approach frequency, and the localizer frequency for an instrument landing system (ILS) landing to runway 30 at JEF. About 2212:24, the first officer asked the controller where to look for the airport,29 and the controller provided position, distance, and heading information. About 1 minute later, the controller provided additional location information for JEF. About 2213:37, the captain asked the first officer whether 26 For more information about these and other events during the airplane’s descent, see section 1.16.1.3. 27 Bleed air refers to pressurized air that is provided by the engines or the APU. 28 At this time, the first officer was recorded transmitting from the right seat, which was his proper position in the cockpit. 29 The airplane had descended out of clouds at an altitude of about 5,000 feet.

Factual Information 6 Aircraft Accident Report the airplane was aligned with the runway, and the first officer notified the controller that he did not see the runway. The controller provided further directional information, and the first officer told the controller that he thought he had the approach end of the runway in sight. The controller received no further transmissions from the flight crew. About 2214:02, the first officer told the captain that he had the runway in sight. The captain questioned the first officer about the location of the runway and then stated, about 2214:17, “we’re not gonna make this.” About 2214:38, the captain stated, “is there a road? We’re not gonna make this runway.” Radar data showed that the airplane then turned left and headed toward a straight and lit section of highway. About 2214:46, the captain stated, “let’s keep the gear up … I don’t want to go into houses here.” About 2214:53, the final radar return was received when the airplane was about 0.58 nautical mile southeast of the crash site and at an altitude of 930 feet. About 2214:54, 2214:58, and 2215:00, the CVR recorded the enhanced ground proximity warning system (GPWS) alerts “too low gear,” “too low terrain,” and “pull up,” respectively. About 2215:03, the CVR recorded the captain stating, “we’re gonna hit houses,” and, about 2 seconds later, the enhanced GPWS alert “pull up.” About 2215:06, the CVR recorded a sound similar to an impact and stopped recording about 1 second afterward. 1.2 Injuries to Persons Table 1. Injury chart. 1.3 Damage to Airplane The airplane was destroyed by impact forces and a postcrash fire. Injuries Flight Crew Cabin Crew Passengers Other Total Fatal 2 0 0 0 2 Serious 0 0 0 0 0 Minor 0 0 0 0 0 None 0 0 0 0 0 Total 2 0 0 0 2

Factual Information 7 Aircraft Accident Report 1.4 Other Damage Trees were damaged during the accident sequence. Also, a garage and items in the backyards of six houses were damaged by the impact of the airplane, a property line fence was damaged when the No. 1 engine separated from the airframe after impact, and nearby houses received heat damage from the postcrash fire. 1.5 Personnel Information 1.5.1 The Captain The captain, age 31, held an airline transport pilot certificate and a Federal Aviation Administration (FAA) first-class medical certificate dated July 22, 2004, with a limitation that required him to wear corrective lenses while exercising the privileges of this certificate. The captain received a type rating on the CL-65 in August 2004. (The CL-600-2B19 airplane is included in the CL-65 type rating.) The captain was hired by Pinnacle Airlines in February 2003. According to the captain’s application for employment, he graduated in May 1995 from Embry-Riddle Aeronautical University in Florida with a bachelor of science degree in aeronautical science. The application indicated that the captain worked as a flight instructor for Embry-Riddle Aeronautical University from August 1996 to October 1999, a first officer on the British Aerospace Jetstream at Trans States Airlines from January 1999 to May 2000, and a captain on the Beech 1900 at Gulfstream International Airlines from June 2000 to September 2002.30 The captain’s résumé indicated that he had received FAA high altitude physiological training. Pinnacle Airlines employment and flight records indicated that the captain had accumulated 6,900 hours of total flying time, including 5,055 hours as a pilot-in-command, 973 hours on the CL-65, and 150 hours as a CL-65 pilot-in-command. He had flown 667, 154, and 75 hours in the 12 months, 90 days, and 30 days, respectively, before the accident. The captain’s last recurrent ground training occurred on December 8, 2003; his last recurrent proficiency check was on August 10, 2004; and his last pilot-in-command line check occurred on August 26, 2004. FAA records indicated no accident or incident history or enforcement action, and a search of records at the National Driver Register found no history of driver’s license revocation or suspension. According to his wife, the captain was in good health and exercised regularly. He did not smoke and used alcohol only occasionally. He did not take prescription or nonprescription medicine (other than daily vitamins and ibuprofen when needed). He had not been sick in the days before the accident. He would generally wake at 0745 and go to sleep no later than 2300 when on reserve and not flying. A company first officer (who knew the captain since they were at Gulfstream International Airlines) stated that no 30 In August 2000, the captain received a type rating on the Beech 1900.

Factual Information 8 Aircraft Accident Report significant changes had occurred in the captain’s life during the year preceding the accident. The captain went to a movie with his wife on the evening before the accident. On the day of the accident, he went to a park with his family, went shopping, and went out for lunch. The captain was on standby status at Detroit Metropolitan Wayne County Airport (DTW), Detroit, Michigan, on the day of the accident. Crew scheduling notified him about 1700 that he was to “deadhead” (that is, travel on a company flight as a nonrevenue passenger) on flight 5809 from DTW to LIT, reposition the accident airplane from LIT to MSP, and remain in Minneapolis overnight. Flight 5809 departed DTW about 1919 and arrived at LIT about 2036. Two Northwest Airlines31 customer service agents, who spoke briefly with the captain after he deplaned, reported that he “looked fine,” “did not appear tired,” and “appeared to be in a good mood.” The captain’s wife did not think that he had flown with the accident first officer before the accident flight. The captain’s wife stated that he had experienced only one previous emergency during his flying career, which occurred while he was with Gulfstream International Airlines. She stated that the landing gear did not extend and that the flight crew had to use the emergency extension procedures. She also stated that the captain had received a letter of commendation from the president of Gulfstream International Airlines, which recognized the captain’s actions during a landing in challenging crosswind conditions. 1.5.1.1 Pilot and Simulator Instructor Interviews Regarding the Captain Most pilots who had flown with the captain had favorable comments about his flying abilities. These pilots stated that the captain operated the airplane in a standard manner, demonstrated good crew resource management (CRM) skills, and was “easy to get along with.” Also, a first officer (who had known the captain since they were at Gulfstream International Airlines) stated that the captain was “the best stick and rudder pilot he had ever flown with.” Another first officer stated that the captain set a tone in the cockpit that made the first officer feel comfortable bringing concerns to the captain’s attention. A first officer who flew with the captain from October 7 to 8, 2004, stated that the flights were conducted in a standard manner with no deviations from the flight crew operating manual (FCOM). Another first officer (who had also known the captain since they were at Gulfstream International Airlines) stated that the captain did not seem to be a risk taker. All of the pilots who were interviewed after the accident stated that the captain had never discussed flying at 41,000 feet. The simulator instructor who conducted part of the captain’s upgrade training stated that, during training, the captain did not always perform checklists according to company procedures and did not always use the correct checklists.32 For example, the instructor stated that the captain would, at times, misstate the status of a checklist item, 31 At LIT, Northwest Airlines provided ground support for Pinnacle Airlines. 32 The simulator instructor stated that he debriefed the captain about these deficiencies.

Factual Information 9 Aircraft Accident Report read a checklist item but not accomplish it, or take action on an airplane system that was not the one noted in the checklist. The instructor also stated that the captain would, at times, see the appropriate checklist displayed in an engine indicating and crew alerting system (EICAS) message33 but would still call for the wrong checklist. In addition, the instructor stated that the captain flew the airplane “just fine” but that his biggest weaknesses were his critical decision-making and judgment. In contrast, the captain’s simulator partner thought that all checklists during their training had been performed according to company procedures and stated that, during the debriefing sessions, the instructor did not make any negative comments about the captain’s decision-making. Another simulator instructor who conducted part of the captain’s upgrade training stated that he had no recollections of the captain rushing checklists and that the captain’s judgment was “above average.” A check airman who conducted part of the captain’s upgrade operating experience stated that the captain displayed the profile that he looked for in upgrading captains: proficiency, judgment, initiative, leadership, deliberate and thoughtful actions, and no rushing. 1.5.2 The First Officer The first officer, age 23, held a commercial pilot certificate with airplane single- and multiengine land and instrument airplane ratings. The first officer also held an FAA first-class medical certificate dated January 14, 2004, with a limitation that required him to wear corrective lenses while exercising the privileges of this certificate. The first officer was hired by Pinnacle Airlines in April 2004. According to the first officer’s application for employment, the first officer attended Broward Community College in Florida from May 2001 to December 2003 and received an associate of science degree in professional pilot technology. In October 2002, the first officer began training at Gulfstream Academy of Aeronautics and subsequently became a first officer on the Beech 1900 for Gulfstream International Airlines.34 Pinnacle Airlines employment and flight records indicated that the first officer had accumulated 761 hours of total flying time, including 222 hours as a CL-65 second-in-command. He had flown 380, 192, and 60 hours in the 12 months, 90 days, and 30 days, respectively, before the accident. The first officer’s initial proficiency check occurred on June 27, 2004. FAA records indicated no accident or incident history or 33 Pinnacle Airlines’ checklists were typically used with EICAS messages. Pilots were to call for the checklist noted in an EICAS message and then use that checklist to guide them through a sequence of actions. 34 The first officer’s personnel file contained letters of recommendation from Gulfstream International Airlines pilots. For example, in an August 10, 2003, letter, a captain who had trained and flown with the first officer wrote that he displayed “capable skills in maneuvering the aircraft smoothly and safely” and that he exhibited “excellent situational awareness and decision-making ability.” The letter further stated that the first officer showed strict adherence to company procedures, emphasized CRM, and had strong communication skills.

Factual Information 10 Aircraft Accident Report enforcement action, and a search of records at the National Driver Register found no history of driver’s license revocation or suspension. According to his father, the first officer was in good health and exercised regularly. The first officer was a nonsmoker and used alcohol only occasionally. He was not taking any prescription or nonprescription medications. The first officer was described as someone who had a positive attitude, was motivated, and was happy to be with Pinnacle Airlines. The first officer was on reserve duty beginning on October 11, 2004. He flew a trip from October 11 to 12 and was on reserve duty on October 13. As with the captain, the first officer was notified during the afternoon of October 14 of the repositioning flight, and he departed DTW about 1919 as a deadheading crewmember and arrived at LIT about

1. A Northwest Airlines customer service agent, who spoke briefly with the first

officer after he deplaned, reported that he “appeared to be in a good mood” and “did not seem tired.” According to his father, the first officer had not previously flown with the accident captain. 1.5.2.1 Pilot and Simulator Instructor Interviews Regarding the First Officer During postaccident interviews, captains who had flown with the first officer described him as a confident pilot who was good with checklists and as someone who would ask questions if he did not understand something. The captain who flew with the first officer on the trip from October 11 to 12, 2004, described him as an “average” first officer. This captain did not note any problems with checklists during the trip. All of the pilots interviewed stated that the first officer had not expressed curiosity about flying at 41,000 feet. A simulator instructor who trained the first officer stated that he was a good pilot with a positive attitude. The instructor also stated that he was not concerned about the first officer’s abilities and that he would have made a fine captain. The simulator check airman who conducted the first officer’s simulator checkride stated that he did a good job on the checkride and that he made only minor mistakes that were not uncommon for first officers to make. 1.6 Airplane Information The accident airplane, a Bombardier CL-600-2B19, serial number (S/N) 7396, was delivered new to Pinnacle Airlines on May 18, 2000. At the time of the accident, the airplane had accumulated 10,168 total flight hours and 9,613 total flight cycles.35 35 An aircraft cycle is one complete takeoff and landing sequence.

Factual Information 11 Aircraft Accident Report On the day of the accident, another flight crew was scheduled to fly the accident airplane from LIT to MSP. The flight crew rejected the takeoff after receiving an EICAS message that read “R 14TH DUCT.” The airplane returned to the gate,36 and a maintenance contractor was called to examine the problem. The maintenance contractor could not find the source of the problem, so two Pinnacle Airlines mechanics were dispatched from Memphis, Tennessee, to LIT to resolve the problem. The mechanics found that the No. 2 engine pylon 14th stage bleed air duct sensing loop had some chafing damage where it passed through a rib in the pylon. The loop was replaced, and the No. 2 engine was tested for about 30 minutes. The airplane was then released for service. The airplane’s actual takeoff weight was 39,336 pounds, which was less than the maximum takeoff weight of 53,000 pounds. The takeoff center of gravity (cg) was 21.6 percent mean aerodynamic chord, which was within the cg limits of 9.0 to 35.0 percent. 1.6.1 Powerplants The airplane was equipped with two General Electric (GE) CF34-3B1 turbofan engines. The No. 1 (left) engine, S/N 872746, was installed on the airplane on April 6, 2004, and had accumulated 8,856 total flight hours and 8,480 total flight cycles since new. The No. 2 (right) engine, S/N 873514, was installed new on the airplane on October 23, 2003, and had accumulated 2,304 total flight hours and 1,971 total cycles since new. The No. 1 engine’s fuel control had been replaced on January 3, 2002. The No. 1 engine had been removed from another company airplane on October 30, 2003 (when the engine had accumulated 7,594 flight hours and 7,422 flight cycles); afterward, Pinnacle Airlines maintenance personnel replaced the stage 9 compressor blades, the scavenge oil lube pump, and the fan inlet sensor and installed the engine on the accident airplane. The No. 2 engine’s fan inlet sensor and fuel control unit had been removed from an engine on another company airplane and were installed on the accident airplane’s No. 2 engine. No other major engine components had been changed on either engine since the time of manufacture. 1.6.2 Systems The airplane was equipped with a Honeywell (formerly Garrett Airesearch) GTCP 36-150RJ APU. The APU can provide electrical and pneumatic power to the airplane’s systems when the main engines are not powering those systems. The maximum altitude permitted for the use of bleed air with this APU is 15,000 feet, although design documents showed that the APU was capable of providing pneumatic power at 21,000 feet. For the CRJ-200, the APU can be started when the airplane is at an altitude that is less than 30,000 feet. A load control valve (LCV) was mounted on the APU 36 Afterward, the crew and passengers were put on another airplane so that the flight to MSP could resume.

Factual Information 12 Aircraft Accident Report pneumatic supply outlet. When the LCV opens, it allows pneumatic power from the APU to become available to each engine’s 10th stage bleed air valves37 and then to the air turbine starters (ATS), which turn energy from pneumatic air into mechanical torque for rotation of the engine cores. Figure 1 shows components in the airplane’s pneumatic supply and start systems, including the APU, LCV, 10th stage bleed air valves, and ATS. Figure 1. Components in the CRJ Pneumatic Supply and Start Systems The pneumatic system also supplied air to the cabin pressurization system, which was digitally controlled to maintain a maximum cabin altitude of 8,000 feet (± 100 feet). The system was designed to provide a cabin altitude/cabin pressure warning38 at a cabin altitude of 10,000 feet and to deploy cabin oxygen masks at a cabin altitude of 14,000 feet. The airplane was equipped with a stall protection system (SPS), which provides the flight crew with warnings of an impending stall condition.39 The stickshaker is one component of the system.40 After stickshaker activation, the SPS protects against aerodynamic stalls via a stickpusher. 37 FDR data showed that the LCV opened at an altitude of 13,000 feet. The LCV remained open during each of the four APU-assisted engine restart attempts and then closed afterward. Bombardier maintenance training manuals indicated that opening the LCV at altitudes above 15,000 feet would result in a cockpit warning. The accident CVR recorded a cockpit warning associated with the LCV opening. FDR data from the accident flight showed that the LCV opened when the airplane was at 15,400 feet and then closed a few seconds later. 38 When this warning occurs, “CABIN ALT” is displayed on the EICAS, and “cabin pressure” is announced in the cockpit. 39 SPS activation criteria depend on the airplane’s AOA, as measured by vanes mounted on the forward fuselage. 40 In addition to the stickshaker, stall warnings are indicated by activation of the engine autoignition, autopilot disconnect, aural warning, and red “STALL PUSH” lights on the glareshield.

Factual Information 13 Aircraft Accident Report 1.6.3 Maintenance Records The Pinnacle Airlines maintenance program requires a service check every 3 days and a routine check every 100 hours. The last service check performed on the accident airplane was on October 13, 2004, and the last routine check was performed on October 7, 2004; no discrepancies were noted during either check. The Pinnacle Airlines maintenance program also requires an A check every 500 hours; this check consists primarily of system inspections, lubrications, and adjustments. The last A check was accomplished on August 18, 2004. Also, the maintenance program includes C checks, which involve detailed visual inspections of flight controls, powerplants, and structures. Until the time that an airplane accumulates 8,000 total flight hours, the C check is performed at phased intervals to prevent the airplane from being out of service for an extended period of time. Once the airplane accumulates 8,000 flight hours, it must be out of service for an extended period of time to perform the full C check.41 The accident airplane’s full C check was performed in September 2003. Finally, Pinnacle Airlines uses a calendar inspection program for “maintenance significant items” and “structural significant items.” These inspections occur every 12, 24, 36, 48, 60, 72, and 96 months. The last inspections that were performed on the accident airplane were the 24- and 48-month inspections, which occurred concurrently during February and March 2004. The airplane’s daily aircraft maintenance logs between April 2001 and October 2004 showed no discrepancies related to the circumstances of this accident. Also, the airplane’s discrepancy list for the 30 days before the accident showed no evidence of any major repairs to the airplane. 1.7 Meteorological Information JEF has an automated surface observing system (ASOS), which is maintained by the National Weather Service (NWS). The ASOS records continuous information on wind speed and direction, cloud cover, temperature, precipitation, and visibility.42 The ASOS transmits an official meteorological aerodrome report (known as a METAR) each hour. The 2153 METAR indicated the following: wind from 290º at 6 knots, visibility unrestricted at 10 miles, ceiling overcast at 4,400 feet, temperature 10º C, dew point 5º C, and altimeter 29.63 inches of mercury (Hg). The 2253 METAR indicated the following: wind from 270º at 5 knots, visibility unrestricted at 10 miles, sky clear below 12,000 feet, temperature 8º C, dew point 5º C, and altimeter 29.63 inches of Hg. 41 After the first full C check at 8,000 hours, all subsequent full C checks are performed every 4,000 hours. 42 Cloud cover is expressed in feet above ground level. Visibility is expressed in statute miles.

Factual Information 14 Aircraft Accident Report The closest upper air sounding43 along the route of flight was from Springfield, Missouri, which was about 50 miles west-southwest of the upset location and about 90 miles south of the accident site. The 1900 sounding showed that the approximate base of the clouds was at an altitude of 4,135 feet, the freezing level was at an altitude of 4,699 feet, the top of the clouds was at an altitude of about 7,000 feet, and another cloud layer was at an altitude of about 18,000 feet. The atmosphere was classified as stable. The maximum wind was from 345º at 60 knots at an altitude of 29,000 feet. The wind was from 315º at 48 knots at an altitude of 41,000 feet. The NWS issued Airman’s Meteorological Information (AIRMET)44 Tango for turbulence, which was valid from 2045 on October 14 to 0300 on October 15, 2004, along the route of flight and over the location of the upset. The AIRMET indicated that occasional light to moderate turbulence could be encountered between 20,000 and 39,000 feet. 1.8 Aids to Navigation No problems with any navigational aids were reported. 1.9 Communications The airplane was handled by air traffic controllers at LIT, the Memphis ARTCC, and the Kansas City ARTCC. No communications problems were reported. 1.10 Airport Information JEF is located 2 miles northeast of Jefferson City at an elevation of 549 feet. The airport has two runways, 9/27 and 12/30. The flight crew was attempting to land on runway 30, which had an ILS available. The airport’s ATC tower was closed at the time of the accident. 1.10.1 Air Traffic Control ATC radar data were primarily obtained from the Kansas City ARTCC long range radar site located in Crocker, Missouri.45 Additional radar data were provided by the LIT ATC tower, the Memphis ARTCC, and the Airport Surveillance Radar-9 radar site located in Columbia, Missouri. 43 An upper air sounding shows the wind profile and the expected clear air turbulence, cloud layers, and icing potential. 44 An AIRMET is an in-flight advisory that notifies en route pilots of the possibility of encountering hazardous flying conditions that may not have been forecast at the time of a preflight briefing. 45 At this radar site, air route surveillance radar data are obtained once every 12 seconds.

Factual Information 15 Aircraft Accident Report The Kansas City ARTCC comprises several sectors (altitudes/areas of responsibility), and the sectors are denoted by numbers. The sector 30 radar controller at the ARTCC handled the accident flight when it was at an altitude of 24,000 feet and above, and the sector 53 radar controller at the ARTCC handled the airplane when it was below an altitude of 24,000 feet. The National Transportation Safety Board conducted postaccident interviews with these controllers. The sector 30 radar controller first became aware of the accident flight when he accepted a handoff from the sector 29 radar controller.46 The flight was at an altitude of 41,000 feet at the time. The sector 30 radar controller stated that he asked the flight crew to confirm that the type of airplane was actually a CRJ because the flight level seemed “odd” for that airplane model. The radar controller stated that the flight crew confirmed that the airplane was a CRJ and that, 1 minute later, the flight crew requested a lower altitude. The radar controller stated that he was coordinating the descent with the sector 29 controller when he heard one of the pilots saying something similar to “emergency” in a stressed voice. The sector 30 radar controller stated that he immediately handled the airplane as if it were experiencing an emergency, notified his supervisor of the situation, and instructed the sector 29 controller to turn away another airplane from the accident airplane. The sector 30 radar controller stated that the flight crew did not provide him with much information about the in-flight situation, so he assumed that the flight crew did not want to deal with additional ATC transmissions during this time. The airplane’s data block had lost altitude information, so the controller began switching between the main and backup radar systems to monitor altitude and rate of descent. The controller stated that he did not receive an altitude readout until the airplane reached 33,000 feet. The sector 30 radar controller stated that the flight crew requested a descent to 13,000 feet. The controller stated that he first coordinated with underlying radar sectors to permit the airplane to descend below 24,000 feet and that he then issued the clearance to 13,000 feet. The controller stated that he then instructed the flight crew to contact the sector 53 radar controller. The sector 30 radar controller assisted the sector 53 radar controller by referring to the JEF approach charts for information about the ILS frequency and the airport beacon. The sector 53 radar controller first became aware of the accident flight when she overheard the sector 30 controller notifying their supervisor of an emergency airplane. She then began monitoring the airplane from her position. The sector 53 radar controller stated that, once the pilots were on the sector 53 frequency and reported that the airplane was descending to 13,000 feet, she advised them of the airports that were available for a landing. After the flight crew requested a lower altitude for the engine restart, the controller assigned an altitude of 11,000 feet. Shortly afterward, the airplane descended through 10,500 feet, and the flight crew notified the controller of a double engine failure. 46 The sector 29 controller was also responsible for the accident flight when it was at an altitude of 24,000 feet and above.

Factual Information 16 Aircraft Accident Report The sector 53 radar controller stated that she immediately called Mizzou approach control to advise that the airplane had lost power and would be descending to land at JEF. The sector 53 radar controller stated that she directed the flight to JEF and provided the minimum instrument altitude for the area and the localizer frequency for the runway 30 ILS approach. The controller stated that the pilots asked her where the airport beacon was located, and she provided them with a description of the beacon in relation to the runway. The controller stated that she received no further voice transmissions from the flight crew and that the last radar contact with the airplane was at an altitude of about 900 feet. The controller stated that, after losing radar contact, she tried to contact the airplane several times but received no response. In addition, ATC transcripts showed that, after the loss of radar contact with the airplane (the final radar return was received about 0.58 nautical mile southeast of the crash site and at an altitude of 930 feet), the Mizzou approach controllers reported the location of a probable accident to the police and fire services in Jefferson City. 1.11 Flight Recorders 1.11.1 Cockpit Voice Recorder The airplane was equipped with a Fairchild model A100S solid-state CVR, S/N 02804. The CVR did not sustain any heat or structural damage, and the audio information was extracted normally and without difficulty. The CVR recording contained four channels of audio data.47 The first channel recorded excellent audio quality information from the observer’s seat audio panel.48 The second channel recorded excellent audio quality information from the copilot’s station. The third channel recorded good audio quality information from the pilot’s station. The fourth channel contained fair audio quality information from the cockpit area microphone. A transcript was prepared of the entire 30-minute 23-second digital recording (see appendix B). The first, second, and third channels all contained audio information from the airplane’s aural warning system, including the synthesized voice of the crew alerting system. The fourth channel also recorded aural warnings but did so via a cockpit speaker. 47 The Safety Board rates the audio quality of CVR recordings according to a five-category scale: excellent, good, fair, poor, and unusable. Appendix B describes each of these categories. 48 Federal regulations state that the first channel is to record audio information from the third flight crewmember station. Because a third flight crewmember was not required for the CRJ-200, the source for the information recorded by the first channel could be determined by the operator. The first channel did not record any intercom or radio communications.

Factual Information 17 Aircraft Accident Report 1.11.2 Flight Data Recorder The accident airplane was equipped with an L3 Communications Fairchild model F-1000 FDR, S/N 01094. The FDR recorded flight information in a digital format using solid-state memory as the recording medium. The FDR was sent to the Safety Board’s laboratory for readout and evaluation. The FDR was in good condition, and the data were extracted normally. About 51 hours of data were recorded on the FDR, including about 55 minutes of data from the accident flight. During the flight, power was lost to the FDR, which resulted in a data dropout of about 3 minutes 56 seconds (2155:20 to 2159:16). Data recorded immediately before the dropout, from 2155:16 to 2155:19, and immediately after the FDR was back on line, from 2159:16 to 2159:21, had some parameters that appeared to be valid but others that appeared to be invalid. The accident airplane’s FDR was not in compliance with the requirements in 14 CFR 121.344, Appendix M. Specifically, the source of the vertical acceleration parameter was not updated at a rate that met the required recording intervals. Also, the pitch attitude parameter was recorded at a higher sample rate than the source was updated. On May 16, 2003, the Safety Board issued Safety Recommendation A-03-15 to the FAA because of problems with the quality of FDR data recorded by several regional jet airplanes, including the CRJ. Section 1.18.3.3 provides information about this safety recommendation. 1.12 Wreckage and Impact Information The main airplane wreckage was located at an elevation of 740 feet. Several tree strikes were identified along the airplane’s flightpath before the main wreckage location. The direction of the tree strikes was on a magnetic heading of about 304º. The first signs of tree strikes were found on a tree that was located about 474 feet from the main wreckage location; the top branches of the tree were severed very slightly. The first tree that showed signs of a major impact was located about 425 feet from the main wreckage location. The tree’s limbs were severed at a height of 43 feet above ground level, and small fragments of the airplane wreckage were found near this tree. About 14 feet of the outboard left wing, including the winglet, was located about 187 feet before the main wreckage location. This wing section showed two large indentations in the leading edge; two large tree limbs with the same diameter as the indentations were located within 12 feet of the wing section. The tree that was struck was located 190 feet before the left wing section. About 92 feet before the main wreckage location, a large tree was slightly damaged on one side. A large group of trees about 18 feet to the right of that tree also showed slight damage. The airplane traveled through the 18-foot gap between the trees. The left wing impacted the ground at the same location as a small tree that was sheared at a height of about 12 feet above ground level. A large ground scar measuring about 87 feet

Factual Information 18 Aircraft Accident Report in length and having a shape similar to the top of the airplane’s nose was located 30 feet before the main wreckage location. The ground scar contained material from the top of the forward cabin. Measurements of tree strikes along the flightpath showed that the airplane was descending at a pitch attitude of about -2.5º. The airplane struck the first trees in a 40º left-wing-down attitude. The airplane impacted the ground nose first in a close-to-inverted attitude. All of the airplane wreckage was accounted for at the accident site. The airplane’s wreckage extended along a 1,234-foot path, beginning with the initial impact point (the first major tree strike), continuing through six residential backyards, and ending past a residential street. 1.12.1 Powerplants Examination of the engines at the accident site found that neither engine exhibited classic rotational damage49 or ingestion evidence. The engines were disassembled and inspected at GE’s manufacturing facility in Lynn, Massachusetts. The engine core rotors were rotated, and neither core was found seized. Teardown inspections found no mechanical failures or evidence of seizure in either engine.50 A materials investigation of the high pressure turbine seal hardware found no abnormal rotational marks. 1.12.2 Systems Inspection and testing of the airplane’s pneumatic supply and start systems found nothing that would have prevented them from providing torque to either engine. The APU was found in its installed position with light soot on its top surfaces. The APU was subsequently examined at Honeywell’s facility in Phoenix, Arizona. A borescope inspection noted no internal physical damage. After the replacement of an impact-damaged part, the APU operated and exceeded the performance requirements for a newly overhauled unit. The LCV was found with light soot and no observable damage. During postaccident testing, the LCV hesitated initially before opening fully the first time, and, with each subsequent opening, the LCV opened more freely than the previous time. (The first test was performed with opening commands that were intentionally applied slower than normal,51 and the subsequent tests were performed at the conditions under which the 49 Classic rotational damage includes reverse bending of rotating airfoils and circumferential scraping signatures along fan blade paths. 50 The inspection disclosed thermal damage to the turbine blades in the No. 2 engine that would have impeded the engine from producing thrust but would not have prevented the core from rotating. (The inspection found no preimpact damage to the No. 1 engine.) 51 Other possible reasons for the initial hesitation included the impact forces that caused the surrounding structure (including the APU mount and housing where the LCV was positioned) to buckle and the dirt and debris that was found inside the APU and the LCV.

Factual Information 19 Aircraft Accident Report LCV was designed to operate.) The testing showed that the LCV was capable of allowing pneumatic power from the APU to enter the 10th stage bleed air valves and then the ATS. Flight control cable continuity could not be established because of the impact damage to the forward portion of the airplane, but CVR and FDR evidence indicated that the flight controls operated normally during the flight. 1.13 Medical and Pathological Information Tissue specimens from the captain and the first officer tested negative for ethanol and a wide range of drugs, including major drugs of abuse. 1.14 Fire The airplane wreckage showed no evidence of an in-flight fire. Major portions of the wreckage showed postcrash fire damage. 1.15 Survival Aspects According to the Boone/Calloway County Medical Examiner’s office, the cause of death for the captain and the first officer was blunt force trauma. 1.16 Tests and Research 1.16.1 Aircraft Performance Study The Safety Board performed an aircraft performance study for this accident. FDR, CVR, weather, and ATC radar and communications data were used to develop the time history of the accident airplane’s motion. These data were time correlated. The study results for the airplane’s performance during the climb to 41,000 feet, aerodynamic stall and upset event, and descent and glide are presented in sections 1.16.1.1 through 1.16.1.3, respectively. 1.16.1.1 Climb to 41,000 Feet FDR data showed that the airplane’s initial takeoff rotation occurred about 2121:45 and that, 3immediately after liftoff, the pitch angle of the airplane was about 6º. Four seconds later, when the airplane was at an altitude of about 450 feet, the first of three pitch-up maneuvers during the ascent occurred when the flight crew moved the control

Factual Information 20 Aircraft Accident Report column to 8º ANU,52 causing the airplane’s pitch angle to increase to 22º and resulting in a vertical load of 1.8 Gs. Immediately afterward, the FDR recorded stickshaker and stickpusher activations, a full AND control column deflection, a decrease in pitch angle, and a drop in vertical load to 0.6 G. After the stickpusher deactivation, the airplane continued to climb at a pitch angle between 10º and 14º ANU. About 2127:17, when the airplane was in level flight at an altitude of 15,000 feet and with the autopilot in vertical speed mode, the second pitch-up maneuver during the ascent began. FDR data showed that the control column moved to 3.8º ANU, causing the airplane’s pitch angle to increase to 17º and resulting in a vertical load of 2.3 Gs. About 2127:26, the flight crew moved the control column 2.5º AND, decreasing the pitch angle to about 6º and the vertical load to 0.3 G about 5 seconds later. Afterward, the flight crew moved the control column 3.4º ANU. Between about 2128:40 and about 2128:43, the flight crew made a left rudder input of 4.2º, a right rudder input of 6.0º, and a left rudder input of 0.4º,53 resulting in lateral loads of -0.16 G, 0.34 G, and -0.18 G, respectively. About 17 seconds later, the flight crew made a right rudder input of 7.7º. About 2132:40, when the airplane was in level flight at an altitude of 24,600 feet with the autopilot engaged and a vertical speed of 600 fpm, the third pitch-up maneuver during the ascent began. The flight crew moved the control column 4º ANU, which increased the airplane’s pitch angle to more than 10º, resulted in a vertical load of 1.87 Gs, and increased the airplane’s vertical speed to 5,000 fpm for several seconds. About 2132:46, the flight crew disconnected the autopilot and moved the control column to 3.8º ANU, which increased the airplane’s pitch angle to about 15º. About 2133:10, the flight crew reengaged the autopilot with a vertical speed of 3,000 fpm, which was reduced to 1,400 fpm by 2133:30 and 1,000 fpm by 2134:00. The autopilot remained engaged in vertical speed mode between the altitudes of 34,000 and 41,000 feet. Between 34,000 and 35,000 feet, the airplane’s vertical speed was 1,000 fpm, the calculated Mach number was about 0.60, and the engines maintained N1 indications of 95.5 percent. As the airplane climbed through 35,000 feet, its vertical speed was reduced to 0. About 2141:00, the airplane leveled off at an altitude of 36,500 feet. Within the next minute, the calculated Mach number increased to 0.64. When the climb resumed, the airplane’s vertical speed was 500 fpm, and the engines’ N1 indications were 52 According to FDR documentation, the control column has a range from -11.9º (forward) to 13.8º (aft). 53 On November 10, 2004, about 1 month after this accident, the Safety Board issued Safety Recommendation A-04-59 to the FAA as a result of its findings from the November 2001 American Airlines flight 587 accident in Belle Harbor, New York. Safety Recommendation A-04-59 asked the FAA to “develop and disseminate guidance to transport-category pilots that emphasizes that multiple full deflection, alternating flight control inputs should not be necessary to control a transport-category airplane and that such inputs might be indicative of an adverse aircraft-pilot coupling event and thus should be avoided.” On January 9, 2006, the FAA stated that it issued Safety Alerts for Operators 05002, “Multiple Full Deflection, Alternating Flight Control Inputs,” which urged directors of safety, directors of operations, and pilots of transport-category airplanes to be familiar with the content of the Airplane Upset Recovery Training Aid and to pay particular attention to the cautions against alternating flight control inputs and aircraft-pilot couplings. As a result, the Board classified Safety Recommendation A-04-59 “Closed—Acceptable Action” on June 9, 2006.

Factual Information 21 Aircraft Accident Report about 95.7 percent. About 2144:00, the airplane was climbing through 37,400 feet. The airplane continued to climb at a vertical speed of 500 fpm during the next 7 minutes until reaching an altitude of 41,000 feet. During this time, the calculated Mach number decreased to 0.57, the pitch angle increased from 3º to 6º, and the engines’ N1 indications decreased to 94.7 percent. Once the airplane reached the selected altitude of 41,000 feet, the autopilot reduced the airplane’s vertical speed to 0, and the airplane leveled off. During the next 3 1/2 minutes, the calculated Mach number decreased to 0.53, the pitch angle and AOA increased to about 7º, and the engines’ N1 indications decreased to 94.2 percent. 1.16.1.2 Aerodynamic Stall and Upset Event About 2154:34, the airplane’s airspeed was 150 knots.54 About 2 seconds later, the stickshaker activated, causing the autopilot to disconnect; at that point, the airplane’s AOA had increased to about 7.5º. Within the next second, the control column moved to about 0º. About 3 1/2 seconds after autopilot disconnect, the flight crew moved the control column 3.5º ANU. The flight crew then moved the control column back toward neutral until it reached about 1.1º ANU. During the next few seconds, the flight crew moved the control column to 4º ANU, which caused the pitch angle to increase to about 8.5º. By 2154:45, the AOA had increased to the point that both the stickshaker and the stickpusher activated. The control column moved forward rapidly in response to the activation of the stickpusher, decreasing the pitch angle to -3.5º, the AOA to 0º, and the vertical load to 0 G. The stickpusher then deactivated, and the flight crew moved the control column past neutral to about 5º ANU, which caused the pitch angle to increase to 8º and the AOA to increase to 11º. During the next 8 seconds, while the airspeed was at 160 knots, the stickshaker and stickpusher activated twice. The stickpusher, during both activations, moved the control column forward in response, and, once the AOA decreased, the control column was then moved past neutral to an ANU position.55 After the stickpusher activations, the control column was moved to about 5.2º and about 5.9º ANU. About 2154:51, the No. 2 engine’s N1 indication decreased from 94 to 84 percent, and the pitch angle decreased to -19.5º about 2154:55. One second later, after the stickpusher had activated and released for the third time, the flight crew moved the control column to 6.8º ANU (which was the largest ANU movement during the pitch oscillations), and the vertical load decreased to -0.8 G. By 2154:57, the stickshaker had activated for the fifth time, and the stickpusher had activated a fourth time, pushing the control column to full nose down (where it remained for the next 4 1/2 seconds). Despite the activation of the stickpusher, the airplane entered an aerodynamic stall as the motion of the airplane continued to increase the AOA 54 All airspeeds in sections 1.16.1.2 through 1.16.1.4 are knots calibrated airspeed. 55 Public hearing testimony by Bombardier Aerospace indicated that, without pilot input, the control column position would return to near neutral after stickpusher cancellation resulting from the AOA decreasing below the deactivation angle.

Factual Information 22 Aircraft Accident Report to its maximum ANU measurable value of 27º. Both engines’ fuel flow indications decreased to near zero by 2154:58, and the airplane’s pitch angle reached a maximum ANU value of 29º at 2154:59. During this time, the airplane’s recorded airspeed was 74 knots, and its recorded altitude increased from 41,000 to 42,000.56 As the pitch angle began to decrease, a left rolling motion began, which eventually reached 82º left wing down. The pitch angle reached a maximum AND value of 32º by about 2155:06. During the next 14 seconds, the flight crew made several control column, control wheel, and rudder inputs to recover the airplane from the upset. During the recovery, the stickpusher activated three more times, both engines’ fuel flow indications remained near zero, and both engines’ N1 settings decreased to about 28 percent. The FDR stopped recording data about 2155:20. The last reliable N2 speed recorded by the FDR before it stopped operating was 46 percent for the No. 1 engine and 51 percent for the No. 2 engine. 1.16.1.3 Descent and Glide Performance The FDR resumed recording data about 2159:16 when the airplane was at an altitude of 29,200 feet. During the 4-minute gap between recorded FDR data, the engines had stopped operating. During the initial part of the descent, the airspeed increased, the pitch angle varied between 1º and -4º, and the descent rate reached a maximum of 5,000 fpm. A maximum airspeed of 236 knots was reached about 2202:12 when the airplane descended through an altitude of 20,500 feet. At an altitude of about 20,300 feet, the airplane leveled off for about 20 seconds and then began to descend again at a rate between 1,800 and 2,000 fpm and at an airspeed of about 200 knots. About 2204:46, the airplane descended through an altitude of 15,000 feet, and the airspeed began to decrease as the pitch angle increased. During the next several minutes, the airspeed remained about 170 knots, and the descent rate was between 1,000 and 2,000 fpm. About 2209:06, when the airplane was at an altitude of 10,000 feet, the flight crew notified the air traffic controller that the airplane needed to land at the closest airport. At that point, the airspeed varied between 180 and 206 knots, and the descent rate varied between 300 and 3,200 fpm. Also, several short control column movements occurred, causing the pitch angle to vary from 3º AND to 2º ANU and the vertical load to increase to 1.3 Gs. The Safety Board obtained glide performance calculations for the accident airplane from Bombardier Aerospace. The reference airspeed for the glide performance calculations was 170 knots, which was the best glide airspeed for the accident airplane’s 56 The recorded airspeed and altitude values may not be accurate because, according to Bombardier, the static source error corrections that are programmed into the air data computers are not calibrated for the high AOA (greater than 27º) experienced at this point in the flight.

Factual Information 23 Aircraft Accident Report estimated gross weight.57 Data from the accident airplane’s FDR showed that the flight spoilers deployed to 5.6º from 28,000 feet until the end of the recording. The glide performance calculations included the drag from the flight spoilers and the air-driven generator (ADG).58 According to the glide performance calculations, at an altitude of 30,000 feet, six airports (including JEF) were within the airplane’s best glide range. JEF was located about 74 miles north-northeast of the upset location.59 The five other airports were the following:60 • Waynesville Regional Airport (TBN), Fort Leonard Wood, Missouri, which was located about 23 miles north-northeast of the upset location; • Floyd W. Jones Lebanon Airport (LBO), Lebanon, Missouri, which was located about 25 miles northwest of the upset location; • Lee C. Fine Memorial Airport (AIZ), Kaiser Lake Ozark, Missouri, which was located about 44 miles north of the upset location; • Springfield-Branson Regional Airport (SGF), Springfield, Missouri, which was located about 50 miles west-southwest of the upset location; and • Rolla National Airport (VIH), Rolla/Vichy, Missouri, which was located about 53 miles north-northeast of the upset location. At an altitude of 20,000 feet, five airports (including JEF) were within the airplane’s best glide range.61 At an altitude of 10,000 feet, only one airport (AIZ) was within the airplane’s best glide range; JEF was just outside the best glide range at that altitude. Figure 2 shows the glide distances to the six airports for the accident airplane. 57 A best glide airspeed provides the airplane with the most distance forward for a given loss of altitude. 58 The ADG deploys automatically and provides backup power when the engines no longer power the primary electrical generators. 59 As stated in section 1.16.1.2, the upset event is characterized by the 82º left-wing-down rolling motion and the -32º pitch angle. 60 These five airports had runways in excess of 5,000 feet. 61 SGF was no longer within the airplane’s best glide range.

Factual Information 24 Aircraft Accident Report Figure 2. Glide Distances for the Accident Airplane 1.16.2 Cockpit Voice Recorder Studies The Safety Board conducted a CVR study to determine flight crew seating positions. The study correlated CVR and ATC audio information with FDR microphone

Factual Information 25 Aircraft Accident Report key data. The audio communications system on the accident airplane sent pilot station position (but not radio source) information to the FDR for its microphone key parameter. This information and voice identification information from the CVR allowed the Board to determine which pilot was transmitting on the radio from which crew seat position. The correlation determined that, during takeoff, the captain made radio transmissions from the left seat (the first officer was recorded from the right seat). The correlation also determined that, about 6 minutes into the ascent, through the upset event, and until after several engine restart attempts, the captain made radio transmissions from the right seat (the first officer was recorded from the left seat). Finally, the correlation determined that, after the flight crew requested to land at JEF until the last transmission to the controller, the first officer made radio transmissions from the right seat (the captain was not recorded during this time period). The flight crew seating positions are summarized in table 2. Table 2. Flight Crew Seating Positions Note: In the CRJ-200, the captain is normally seated on the left, and the first officer is normally seated on the right. a Although the CVR and FDR were functioning during this time, they did not record any cockpit audio or microphone key data from the left audio panel after 2205:53. The lack of CVR and FDR information from an audio panel indicates that its dedicated controller board has lost power (even though the rest of the audio communication system remains powered) or that the panel selector switch has been set to “EMER” (emergency). The CVR study also documented events related to engine checklist use and flight crew oxygen mask use; some of these events are shown in table 3. Oxygen use by the flight crew is further discussed in section 1.18.1. Table 3. Engine Checklist and Oxygen Mask Use Events Time Left audio panel Right audio panel 2121:00 to 2124:14 Captain First officer 2126:43 to 2206:59 First officer Captain 2209:06 to 2214:39 No informationa First officer Time Event 2156:42 Start of double engine failure checklist. 2157:04 Crew alerting system warning of cabin pressure. 2158:21 Comment to use oxygen mask. 2158:41 Sound similar to oxygen flow starting in oxygen mask. 2201:36 Double engine failure checklist—windmill restart procedure.

Factual Information 26 Aircraft Accident Report In addition, the Safety Board conducted a CVR sound spectrum study to determine whether any noise was recorded by the CVR during the four APU-assisted engine restart attempts that would indicate ATS operation. Each CVR channel was examined across the full frequency range for signal changes, appearances, and disappearances, but nothing associated with any of the engine restart attempts was found. 1.16.3 Engine Tests The accident FDR showed decreasing engine core-driven accessory parameter indications62 after the double engine failure. About 15 minutes afterward, engine oil temperature cooling rates leveled off momentarily, and slight engine hydraulic pump pressure indications were noted. This signal activity was inconsistent with the engines’ zero N2 indications. Engine tests were performed at Pinnacle Airlines’ maintenance facility in Memphis and the Bombardier Aerospace Flight Test Center in Wichita, Kansas. A test to evaluate the engine oil temperature anomalies demonstrated that, after a period of normal engine operation, changes in engine oil temperature that were consistent with the accident Time Event 2202:14 Double engine failure checklist—APU bleed air restart procedure. 2204:06 Comment to use oxygen masks. 2204:09 Sound similar to oxygen flow starting in oxygen mask. 2204:13 Comment regarding cabin altitude of 15,400 feet and need to be on oxygen. 2206:23 Sound similar to oxygen mask removal. 2207:04 Double engine failure checklist—relight attempt of No. 1 engine using APU bleed air procedure. 2207:20 Sound similar to oxygen flow in oxygen masks. 2207:41 Double engine failure checklist—relight attempt of No. 2 engine using APU bleed air procedure. 2208:11 Sound similar to oxygen mask removal. 2208:15 Sound similar to oxygen mask removal. 2209:32 Double engine failure checklist—relight attempt of engine using APU bleed air procedure. 2211:42 Double engine failure checklist—relight attempt of engine using APU bleed air procedure. 62 These parameters included fuel flow, oil pressure, oil temperature, and engine hydraulic pressure.

Factual Information 27 Aircraft Accident Report FDR anomalies would result when APU-assisted restarts were attempted with the engine core rotor locked. The test also demonstrated that the FDR could record small hydraulic pressure signals while the engine core was prevented from rotating. A test to evaluate the slight increases (25 to 30 pounds per square inch gauge [psig]) in core-driven hydraulic pump pressure indications63 showed that hydraulic pump pressure would begin to indicate on the FDR with about 35 rpm of core rotation. Another test showed that N2 signals would begin to indicate on the FDR and in the cockpit with about 70 rpm of core rotation. A test demonstrated that the ATS was capable of rotating an engine core from zero N2 with 10th stage duct pressures as low as 6 psig (as detected by the EICAS) and that 25- to 30-psig hydraulic pump pressures could be recorded on the FDR as long as engine core rotation was sustained at a speed of about 35 rpm. This test also showed that, by the time that engine core rotation had reached a speed of 75 rpm, hydraulic pump pressures had increased quickly to 1,500 psig. 1.16.4 Load Control Valve Simulation Study As stated in section 1.6.2, the LCV allows pneumatic power from the APU to become available to each engine during the start sequence. In the pneumatic system, the LCV and its associated ducts are the components that support both engines. Thus, a malfunction of the LCV could result in a failure to achieve indications of engine rotation on either engine. To determine the minimum amount of LCV opening needed to result in initial engine rotation, as indicated by FDR data, and whether a minimum LCV opening value during the four APU-assisted engine restart attempts could be determined, the Safety Board conducted a computer-based simulation study that was validated against existing flight test data provided by Bombardier. For the simulation study, the Safety Board used the results of previous ground and flight tests that provided data about the minimum torque output required from the ATS to initiate detectable core rotation from 0 rpm. As indicated in section 1.16.3, the tests showed that about 35 rpm of core rotation was needed to detect an indication of hydraulic pump pressures64 on the FDR and that about 70 rpm of core rotation was needed to detect an indication of N2 on the FDR and in the cockpit. The tests also showed, and data from Honeywell indicated, that about 6 psig at the ATS inlet with 27.5 pounds per minute of corrected airflow65 could result in detectable core rotation. FDR data for the accident flight showed that the LCV was open throughout each APU-assisted restart attempt. Although the LCV normally opens fully (85º) during an 63 Normal hydraulic system operating pressure is 3,000 psig, and signals of 25 to 30 psig are outside of the system transducer’s validated measurement range. 64 The hydraulic pump is driven by engine core rotation. 65 Because airflow changes based on altitude and temperature, corrected airflow provides a common reference point that recalculates airflow in terms of a standard day at sea level (that is, 59º F and 29.92 inches of Hg).

Factual Information 28 Aircraft Accident Report APU-assisted engine restart, the FDR parameter for the LCV position shows that the valve is open once it reaches a position that is greater than 4.8º from its normally closed position. The simulation showed that, for a normally functioning engine, the LCV needed to be open by about 8º to produce enough torque at the ATS output to initiate detectable core rotation from a stopped condition.66 However, at this 8º setting, the LCV-supplied air volume that reached the ATS start valve diminished once the start valve opened, and then the LCV and other downstream pneumatic system valves closed because the pressure provided was insufficient to keep them opened. This result was not consistent with the FDR data from the accident flight, which showed that the 10th stage bleed air valves remained open from 25 seconds (in accordance with guidance on the double engine failure checklist, as shown in appendix C) to about 105 seconds during all four engine restart attempts and that the LCV remained open during each restart attempt. Also, the CVR did not include any discussion to indicate that the 10th stage or start valve functions deviated from what the pilots would normally observe during an APU-assisted start on the ground. The simulation also showed that, with an LCV opening of at least 18º, all of the pneumatic supply valves would be kept open, as was seen on the accident FDR. An LCV opening of at least 18º was also sufficient to initiate and maintain detectable rotation of the core rotor from 0 rpm.67 1.17 Organizational and Management Information Pinnacle Airlines, Inc., is a wholly owned subsidiary of Northwest Airlines, Inc., and is based in Memphis. The airline was established in 1985 as Express Airlines I. Between 1985 and 2000, Express Airlines I operated turboprop airplanes only. In 2001, Express Airlines I began integrating CRJ turbojet airplanes into its fleet and, in 2002, changed its name to Pinnacle Airlines. By 2003, Pinnacle Airlines had phased out turboprop airplanes from its operations and operated CRJ turbojet airplanes only. At the time of the accident, the company employed about 900 pilots and had a fleet of 110 CRJs that provided service to destinations in the United States and Canada. 1.17.1 Ground School and Simulator Training 1.17.1.1 Upset Training Pinnacle Airlines provided upset training to newly hired pilots during ground school and simulator training. According to a Pinnacle Airlines ground school instructor, pilots received 6 hours of upset training during the general operational subjects module. 66 This initiation was based on ground start conditions that were corrected for altitude. However, the pressure, altitude, and temperature did not account for airspeed, which would have reduced the required onboard pneumatic pressure and flow requirements. 67 The rotation would not likely be fast enough for an engine’s starting sequence to be completed.

Factual Information 29 Aircraft Accident Report The subjects covered during this training included swept-wing design characteristics and high altitude aerodynamics.68 Also, pilots received a copy of the Pinnacle Airlines Jet Upset Student Guide. A Pinnacle Airlines simulator instructor stated that pilots received about 20 minutes of upset training in the simulator. The training consisted of Mach tuck and Mach buffet demonstrations69 and unusual attitude recoveries. Also, the simulator instructor discussed operations at high altitudes where low indicated airspeeds yielded high true airspeeds (and a high Mach number) at high AOAs, but the training did not include any maneuvers or stalls at high altitudes. After the accident, Pinnacle Airlines revised the upset training sections of its ground school instructor guide, ground school curriculum, and the Jet Upset Student Guide to include stalls and airplane maneuvers at an altitude of 37,000 feet. Also, the airline enhanced upset training in the simulator by having pilots perform maneuvers at high altitudes. 1.17.1.2 High Altitude Climbs According to Pinnacle Airlines ground school instructors, high altitude climbs, recommended climb profiles, and altitude and climb capability charts70 were discussed with newly hired pilots during the general operational subjects module (specifically, the upset training and performance sections of the module). Simulator instructors stated that they discussed high altitude climbs and recommended climb profiles with newly hired pilots during pre- and postsimulator briefings but did not demonstrate or have the pilots practice high altitude climb techniques. The Pinnacle Airlines Flight Operational Quality Assurance (FOQA) program71 manager stated that the CRJ service ceiling of 41,000 feet was discussed during ground school. Company check airmen, simulator instructors, and pilots stated that operations at 41,000 feet were neither discussed nor demonstrated during simulator training. A simulator instructor stated that 41,000 feet was not an altitude at which pilots wanted to operate very often. 68 High altitude is 25,000 feet and above. 69 A Mach tuck is the result of an aft shift in the center of lift, causing a nose-down pitching moment. A Mach buffet is the airflow separation behind a shock wave pressure barrier that results when the airflow over flight surfaces exceeds the speed of sound. 70 See section 1.17.2.1 for more information about Pinnacle Airlines’ altitude and climb capability charts. 71 A traditional FOQA program is an FAA-approved, voluntary program for the routine collection and analysis of FDR data gathered during aircraft operations. At the time of the accident, Pinnacle Airlines did not have a traditional FOQA program in place; instead, the program was designed to manage the check airmen through flight monitoring. At the time of the June 2005 public hearing for this accident (see appendix A), Pinnacle Airlines was working toward the deployment of a traditional FOQA program. In October 2006, the company reported that it was operating an FAA-approved FOQA program and was collecting an average of 2,000 hours of data each month.

Factual Information 30 Aircraft Accident Report In November 2004, Pinnacle Airlines revised the performance section of its ground school instructor guide to include more specific high altitude climb information and procedures, including a minimum climb profile speed above 10,000 feet of 250 knots or 0.7 Mach, whichever was lower.72 Also, the company added a high altitude climb scenario to its simulator training. 1.17.1.3 Double Engine Failure According to postaccident interviews with the CRJ program manager, check airmen, simulator instructors, and pilots at Pinnacle Airlines, the double engine failure checklist items were discussed during ground school and one of the simulator briefings. They stated that the simulator sessions did not include a scenario in which a double engine failure had occurred or a scenario in which the ADG had been deployed. Also, they stated that, during ground school, pilots were required to pass written and oral examinations on all memory checklist items, including those for the double engine failure procedure (see section 1.17.2.2). In December 2004, Pinnacle Airlines issued a revised simulator instructor guide to include single and double engine failures at 35,000 feet during new hire and captain upgrade simulator training. Pilots are now required to use the ATS-assisted restart procedures for a single engine failure and windmill restart procedures for a double engine failure. These exercises familiarize the pilots with emergency power-only procedures and the effects of ADG deployment. The revised simulator instructor guide also includes an exercise during which the pilots start the APU as the airplane descends through 30,000 feet. 1.17.1.4 Stall Recognition and Recovery Training Pinnacle Airlines’ stall recognition and recovery simulator training was conducted at an altitude of 10,000 feet and with various airplane configurations. For all of the approach-to-stall profiles, the pilot was expected to initiate actions to recover from an impending stall when the first indication of a stall (which was usually the activation of the stickshaker) occurred.73 One purpose of the training was to ensure that a pilot could prevent a full stall from occurring. Another purpose of the training was to demonstrate that a pilot had mastered the airplane throughout its speed range and was able to initiate a standard recovery using the appropriate flight control inputs and callouts. The training did not include high altitude stalls, full stalls, or recoveries from full stalls. The Pinnacle Airlines CRJ program manager stated that the company’s approach-to-stall profiles did not normally progress to stickpusher activation, which he thought was consistent with industry stall training. He stated that a pilot might experience 72 This information was also incorporated into Pinnacle Airlines’ CRJ FCOM Operating Limitations section, as indicated in section 1.17.2.1. 73 The Pinnacle Airlines CRJ FCOM, volume 1, Flight Instruments—Air Data System, dated January 2003, showed that the low speed cue on the airspeed indicator was another indication to the flight crew of an impending stall.

Factual Information 31 Aircraft Accident Report stickpusher activation during simulator training if the pilot overcorrected in response to the stickshaker. According to the program manager, if this situation were to occur, Pinnacle Airlines instructed the pilot to work with the stickpusher upon activation to decrease the AOA and gradually return to the starting altitude for the maneuver. Also, the program manager stated that pilots were required to test the stickpusher before the first flight of each day as part of the preflight check of the SPS. In December 2004, Pinnacle Airlines issued a revised simulator instructor guide to include, for new hire, captain upgrade, and recurrent simulator training, a high altitude stall demonstration with the autopilot engaged74 and a high altitude stall buffet margin demonstration. 1.17.1.5 Crew Resource Management Training At the time of the accident, Pinnacle Airlines provided 8 hours of CRM training to pilots during initial training. The course was presented in lecture format and included PowerPoint slides, scenario-based questions, handouts, and videotapes. The topics covered during the course were resource management, human factors, communication, workload management, team building, and technical proficiency. Accident events and scenarios were also discussed. During recurrent and upgrade training, pilots received a 2-hour version of the course. Pinnacle Airlines managers, instructors, and pilots stated that CRM concepts were reinforced and evaluated during simulator training. They stated that crew coordination and assertiveness were stressed and that instructors discussed crew performance indicators during debriefings. The director of flight operations at Pinnacle Airlines stated that the key measures of CRM effectiveness were crew coordination, workload management, communications, and situational awareness. This director also stated that he had seen pilots using good CRM skills during line operations. The Pinnacle Airlines FOQA manager and a first officer with the company stated that CRM training provided first officers with the tools they needed to challenge captains if necessary. After the accident, Pinnacle Airlines restructured CRM training to provide additional focus on decision-making and the need to adhere to standard operating procedures. 1.17.1.6 Leadership Training At the time of the accident, Pinnacle Airlines provided a 2-hour leadership training module during the 8-day captain upgrade training course. Topics covered during the training were leadership authority, responsibility, and leadership styles. 74 For the training that was in effect at the time of the accident, the autopilot was used only for the approach to stall in the landing configuration.

Factual Information 32 Aircraft Accident Report Pinnacle Airlines had a target of 10 percent for its captain upgrade first-time failure rate. In July 2004, when the rate was 22 percent, FAA and company personnel met to discuss how to reduce the failure rate. Pinnacle Airlines personnel stated that data showed that the most cited reasons for upgrade failure were leadership and judgment. The FAA principal operations inspector (POI) stated that this finding showed that the failures were primarily because of deficiencies in “captain thinking skills” rather than “stick and rudder skills.” As a result, Pinnacle Airlines management decided to place more emphasis on leadership during upgrade training75 and increase the minimum number of hours required for upgrade operational experience76 from 10 to 25. A Pinnacle Airlines simulator instructor worked with the company’s CRJ lead instructor to develop a new 8-hour leadership course. The course includes modules on leadership, authority, and responsibility; briefing and debriefing scenarios; decision-making processes, including those during an emergency; dry run line-oriented flight training scenarios; and risk management and resource utilization. The FAA observed the leadership course in November 2004 as part of the approval process; afterward, Pinnacle Airlines added the course to upgrade training. In October 2006, the company reported that about 92 percent of the pilots upgrading to captain passed the training the first time and that the overall captain upgrade training pass rate was 95 percent. 1.17.2 Flight Manuals 1.17.2.1 High Altitude Climbs At the time of the accident, the Pinnacle Airlines CRJ FCOM, volume 2, Maneuvers, page 7, dated June 2004, listed the following three climb profiles: high speed, 320 knots/0.77 Mach; normal speed, 290 knots/0.74 Mach; and long range, 250 knots/0.70 Mach. Pinnacle Airlines indicated that, to maintain an airspeed at or above 250 knots/0.70 Mach, the airplane’s vertical speed during the climb should be at least 300 fpm. Also, the Pinnacle Airlines CRJ FCOM, volume 2, Operating Limitations, page 4, dated April 2003, stated that the maximum operating altitude for CRJs was 41,000 feet. 75 During postaccident interviews, Pinnacle Airlines’ FOQA manager stated that a weakness in captains was their leadership skills, and Pinnacle Airlines’ director of flight operations stated that management training would help captains with their decision-making. 76 Upgrade operational experience, which occurs after a new captain has completed upgrade training, is when the new captain conducts flight operations in the presence of a check airman.

Factual Information 33 Aircraft Accident Report The Pinnacle Airlines CRJ FCOM, volume 2, Performance, pages 50 through 52, dated June 2002, presented altitude and climb capability charts. Pilots were required to consult these charts anytime a flight was operating above 36,000 feet because of a flight management system (FMS) limitation above that altitude.77 A climb capability chart showed the 300-fpm climb ceiling for an airspeed of 250 knots/0.70 Mach and the maximum cruise thrust limit altitude for cruise speeds of 0.74, 0.77, and 0.80 Mach and long range cruise. This information was provided for airplane weights between 34,000 and 52,000 pounds and outside air temperatures from the International Standard Atmosphere (ISA) temperature to ISA + 10º C.78 After the accident, Pinnacle Airlines added the following restriction to its CRJ FCOM volume 2 Operating Limitations section: “minimum climb profile speed above 10,000 feet MSL will be 250/.70M whichever was lower.” Also, Pinnacle Airlines added the altitude and climb capability charts to its Quick Reference Handbook (which is required to be on all company airplanes) to make it easier for pilots to reference the information. In addition, on October 22, 2004, Pinnacle Airlines issued Alert Bulletin 04-54, which stated that all company flights were not to exceed an altitude of 37,000 feet and that flight crews were not to accept or request ATC clearance above this altitude. Finally, the Pinnacle Airlines Ground School Instructor’s Guide, Performance section, page 35, dated November 2004, stated the following: “when a 300 FPM rate of climb cannot be achieved at the minimum climb speed, the aircraft will be leveled off and a new altitude coordinated with ATC.” 1.17.2.2 Double Engine Failure The Pinnacle CRJ FCOM, volume 2, Emergency Procedures, pages 8 through 13, dated July 2003, detailed the procedure for an in-flight double engine failure.79 For this procedure, the flying pilot is responsible for calling for the double engine failure checklist memory items, and the nonflying pilot is responsible for performing the memory items and reading and performing the remaining items on the checklist. 77 FCOM volume 2, Operating Limitations, pages 30 and 31, dated June 2004, stated that “the FMS calculated thrust setting must not be used if the pressure altitude is greater than 36,000 feet.” The Bombardier chief pilot stated that the reason for the FMS limitation above 36,000 feet was because of the inaccurate calculations above that altitude. Further, according to Bombardier, at altitudes above 36,000 feet, the conversion from static air temperature to the International Standard Atmosphere (ISA) deviation is incorrect within the FMS, resulting in an error in the N1 indication at those altitudes. (A detailed explanation of ISA appears in the next footnote.) Bombardier’s Flight Planning and Cruise Control Manual and Quick Reference Handbook contain charts that show the proper N1 indication for altitudes between 36,000 and 41,000 feet. 78 The International Civil Aviation Organization defines ISA as a sea-level pressure of 1,013.2 millibars at a temperature of 15º C, with temperature decreasing at a standard rate of 2º C per 1,000 feet until reaching the tropopause (the boundary between the troposphere—the lowest region of the earth’s atmosphere—and the stratosphere—the middle region of the earth’s atmosphere). In the standard atmosphere, the tropopause is at 36,000 feet. On the night of the accident, the tropopause was at 27,600 feet, and the temperature at 41,000 feet, -47.1º C, was 9.4º C more than the ISA temperature for that altitude. 79 This information also appeared in the Quick Reference Handbook.

Factual Information 34 Aircraft Accident Report The double engine failure checklist required pilots to establish and maintain an airspeed of 240 knots (a memory item) until they were ready to restart the engines. The double engine failure checklist also required pilots to use the windmill restart procedure if the airplane were at an altitude that was at or below 21,000 feet and above 13,000 feet. Requirements of the procedure included an airspeed of at least 300 knots to achieve an N2 indication of 12 percent. The double engine failure checklist stated, “an altitude loss of approximately 5,000 feet can be expected when accelerating from 240 to 300 KIAS [knots indicated airspeed].” The double engine failure checklist also required pilots to use the APU bleed air restart procedure if the airplane were at an altitude of 13,000 feet or below. This procedure required pilots to maintain an airspeed of between 170 and 190 knots until they were ready to initiate the APU-assisted engine restart. The procedure also required pilots to attempt to start one engine at a time and that, if either engine were restarted, an N2 indication of 28 percent was required before the thrust lever could be moved to idle. The double engine failure checklist also stated that, if neither engine were restarted, the flight crew should “consider a forced landing or a ditching.” In May 2005, Pinnacle Airlines issued changes to its double engine failure checklist. Specifically, the company rewrote the windmill relight procedure to make it easier for pilots to follow. Also, the company incorporated other changes to the checklist based on revisions made by Bombardier earlier that month to clarify the information within the checklist. For example, the double engine failure checklist that was in effect at the time of the accident indicated that 240 knots was the “target” airspeed to be maintained until the flight crew was ready to restart the engines, but the revised checklist indicated that 240 knots was the “minimum” airspeed to be maintained. Also, the revised checklist included the following caution: Failure to maintain positive N2 may preclude a successful relight. If required, increase airspeed to maintain positive N2 indication. In addition, the windmill relight procedure included the following revised note and added the following caution, respectively: An altitude loss of approximately 5,000 feet can be expected when accelerating from 240 to 300 KIAS and may require pitch attitudes of 10 degrees nose down.[80] 300 KIAS or greater is required to achieve sufficient N2 for start. Airspeed must be maintained until at least one engine relights (stable idle) or start attempts abandoned. 80 To this note, Pinnacle Airlines added, “if possible, crews should start accelerating to achieve 300 KIAS upon reaching 21,000 feet.”

Factual Information 35 Aircraft Accident Report Appendix C shows Pinnacle Airlines’ double engine failure checklist at the time of the accident, and appendix D shows the airline’s revised double engine failure checklist. 1.17.2.3 Stall Protection System The Pinnacle Airlines CRJ FCOM, volume 1, Flight Controls, pages 10-20 and 10-21, dated January 2003, stated the following about the SPS:81 As a high AOA is approached, continuous ignition is activated. If the AOA continues to increase, the stick shakers are activated and the autopilot is disengaged. If the AOA still continues to increase, the stick pusher mechanism is activated, STALL lights on the glareshield panel flash red, and the warbler sounds. 1.17.2.4 Flight Operations Pinnacle Airlines’ Flight Operations Manual, Normal Procedures, section 4.30.1, “Safe Aircraft Operations,” dated August 2003, stated the following: “Pilots are prohibited from operating aircraft in a careless or reckless manner so as to endanger life or property. Maneuvers not necessary for the safe and orderly progress of flight are prohibited.” Section 4.30.2, “Absence From The Cockpit,” dated August 2003, stated that “all flight crewmembers shall remain at their duty stations during takeoff, landing and while enroute.”82 After the accident, Pinnacle Airlines issued a revision to its Flight Operations Manual. Normal Procedures, section 4.30.6, “Crew Composition,” dated May 2005, stated, “the minimum flight crew for all operations shall be a Captain and a First Officer. The Captain must occupy the left seat and the First Officer must occupy the right seat.” 1.17.3 Federal Aviation Administration Oversight The Memphis Flight Standards District Office (FSDO) is responsible for oversight of Pinnacle Airlines. The supervisor of the Pinnacle Airlines certificate management unit stated that, after he was assigned to the position in October 2002, he appointed temporary principal inspectors because he wanted a “fresh set of eyes” to evaluate the airline’s compliance with the Federal Aviation Regulations. He also stated that, before his assignment, Pinnacle Airlines seemed to not pay much attention to the FAA and that the appointment of temporary principal inspectors would help the FAA achieve a fresh start with the airline. He further stated that, as a result of this action, Pinnacle Airlines agreed to improve its working relationship with the FAA. 81 A review of the SPS’ performance during the flight matched the system’s nominal performance requirements. 82 According to the document, the only exception to this policy is when the absence of a flight crewmember is necessary for the performance of duties in connection with the operation of the airplane or for physiological needs.

Factual Information 36 Aircraft Accident Report In January 2003, the POI was removed from that position because he did not have a CRJ type rating. Three acting POIs (including the certificate management unit supervisor) were on the Pinnacle Airlines certificate until the POI position was permanently filled in July 2004. The new POI had been the assistant POI for Pinnacle Airlines from July 2003 to January 2004, at which time he began 5 months of inspector training at the FAA Academy in Oklahoma City, Oklahoma. The POI currently has two assistant POIs to help him with his workload. 1.18 Additional Information 1.18.1 Oxygen Mask Use During the Accident Flight As stated in section 1.6.2, the cabin pressurization system was designed to provide a cabin altitude/cabin pressure warning at a cabin altitude of 10,000 feet. The CVR recorded the first activation of the cabin pressure warning about 2157:04. The FDR did not record the cabin altitude warning signal about this time because FDR operation had temporarily ceased about 2155:20. The cabin altitude signal was recorded when FDR operation resumed about 2159:16; at that time, the airplane was descending from an altitude of 29,200 feet. The FDR showed that the oxygen masks did not deploy until the airplane descended to an altitude of 22,531 feet (about 2201:45). The CVR recorded, about 2204:06, the captain stating, “get on oxygen,” and, 3 seconds later, a sound similar to oxygen flow in oxygen masks.83 About 2204:13, the CVR recorded the captain stating, “we’re at cabin altitude … fifteen thousand four hundred. We need to be on oxygen.” About 2204:45, as the airplane descended through an altitude of 16,423 feet, the cabin altitude stopped climbing and started descending. About 2206:23, the CVR recorded a sound similar to oxygen mask removal. The CVR again recorded a sound similar to oxygen flow in oxygen masks about 2207:20 and then a sound similar to oxygen mask removal about 2208:11 and about 2208:15. The cabin altitude warning signal was no longer present in the FDR recording when the airplane descended through an altitude of 10,020 feet (about 2209:05). 1.18.2 Core Lock During the investigation of this accident, the Safety Board learned that GE CF34-1 and CF34-3 engines84 had a history of failing to rotate during in-flight restart attempts on airplanes undergoing production acceptance flight testing at Bombardier. The manufacturers referred to this condition as “core lock.” Bombardier first identified this problem in 1983 during Challenger certification tests, and GE attributed the problem to interference contact at an air seal in the high pressure turbine. 83 The CVR had previously recorded the first officer stating, “we need our oxygen masks,” about 2158:21 and a sound similar to oxygen flow starting in oxygen masks about 2158:41. 84 Bombardier airplanes that are powered by either GE CF34-1 or CF34-3 engine models are the Challenger 601, Challenger 604, CRJ-100, CRJ-200, and CRJ-440.

Factual Information 37 Aircraft Accident Report The CF34 high pressure turbine air seals are designed to control cooling and balance airflow. The seals include teeth on the rotating components that grind operating grooves into abradable surfaces on the stationary components. The efficiency of these seals significantly affects engine performance, so the seals are designed to operate with minimal clearances. Bombardier added a procedure that screened for core lock to the production acceptance flight tests for its airplanes powered by CF34-1 and CF34-3 engines. At the time of the accident, this screening procedure was as follows: 1. Climb to 31,000 feet. 2. Retard the test engine throttle to idle and stabilize for 5 minutes.85 3. Shut down the test engine. 4. Descend at 190 knots. 5. Slow the aircraft until N2 is reduced to 0 percent. 6. At 8 1/2 minutes from shutdown, push over to 320 knots. 7. If N2 is 0 rpm at 21,000 feet, the engine is declared to be core locked. Engines that are found to be core locked are reworked using an in-flight “grind-in” procedure that was designed to remove seal material at the interference location. Engines that undergo grind-in rework are then rescreened for core lock. The grind-in procedure is as follows: 1. ATS cross-bleed start. 2. Ascend to 31,000 feet. 3. Repeat core lock screening procedure but descend at an airspeed of about 240 knots to establish 4 percent N2. 4. Maintain 4 percent N2 for at least 8 1/2 minutes. 5. Confirm that no core lock exists by repeating screening procedure. As testimony during the Safety Board’s June 2005 public hearing on the Pinnacle Airlines accident indicated, neither Bombardier nor GE considered core lock to be a safety-of-flight issue. The manufacturers claimed that engines that passed the screening procedure, with or without grind-in rework, would not core lock as long as the 240-knot airspeed was maintained. Bombardier’s core lock screening procedure requires a cool-down period before engine shutdown to stabilize internal temperatures and clearances. However, this procedure does not produce the more severe thermal distress associated with the high power, high altitude flameouts that were experienced during the accident flight. As stated in the Safety Board’s November 20, 2006, safety recommendation letter to the FAA,86 the successful 85 After the accident, Transport Canada mandated that Bombardier change the engine stabilization time from 5 to 2 minutes. 86 This letter transmitted Safety Recommendations A-06-70 through -76. For information about these recommendations, see section 1.18.3.1.

Factual Information 38 Aircraft Accident Report demonstration of Bombardier’s flight test procedure might not ensure that an engine will not experience core lock if the core is allowed to stop rotating after a high power, high altitude flameout. In its letter, the Board noted that the No. 1 accident engine had successfully passed the screening procedure during initial production acceptance testing.87 The Board further stated that the successful demonstration of Bombardier’s flight test procedure might not ensure that slowing the airplane to an airspeed of 170 to 190 knots is sufficient to maintain core rotation during an attempted APU-assisted restart. 1.18.3 Previous Related Safety Recommendations 1.18.3.1 Core Lock On November 20, 2006, the Safety Board issued Safety Recommendations A-06-70 through -76 to the FAA to address the safety hazards associated with core lock, which can prevent pilots from restarting an engine after a double engine failure during flight. Safety Recommendations A-06-70 through -76 asked the FAA to do the following: For airplanes equipped with CF34-1 or CF34-3 engines, require manufacturers to perform high power, high altitude sudden engine shutdowns; determine the minimum airspeed required to maintain sufficient core rotation; and demonstrate that all methods of in-flight restart can be accomplished when this airspeed is maintained. (A-06-70) Ensure that airplane flight manuals of airplanes equipped with CF34-1 or CF34-3 engines clearly state the minimum airspeed required for engine core rotation and that, if this airspeed is not maintained after a high power, high altitude sudden engine shutdown, a loss of in-flight restart capability as a result of core lock may occur. (A-06-71) Require that operators of CRJ-100, -200, and -440 airplanes include in airplane flight manuals the significant performance penalties, such as loss of glide distance and increased descent rate, that can be incurred from maintaining the minimum airspeed required for core rotation and windmill restart attempts. (A-06-72) Review the design of turbine-powered engines (other than the CF34-1 and CF34-3, which are addressed in Safety Recommendation A-06-70) to determine whether they are susceptible to core lock and, for those engines so identified, require manufacturers of airplanes equipped with these engines to perform high power, high altitude sudden engine shutdowns and determine the minimum airspeed to maintain sufficient core rotation so that all methods of in-flight restart can be accomplished. (A-06-73) 87 The No. 2 accident engine was installed new as a spare engine and was not subjected to the core lock screening procedure because it applies only to engines that are installed in Bombardier’s production airplanes.

Factual Information 39 Aircraft Accident Report For those airplanes with engines that are found to be susceptible to core lock (other than the CF34-1 and CF34-3, which are addressed in Safety Recommendation A-06-71), require airplane manufacturers to incorporate information into airplane flight manuals that clearly states the potential for core lock; the procedures, including the minimum airspeed required, to prevent this condition from occurring after a sudden engine shutdown; and the resulting loss of in-flight restart capability if this condition were to occur. (A-06-74) Require manufacturers to demonstrate, as part of 14 Code of Federal Regulations Part 25 certification tests, if restart capability exists from a core rotation speed of 0 indicated rpm after high power, high altitude sudden engine shutdowns. For those airplanes determined to be susceptible to core lock, mitigate the hazard by providing design or operational means to ensure restart capability. (A-06-75) Establish certification requirements that would place upper limits on the value of the minimum airspeed required and the amount of altitude loss permitted for windmill restarts. (A-06-76) Appendix E shows the complete safety recommendation letter. 1.18.3.2 Crew Professionalism On October 8, 1974, the Safety Board issued Safety Recommendations A-74-85 and -86 as a result of the September 27, 1973, Texas International Airlines flight 655 accident in Mena, Arkansas,88 and the September 11, 1974, Eastern Air Lines flight 212 accident in Charlotte, North Carolina.89 The Board’s final report on the Texas International Airlines accident stated that the captain failed to follow approved procedures. The probable cause of the Eastern Air Lines accident was the flight crew’s lack of altitude awareness at critical points during the approach resulting from poor cockpit discipline (specifically, the crew did not follow prescribed procedures).90 Safety Recommendation A-74-85 asked the FAA to do the following: Initiate a movement among the pilots associations to form new professional standards committees and to regenerate old ones. These committees should: a) monitor their ranks for any unprofessional performance. 88 For more information, see National Transportation Safety Board, Texas International Airlines, Inc., Convair 600, N94230, Mena, Arkansas, September 27, 1973, Aircraft Accident Report NTSB/AAR-74/04 (Washington, DC: NTSB, 1974). 89 For more information, see National Transportation Safety Board, Eastern Air Lines, Inc., Douglas DC-9-31, N8984E, Charlotte, North Carolina, September 11, 1974, Aircraft Accident Report NTSB/AAR-75/09 (Washington, DC: NTSB, 1975). 90 The Safety Board’s safety recommendation letter cited five previous air carrier accidents as examples of a “casual acceptance” of the flight environment (Martha’s Vineyard, Massachusetts, 1971; Fort Lauderdale, Florida, 1972; New Haven, Connecticut, 1972; Toledo, Ohio, 1973; and Boston, Massachusetts, 1973). The letter added that the Eastern Air Lines accident also reflected “serious lapses in expected professional conduct.”

Factual Information 40 Aircraft Accident Report b) alert those pilots who exhibit unprofessionalism to its dangers and try, by example and constructive criticism of performance required, to instill in them the high standards of the pilot group. c) strengthen the copilot’s sense of responsibility in adhering to prescribed procedures and safe practices. d) circulate the pertinent information contained in accident reports to pilots through professional publications so that members can learn from the experience of others. On October 17, 1974, the FAA stated that it considered it more appropriate to work with airline management rather than pilot groups to increase and promote crew discipline and professionalism. The FAA also stated that it discussed this subject at length with the Air Transport Association,91 which provided assurance that efforts would be made to stress the importance of professionalism. On March 10, 1977, the Safety Board classified Safety Recommendation A-74-85 “Closed—Acceptable Action.” Safety Recommendation A-74-86 asked the FAA to do the following: Develop an air carrier pilot program, similar to the general aviation accident prevention program (FAA Order 8000.8A), that will emphasize the dangers of unprofessional performance in all phases of flight. The program could be presented in seminar form, using audio/visual teaching aids, to call to the pilots’ attention all facets of the problem. On October 17, 1974, the FAA stated that many airlines have established accident prevention programs and have periodically conducted seminars. The FAA also stated that it has participated in these seminars and would increase its participation in the future. The FAA further stated that it would urge its field offices to emphasize the dangers of unprofessional performance and that it would hold meetings with the Air Transport Association to discuss this subject. On March 10, 1977, the Safety Board classified Safety Recommendation A-74-86 “Closed—Acceptable Action.” 1.18.3.3 Flight Data Recorder Data On May 16, 2003, the Safety Board issued Safety Recommendation A-03-15 to the FAA because of problems with the quality of FDR data recorded by several regional jet airplanes. Safety Recommendation A-03-15 asked the FAA to do the following: Require that all Embraer 145, Embraer 135, Canadair CL-600 RJ, Canadair Challenger CL-600, and Fairchild Dornier 328-300 airplanes be modified with a digital flight data recorder system that meets the sampling rate, range, and accuracy requirements specified in 14 Code of Federal Regulations Part 121.344, Appendix M. 91 The Air Transport Association is the trade organization of the largest U.S. airlines.

Factual Information 41 Aircraft Accident Report On June 9, 2005, the FAA stated the following: • Regarding the Embraer 145 and 135, Embraer released Service Bulletin (SB) 145-31-0042, Revision 2, to correct known FDR anomalies, and the Brazilian Department of Civil Aviation issued Airworthiness Directive (AD) 2004-12-03, requiring incorporation of the Embraer SB within 18 months. The FAA advised U.S. operators of the Embraer 145 and 135 of the Brazilian AD and planned to release a corresponding AD. (As of December 1, 2006, the FAA had not issued the corresponding AD.) • Regarding the Canadair CL-600-2B19 (CRJ-100, -200, and -440) and CL-600-2B16 (Challenger 604), the Canadian airworthiness authority, Transport Canada, reported that Bombardier confirmed that the FDR system on these airplanes exhibited low update rates on the normal acceleration and pitch attitude parameters.92 Bombardier and Rockwell Collins, the supplier of the system that established the parameter update rates on these airplane models, were planning to develop a plan and schedule for correcting this problem. The FAA was working with Transport Canada to get expeditious action from Bombardier on this issue. • Regarding the Fairchild Dornier 328-300, AvCraft Aviation (which acquired the rights to the 328 program), in cooperation with Honeywell (the manufacturer of the 328-300 FDR system), completed an extensive review of FDR data from two incidents and several flight tests. They concluded that all FDR parameters were updated at a rate equal to or exceeding those required by 14 CFR 121.344, Appendix M, when the data were analyzed with the proper frame rate and at the maximum accuracy. On September 28, 2005, the Safety Board agreed that no problems existed with the FDR parameters on the Fairchild Dornier 328-300 airplane. The Board also stated that, pending the FAA’s issuance of an AD that mandated compliance with Embraer SB 145-31-0042, Revision 2, and an AD that mandated correction to CRJ-100, -200, and -440 and Challenger 604 FDR systems, Safety Recommendation A-03-15 was classified “Open—Acceptable Response.” 1.18.4 Federal Aviation Administration Notice On March 1, 2005, the FAA issued Notice N8000.296, “Pilot Judgment and Decisionmaking,” after six accidents that occurred between October and November 2004. These accidents were Pinnacle Airlines flight 3701, Corporate Airlines flight 5966,93 and 92 Bombardier indicated that other recorded parameters on the CRJ-100, -200, and -440 and Challenger 604 airplanes were updated at rates that were in compliance with the regulations. Bombardier also noted that the update rates for all FDR parameters on CL-600-2C10 (CRJ-700) and CL-600-2D24 (CRJ-900) airplanes complied with the regulations. 93 For more information, see National Transportation Safety Board, Collision With Trees and Crash Short of the Runway, Corporate Airlines Flight 5966, BAE Systems BAE J3201, N875JX, Kirksville, Missouri, October 19, 2004, Aircraft Accident Report NTSB/AAR-06/01 (Washington, DC: NTSB, 2006).

Factual Information 42 Aircraft Accident Report accidents involving a Learjet 35A at San Diego, California; a King Air 200 at Stuart, Virginia; a Challenger 600 at Montrose, Colorado; and a Gulfstream III at Houston, Texas.94 The notice was issued to POIs of operators of airplanes with 70 or fewer passenger seats, corporate managers and trainers, and individual pilots to encourage the promotion of “soft skills” as a first line of defense against accidents caused by lapses in human performance. The FAA defined soft skills as those that go beyond the technical knowledge and psychomotor skills that are necessary to fly an airplane. Such skills include adherence to standard operating procedures, decision-making, judgment, CRM, and professionalism. The notice required POIs to convey information about the importance of soft skills in preventing human error and the existing FAA guidance on that topic. The notice also recommended that operators ensure that their programs reflected the human factor principles that were outlined in FAA guidance about CRM and standard operating procedures. In addition, the notice indicated that individual pilots should examine their own decision-making habits in terms of professionalism, thoroughness of preparation, and adherence to standard operating procedures. The notice expired on March 1, 2006.95 In a November 2006 memorandum to the Safety Board, the FAA stated that it incorporated soft skills into Part 121 CRM training requirements and that a rewrite (which is currently in progress) of FAA Order 8400.10, Air Transportation Operations Inspector’s Handbook, would emphasize soft skills. 1.18.5 Bombardier All Operator Message On December 14, 2004, Bombardier issued an all operator message that included the following information about high altitude operations: Climb profiles as detailed in the AFM [airplane flight manual] must be strictly adhered to. Climbing below the recommended profile speed may place the airplane behind the energy curve when it arrives at the desired altitude and it may not be capable of remaining at that altitude. This may be evident by an aircraft nose-high attitude and its failure to accelerate. The autopilot should be engaged and performance closely monitored during the upper portion of the climb and immediately following the level off. When the selected altitude is reached, under normal conditions, the aircraft will accelerate to the desired cruise speed. 94 For more information on these accidents, see LAX05FA015, IAD05MA006, DEN05MA029, and DCA05MA011, respectively, at the Safety Board’s Web site at http://www.ntsb.gov. 95 All FAA notices expire 1 year after issuance. Because the notices are temporary by nature, they are rarely renewed.

Factual Information 43 Aircraft Accident Report Situational awareness must be maintained at all times when the aircraft reaches the desired cruising altitude. If the … [AOA] is excessively high, the performance may be such that the aircraft is not capable of maintaining the altitude and the airspeed may begin to decay. Under these circumstances, a descent must be initiated immediately. Do not wait for the onset of continuous ignition or stick shaker before attempting a descent from an altitude where continued operation is not possible. Descend immediately. In the event that a stick shaker/approach to stall occurs, the crew should expect that a deliberate loss of altitude will likely be required in order to restore the aircraft to a normal energy state and to prevent an aerodynamic stall and possible departure from controlled flight.

44 Aircraft Accident Report 2. Analysis 2.1 General The captain and the first officer were properly certificated and qualified under Federal regulations. No evidence indicated any medical or behavioral conditions that might have adversely affected their performance during the accident flight. Flight crew fatigue and hypoxia were not factors in this accident. The accident airplane was properly certified, equipped, and maintained in accordance with Federal regulations. The recovered components showed no evidence of any structural or system failures or any engine failures before the time of the upset event. Weather was not a factor in this accident. The accident was not survivable. This analysis discusses the accident sequence, including the flight crew’s decision to climb to 41,000 feet and the improper climb speed; the crew’s improper actions during the stall event; and the crew’s failure to restart the engines, inform air traffic controllers of the double engine failure, and initiate an emergency landing in a timely manner. The analysis also addresses flight crew training (in the areas of high altitude climbs, stall recognition and recovery, and double engine failures) as well as flight crew professionalism. In addition, the analysis addresses problems with the quality of some parameters recorded by FDRs on regional jet airplanes, including the CRJ-200. 2.2 Accident Sequence 2.2.1 Climb to 41,000 Feet The flight plan for the accident flight indicated that the planned cruise altitude was 33,000 feet. However, the ATC and CVR transcripts showed the flight crew’s desire to climb to an altitude of 41,000 feet, which is the CRJ maximum operating altitude.96 During postaccident interviews, Pinnacle Airlines pilots stated that some pilots had expressed curiosity about operating the airplane at 41,000 feet and that a “[flight level] 410 club” existed at the airline. When the airplane was at an altitude of 450 feet, the first of three aggressive pitch-up maneuvers during the ascent occurred. During the first maneuver, the flight crew moved the control column to 8º ANU, causing the airplane’s pitch angle to increase to 22º and resulting in a vertical load of 1.8 Gs. The maneuver also caused the stickshaker and 96 It is not known which pilot first suggested that the flight be operated at an altitude of 41,000 feet. However, CVR evidence showed that both pilots were willing participants in the decision to climb to 41,000 feet.

Analysis 45 Aircraft Accident Report stickpusher to activate. After stickpusher activation, the FDR recorded a full nose-down control column deflection. When the airplane was at an altitude of 15,000 feet, the second pitch-up maneuver occurred. The flight crew moved the control column to 3.8º ANU, causing the airplane’s pitch angle to increase to 17º and resulting in a vertical load of 2.3 Gs. Afterward, the flight crew made rudder inputs of 4.2º to the left, 6.0º to the right, and 0.4º to the left followed 17 seconds later by a 7.7º right rudder input. When the airplane was at an altitude of 24,600 feet, the third pitch-up maneuver occurred. The flight crew moved the control column to 4º ANU, causing the pitch angle to increase to more than 10º and resulting in a vertical load of 1.87 Gs. The pilots’ intentional maneuvers, which were not required for any operational reason or safety consideration, placed the airplane in a flight regime that likely exceeded the airplane’s certificated flight envelope.97 The CVR recording showed that both pilots repeatedly expressed excitement before and after reaching the 41,000-foot altitude. For example, the CVR recorded the first officer stating, “man we can do it. Forty one it,” “there’s four one oh my man,” and “this is … great.” The CVR also recorded the captain stating, “look how high we are.” In addition, when one of the air traffic controllers handling the flight stated to the flight crew, “I’ve never seen you guys up at forty one there,” the captain replied, “we don’t have any passengers on board so we decided to have a little fun and come on up here” and “this is actually our service ceiling.” The Safety Board concludes that the pilots’ aggressive pitch-up and yaw maneuvers during the ascent and their decision to operate the airplane at its maximum operating altitude (41,000 feet) were made for personal and not operational reasons. Pinnacle Airlines required that a climb to 41,000 feet be conducted at an airspeed of 250 knots (0.70 Mach).98 However, FDR data showed that the flight crew conducted the climb from 37,000 to 41,000 feet at an airspeed that decreased from 203 knots (0.63 Mach) at the start of the climb to 163 knots (0.57 Mach) as the airplane leveled off at 41,000 feet. FDR data also showed that the flight crew conducted the climb from 37,000 to 41,000 feet with the autopilot vertical speed mode engaged and a commanded vertical speed of 500 fpm. The airplane could not sustain the required airspeed while climbing at 500 fpm, which resulted in the 40-knot loss of airspeed, and, once level at 41,000 feet, the airplane was operating in a “region of reversed command”99 in which available thrust was not sufficient to increase airspeed. The flight crew should have used the autopilot airspeed mode rather than the vertical speed mode to prevent the loss of airspeed. The Safety Board concludes that the flight crew’s inappropriate use of the vertical speed mode during the climb was a misuse of automation that allowed the airplane to reach 41,000 feet in a critically low energy state. 97 The pilots were experienced in the airplane, so the maneuvering would not have been the result of improper control inputs by a pilot who was unfamiliar with the airplane’s handling characteristics. 98 Specifically, the climb should be conducted at 250 knots until Mach 0.7 is reached, at which point Mach 0.7 becomes the primary indicator of airspeed. 99 Region of reversed command is also known as operating “on the back side of the power curve.” It occurs when the available engine thrust cannot overcome the increased induced drag associated with low airspeed. As a result, the airplane cannot accelerate and may decelerate.

Analysis 46 Aircraft Accident Report Statements on the CVR recording indicated that the pilots did not fully understand the aerodynamic and performance considerations associated with operations at an altitude of 41,000 feet. Specifically, about 2154:07, the captain stated, “we’re losing here. We’re gonna be … coming down in a second here.” About 3 seconds later, the captain stated, “this thing ain’t gonna … hold altitude. Is it?” The first officer responded, “it can’t man. We … (cruised/greased) up here but it won’t stay.” About 2154:19, the captain stated, “yeah that’s funny we got up here it won’t stay up here.”100 Pinnacle Airlines’ ground school upset training addressed high altitude aerodynamics, swept-wing design characteristics, and the use of performance charts. Also, the company’s ground school performance training provided pilots with instruction on how to use climb capability charts to determine thrust settings for altitudes above 36,000 feet. The CVR recording did not indicate whether the flight crew consulted the company’s altitude and climb ability charts before initiating the climb to 41,000 feet. However, the Safety Board concludes that the improper airspeed during the climb demonstrated that the pilots did not understand how airspeed affects airplane performance and did not realize the importance of conducting the climb according to the published climb capability charts. Section 2.3.1 discusses high altitude training for regional jet operations. 2.2.2 Aerodynamic Stall and Upset Event Even though the pilots recognized that the airplane’s performance was deteriorating, neither pilot appeared to respond to this situation with urgency. The pilots contacted the controller about 2154:32 and requested a lower altitude; however, during the time that the controller was coordinating the descent, the airplane’s airspeed further deteriorated to Mach 0.53 (150 knots), and the stickshaker activated for the first of five times. Afterward, the stickshaker activated four times, and the stickpusher activated four times, pushing the control column forward automatically.101 The flight crew responded to the stickpusher each time by pulling back on the control column. These control column inputs caused the airplane’s pitch angle to increase to a maximum ANU value of 29º about 2154:59, and then the airplane entered an aerodynamic stall. Afterward, the airplane’s pitch angle decreased to a maximum AND value of 32º about 2155:06. While the pitch angle was decreasing, a left rolling motion began, which eventually reached 82º left wing down, and the N1 and fuel flow indications for both engines declined steadily to zero, indicating that both engines had flamed out. The Safety Board concludes that the upset event exposed both engines to inlet airflow disruption conditions that led to engine stalls and a complete loss of engine power. The double engine failure is further discussed in section 2.2.3. 100 During postaccident interview, several company pilots stated that, even though they had been able to climb the CRJ to 41,000 feet, the airplane was not able to stay at that altitude for an extended period because the airplane’s performance had deteriorated. 101 During the public hearing on this accident, a Bombardier engineer testified that the stickpusher had functioned normally during the flight.

Analysis 47 Aircraft Accident Report During the investigation, the aircraft performance group determined that the stickshaker was functioning normally102 but that the airspeed indicator’s low speed cue was 10 knots low. As a result, at the time of stickshaker activation, the low speed cue was indicating that the airplane’s speed was 10 knots above the stickshaker speed. The erroneous information shown by the low speed cue resulted from a software error.103 According to Pinnacle Airlines, its flight crewmembers were taught that the top of the low speed cue indicated the airspeed at which the stickshaker would initially activate. However, the flight crews were also trained to respond to stickshaker activation, regardless of whether the airspeed was above the low speed cue, because the stickshaker is the primary warning to pilots of an impending stall. In addition, when an airplane’s speed is about 10 knots from the top of the low speed cue, especially when operating at an altitude of 41,000 feet, pilots should realize that the airplane is dangerously close to an impending stall. When the stickshaker activated during the accident flight, the pilots should have immediately attempted to accelerate the airplane to a safe airspeed by descending; sufficient reserve power was not available from the engines while the airplane was at 41,000 feet. Thus, the accident pilots should have responded appropriately to the stickshaker and used the low speed cue only as a secondary indication showing that the airspeed was dangerously slow. Even though the flight crew was eventually able to recover the airplane from the upset event, the flight control inputs made during the upset were opposite of what was required to recover the airplane. FDR data showed that the flight crew moved the control column aft after the first stickpusher activation and that the crew moved the control column aft with increasing magnitude after the next three activations of the stickpusher. A reason that might explain why the pilots made these flight control inputs, which exacerbated the upset event, was that Pinnacle Airlines’ stall recognition and recovery simulator training focused on recovery with a minimum loss of altitude (which is common throughout the aviation industry). As a result, the pilots were trained to apply power to restore the energy state of the airplane and to maintain altitude.104 In this accident, the pilots’ inputs could have been the result of their attempt to recover using a minimal altitude loss recovery technique, and, as the repeated stall events occurred with increasing nose-down pitch attitude, the pilots could have been instinctively trying to arrest the 102 The Safety Board compared the AOA recorded on the FDR at the time of the stickshaker activations with Bombardier’s stickshaker design criteria for the flight condition and determined that the stickshaker activated at the expected AOA (about 7.8º) and airspeed (about 150 knots). 103 In December 2004, the FAA sent a letter to Transport Canada that recommended, among other things, that Bombardier change “the airspeed tape display software to more accurately depict the top of the Low Speed Awareness (top of the red band) at all altitudes and Mach Numbers.” In February 2005, Bombardier indicated that it would include an appropriate design change the next time the stall protection computer and the air data computer were modified and that, in the interim, its FCOM would be revised to provide necessary guidance material on changes to the computation required to determine the low speed cue. In November 2006, Bombardier stated that it had not yet scheduled the modification; in December 2006, Bombardier issued the revised FCOM. 104 The Safety Board could not determine whether the pilots applied power because the throttle lever angle parameter was not recorded on the FDR.

Analysis 48 Aircraft Accident Report nose-down pitch moment or responding inappropriately to the stickpusher. The Safety Board concludes that the pilots’ lack of exposure to high altitude stall recovery techniques contributed to their inappropriate flight control inputs during the upset event. Section 2.3.2 discusses stall recognition and recovery training. 2.2.3 Double Engine Failure About 2155:06, the flight crew declared an emergency and asked the controller to stand by. CVR evidence showed that the flight crew recognized the nature of the emergency; specifically, about 2155:23, one pilot stated to the other, “we don’t have any engines.” However, the CVR also showed that the flight crew did not begin the first item of the double engine failure checklist (which is a memory item) until 1 minute 19 seconds after the statement on the CVR recording about the double engine failure. Also, FDR data showed that the pilots did not achieve and maintain the target airspeed of 240 knots (another memory item on the checklist). Because the flight crew did not achieve this airspeed, both engines’ cores had decelerated and stopped before the airplane descended through an altitude of 28,000 feet. The double engine failure checklist indicated that, between the altitudes of 21,000 and 13,000 feet, the windmill restart procedure should be used to relight the engines. This procedure required that the pitch attitude of the airplane be reduced to and maintained at -8º to accelerate the airplane to an airspeed of 300 knots or greater. However, the pitch inputs made by the flight crew were not of sufficient magnitude and were not sustained. As a result, the crew did not achieve the 300-knot or greater airspeed required for the procedure; FDR data showed that the highest airspeed attained during the restart attempt was 236 knots and that the engines’ N2 (core rotation) indications remained at zero. The Safety Board concludes that the captain did not take the necessary steps to ensure that the first officer achieved the 300-knot or greater airspeed required for the windmill engine restart procedure and then did not demonstrate command authority by taking control of the airplane and accelerating it to at least 300 knots. The Safety Board further concludes that the first officer’s limited experience in the airplane might have contributed to the failed windmill restart attempt because he might have been reluctant to command the degree of nose-down attitude that was required to increase the airplane’s airspeed to 300 knots. Because the flight crewmembers were unsuccessful in their attempt to relight the engines using the windmill procedure, they elected to descend the airplane to an altitude of 13,000 feet so that they could attempt to restart the engines with the APU. Once the airplane descended to an altitude of 13,000 feet, the flight crew attempted four APU-assisted engine restarts (two attempts per engine) during a 5-minute period (2207:04 to 2212:07) and between the altitudes of about 12,900 and about 5,000 feet. FDR data showed that the N2 indications for both engines remained at zero during the restart attempts. The Safety Board concludes that, despite their four APU-assisted engine restart attempts, the pilots were unable to restart the engines because their cores had locked. Without core rotation, recovery from the double engine failure was not possible.105 105 Section 2.2.3.1 discusses the flight crew’s performance of the double engine failure checklist.

Analysis 49 Aircraft Accident Report The Safety Board considered whether engine hardware was a factor contributing to the lack of core rotation. However, engine teardowns found no mechanical failures or evidence of any condition that would have prevented engine core rotation. The Safety Board then considered whether an electrical or mechanical problem interfered with the ability of the cores to achieve rotation. However, inspection and testing of the APU and other airplane start system components found no conditions that would have prevented torque delivery to either engine during the four APU-assisted restart attempts. Also, FDR data showed that the LCV was open during these restart attempts,106 and testing showed that it was capable of providing pneumatic power from the APU to start initial rotation in each engine. A systems simulation study (see section 1.16.4) showed that the LCV had likely opened by at least 18º during the flight, which should have resulted in some detectable core rotation if the engine cores were capable of rotation. In addition, the change in engine oil temperatures107 showed that air was flowing through the ATS. This finding, along with the results of the airplane start system component testing, showed that the LCV was likely fully open. The Safety Board considered whether the slight increases in core-driven hydraulic pump pressures shown on the FDR during the final minutes of the flight (as described in section 1.16.3) were evidence of engine core rotation. The airplane’s start system was operating normally during the restart attempts; thus, if the cores were free to rotate, they would have quickly accelerated. As a result, the Board determined that the slight increases in hydraulic pump pressures that were recorded on the FDR were not the result of engine core rotation. On the basis of the information discussed in section 1.18.2, the Safety Board concludes that the GE CF34-1 and CF34-3 engines had a history of failing to rotate during in-flight restart attempts on airplanes undergoing production acceptance testing at Bombardier. GE attributed the problem to interference contact at an air seal in the high pressure turbine and, along with Bombardier, referred to this condition as core lock. The lack of core rotation on the accident airplane engines was similar to the instances of core lock experienced by CF34 engines during Bombardier’s acceptance testing, except that the accident airplane engines were exposed to more severe thermal distress than the engines on the production airplanes. Specifically, the accident airplane’s engines flamed out from high power and high altitude, whereas the engines installed on the production airplanes were shut down only after their internal temperatures were stabilized.108 Flameouts at high power and high altitude produce even greater thermal distress because internal temperatures are the hottest at high power settings and the air is colder at high altitudes. The increased thermal shock exacerbates the loss of component clearance 106 The FDR parameter for the LCV position shows that the valve is open once it reaches a position that is greater than 4.8º from its normally closed position. 107 The FDR recorded a steady decline in engine oil temperature after the upset and showed that this steady decline ceased at the time of the engine restart attempts. 108 On November 20, 2006, the Safety Board issued recommendations to the FAA to address this and other core lock-related issues; see sections 1.18.3.1 and 4.3 for information.

Analysis 50 Aircraft Accident Report and alignment. Because the accident engines flamed out under these conditions, axial misalignment caused the seal teeth, which were positioned aft of their normal operating grooves, to contact stationary abradable material when radial seal clearances closed down. Once core rotation stopped, binding prevented core rotation from resuming during the windmill and APU-assisted restart attempts. No physical evidence of core lock was found inside the engines because the thermally induced interference occurred after core rotation had stopped and operating clearances were restored afterward as the engine cooled. The Safety Board concludes that both engines experienced core lock because of the flameout from high power and high altitude, which resulted from the pilot-induced extreme conditions to which the engines were exposed, and the pilots’ failure to achieve and maintain the target airspeed of 240 knots, which caused the engine cores to stop rotating; both of these factors were causal to this accident. 2.2.3.1 Performance of the Double Engine Failure Checklist A critical error made by the flight crew while performing the double engine failure checklist was failing to establish and maintain an airspeed of 240 knots before beginning the procedures to restart the engines. During the public hearing on this accident, a GE manager testified, “as long as core rotation is maintained, you will not have core lock … we have a body of data that shows that 240 knots maintains core rotation.” Another critical error made by the flight crew was failing to increase the airspeed to at least 300 knots before beginning the windmill restart procedure. About 2159:16, when the FDR resumed operation after a loss of power lasting about 4 minutes, the airplane’s airspeed was 178 knots. About 2200:38, the captain told the first officer to increase the airspeed to above 300 knots, and the first officer acknowledged this instruction. About 1 minute later, the captain again told the first officer to increase the airspeed to 300 knots. However, FDR data showed that the maximum airspeed achieved during the procedure—236 knots—was achieved only briefly. Other errors in the performance of the double engine failure checklist included the captain’s failure to call out the items using standard phraseology and indicate when the checklist was complete. According to the simulator instructor who conducted part of the captain’s upgrade training, the captain did not always perform checklists according to company procedures.109 This reported behavior in the simulator was consistent with the captain’s performance of the double engine failure checklist. Specifically, although the checklist procedures were clear, the captain did not effectively manage the execution of the checklist or ensure that the first officer had achieved the necessary airspeed, which is inconsistent with the basic tenets of CRM and basic airmanship. 109 As discussed in section 1.5.1, the instructor stated that the captain would, at times, misstate the status of a checklist item, read a checklist item but not accomplish it, take action on an airplane system that was not the one noted in the checklist, or see the appropriate checklist displayed in an EICAS message but still call for the wrong checklist.

Analysis 51 Aircraft Accident Report In addition to the captain’s previous difficulties in executing checklists, two additional factors likely played a role in the flight crew’s performance of the double engine failure checklist. The first factor was the stress associated with the situation. The stress included changes to the cockpit environment, such as the reduced cockpit lighting and the increase in ambient noise associated with the deployment of the ADG. Another stressor was the instrumentation available to the captain during the 4-minute period in which the ADG was the sole source of power—from the right seat, he would not have had a primary flight display showing airspeed and altitude; thus, he would have had to look over to the left side of the instrument panel or use the standby instruments in the center of the panel while performing the double engine failure checklist and other nonflying pilot duties. Also, the stress of the situation might have caused both pilots to experience attentional tunneling, that is, the focusing of attention on a single task or portions of a task, which results in neglecting other critical tasks. For example, the captain did not recognize that the airspeed required for N2 rotation (which was necessary for restarting the engines) had not been achieved. The second factor was that the pilots had only received ground school instruction on the double engine failure checklist. Thus, it is possible that they were executing it for the first time. Even though maintaining an airspeed of 240 knots was a memory item on the checklist, it is possible that the pilots did not realize the importance of this airspeed to the success of the restart sequence. The Safety Board concludes that the importance of maintaining a minimum airspeed to keep the engine cores rotating was not communicated to the pilots in airplane flight manuals. For example, at the time of the accident, Bombardier’s and Pinnacle Airlines’ double engine failure checklists stated that 240 knots was the “target” airspeed for the procedure but did not indicate that this airspeed was essential to the success of the restart procedure. As a result of the accident, Bombardier and Pinnacle Airlines revised their double engine failure checklist to indicate that 240 knots was the “minimum” airspeed and that the failure to maintain positive core rotation might prevent a successful restart. It is also possible that, after the double engine failure, the pilots were attempting to operate the airplane at its best glide speed of 170 knots, which is 70 knots less than the speed needed to maintain engine core rotation. The Safety Board examined whether the seat swap would have affected the pilots’ performance during the double engine failure checklist.110 The captain, who was responsible for performing the checklist, had significant experience in the right seat of the airplane, so the position of the controls and switches would have been familiar to him. Further, the tasks that the captain was performing for the checklist were not well practiced because of the lack of training in this area (as discussed in section 2.3.3), so he would not have developed any habit patterns or motor memory skills from the left seat that would have interfered with his ability to perform from the right seat. The lack of a flight display on the right side of the cockpit should not have affected the captain’s ability to recognize that the required airspeeds had not been achieved because airspeed was clearly presented on the standby instrument and the left-side primary flight display. The first officer was 110 It is not known which pilot suggested that the first officer sit in the captain’s seat during most of the accident flight. However, both pilots demonstrated poor judgment in allowing the seat swap to occur.

Analysis 52 Aircraft Accident Report responsible for flying the airplane, and the seat swap should not have affected his ability to achieve the commanded speeds. Thus, the pilots’ seat swap, although contrary to standard operating practice, was not a factor that affected the pilots’ performance of the double engine failure checklist.111 The Safety Board concludes that the captain’s previous difficulties in checklist management, the situational stress, and the lack of simulator training involving a double engine failure contributed to the flight crew’s errors in performing the double engine failure checklist. 2.2.4 Communications With Air Traffic Controllers and Management of Forced Landing About 2206:40, the controller (at the sector 53 position) asked the pilots whether they wanted to land. The captain, during his reply to the controller, failed to disclose the true nature of the emergency, stating, “just stand by right now we’re gonna start this other engine and see … if everything is okay.” About 2209:06, the first officer informed the controller that the airplane was experiencing a double engine failure. This notification happened almost 14 minutes after the flight crew first recognized (according to CVR evidence) that a double engine failure had occurred. During that time, the flight crew had numerous opportunities to notify the controller of the double engine failure. For example, the controller (at the sector 30 position) had earlier asked the flight crew about the nature of the emergency, but the captain responded, “we had an engine failure up there … so we’re gonna descend down now to start our other engine.” This controller then stated, “understand controlled flight on a single engine right now,” but the captain did not correct this information by informing the controller of the actual situation. Thus, the transmissions describing a loss of only one engine indicated that the captain intentionally conveyed information to the controllers that did not represent his own understanding of the situation. During postaccident interviews, company pilots stated that, if an emergency situation (such as the loss of one or both engines) were to occur, they were instructed to provide relevant information to air traffic controllers, as workload and conditions allowed, about the nature of the emergency and the assistance that was needed. By misleading the controllers about the true nature of the emergency, the captain lost the full use of a valuable resource in an emergency situation.112 For example, if the captain had notified the controller early in the descent about the double engine failure, the controller would have likely provided the pilots with suggested vectors for a descent to and landing at an airport within the airplane’s best glide range. 111 About 2208:17, after the sound of oxygen mask use ceased, the CVR recorded the captain stating “switch,” indicating that the captain was preparing to return to the left seat and have the first officer return to the right seat. 112 The captain’s inaccurate communications to the controllers about the loss of only one engine were also inconsistent with the basic tenets of CRM.

Analysis 53 Aircraft Accident Report The company’s double engine failure procedure stated that, if neither engine was restarted, the flight crew should consider a forced (emergency) landing. Five airports that were suitable for an emergency landing were located within 60 miles of the upset location (see section 1.16.1.3). However, the flight crew did not consider making an emergency landing at any of these airports. Between the time that the flight crew first realized that a double engine failure had occurred and the time that the captain notified the controller of the actual situation, the airplane had descended from 35,000 to 10,000 feet. When the airplane was at an altitude of 10,000 feet, only one airport (AIZ) was still within the airplane’s best glide range, but the pilots had already overflown that airport. At that altitude, JEF was just outside the airplane’s best glide range.113 The aircraft performance study for this accident showed that drag produced by the 5.6º spoiler deployment had a minimal effect on the airplane’s ability to reach JEF. A double engine failure in a two-engine airplane is an emergency situation that requires timely action to stabilize the situation and effective coordination of all available resources and options to ensure a successful outcome. The flight crew’s failure to discuss an emergency landing during most of the descent demonstrated the crew’s poor judgment. Also, the captain’s failure to inform the controllers about the true nature of the situation early in the descent demonstrated the pilots’ apparent reluctance to have their deviation from standard operating procedures and their unprofessional behavior detected. Multiple opportunities existed during the descent for the pilots to talk with controllers and between themselves about the need to make an emergency landing. The pilots acted in a manner that was not consistent with ensuring safety of flight or effectively managing an in-flight emergency. The Safety Board concludes that the pilots’ failure to prepare for an emergency landing in a timely manner, including communicating with air traffic controllers immediately after the emergency about the loss of both engines and the availability of landing sites, was a result of their intentional noncompliance with standard operating procedures, and this failure was causal to the accident. 2.2.5 Accident Sequence Summary This accident was not the result of a single action, decision, or mistake by the flight crew. Instead, the accident was the result of poorly performing pilots who intentionally deviated from standard operating procedures and basic airmanship. Also, CVR evidence showed that the pilots’ tone in the cockpit was unprofessional114 and that their attitude was inconsistent with the demands associated with, and the precision required for, flying a high performance turbojet airplane. 113 On the basis of the airplane’s location at this point in the flight, the air traffic controller correctly directed the airplane to JEF, which was essentially straight ahead along the airplane’s flightpath. If the airplane had been directed to AIZ, a 160º left turn would have been required, which would have cost the airplane altitude, airspeed, and distance. 114 As indicated in the CVR transcript in appendix B, the flight crew’s conversation was generally casual, and sounds of joking and laughing were heard during the recording. Also, the transcript showed that the captain left his duty station unnecessarily to get a soft drink.

Analysis 54 Aircraft Accident Report According to models of human error, the pilots’ performance during the climb and their decision to operate at 41,000 feet can be described as “optimizing violations,” which occur when someone disregards defined procedures intentionally to make a job more interesting or engaging, to push limits, or to impress another.115 For example, the pilots’ CVR statements about operating at an altitude of 41,000 feet were consistent with thrill-seeking behavior. It is not possible to determine the specific reasons that the pilots demonstrated these optimizing violations. However, according to situational control theory, the chance that someone will violate a rule increases when such a violation results in personal achievement and is likely to go undetected.116 In this case, the Part 91 repositioning flight with no passengers or other crewmembers on board presented the pilots with an opportunity to reach personal milestones associated with aggressive maneuvering and operating the airplane at its maximum operating altitude. The Safety Board’s investigation of this accident did not reveal any evidence that the pilots had previously engaged in the unprofessional behavior demonstrated during the accident flight. Also, the CVR recording contained no indication that the pilots anticipated the adverse outcome resulting from their intentional deviations from standard operating procedures. Such intentional deviations can compromise the margins of safety that are in place as a result of procedures established by the company, the manufacturer, and the FAA. A consequence associated with compromising these margins of safety is that the operator becomes more vulnerable to the catastrophic effects of unintentional errors.117 Evidence indicated that the critical human performance failures during the flight were the result of intentional behavior and were not consistent with typical errors (slips, lapses, and mistakes) found in most flight crew-involved accidents involving Part 121 operators. Although the pilots demonstrated some performance failures and deficiencies in basic airmanship that were consistent with the more typical errors found in accidents, such as their failure to achieve required airspeeds during the descent (see section 2.2.3), the pilots’ overall actions during the accident flight were not consistent with the degree of discipline, maturity, and responsibility required of professional pilots. The Safety Board concludes that the pilots’ unprofessional operation of the flight was intentional and causal to this accident because the pilots’ actions led directly to the upset and their improper reaction to the resulting in-flight emergency exacerbated the situation to the point that they were unable to recover the airplane. The Safety Board is concerned about the willful misconduct demonstrated by the pilots during the accident flight. The Board has investigated other recent accidents in which pilots did not adhere to standard operating procedures and demonstrated a lack of cockpit discipline. Section 2.4 discusses this problem and the need for broad industry action involving pilots, operators, and the FAA to address the problem. 115 J.T. Reason, Human Error (New York: Cambridge University Press, 1990). 116 D. Huntzinger, “Pilots Behaving Badly,” Vector (New Zealand: Civil Aviation Authority, January/February 2001). 117 P.T.W. Hudson, W.L.G. Verschuur, D. Parker, R. Lawton, and G. van der Graff, “Bending the Rules: Managing Violation in the Workplace.” For more information about this paper, see http://www.energyinst.org.uk/heartsandminds/docs/bending.pdf.

Analysis 55 Aircraft Accident Report 2.3 Flight Crew Training 2.3.1 High Altitude Training High altitude climbs were not practiced during Pinnacle Airlines’ simulator training. The circumstances of the accident flight and the actions taken by Pinnacle Airlines and Bombardier after the accident to increase awareness of CRJ performance capabilities and limitations during high altitude operations118 indicate that high altitude training at regional jet operators may not be adequate. Regional airlines are typically the journeyman career step for professional pilots seeking employment with major air carriers. Until the advent of the regional jet, pilots at regional airlines typically operated turboprop airplanes. Because turboprop airplanes do not have the performance capabilities of, or operate at the same speeds and flight levels as, a regional jet, it is possible that some regional airline pilots were not adequately trained to make the transition to a turbojet airplane. Also, regional airline pilots with military flight training may have received more thorough high altitude training compared with civilian pilots; however, the number of regional airline pilots who had previously received military flight training has decreased since the 1980s.119 Because of advances in airplane equipment (turboprop to turbojet airplanes) at regional airlines and changes in the pilot force transitioning to regional jet operations, the current training methods and syllabuses for high altitude training at these operators may be in need of an industrywide revision. The Safety Board concludes that revised high altitude training syllabuses for pilots who operate regional jet airplanes would help ensure that these pilots possess a thorough understanding of the airplanes’ performance capabilities, limitations, and high altitude aerodynamics. Therefore, the Safety Board believes that the FAA should work with members of the aviation industry to enhance the training syllabuses for pilots conducting high altitude operations in regional jet airplanes. The syllabuses should include methods to ensure that these pilots possess a thorough understanding of the airplanes’ performance capabilities, limitations, and high altitude aerodynamics. The Safety Board further believes that the FAA should determine whether the changes to be made to the high altitude training syllabuses for regional jet airplanes, as requested in Safety Recommendation A-07-1, would also enhance the high altitude 118 As previously stated, Bombardier issued an all operator message to remind pilots of the importance of adhering to prescribed performance charts when operating at high altitudes and to inform them that climbing at a too-slow airspeed might result in performance deterioration once altitude is achieved. Pinnacle Airlines revised its FCOM to limit the minimum climb speed above 10,000 feet to 250 knots/0.70 Mach, whichever was lower. The company also placed altitude and climb capability charts into the Quick Reference Handbook for easy access during flight and issued guidance to pilots regarding the need to limit operation of the airplane to 37,000 feet or below. In addition, the company’s ground training now includes additional emphasis on these issues in the performance and high altitude training segments and a demonstration of these areas during simulator training. 119 During the 1980s, about 80 percent of the pilots hired by all commercial airlines had military flight training, but, according to the FAA in 2001, this number has decreased to about 40 percent.

Analysis 56 Aircraft Accident Report training syllabuses for all other transport-category jet airplanes and, if so, require that these changes be incorporated into the syllabuses for those airplanes. 2.3.2 Stall Recognition and Recovery Training The stall recognition and recovery training at Pinnacle Airlines, as well as elsewhere in the aviation industry, focuses on approach to stalls and recovery with minimum loss of altitude. Because most stalls occur when the airplane is maneuvering at lower altitudes,120 recoveries are practiced during training by applying power to restore the energy state of the airplane and maintaining pitch. Although this strategy can be effective at lower altitudes where the airplane has excess thrust, it is not effective when the airplane is at high altitudes, as demonstrated by the circumstances of this accident, or when a full stall has developed with resulting disruption of airflow to the engines, as demonstrated by the circumstances of the 1996 ABX Air accident in Narrows, Virginia.121 After the accident, Pinnacle Airlines added to its simulator training a high altitude buffet demonstration that emphasizes the need to get the airplane’s nose down to increase airspeed when engine thrust is marginal. Also, Bombardier’s all operator message that was issued after the accident stated, in part, the following: “in the event that a stick shaker/approach to stall occurs, the crew should expect that a deliberate loss of altitude will likely be required to restore the aircraft to a normal energy state and to prevent an aerodynamic stall and possible departure from controlled flight.” The Safety Board concludes that, because most training for stalls occurs with the airplane at low altitudes, the training methods may introduce a bias in stall recovery techniques by encouraging pilots to minimize altitude loss and not fully recognizing other available recovery techniques. Therefore, the Safety Board believes that the FAA should require that air carriers provide their pilots with opportunities to practice high altitude stall recovery techniques in the simulator during which time the pilots demonstrate their ability to identify and execute the appropriate recovery technique. Another factor that might have contributed to the improper control inputs during the stall event was the flight crew’s unfamiliarity with the stickpusher system on this airplane. The crew would have been exposed to stickpusher activation during systems training and the first-flight-of-the-day operational checks of the system, and, in the case of the accident flight, the crew experienced the system’s activation during one of the pitch-up maneuvers made during the climb. However, it is unclear the extent to which either pilot 120 At the time of the accident, Pinnacle Airlines conducted its stall recognition and recovery simulator training at an altitude of 10,000 feet. 121 During that accident investigation, the Safety Board found that the flying pilot applied inappropriate control column back pressure during the stall recovery attempt and that his performance of the stall recovery procedure, which was established in the company’s operations manual, was inadequate. In its final report on the accident, the Safety Board stated that the probable causes included “the inappropriate control inputs applied by the flying pilot during a stall recovery attempt” and “the failure of the nonflying pilot-in-command to recognize, address, and correct these inappropriate control inputs.” For more information, see National Transportation Safety Board, Uncontrolled Flight Into Terrain, ABX Air (Airborne Express), Douglas DC-8-63, N827AX, Narrows, Virginia, December 22, 1996, Aircraft Accident Report NTSB/AAR-97/05 (Washington, DC: NTSB, 1997).

Analysis 57 Aircraft Accident Report had experience with the stickpusher system during simulator training because the industry standard for stall training was to initiate recovery at the onset of the stickshaker, which, during a proper recovery, would preclude stickpusher activation. During the Safety Board’s public hearing on this accident, a Bombardier training pilot testified that he had seen pilots during training respond incorrectly to stickpusher activation because “they are scared, and they don’t know what to do [or] how to react.” He added, “proper training is a huge factor, to make sure that if you end up on a pusher, this is what you need to do.” The Safety Board acknowledges that additional training may be required to improve pilot response to stickpusher activation. However, current training protocols and FAA standards train pilots to initiate stall recovery before stickpusher activation. As a result, there may be unintended consequences and negative transfer associated with the inclusion of stickpusher training into simulator training protocols without careful and deliberate study. Because of these concerns, the Safety Board concludes that additional training might improve pilot response to stickpusher activation, but such training, if not provided correctly, could have an adverse impact on existing stall recognition and recovery protocols. Therefore, the Safety Board believes that the FAA should convene a multidisciplinary panel of operational, training, and human factors specialists to study and submit a report on methods to improve flight crew familiarity with and response to stickpusher systems and, if warranted, establish training requirements for stickpusher-equipped airplanes based on the findings of this panel. 2.3.3 Double Engine Failure Training At the time of the accident, double engine failure scenarios were not practiced during Pinnacle Airlines’ simulator training. After the accident, the company incorporated a double engine failure scenario into its simulator training syllabus. During this scenario, a double engine failure occurs at an altitude of 35,000 feet, and flight crews are required to use the windmill restart procedure to relight the engines. The Pinnacle Airlines CRJ program manager stated that this scenario would help familiarize the crew with the emergency power-only procedures and the effects of an ADG deployment. Also, in May 2005, Pinnacle Airlines made changes to its double engine failure checklist based on the changes made by Bombardier earlier that month. These changes highlighted the airspeeds required for the procedure. For example, the revised checklist stated that a minimum (rather than target) airspeed of 240 knots must be maintained until the pilot was ready to restart the engines. Also, the changes indicated that 300 knots or greater was required to achieve a sufficient N2 for the windmill restart and that this airspeed must be maintained until at least one engine was restarted or restart attempts were abandoned. Further, the revised checklist recognized the need to sacrifice altitude for airspeed by indicating that the 5,000-foot altitude loss that could be expected when accelerating from 240 to 300 knots might require pitch attitudes of 10º AND and that pilots should start accelerating to achieve 300 knots at an altitude of 21,000 feet.

Analysis 58 Aircraft Accident Report In addition, Pinnacle Airlines’ revised double engine failure checklist placed the following information in a box labeled “CAUTION”: “failure to maintain positive N2 may preclude a successful relight. If required, increase airspeed to maintain N2 indication.” According to the FAA’s guidance on checklist design,122 a caution is defined as “an instruction concerning a hazard that if ignored could result in damage to an aircraft component or system – which would make continued safe flight improbable.” The FAA’s guidance defines a warning as “an instruction about a hazard that, if ignored, could result in injury, loss of aircraft control, or loss of life.” Because of the circumstances of this accident, the Safety Board questions the appropriateness of placing information about the consequences of not maintaining positive N2 into a cautionary note when the FAA’s definitions suggest that a warning box would be a more appropriate transmission of that information to pilots. Pinnacle Airlines’ revised simulator training provides company pilots with an opportunity to reinforce the knowledge they obtained in ground school on the double engine failure checklist items, and the company’s revised checklist generally highlights the information that is necessary for pilots to successfully perform the double engine failure procedure. The Safety Board concludes that some of the changes made by Pinnacle Airlines to its double engine failure training and checklist guidance would benefit pilots at other air carriers that operate the CRJ because such training would provide pilots with the opportunity to practice double engine failure restart procedures in the simulator and the guidance would ensure that pilots were aware of the minimum airspeeds needed during the procedures. Therefore, the Safety Board believes that the FAA should verify that all CRJ operators incorporate guidance in their double engine failure checklist that clearly states the airspeeds required during the procedure and require the operators to provide pilots with simulator training on executing this checklist. 2.4 Flight Crew Professionalism 2.4.1 Part 91 Operations As stated in section 2.2.5, the accident flight, a Part 91 repositioning flight with no passengers or other crewmembers on board, presented the pilots with an opportunity to aggressively maneuver the airplane and operate it at the CRJ maximum operating altitude. Section 2.2.5 also noted that these behaviors were examples of optimizing violations, which occur when someone disregards defined procedures intentionally to make a job more interesting or engaging, to push limits, or to impress another. Although Pinnacle Airlines had protections in place for minimizing errors and unprofessional behavior during line operations,123 the company did not have effective protections in place for preventing optimizing violations during Part 91 operations. For example, even though the 122 Federal Aviation Administration, Human Performance Considerations in the Use and Design of Aircraft Checklists (Washington, DC: FAA, 1995). 123 These protections included pilot selection criteria, pilot training, company policies and procedures, and pilot oversight (line checks and pilot reports).

Analysis 59 Aircraft Accident Report accident pilots were generally described favorably by instructors, check airmen, and other pilots,124 the FAA’s operations supervisor of the Memphis FSDO stated, during the Safety Board’s public hearing on the accident, that, before this accident, “we had no idea that anybody would ever switch seats during a flight and not operate in accordance with the standard operating procedures for the company.”125 After the accident, Pinnacle Airlines began to review FDR data for all nonrevenue flights.126 The company’s decision to examine FDR data from these flights directly addressed the vulnerability of these operations to optimizing violations. During the Safety Board’s public hearing for this accident, the company’s chief pilot stated that the review of FDR data would serve as oversight for Part 91 flights because “the pilots will know that they’re being monitored.” Also, the company’s vice president of safety and regulatory compliance testified, “we want to make sure the aircraft is being operated in non-revenue operations exactly the way it’s being operated in [Part] 121 operations.” During the investigation of this accident, a management pilot from another company with a CRJ fleet stated that “repositioning flights seemed to bring out the worst in their company’s pilots.” This pilot also stated that a review of FDR data from his company’s repositioning flights showed that high bank angles and steep descents occurred often and that pilots were taking the opportunity to perform excessive maneuvers that they could not perform with passengers on board. The Safety Board investigated an April 1993 accident in which an airplane operated by two GP Express Airlines pilots (with no passengers or other crewmembers aboard) crashed during a Part 91 training flight while the pilots were attempting to execute a prohibited aerobatic maneuver at night. The Board determined that the probable causes of that accident included the pilots’ deliberate disregard for company and Federal 124 There were a few exceptions to these favorable comments. For example, the simulator instructor who conducted part of the captain’s upgrade training stated that, in addition to the captain’s problems performing checklists in accordance with company procedures (as discussed in section 2.2.3.1), his biggest weaknesses were his critical decision-making and judgment. Also, the first officer was described as average by the captain who flew with him during his last trip before the accident flight. 125 The Safety Board notes that, during the investigation of the January 1983 takeoff accident at DTW involving United Airlines flight 2885 (a cargo flight), the Board determined that the second officer had occupied the seat of the first officer and conducted the takeoff. The Board also determined that, on the basis of postaccident interviews with United Airlines pilots, seat swapping was not a prevalent practice at the airline. In its final report on this accident, the Board stated its concern about the flight crew’s “disregard of federal and company rules and regulations.” The Board determined that the probable cause of the accident included the flight crew’s failure to follow procedural checklist requirements. Contributing to the cause of the accident was the captain’s decision to allow the second officer, who was not qualified to act as a pilot, to occupy the seat of the first officer and to conduct the takeoff. For more information, see National Transportation Safety Board, United Airlines Flight 2885, Detroit, Michigan, January 11, 1983, N8053U, McDonnell Douglas DC-8-54F, Aircraft Accident Report NTSB/AAR-83/07 (Washington, DC: NTSB, 1983). 126 In October 2006, Pinnacle Airlines stated that it was sampling random Part 91 flights and that a review of these data showed no abnormalities associated with these flights.

Analysis 60 Aircraft Accident Report procedures and the company’s failure to instill in their pilots professionalism that is consistent with the highest levels of safety.127 The circumstances of the Pinnacle Airlines and the GP Express Airlines accidents and the statements of a management pilot from another company with a CRJ fleet demonstrate the opportunity for pilots to behave unprofessionally during Part 91 operations that are conducted without passengers or other crewmembers. Even when protections are in place to mitigate risks during regional airline operations, unprofessional behavior by pilots during Part 91 flights still occurs for multiple reasons, including the perception of a low risk of detection. The airplanes used by regional airlines are lighter, smaller, and more agile than those used by larger air carrier operators, which may increase the potential for unprofessional behavior during Part 91 flights. For regional operators that have the ability to download FDR data, routine monitoring of Part 91 flights can be an effective method to ensure that the flights are conducted according to standard operating procedures. For those operators that do not have the ability to review FDR data from Part 91 flights, alternative methods to mitigate risk include specific guidance to pilots on the expectations of performance for these flights and additional oversight for flight crews conducting the flights. The Safety Board concludes that more scrutiny of regional air carrier pilots during nonrevenue flights would minimize the opportunity for unprofessional behavior to occur. Therefore, the Safety Board believes that the FAA should require regional air carriers operating under 14 CFR Part 121 to provide specific guidance on expectations for professional conduct to pilots who operate nonrevenue flights. The Safety Board further believes that, for those regional air carriers operating under 14 CFR Part 121 that have the capability to review FDR data, the FAA should require that the air carriers review FDR data from nonrevenue flights to verify that the flights are being conducted according to standard operating procedures. 2.4.2 Industrywide Issues In addition to the Pinnacle Airlines accident, the Safety Board has investigated recent accidents involving the lack of cockpit discipline and adherence to standard operating procedures. These accidents include the following: • Corporate Airlines flight 5966, Kirksville, Missouri, October 19, 2004. The flight crew did not follow established procedures for a nonprecision approach at night in instrument meteorological conditions, did not adhere to the 127 National Transportation Safety Board, Controlled Flight Into Terrain, GP Express Airlines, Inc., N115GP, Beechcraft C-99, Shelton, Nebraska, April 28, 1993, Aircraft Accident Report NTSB/AAR-94/01 SUM (Washington, DC: NTSB, 1994).

Analysis 61 Aircraft Accident Report established division of duties between the flying and nonflying pilot, and did not adhere to the sterile cockpit rule.128 • Air Tahoma flight 185, Covington, Kentucky, August 13, 2004. The captain did not follow crossfeed procedures for balancing the fuel in the airplane’s fuel tanks, which led to fuel starvation in the left tank.129 • Executive Airlines flight 5401, San Juan, Puerto Rico, May 9, 2004. The captain failed to execute proper techniques to recover from bounced landings and failed to execute a go-around.130 • Aviation Charter King Air A100, Eveleth, Minnesota, October 25, 2002. The flight crew was not adhering to company approach procedures and was not effectively applying CRM techniques during the approach segment of the flight.131 • Federal Express Flight 1478, Tallahassee, Florida, July 26, 2002. The flight crew failed to adhere to company procedures for flying and monitoring a stabilized approach.132 Pilots and operators have responsibility for a flight crew’s cockpit discipline and adherence to standard operating procedures, as discussed in sections 2.4.2.1 and 2.4.2.2. 2.4.2.1 Pilot Responsibilities The Safety Board has long been concerned about issues of crew professionalism and adherence to standard operating procedures. For example, on October 8, 1974, as a result of several fatal air carrier accidents involving pilot performance (as described in section 1.18.3.2), the Board issued Safety Recommendation A-74-85, which asked the FAA to initiate a movement among pilot associations to form new, and regenerate old, professional standards committees to promote crew discipline and professionalism. (The Safety Board classified Safety Recommendation A-74-85 “Closed—Acceptable Action” on March 10, 1977.) 128 In its final report on this accident, the Safety Board concluded that the pilots’ nonessential conversation below 10,000 feet msl “was contrary to established sterile cockpit regulations and reflected a demeanor and cockpit environment that fostered deviation from established standard procedures, crew resource management discipline, division of duties, and professionalism, reducing the margin of safety well below acceptable limits during the accident approach and likely contributing to the pilots’ degraded performance.” For more information, see NTSB/AAR-06/01. 129 National Transportation Safety Board, Crash During Approach to Landing, Air Tahoma, Inc., Flight 185, Convair 580, N586P, Covington, Kentucky, August 13, 2004, Aircraft Accident Report NTSB/AAR-06/03 (Washington, DC: NTSB, 2006). 130 National Transportation Safety Board, Crash During Landing, Executive Airlines (doing business as American Eagle) Flight 5401, Avions de Transport Regional 72-212, N438AT, San Juan, Puerto Rico, May 9, 2004, Aircraft Accident Report NTSB/AAR-05/02 (Washington, DC: NTSB, 2005). 131 National Transportation Safety Board, Loss of Control and Impact With Terrain, Aviation Charter, Inc., Raytheon (Beechcraft) King Air A100, N41BE, Eveleth, Minnesota, October 25, 2002, Aircraft Accident Report NTSB/AAR-03/03 (Washington, DC: NTSB, 2003). 132 National Transportation Safety Board, Collision With Trees on Final Approach, Federal Express Flight 1478, Boeing 727-232, N497FE, Tallahassee, Florida, July 26, 2002, Aircraft Accident Report NTSB/AAR-04/02 (Washington DC: NTSB, 2004).

Analysis 62 Aircraft Accident Report Most pilot unions have professional standards committees, which are peer consultation programs that are designed to, among other things, provide counseling and support to pilots who have demonstrated behavior that might adversely affect their ability to perform their duties in a professional manner. Trained volunteer pilots who are members of these committees provide peer support, counseling, intervention, and mediation to pilots at the airlines that the unions represent. Airline pilots can seek these services on their own, or they can be referred to the professional standards committee by, for example, company managers who have become aware of a potential problem. Pilot union professional standards committees appear to be an effective structure to help promote and ensure professionalism among pilots. However, not all air carrier pilots have access to these professional standards committees. For those pilots without such access, communications about the importance of professionalism can be delivered through company and FAA personnel. It is clear, on the basis of the overall safety and reliability of the National Airspace System, that most pilots conduct operations with a high degree of professionalism. Nevertheless, a problem still exists in the aviation industry with some pilots acting unprofessionally and not adhering to standard operating procedures, as demonstrated by the recent accidents investigated by the Safety Board that are cited in section 2.4.2. After a series of six accidents between October and November 2004, the FAA issued Notice N8000.296, “Pilot Judgment and Decisionmaking” (see section 1.18.4). The notice, among other things, highlighted the pilot’s role in ensuring safety of flight. Specifically, the notice recommended that individual pilots examine their own decision-making habits in terms of professionalism, thoroughness of preparation, and adherence to standard operating procedures. The FAA stated that it has since incorporated soft skills into Part 121 CRM training requirements and that a rewrite of FAA Order 8400.10, Air Transportation Operations Inspector’s Handbook, would emphasize soft skills. Pilots are ultimately responsible for safely conducting a flight and for recognizing the importance of adhering to standard operating procedures and acting professionally. Although broad, systemwide interventions can be applied to help address the problem of pilots not adhering to standard operating procedures or acting unprofessionally, the most direct intervention is to address any deficiencies in these areas at the level of the pilot. Because pilot unions have expertise in safety, training, and operations and have a vested interest in advancing professional standards among the pilots they represent, these groups are well positioned to take a leadership role to establish new educational approaches for reinforcing professionalism in the aviation industry. The Safety Board concludes that providing additional education to pilots on the importance of professionalism could help reduce the instances of pilots not maintaining cockpit discipline or not adhering to standard operating procedures. Therefore, the Safety Board believes that the FAA should work with pilot associations to develop a specific program of education for all air carrier pilots that addresses professional standards and their role in ensuring safety of flight. The program should include associated guidance information and references to recent

Analysis 63 Aircraft Accident Report accidents involving pilots acting unprofessionally or not following standard operating procedures. 2.4.2.2 Operator Responsibilities Operators also are responsible for monitoring their pilots’ adherence to standard operating procedures and reinforcing expectations for professional standards of behavior. Operators have traditionally identified nonstandard performance in line operations during checkrides or line observations conducted by company check airmen or management personnel. A problem with this method of oversight is that pilots might perform differently during a checkride or a line observation because of the presence of a company check airman in the cockpit. To help evaluate pilot performance during line operations, air carriers can implement voluntary safety programs, such as the FOQA program. This program is especially well suited for detecting exceedances that may occur during flight, such as high bank angles and unstabilized approaches, and assessing whether crews are conducting flights according to standard operating procedures. However, the FOQA program requires equipment and support structures that some air carriers may not be able to maintain, such as the capability to download FDR data. According to the FAA, as of November 2006, 18 air carriers operating under Part 121 had implemented approved FOQA programs. Another FAA-approved, voluntary safety program is the Aviation Safety Action Program (ASAP). This program encourages pilots to report safety concerns in a nonpunitive environment, which allows the air carrier and the FAA to act on this information before an accident or an incident occurs.133 Although an ASAP does not have the technical requirements associated with a FOQA program, an ASAP depends on the willingness of pilots to voluntarily submit reports about other pilots or themselves. The FAA stated that, as of November 2006, it had accepted 51 ASAP memorandums of understanding for pilots.134 (Of these ASAP memorandums of understanding, 49 were for Part 121 operators, and 2 were for Part 135 operators.) In addition to the FOQA program and the ASAP, operators can assess pilot performance during line operations with the Line Operations Safety Audit (LOSA), which was developed in 1994 through FAA-sponsored research, known as the Human Factors Research Project, at the University of Texas at Austin.135 The LOSA program is an observational process that assesses CRM practices, the management of threats to safety, and human error during flight operations. Trained personnel associated with the project conduct line observations under conditions of confidentiality so that the operator is provided only with details of the observations and no information about the pilots who 133 At the time of the June 2005 public hearing, Pinnacle Airlines had committed to establishing an ASAP for its pilots. In October 2006, the company reported that it was operating an FAA-approved ASAP for its pilots. 134 The ASAP also includes dispatchers, flight attendants, and mechanics. Pinnacle Airlines reported that it planned to expand its ASAP to the company’s maintenance department during 2007. 135 For more information, see http://homepage.psy.utexas.edu/homepage/group/HelmreichLAB.

Analysis 64 Aircraft Accident Report were involved. As a result, in contrast to a company line check, LOSA observations do not result in adverse actions against pilots who did not perform well during their observation. LOSA methodology is well suited to assess the soft skills used by air carrier pilots (see section 1.18.4), and the observations can be used to identify intentional deviations from standard operating procedures or prescribed rules and allow the operator to identify reasons for these deviations. Notably, LOSA can address and document these issues to a greater extent than the FOQA program or the ASAP because, as previously stated, FOQA programs require the capability to download FDR data and an ASAP requires the willingness of pilots to submit reports about fellow pilots or themselves.136 Also, LOSA observations have identified rule violations and deviations from procedures, which suggests that the pilots being observed do not view the LOSA observers as a threat (as they might view company check airmen) and would be likely to perform in the same manner as they would without an observer present. After the accident, and as a result of a high initial failure rate for upgrading captains before the accident (see section 1.17.1.6), Pinnacle Airlines made several changes to its training program to address professionalism. These changes included increasing the minimum number of hours (from 10 to 25) that are required for upgrade operational experience, restructuring CRM training to provide additional focus on decision-making and the need to adhere to standard operating procedures, and placing additional emphasis on leadership during upgrade training. However, the effectiveness of these changes in increasing professionalism, leadership, and adherence to standard operating procedures would be difficult to evaluate fully without LOSA observations.137 On April 27, 2006, the FAA issued Advisory Circular (AC) 120-90, Line Operations Safety Audits. The AC provides the rationale and procedures for conducting a LOSA observation at an air carrier and explains that the program is distinct from, but complementary to, the FOQA program and the ASAP. By incorporating LOSA observations into their internal oversight programs, Part 121 air carriers would have another method to monitor their pilots’ adherence to standard operating procedures and standards of professionalism. The Safety Board concludes that LOSA observations can provide operators with increased knowledge about the behavior demonstrated by pilots during line operations. Therefore, the Safety Board believes that the FAA should require that all 14 CFR Part 121 operators incorporate into their oversight programs periodic LOSA observations and methods to address and correct findings resulting from these observations. In addition to the need for air carriers to incorporate LOSA observations into their oversight methods, air carriers need to ensure safety through a formalized system safety 136 Despite these issues, the Safety Board recognizes that the FOQA program and the ASAP provide air carriers with valuable information about the quality of their operations. 137 The LOSA program samples all activities in normal operations, whereas the FOQA program and the ASAP rely on outcomes (flight parameter exceedances and adverse pilot-reported events, respectively) to generate data.

Analysis 65 Aircraft Accident Report process. One such process is a safety management system (SMS) program, which incorporates proactive safety methods for air carriers to identify hazards, mitigate risk, and monitor the extent that the carriers are meeting their objectives. Program components include safety policy, safety risk management, safety assurance, and safety promotion. Tools such as the FOQA, ASAP, and LOSA programs are relevant to the safety assurance component of an SMS program because they provide a direct means for air carriers to evaluate the quality of their training and operations. These tools can also be used in the safety risk management component of an SMS program because they can help uncover hazards to system operation. SMS program initiatives have been developed in the international aviation industry. For example, the European Joint Aviation Authorities recommend, but do not require, air carriers to establish an SMS program. Also, in June 2005, Transport Canada passed regulations requiring that air carriers operating under Canadian Aviation Regulations Part 705 (Part 121 equivalent) fully implement an approved SMS program by September 2008. In addition, International Civil Aviation Organization (ICAO) Annex 6, “Operation of Aircraft,” states the following: “from January 1, 2009, [Member] States shall require, as part of their safety program, that an operator implements a safety management system acceptable to the State of the Operator that, at a minimum: (a) identifies safety hazards; (b) ensures that remedial action necessary to maintain an acceptable level of safety is implemented; (c) provides for continuous monitoring and regular assessment of the safety level achieved; and (d) aims to make continuous improvement to the overall level of safety.”138 In June 2006, the FAA published AC 120-92, “Introduction to Safety Management Systems for Air Operators.” The AC provides guidance for SMS program development for air carriers and others in the aviation industry. The guidance was based on the FAA’s review of existing SMS programs worldwide, its own internal SMS programs, and other system safety approaches. An appendix to the AC contains a listing of functional requirements for operators to use as minimum standards when creating an SMS program. During a December 14, 2006, briefing to the Safety Board, the FAA stated that it intended to comply with the ICAO requirement for Member States to require that operators implement an SMS program by January 1, 2009. A rulemaking project team has been formed, and the rulemaking project team leader stated that the team’s first meeting was held in December 2006. In addition to these initial rulemaking activities, the FAA stated that it planned to initiate a series of SMS proof-of-concept trials in late 2007. During these trials, the FAA intends to work with a few operators that have voluntarily implemented SMS to gather the data needed for additional guidance material and to support the agency’s rulemaking efforts. The Board is encouraged by the FAA’s initial activities to implement an SMS program. However, until the FAA issues a notice of proposed rulemaking, the Board cannot fully evaluate whether the FAA will meet ICAO’s minimum requirements for an SMS program. 138 In November 2005, ICAO asked Member States to provide the organization with information about the development of SMS programs. During 2006, ICAO published a safety management manual that addressed concepts and processes required to implement an SMS program.

Analysis 66 Aircraft Accident Report Historically, the FAA’s approach to its oversight of air carriers has emphasized surveillance to ensure regulatory compliance. However, in 1998, the FAA established the Air Transportation Oversight System (ATOS), a systems safety approach to air carrier oversight. The ATOS program was initially deployed at the 10 largest U.S. air carriers. The benefits of the ATOS program’s system safety approach to air carrier oversight, compared with the oversight conducted as part of the National Work Program Guidelines,139 include a more integrated approach to oversight that better identifies risks to system safety and a more effective allocation of oversight resources to problem areas.140 The Safety Board has previously expressed concerns about the ATOS program. In its March 12, 2001, letter to the FAA about Safety Recommendation A-98-51,141 the Board stated its concern that the FAA had not addressed how the ATOS program would ensure that systemic problems were identified and corrected before they resulted in an accident. As a result, the Board classified Safety Recommendation A-98-51 “Open— Unacceptable Response.” Also, in its report on the Alaska Airlines accident, the Board addressed its concerns about ATOS implementation and the program’s ability to detect problem areas.142 Other concerns about the FAA’s implementation of ATOS have been noted. For example, according to a Government Accountability Office (GAO) report,143 the FAA’s ATOS transition plan, dated March 1, 2004, did not set dates beyond fiscal year 2005 for moving additional air carriers to the ATOS program, and, as of September 2005, 15 air carriers were under the ATOS program. Also, the GAO testified in November 2005 that the National Work Program Guidelines were still being used at those passenger airlines that were not covered under ATOS.144 The FAA acknowledged that staffing and budgetary resources were affecting ATOS deployment. During October 2005, the FAA initiated its System Approach for Safety Oversight CFR Part 121 Pilot Project. The objectives of the project are to revise ATOS so that the program can handle all Part 121 air carriers; provide new policies, processes, and tools for measuring safety; and roll out the latest version of the ATOS program to all Part 121 air carriers by December 31, 2007.145 The FAA stated that 139 The National Work Program Guidelines are part of a traditional inspection program to ensure that airlines comply with safety regulations. The guidelines have been in effect since 1985. 140 To apply some benefits of the system safety approach used in the ATOS program to those air carriers that were not covered by ATOS, the FAA deployed the Surveillance and Evaluation Program during 2002 to augment the oversight conducted as part of the National Work Program Guidelines. 141 This recommendation, which was issued as a result of the Safety Board’s investigation of the August 7, 1997, Fine Airlines flight 101 accident, can be found on the Board’s Web site. 142 National Transportation Safety Board, Loss of Control and Impact With Pacific Ocean, Alaska Airlines Flight 261, McDonnell Douglas MD-83, N963AS, About 2.7 Miles North of Anacapa Island, California, January 31, 2000, Aircraft Accident Report NTSB/AAR-02/01 (Washington, DC: NTSB, 2002). 143 Government Accountability Office, Aviation Safety: System Safety Approach Needs Further Integration Into FAA’s Oversight of Airlines, GAO-05-726 (Washington, DC: GAO, 2005) 144 Government Accountability Office, Aviation Safety: FAA’s Safety Oversight System Is Effective but Could Benefit From Better Evaluation of Its Programs’ Performance, GAO-06-266T (Washington, DC: GAO, 2005).

Analysis 67 Aircraft Accident Report preparations were underway to keep this transition on schedule. Even if this project is completed according to its intended timetable, it will still take time to determine whether ATOS is an effective oversight method. The Safety Board is concerned about the delay in deploying ATOS to additional Part 121 air carriers because they are not receiving the benefits of a system safety approach to oversight.146 Although the ATOS and SMS programs are complementary and are designed to work in an integrated manner, an air carrier does not need to be under ATOS oversight to effectively develop its own SMS program. The FAA’s initial guidance in AC 120-92 should facilitate the process of developing and implementing an SMS program. Existing voluntary system safety tools, such as the FOQA, ASAP, and LOSA programs, have demonstrated their effectiveness in monitoring flight operations and are considered integral safety assurance components to an SMS program, but these programs do not have universal application in the aviation industry. The Safety Board concludes that all air carriers would benefit from SMS programs because they would require the carriers to incorporate formal system safety methods into the carriers’ internal oversight programs. Therefore, the Safety Board believes that the FAA should require that all 14 CFR Part 121 operators establish SMS programs. The Safety Board acknowledges that it may take time for the FAA to complete SMS rulemaking and for air carrier SMS programs to become fully operational. In its review of air carriers with FOQA programs at the end of 2006, the Board found that, besides Pinnacle Airlines, only one other regional air carrier had a FOQA program. (The Board is aware of at least one other regional air carrier that is working toward implementing a FOQA program.) Although system safety tools such as FOQA and ASAP have demonstrated safety benefits, the Board is concerned that these programs are not used more widely by regional air carriers. Because of the limited number of regional air carriers in the lists of approved ASAP and FOQA programs, the Safety Board concludes that the establishment of an ASAP and a FOQA program at regional air carriers would provide the carriers with a means to evaluate the quality of their operations. Therefore, the Safety Board believes that the FAA should strongly encourage and assist all regional air carriers operating under 14 CFR Part 121 to implement an approved ASAP and an approved FOQA program. 145 For more information, see System Approach for Safety Oversight Program Update, dated July 7, 2006, at http://www.faa.gov/safety/programs_initiatives/oversight/saso/update. Also, in December 2006, the FAA stated that 46 air carriers operating under Part 121 were under the ATOS program. 146 The Safety Board notes that some air carriers that are not covered under ATOS, including Pinnacle Airlines, have begun using ATOS job aids and inspection guidelines generated for FAA inspectors in their own internal audit programs.

Analysis 68 Aircraft Accident Report 2.5 Quality of Flight Data Recorder Data for Regional Jet Airplanes On May 16, 2003, the Safety Board issued Safety Recommendation A-03-15 to the FAA because of problems with the quality of FDR data recorded by several regional jet airplanes. Safety Recommendation A-03-15 asked the FAA to do the following: Require that all Embraer 145, Embraer 135, Canadair CL-600 RJ, Canadair Challenger CL-600, and Fairchild Dornier 328-300 airplanes[147] be modified with a digital flight data recorder system that meets the sampling rate, range, and accuracy requirements specified in 14 Code of Federal Regulations Part 121.344, Appendix M. On June 9, 2005, the FAA stated that Embraer had released an SB to correct known FDR anomalies on the Embraer 145 and 135 and that the Brazilian Department of Civil Aviation issued an AD that required incorporation of the Embraer SB within 18 months. The FAA also stated that it planned to release a corresponding AD. In addition, the FAA stated that it was working with Transport Canada to get expeditious action from Bombardier regarding the problem of low update rates on the normal acceleration and pitch attitude parameters for Canadair CL-600-2B19 (CRJ-100, -200, and -440) and CL-600-2B16 (Challenger 604) airplanes. On September 28, 2005, the Safety Board stated that, pending the FAA’s issuance of ADs that mandated correction to the Embraer 145 and 135 and CRJ-100, -200, and -440 and Challenger 604 FDR systems, Safety Recommendation A-03-15 was classified “Open—Acceptable Response.” Since the time of the Pinnacle Airlines accident, the Safety Board has downloaded FDR data from seven events involving CL-600-2B19 airplanes—the most recent of which occurred on August 27, 2006.148 All of these downloads showed that the FDRs recorded the vertical acceleration and pitch parameters from sources that did not meet the recording intervals required by 14 CFR 121.344, Appendix M, as was the case with the FDR installed on the Pinnacle Airlines accident airplane. In November 2006, Bombardier told the Safety Board that production of Challenger 604 airplanes had ceased and that the Challenger 605 model had replaced the Challenger 604 model. Bombardier also stated that the sampling rate problem had been corrected in the FDRs installed on Challenger 605 airplanes. However, the Board notes that Challenger 604 airplanes that are currently in service will still have FDRs with sampling rate problems. Bombardier further stated that, for FDRs installed on CRJ-100, -200, and -440 airplanes, the sampling rate problem would be corrected during the next applicable digital 147 As stated in section 1.18.3.3, on September 28, 2005, the Safety Board stated that no problems existed with the FDR parameters on the Fairchild Dornier 328-300 airplane. 148 This FDR was installed aboard the Comair Airlines flight 5191 accident airplane, which crashed in Lexington, Kentucky, after the pilots attempted to take off from the wrong runway. For information about this accident, see DCA06MA064 at the Safety Board’s Web site at http://www.ntsb.gov.

Analysis 69 Aircraft Accident Report control unit update, which was scheduled for the second or third quarter of 2007, and that airplanes would be retrofitted within the 18 months that followed. Thus, if this schedule were maintained, the sampling rate problem would not be fixed on all CL-600-2B19 airplanes until late 2008 or early 2009. Also, as of December 1, 2006, the FAA had not issued an AD to correct FDR anomalies on Embraer 145 and 135 airplanes. The Safety Board concludes that the parameter quality problems with the FDR systems installed on Canadair CL-600-2B19, Challenger 604, and Embraer 145 and 135 airplanes need to be corrected so that future investigations involving these airplane models are not hindered by inaccurate or incomplete data. Therefore, the Safety Board reiterates Safety Recommendation A-03-15. Further, the Board classifies Safety Recommendation A-03-15 “Open—Unacceptable Response.”

70 Aircraft Accident Report 3. Conclusions 3.1 Findings 1. The captain and the first officer were properly certificated and qualified under Federal regulations. No evidence indicated any medical or behavioral conditions that might have adversely affected their performance during the accident flight. Flight crew fatigue and hypoxia were not factors in this accident. 2. The accident airplane was properly certified, equipped, and maintained in accordance with Federal regulations. The recovered components showed no evidence of any structural or system failures or any engine failures before the time of the upset event. 3. Weather was not a factor in this accident. 4. The accident was not survivable. 5. The pilots’ aggressive pitch-up and yaw maneuvers during the ascent and their decision to operate the airplane at its maximum operating altitude (41,000 feet) were made for personal and not operational reasons. 6. The flight crew’s inappropriate use of the vertical speed mode during the climb was a misuse of automation that allowed the airplane to reach 41,000 feet in a critically low energy state. 7. The improper airspeed during the climb demonstrated that the pilots did not understand how airspeed affects airplane performance and did not realize the importance of conducting the climb according to the published climb capability charts. 8. The upset event exposed both engines to inlet airflow disruption conditions that led to engine stalls and a complete loss of engine power. 9. The pilots’ lack of exposure to high altitude stall recovery techniques contributed to their inappropriate flight control inputs during the upset event.

1. The captain did not take the necessary steps to ensure that the first officer achieved

the 300-knot or greater airspeed required for the windmill engine restart procedure and then did not demonstrate command authority by taking control of the airplane and accelerating it to at least 300 knots.

Conclusions 71 Aircraft Accident Report

1. The first officer’s limited experience in the airplane might have contributed to the

failed windmill restart attempt because he might have been reluctant to command the degree of nose-down attitude that was required to increase the airplane’s airspeed to 300 knots.

1. Despite their four auxiliary power unit-assisted engine restart attempts, the pilots

were unable to restart the engines because their cores had locked. Without core rotation, recovery from the double engine failure was not possible.

1. The General Electric CF34-1 and CF34-3 engines had a history of failing to rotate

during in-flight restart attempts on airplanes undergoing production acceptance testing at Bombardier.

1. Both engines experienced core lock because of the flameout from high power and

high altitude, which resulted from the pilot-induced extreme conditions to which the engines were exposed, and the pilots’ failure to achieve and maintain the target airspeed of 240 knots, which caused the engine cores to stop rotating; both of these factors were causal to this accident.

1. The importance of maintaining a minimum airspeed to keep the engine cores rotating

was not communicated to the pilots in airplane flight manuals.

1. The captain’s previous difficulties in checklist management, the situational stress, and

the lack of simulator training involving a double engine failure contributed to the flight crew’s errors in performing the double engine failure checklist.

1. The pilots’ failure to prepare for an emergency landing in a timely manner, including

communicating with air traffic controllers immediately after the emergency about the loss of both engines and the availability of landing sites, was a result of their intentional noncompliance with standard operating procedures, and this failure was causal to the accident.

1. The pilots’ unprofessional operation of the flight was intentional and causal to this

accident because the pilots’ actions led directly to the upset and their improper reaction to the resulting in-flight emergency exacerbated the situation to the point that they were unable to recover the airplane.

1. Revised high altitude training syllabuses for pilots who operate regional jet airplanes

would help ensure that these pilots possess a thorough understanding of the airplanes’ performance capabilities, limitations, and high altitude aerodynamics.

1. Because most training for stalls occurs with the airplane at low altitudes, the training

methods may introduce a bias in stall recovery techniques by encouraging pilots to minimize altitude loss and not fully recognizing other available recovery techniques.

Conclusions 72 Aircraft Accident Report

1. Additional training might improve pilot response to stickpusher activation, but such

training, if not provided correctly, could have an adverse impact on existing stall recognition and recovery protocols.

1. Some of the changes made by Pinnacle Airlines to its double engine failure training

and checklist guidance would benefit pilots at other air carriers that operate the Canadair regional jet because such training would provide pilots with the opportunity to practice double engine failure restart procedures in the simulator and the guidance would ensure that pilots were aware of the minimum airspeeds needed during the procedures.

1. More scrutiny of regional air carrier pilots during nonrevenue flights would minimize

the opportunity for unprofessional behavior to occur.

1. Providing additional education to pilots on the importance of professionalism could

help reduce the instances of pilots not maintaining cockpit discipline or not adhering to standard operating procedures.

1. Line Operations Safety Audit observations can provide operators with increased

knowledge about the behavior demonstrated by pilots during line operations.

1. All air carriers would benefit from Safety Management System programs because

they would require the carriers to incorporate formal system safety methods into the carriers’ internal oversight programs.

1. The establishment of an Aviation Safety Action Program and a Flight Operational

Quality Assurance program at regional air carriers would provide the carriers with a means to evaluate the quality of their operations.

1. The parameter quality problems with the flight data recorder systems installed on

Canadair CL-600-2B19, Challenger 604, and Embraer 145 and 135 airplanes need to be corrected so that future investigations involving these airplane models are not hindered by inaccurate or incomplete data.

Conclusions 73 Aircraft Accident Report 3.2 Probable Cause The National Transportation Safety Board determines that the probable causes of this accident were (1) the pilots’ unprofessional behavior, deviation from standard operating procedures, and poor airmanship, which resulted in an in-flight emergency from which they were unable to recover, in part because of the pilots’ inadequate training; (2) the pilots’ failure to prepare for an emergency landing in a timely manner, including communicating with air traffic controllers immediately after the emergency about the loss of both engines and the availability of landing sites; and (3) the pilots’ improper management of the double engine failure checklist, which allowed the engine cores to stop rotating and resulted in the core lock engine condition. Contributing to this accident were (1) the core lock engine condition, which prevented at least one engine from being restarted, and (2) the airplane flight manuals that did not communicate to pilots the importance of maintaining a minimum airspeed to keep the engine cores rotating.

74 Aircraft Accident Report 4. Safety Recommendations 4.1 New Recommendations As a result of the investigation of this accident, the National Transportation Safety Board makes the following recommendations to the Federal Aviation Administration: Work with members of the aviation industry to enhance the training syllabuses for pilots conducting high altitude operations in regional jet airplanes. The syllabuses should include methods to ensure that these pilots possess a thorough understanding of the airplanes’ performance capabilities, limitations, and high altitude aerodynamics. (A-07-1) Determine whether the changes to be made to the high altitude training syllabuses for regional jet airplanes, as requested in Safety Recommendation A-07-1, would also enhance the high altitude training syllabuses for all other transport-category jet airplanes and, if so, require that these changes be incorporated into the syllabuses for those airplanes. (A-07-2) Require that air carriers provide their pilots with opportunities to practice high altitude stall recovery techniques in the simulator during which time the pilots demonstrate their ability to identify and execute the appropriate recovery technique. (A-07-3) Convene a multidisciplinary panel of operational, training, and human factors specialists to study and submit a report on methods to improve flight crew familiarity with and response to stickpusher systems and, if warranted, establish training requirements for stickpusher-equipped airplanes based on the findings of this panel. (A-07-4) Verify that all Canadair regional jet operators incorporate guidance in their double engine failure checklist that clearly states the airspeeds required during the procedure and require the operators to provide pilots with simulator training on executing this checklist. (A-07-5) Require regional air carriers operating under 14 Code of Federal Regulations Part 121 to provide specific guidance on expectations for professional conduct to pilots who operate nonrevenue flights. (A-07-6)

Safety Recommendations 75 Aircraft Accident Report For those regional air carriers operating under 14 Code of Federal Regulations Part 121 that have the capability to review flight data recorder (FDR) data, require that the air carriers review FDR data from nonrevenue flights to verify that the flights are being conducted according to standard operating procedures. (A-07-7) Work with pilot associations to develop a specific program of education for air carrier pilots that addresses professional standards and their role in ensuring safety of flight. The program should include associated guidance information and references to recent accidents involving pilots acting unprofessionally or not following standard operating procedures. (A-07-8) Require that all 14 Code of Federal Regulations Part 121 operators incorporate into their oversight programs periodic Line Operations Safety Audit observations and methods to address and correct findings resulting from these observations. (A-07-9) Require that all 14 Code of Federal Regulations Part 121 operators establish Safety Management System programs. (A-07-10) Strongly encourage and assist all regional air carriers operating under 14 Code of Federal Regulations Part 121 to implement an approved Aviation Safety Action Program and an approved Flight Operational Quality Assurance program. (A-07-11) 4.2 Previously Issued Recommendation Reiterated and Classified in This Report The Safety Board reiterates the following recommendation to the Federal Aviation Administration: Require that all Embraer 145, Embraer 135, Canadair CL-600 RJ, Canadair Challenger CL-600, and Fairchild Dornier 328-300 airplanes be modified with a digital flight data recorder system that meets the sampling rate, range, and accuracy requirements specified in 14 Code of Federal Regulations Part 121.344, Appendix M. (A-03-15) Further, Safety Recommendation A-03-15 (previously classified “Open— Acceptable Response”) is classified “Open—Unacceptable Response” in section 2.5 of this report. For information about this recommendation, see sections 1.18.3.3 and 2.5 of this report.

Safety Recommendations 76 Aircraft Accident Report 4.3 Previously Issued Recommendations Resulting From This Accident Investigation As a result of the investigation into this accident, the Safety Board issued the following recommendations to the Federal Aviation Administration on November 20, 2006: For airplanes equipped with CF34-1 or CF34-3 engines, require manufacturers to perform high power, high altitude sudden engine shutdowns; determine the minimum airspeed required to maintain sufficient core rotation; and demonstrate that all methods of in-flight restart can be accomplished when this airspeed is maintained. (A-06-70) Ensure that airplane flight manuals of airplanes equipped with CF34-1 or CF34-3 engines clearly state the minimum airspeed required for engine core rotation and that, if this airspeed is not maintained after a high power, high altitude sudden engine shutdown, a loss of in-flight restart capability as a result of core lock may occur. (A-06-71) Require that operators of CRJ-100, -200, and -440 airplanes include in airplane flight manuals the significant performance penalties, such as loss of glide distance and increased descent rate, that can be incurred from maintaining the minimum airspeed required for core rotation and windmill restart attempts. (A-06-72) Review the design of turbine-powered engines (other than the CF34-1 and CF34-3, which are addressed in Safety Recommendation A-06-70) to determine whether they are susceptible to core lock and, for those engines so identified, require manufacturers of airplanes equipped with these engines to perform high power, high altitude sudden engine shutdowns and determine the minimum airspeed to maintain sufficient core rotation so that all methods of in-flight restart can be accomplished. (A-06-73) For those airplanes with engines that are found to be susceptible to core lock (other than the CF34-1 and CF34-3, which are addressed in Safety Recommendation A-06-71), require airplane manufacturers to incorporate information into airplane flight manuals that clearly states the potential for core lock; the procedures, including the minimum airspeed required, to prevent this condition from occurring after a sudden engine shutdown; and the resulting loss of in-flight restart capability if this condition were to occur. (A-06-74)

Safety Recommendations 77 Aircraft Accident Report Require manufacturers to determine, as part of 14 Code of Federal Regulations Part 25 certification tests, if restart capability exists from a core rotation speed of 0 indicated rpm after high power, high altitude sudden engine shutdowns. For those airplanes determined to be susceptible to core lock, mitigate the hazard by providing design or operational means to ensure restart capability. (A-06-75) Establish certification requirements that would place upper limits on the value of the minimum airspeed required and the amount of altitude loss permitted for windmill restarts. (A-06-76) For additional information about these recommendations, see section 1.18.3.1 of this report. BY THE NATIONAL TRANSPORTATION SAFETY BOARD MARK V. ROSENKER Chairman ROBERT L. SUMWALT Vice Chairman DEBORAH A. P. HERSMAN Member KATHRYN O. HIGGINS Member STEVEN R. CHEALANDER Member Adopted: January 9, 2007

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79 Aircraft Accident Report 5. Appendixes Appendix A Investigation and Hearing Investigation The National Transportation Safety Board was initially notified of this accident on October 14, 2004, after air traffic controllers lost contact with the airplane. A go-team was assembled and departed for Jefferson City, Missouri, on the morning of October 15, 2004, and arrived on scene later that day. Accompanying the team to Jefferson City was former Member Carol Carmody. The following investigative teams were formed: Aircraft Operations, Human Performance, Aircraft Structures, Aircraft Systems, Powerplants, Air Traffic Control, Meteorology, Aircraft Performance, Maintenance Records, Cockpit Voice Recorder, and Flight Data Recorder. While the investigative team was in Jefferson City, specialists were assigned to conduct the readout of the flight data recorder and transcribe the recording from the cockpit voice recorder at the Safety Board’s laboratory in Washington, D.C. Parties to the investigation were the Federal Aviation Administration (FAA), Pinnacle Airlines, the Air Line Pilots Association (ALPA), the National Air Traffic Controllers Association, General Electric (GE) Engines, Honeywell, Hamilton Sunstrand, and Rockwell Collins. In accordance with the provisions of Annex 13 to the Convention on International Civil Aviation, the Transportation Safety Board of Canada (the Safety Board’s counterpart agency in Canada) participated in the investigation as the representative of the State of Design and Manufacture. Transport Canada and Bombardier Aerospace participated in the investigation as technical advisors to the Transportation Safety Board of Canada, as provided in Annex 13. Public Hearing A public hearing was held from June 13 to 15, 2005, in Washington, D.C. Member Deborah A.P. Hersman presided over the hearing. The issues discussed at the public hearing were aircraft and engine certification and operator and FAA oversight of flight operations and flight crew training. Parties to the public hearing were the FAA, Pinnacle Airlines, ALPA, Bombardier Aerospace, GE Engines, and Honeywell.

80 Aircraft Accident Report Appendix B Cockpit Voice Recorder The following is the transcript of the Fairchild A100S cockpit voice recorder, serial number 02804, installed on Pinnacle Airlines flight 3701, a Bombardier CL-600- 2B19, N8396A, which crashed in Jefferson City, Missouri, on October 14, 2004.

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143 Aircraft Accident Report Appendix C Pinnacle Airlines’ Double Engine Failure Checklist at the Time of the Accident

Appendix C 144 Aircraft Accident Report

Appendix C 145 Aircraft Accident Report

Appendix C 146 Aircraft Accident Report

Appendix C 147 Aircraft Accident Report

Appendix C 148 Aircraft Accident Report

149 Aircraft Accident Report Appendix D Pinnacle Airlines’ Revised Double Engine Failure Checklist REVISION 8—MAY 31, 2005 EP 1-5 POWERPLANT EMERGENCIES QUICK REFERENCE HANDBOOK Pinnacle Airlines Northwest Airlink CANADAIR REGIONAL JET CAUTION Failure to maintain positive N2 may preclude a suc- cessful relight. If required, increase airspeed to main- tain N2 indication. 6. Oxygen Masks (if required)................................................... DON 7. Proceed to nearest suitable airport in preparation for a possible dead- stick landing. 8. APU (below 30,000 feet)................................................... START 9. APU GEN (if APU available)................................................... ON Windmilling relight possible (requires airspeed of not less than 300 KIAS): (From 21,000 feet or below) 9. Relight Using Windmilling Procedure (See Page EP 1-6) ................................................. ACCOMPLISH Maintain 240 KIAS until ready to initiate windmill start. (From 13,000 feet and below) 9. Relight Using APU Bleed Air Procedure (See Page EP 1-8))................................................ ACCOMPLISH Maintain between 190 KIAS (51,000 pounds) and 170 KIAS ( 36,000 pounds). — CONTINUED — Double Engine Failure 1. CONT IGNITION.................................................................... ON If engines continue to run down: 2. Thrust Levers (both).................................................... SHUT OFF 3. ADG Manual Deploy Handle............................................... PULL When ADG power is established: 4. STAB TRIM CH 2.......................................................... ENGAGE 5. Minimum Airspeed.................................................... ESTABLISH AIRPLANE FLIGHT LEVEL MINIMUM AIRSPEED ABOVE FL 340 0.7 MACH BELOW FL 340 240 KIAS Maintain airspeed until ready to restart engines. NO YES ?

Appendix D 150 Aircraft Accident Report EP 1-6 REVISION 8—MAY 31, 2005 POWERPLANT EMERGENCIES QUICK REFERENCE HANDBOOK Pinnacle Airlines Northwest Airlink CANADAIR REGIONAL JET NOTE NOTE An altitude loss of approximately 5,000 feet can be expected when accelerating from 240 to 300 KIAS and may require pitch attitudes of 10° nose down. If possible, crews should start accelerating to achieve 300 KIAS upon reaching 21,000 feet. Attempt to start both engines at the same time: 1. Airspeed................ ACCELERATE TO 300 KIAS OR GREATER CAUTION 300 KIAS or greater is required to achieve sufficient N2 for start. Airspeed must be maintained until at least one engine relights (stable idle) or start attempts abandoned. At 21,000 feet and below: 2. CONT IGNITION ................................................. CONFIRM ON 3. L and R FUEL BOOST PUMP Switches..................................................... CONFIRM ON When ITT is 90°C or less and N2 is:

●At least 12% (above 15,000 feet) or

●At least 9% (15,000 feet and below): 4. Thrust Levers (both) .............................................................. IDLE 5. Engine Indications....................................................... MONITOR At least one engine relights within 25 seconds: 1. Thrust Lever(s) .................................................... AS REQUIRED 2. Affected GEN............................................................. CHECK ON Operative engine: 3. L AND/OR R 10th STAGE BLEED(s) ................. CHECK OPEN 4. Applicable PACK(s) ................................................... CHECK ON Reestablish normal power: 5. ADG Manual Deploy Handle.............................................. STOW 6. ADG PWR TXFR....................................................... OVERRIDE 7. Single Engine Procedures (See Page AP 1-2)................................................. ACCOMPLISH IF REQUIRED —END— 6. Thrust Levers................................................................ SHUTOFF — CONTINUED — Double Engine Failure (Cont) Relight using windmilling: NO YES ?

Appendix D 151 Aircraft Accident Report AUGUST 1, 2002 EP 1-7 POWERPLANT EMERGENCIES QUICK REFERENCE HANDBOOK Pinnacle Airlines Northwest Airlink CANADAIR REGIONAL JET Another windmilling relight attempt still possible: 7. Airspeed............................................................ 300 TO 335 KIAS 8. Wait 30 seconds, then repeat relight procedure. 7. Relight using APU bleed air. — CONTINUED — Double Engine Failure (Cont) Relight using windmilling: NO YES ?

Appendix D 152 Aircraft Accident Report EP 1-8 REVISION 8—MAY 31, 2005 POWERPLANT EMERGENCIES QUICK REFERENCE HANDBOOK Pinnacle Airlines Northwest Airlink CANADAIR REGIONAL JET From 13,000 feet and below: 1. Target airspeed...................................................... REESTABLISH AIRPLANE WEIGHT TARGET BEST GLIDE SPEED 51,000 lb 190 KIAS 36,000 lb 170 KIAS 2. CONT IGNITION ................................................. CONFIRM ON 3. L and R FUEL BOOST PUMP Switches............. CONFIRM ON 4. ANTI-ICE, WING and COWL Switches ....................... ALL OFF 5. L and R 10th STAGE BLEED Switches ......... SELECT CLOSED 6. APU LCV Switch................................................. SELECT OPEN Attempt to start one engine at a time: 7. L or R ENG START ............................................................. PUSH When N2 is 28% or greater and ITT is 90°C or less: 8. Thrust Lever .......................................................................... IDLE 9. Engine Indications....................................................... MONITOR Engine relights (within 25 seconds): 1. Thrust Lever ......................................................... AS REQUIRED 2. Operative GEN .......................................................... CHECK ON Operative engine: 3. Applicable 10TH STAGE BLEED........................ CHECK OPEN 4. Applicable PACK ....................................................... CHECK ON Reestablish normal power: 5. ADG Manual Deploy Handle.............................................. STOW 6. ADG PWR TXFR....................................................... OVERRIDE 7. Single Engine Procedures (See Page AP 1-2)................................................. ACCOMPLISH — END — 8. Affected Engine, Thrust Lever ..................................... SHUTOFF 9. Affected ENG STOP ............................................................ PUSH 10. Attempt relight on other engine. — CONTINUED — Double Engine Failure (Cont) Relight usingAPU bleed air: NO Neither engine is restarted: YES ?

Appendix D 153 Aircraft Accident Report REVISION 8—MAY 31, 2005 EP 1-9 POWERPLANT EMERGENCIES QUICK REFERENCE HANDBOOK Pinnacle Airlines Northwest Airlink CANADAIR REGIONAL JET 1. Consider a forced landing or ditching. Notify cabin crew. 2. Thrust Levers (both) ..................................................... SHUTOFF 3. Target airspeed..................................................... REESTABLISH AIRPLANE WEIGHT TARGET BEST GLIDE SPEED 51,000 lb 190 KIAS 36,000 lb 170 KIAS 4. Prepare for a forced landing or ditching (See Page EP 7-2). — — — END — — — Double Engine Failure (Cont) Neither engine is restarted:

154 Aircraft Accident Report Appendix E Core Lock Safety Recommendation Letter E P L U R IB US UN U M N A T I O N A L T R A S P O R T A T I O N B O A R D S A FE T Y N National Transportation Safety Board Washington, D.C. 20594 Safety Recommendation Date: November 20, 2006 In reply refer to: A-06-70 through -76 Honorable Marion C. Blakey Administrator

Federal Aviation Administration Washington, DC 20591 On October 14, 2004, Pinnacle Airlines flight 3701 (doing business as Northwest Airlink), N8396A, a Bombardier CL-600-2B191 equipped with General Electric (GE) CF34-3 turbofan engines, crashed into a residential area about 2.5 miles south of Jefferson City Memorial Airport (JEF), Jefferson City, Missouri. The airplane was on a repositioning flight2 from Little Rock National Airport, Little Rock, Arkansas, to Minneapolis-St. Paul International Airport, Minneapolis, Minnesota. The captain and the first officer were killed, and the airplane was destroyed. No one on the ground was injured. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 91 on an instrument flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident. The accident flight crew decided to climb to the airplane’s maximum operating altitude of 41,000 feet.3 The airplane arrived at 41,000 feet at less than its best rate of climb speed and slowed to its stall speed. An aerodynamic stall followed, which resulted in a loss of control of the airplane. The flight data recorder (FDR) and the cockpit voice recorder (CVR) indicated that the engines were operating normally before the upset. The flight crew recovered the airplane from the upset at an altitude of 34,000 feet. However, during the upset, the airflow to the engine inlets was disrupted, and both engines flamed out.4 The rotation speed of both engines’ cores (N2) continued to decrease.5 Before the airplane descended to an altitude of 28,000 feet, the core 1 The accident airplane was a Canadair regional jet (CRJ) -200 model, which is one of three models in the CL-600-2B19 series. (The other two models are the CRJ-100 and CRJ-440.) Bombardier acquired Canadair in December 1986. 2 A repositioning flight relocates an airplane to the airport where the airplane’s next flight is scheduled. Repositioning flights do not carry passengers or cargo. 3 A maximum operating altitude is the maximum density altitude at which the best rate of climb airspeed will produce a 100-feet-per-minute (fpm) climb at maximum weight, while in a clean configuration, and with maximum continuous power. For the CRJ-200, the maximum operating altitude represents the maximum capability of the airplane; the actual climb capability will primarily depend on airspeed, weight, and ambient temperature. The accident airplane was not at maximum weight and was capable of climbing at a rate greater than 100 fpm while at an altitude of 41,000 feet if the airspeed had been maintained at Mach 0.7 during the climb and at altitude. 4 A flameout is an interruption of a turbine engine’s combustion process that results in an uncommanded engine shutdown. 5 A turbine engine gas generator section is commonly referred to as the core. 7695A

Appendix E 155 Aircraft Accident Report 2 rotation speed of both engines had reached 0 indicated rpm. The flight crew attempted to restart the engines several times but was unable to do so. The flight crew then attempted to make an emergency landing at JEF, but the airplane crashed before reaching the airport.6 This accident is still under investigation, and the National Transportation Safety Board has not yet determined the probable cause of the accident. Nonetheless, the investigation has revealed a safety issue regarding a condition that can preclude pilots from restarting an engine after a double engine failure. Restart Attempts for Accident Engines Pinnacle Airlines’ double engine failure checklist at the time of the accident indicated that pilots were to maintain a target airspeed of 240 knots.7 The purpose of maintaining this airspeed was to keep the engine cores rotating at an appropriate speed for either a windmill restart8 or an auxiliary power unit (APU)-assisted restart.9 FDR data and the CVR recording showed that the flight crew did not accelerate the airplane after the upset and that the engine core rotation slowed to 0 indicated rpm. FDR data also showed that the crew did not achieve the 240-knot airspeed before or after attempting to restart the engines. The flight crew first attempted to restart the engines using the windmill restart procedure. A windmill restart requires accelerating the airplane to an airspeed of at least 300 knots to increase the core rotation speed before the attempted restart. FDR data showed that the crew did not achieve the 300-knot airspeed (the maximum airspeed recorded by the FDR was 236 knots) and that the engine cores remained at 0 indicated rpm during the restart attempt. The CVR recording indicated that the flight crewmembers then elected to descend to an altitude of 13,000 feet so that they could attempt to restart the engines using the APU-assisted restart procedure, which requires slowing the airplane to 170 or 190 knots (depending on the airplane’s weight) before initiating the restart. Once the airplane descended to an altitude of 13,000 feet, the flight crew attempted four APU-assisted engine restarts (two attempts per engine), but FDR data showed that the engine cores still remained at 0 indicated rpm. The accident airplane’s APU and start system components were found mostly intact at the accident scene. Examination and testing of these components found nothing that would have prevented adequate torque from being delivered to the engines for the restart attempts. Engine disassembly inspections found no mechanical failures or evidence of any condition that would have prevented engine core rotation. Although the inspections disclosed thermal damage in the No. 2 engine that would have impeded the engine’s ability to produce thrust, this damage would not have prevented core rotation during an attempted restart.10 6 For more information about this accident, see DCA05MA003 at the Safety Board’s Web site at http://www.ntsb.gov. 7 All airspeeds cited in this letter are knots indicated airspeed. 8 A windmill restart is an emergency in-flight procedure in which the effect of ram airflow passing through the engine as the airplane moves through the air provides rotational energy to turn the core. 9 Pinnacle Airlines’ double engine failure checklist indicated that the windmill restart procedure was to be used at altitudes from 21,000 to 13,000 feet and that the APU-assisted restart procedure was to be used at altitudes of 13,000 feet and below. 10 The inspections found no preimpact damage to the No. 1 engine.

Appendix E 156 Aircraft Accident Report 3 Manufacturer’s Core Lock Screening Procedure During the accident investigation, the Safety Board learned that GE CF34-1 and CF34-3 engines11 had a history of failing to rotate during in-flight restart attempts on airplanes undergoing production acceptance flight testing at Bombardier. The manufacturers referred to this condition as “core lock.” Bombardier first identified this problem in 1983 during Challenger certification tests, and GE attributed the problem to interference contact at a high pressure turbine (HPT) air seal. The CF34 HPT air seals are designed to control cooling and balance airflow. The seals include teeth on the rotating components that grind operating grooves into abradable surfaces on the stationary components. The efficiency of these seals significantly affects engine performance, so the seals are designed to operate with minimal clearances. Bombardier added a procedure to the production acceptance flight tests for its CF34-1- and CF34-3-powered airplanes to screen engines for the potential to experience core lock. At the time of the accident, this screening procedure was as follows:

1. Climb to flight level 310.
2. Retard the test engine throttle to idle and stabilize for 5 minutes.
3. Shut down the test engine.
4. Descend at 190 knots.
5. Slow the aircraft until N2 is reduced to 0 percent.
6. At 8 1/2 minutes from shutdown, push over to 320 knots.
7. If N2 is 0 rpm at flight level 210, the engine is declared to be core locked.

Engines that are found to be core locked are reworked using an in-flight “grind-in” procedure that was designed to remove seal material at the interference location.12 Engines that undergo grind-in rework are then rescreened for core lock. The grind-in procedure, which includes a cross-bleed start for the core locked engine, is as follows:

1. Air turbine starter cross-bleed start.
2. Ascend to flight level 310.
3. Repeat core lock screening procedure but descend at an airspeed of about 240 knots

to establish 4 percent N2.

1. Maintain 4 percent N2 for at least 8 1/2 minutes.
2. Confirm that no core lock exists by repeating screening procedure.

As testimony during the Safety Board’s June 2005 public hearing on the Pinnacle Airlines accident indicated, neither Bombardier nor GE considered core lock to be a safety-of-flight issue. The manufacturers claimed that engines that passed the screening procedure, with or without grind-in rework, would not core lock as long as the 240-knot airspeed was maintained. 11 Bombardier airplanes that are powered by either GE CF34-1 or CF34-3 engine models are the Challenger 601, Challenger 604, CRJ-100, CRJ-200, and CRJ-440. 12 Newly manufactured engines undergo a test cell seal grind-in before delivery.

Appendix E 157 Aircraft Accident Report 4 Turbine Engine Shutdowns The operating temperatures in parts of the HPT reach more than 2,000q Fahrenheit. After a turbine engine has been operating, its rotating and stationary components have expanded to their normal operating dimensions and clearances. When an engine is shut down, its rotating and stationary components do not contract at the same rates because of differences in their material properties and their exposure to cooling air. Temporary losses of clearance between the rotating and stationary components and misalignment between the rotating teeth and stationary grooves of the air seal occur until the temperatures of the components reach equilibrium. Because of this characteristic, turbine engine shutdown procedures include operation for several minutes at a lower power setting to permit internal temperatures and clearances to stabilize. Engines that flame out suddenly in flight experience more severe thermal changes that may result in losses of clearance so that the rotating and stationary components rub or bind. More importantly, flameouts at high power and high altitude conditions produce even greater thermal distress because internal temperatures are the hottest at high power settings and the air is colder at high altitudes. The increased thermal shock exacerbates the loss of component clearance and alignment. Because the accident engines flamed out under these conditions, axial misalignment caused the seal teeth, which were positioned aft of their normal grooves, to contact stationary abradable material when radial seal clearances closed down. Once core rotation stopped, binding prevented core rotation from resuming during the windmill or APU-assisted restart attempts. Thus, the lack of core rotation on the accident airplane engines could be explained by the core lock phenomenon. Potential for Core Lock in CF34-1 and CF34-3 Engines Bombardier’s core lock screening procedure requires a cool-down period before engine shutdown to stabilize internal temperatures and clearances.13 However, as previously discussed, this procedure does not produce the more severe thermal distress associated with the high power, high altitude flameouts that occurred during the accident flight. Thus, the successful demonstration of Bombardier’s production flight test procedure may not ensure that an engine will not experience core lock if the core is allowed to stop rotating after a high power, high altitude flameout. In fact, the Safety Board notes that the No. 1 accident engine had successfully passed the screening procedure during initial production acceptance testing.14 Also, the successful demonstration of Bombardier’s production flight test procedure may not ensure that slowing the airplane to an airspeed of 170 to 190 knots is sufficient to maintain core rotation during an attempted APU-assisted restart. During the public hearing for the Pinnacle Airlines accident, a GE manager testified, “As long as core rotation is maintained, you will not have core lock … we have a body of data 13 After the accident, Transport Canada mandated that Bombardier change the engine stabilization time from 5 to 2 minutes. 14 The No. 2 accident engine was installed new as a spare engine and was not subject to the the core lock screening procedure because it applies only to engines that are installed in Bombardier’s production airplanes.

Appendix E 158 Aircraft Accident Report 5 that shows that 240 knots maintains core rotation.”15 This testimony suggests that the most effective way to mitigate the safety risk of core lock during in-flight restarts is to use an operational procedure to keep an engine’s core rotating until a restart can be attempted. The Safety Board is unaware of flight test data that demonstrate that 240 knots is sufficient to keep the core rotating after the more severe thermal distress associated with a high power, high altitude flameout. Thus, the Board is concerned that sufficient testing and engineering analysis have not been performed to demonstrate whether the 240-knot airspeed is effective in maintaining core rotation and preventing core lock after high power, high altitude flameouts. The Safety Board concludes that it is critical to identify the airspeed needed to maintain core rotation in CF34-1 and CF34-3 engines after high power, high altitude flameouts and to ensure that restart procedures can be accomplished under such conditions. Therefore, the Safety Board believes that, for airplanes equipped with CF34-1 or CF34-3 engines, the Federal Aviation Administration (FAA) should require manufacturers to perform high power, high altitude sudden engine shutdowns; determine the minimum airspeed required to maintain sufficient core rotation; and demonstrate that all methods of in-flight restart can be accomplished when this airspeed is maintained.16 The importance of maintaining a minimum airspeed to keep the engine cores rotating was not communicated to pilots in airplane flight manuals (AFM). For example, at the time of the accident, Bombardier’s and Pinnacle Airlines’ double engine failure checklists stated that 240 knots was the “target” airspeed for the procedure but did not indicate that this airspeed was essential to the success of the restart procedure. As a result of the accident, Bombardier and Pinnacle Airlines revised their double engine failure checklists to indicate that 240 knots was the “minimum” airspeed and that the failure to maintain positive core rotation might prevent a successful restart.

The Safety Board concludes that it is important for pilots to be aware of the possibility of core lock and the specific actions that are needed to preclude this condition. Therefore, the Safety Board believes that the FAA should ensure that AFMs of airplanes equipped with CF34-1 or CF34-3 engines clearly state the minimum airspeed required for engine core rotation and that, if this airspeed is not maintained after a high power, high altitude sudden engine shutdown, a loss of in-flight restart capability as a result of core lock may occur. Performance Penalties for CRJ-100, -200 and -440 Airplanes The 240-knot airspeed included in Bombardier’s and Pinnacle Airlines’ double engine failure checklists is 70 knots greater than the airplane’s best glide speed17 (at an airplane weight of 36,000 pounds) of 170 knots. To maintain the 240-knot airspeed with no engine power and 15 The GE manager further testified that the 240-knot airspeed also served to maintain a minimal hydraulic pressure. 16 The Safety Board notes that Bombardier Aerospace and Transport Canada have performed high altitude, high power engine shutdowns to verify the 240-knot target airspeed included in Bombardier’s double engine failure checklist. The APU-assisted in-flight restart process has not yet been verified. 17 An airplane’s best glide speed provides the airplane with the most distance forward for a given loss of altitude.

Appendix E 159 Aircraft Accident Report 6 transition to a 300-knot airspeed for a windmill restart, a flight crew must significantly increase the airplane’s descent rate, thereby reducing the range of available landing locations if a forced (emergency) landing were to become necessary as a result of a failure to restart at least one engine. Because of the effect that this loss of glide range could have on a flight crew’s ability to find a viable emergency landing site, the Safety Board concludes that CRJ-100, -200, and -440 pilots must be fully aware of the performance penalties that can be incurred while maintaining core rotation and attempting a windmill restart. Therefore, the Safety Board believes that the FAA should require that operators of CRJ-100, -200, and -440 airplanes include in AFMs the significant performance penalties, such as loss of glide distance and increased descent rate, that can be incurred from maintaining the minimum airspeed required for core rotation and windmill restart attempts. Potential for Core Lock in Other Engine Models Turbine-powered airplanes other than the Challenger 601 and 604 and the CRJ-100, -200, and -440 have turbine engine components with a similar physical design as those for the CF34-1 and CF34-3 engines. As a result, the Safety Board concludes that other turbine engines may also be susceptible to core lock after high power, high altitude flameouts. Therefore, the Safety Board believes that the FAA should review the design of turbine-powered engines (other than the CF34-1 and CF34-3, which are addressed in Safety Recommendation A-06-70) to determine whether they are susceptible to core lock and, for those engines so identified, require manufacturers of airplanes equipped with these engines to perform high power, high altitude sudden engine shutdowns and determine the minimum airspeed to maintain sufficient core rotation so that all methods of in-flight restart can be accomplished. Further, the Safety Board believes that, for those airplanes with engines that are found to be susceptible to core lock (other than the CF34-1 and CF34-3, which are addressed in Safety Recommendation A-06-71), the FAA should require airplane manufacturers to incorporate information into AFMs that clearly states the potential for core lock; the procedures, including the minimum airspeed required, to prevent this condition from occurring after a sudden engine shutdown; and the resulting loss of in-flight restart capability if this condition were to occur. In addition, the Safety Board believes that the FAA should require manufacturers to determine, as part of 14 CFR Part 25 certification tests, if restart capability exists from a core rotation speed of 0 indicated rpm after high power, high altitude sudden engine shutdowns. For those airplanes determined to be susceptible to core lock, the FAA should mitigate the hazard by providing design or operational means to ensure restart capability. Windmill Restart Requirements Airplane manufacturers rely on the windmill method as the primary means of restart after an all-engine flameout event. Consequently, the portion of the flight envelope in which a windmill restart is effective is critical to flight safety. However, increases in the bypass ratios of turbofan engines over the years have significantly reduced the windmill restart portion of the in-flight restart envelope. Specifically, the engines powering many current transport-category airplanes bypass between 80 and 90 percent of the airflow entering the inlet around the engine core, so as little as 10 percent of the inlet air enters the core during normal operation. Thus, the

Appendix E 160 Aircraft Accident Report 7 cores of high bypass ratio engines, such as the CF34,18 require significantly higher airspeeds to achieve windmill restart than the cores of low bypass engines installed on older generation airplanes. After an all-engine high power flameout, pilots need to sacrifice a substantial amount of altitude to achieve the higher airspeeds that are necessary for a windmill restart with high bypass engines. However, depending on the altitude where the shutdown occurred, a pilot may not have enough altitude available to use this restart option. Certification requirements currently address the minimum airspeed needed to ensure windmill restart capability. However, there is no upper limit on the value of the minimum airspeed required for a windmill restart and no limit on the amount of altitude loss that can occur during a windmill restart. If the minimum airspeed value is too high, an excessive amount of altitude loss may be needed to accomplish a windmill restart. In September 1999, the FAA issued a notice of availability and request for comments on a proposed Propulsion Mega Advisory Circular,19 which addressed this and other engine certification-related issues, but the FAA has taken no subsequent action. The Safety Board concludes that, during design, airplane manufacturers must consider that a pilot’s ability to restart high bypass turbine engines after an all-engine flameout might be compromised if an excessive airspeed or an excessive amount of altitude loss were needed for the restart. Therefore, the Safety Board believes that the FAA should establish certification requirements that would place upper limits on the value of the minimum airspeed required and the amount of altitude loss permitted for windmill restarts. Therefore, the National Transportation Safety Board recommends that the Federal Aviation Administration: For airplanes equipped with CF34-1 or CF34-3 engines, require manufacturers to perform high power, high altitude sudden engine shutdowns; determine the minimum airspeed required to maintain sufficient core rotation; and demonstrate that all methods of in-flight restart can be accomplished when this airspeed is maintained. (A-06-70) Ensure that airplane flight manuals of airplanes equipped with CF34-1 or CF34-3 engines clearly state the minimum airspeed required for engine core rotation and that, if this airspeed is not maintained after a high power, high altitude sudden engine shutdown, a loss of in-flight restart capability as a result of core lock may occur. (A-06-71) Require that operators of CRJ-100, -200, and -440 airplanes include in airplane flight manuals the significant performance penalties, such as loss of glide distance and increased descent rate, that can be incurred from maintaining the minimum airspeed required for core rotation and windmill restart attempts. (A-06-72) 18 The CF34 engine bypasses about 85 percent of inlet air past the core. 19 For more information, see 64 Federal Register 52819, September 30, 1999.

Appendix E 161 Aircraft Accident Report 8 Review the design of turbine-powered engines (other than the CF34-1 and CF34-3, which are addressed in Safety Recommendation A-06-70) to determine whether they are susceptible to core lock and, for those engines so identified, require manufacturers of airplanes equipped with these engines to perform high power, high altitude sudden engine shutdowns and determine the minimum airspeed to maintain sufficient core rotation so that all methods of in-flight restart can be accomplished. (A-06-73) For those airplanes with engines that are found to be susceptible to core lock (other than the CF34-1 and CF34-3, which are addressed in Safety Recommendation A-06-71), require airplane manufacturers to incorporate information into airplane flight manuals that clearly states the potential for core lock; the procedures, including the minimum airspeed required, to prevent this condition from occurring after a sudden engine shutdown; and the resulting loss of in-flight restart capability if this condition were to occur. (A-06-74) Require manufacturers to determine, as part of 14 Code of Federal Regulations Part 25 certification tests, if restart capability exists from a core rotation speed of 0 indicated rpm after high power, high altitude sudden engine shutdowns. For those airplanes determined to be susceptible to core lock, mitigate the hazard by providing design or operational means to ensure restart capability. (A-06-75) Establish certification requirements that would place upper limits on the value of the minimum airspeed required and the amount of altitude loss permitted for windmill restarts. (A-06-76) Chairman ROSENKER, Vice Chairman SUMWALT, and Members HERSMAN and HIGGINS concurred with these recommendations. [Original Signed] By: Mark V. Rosenker

Chairman

FD07329 ｜ 2007_美国_AAR0702.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2007 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

aviation Crash During Approach to Landing Circuit City Stores, Inc. Cessna Citation 560, N500AT Pueblo, Colorado February 16, 2005 ACCIDENT REPORT NTSB/AAR-07/02 PB2007-910403

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Aircraft Accident Report Crash During Approach to Landing Circuit City Stores, Inc. Cessna Citation 560, N500AT Pueblo, Colorado February 16, 2005 NTSB/AAR-07/02 PB2007-910403 National Transportation Safety Board Notation 7713C 490 L’Enfant Plaza, S.W. Adopted January 23, 2007 Washington, D.C. 20594 E

P L U R IB US UN U M

N A T I O N A L

T R A S P O R T A T I O N

B O A R D S A FE T Y N

National Transportation Safety Board. 2007. Crash During Approach to Landing, Circuit City Stores, Inc., Cessna Citation 560, N500AT, Pueblo, Colorado, February 16, 2005, Aircraft Accident Report NTSB/AAR-07/02. Washington, DC. Abstract: This report explains the accident involving a Cessna Citation 560, N500AT, operated by Martinair, Inc., for Circuit City Stores, Inc., which crashed about 4 nautical miles east of Pueblo Memorial Airport, Pueblo, Colorado, while on an instrument landing system approach to runway 26R. The safety issues discussed in this report include inadequate training on operations in icing conditions, inadequate deice boot system operational guidance, the need for automatic deice boot systems, inadequate certification requirements for flight into icing conditions, and inadequate stall warning margins in icing conditions. The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Web at http://www.ntsb.gov. Other information about available publications also may be obtained from the Web site or by contacting: National Transportation Safety Board Public Inquiries Section, RE-51 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (800) 877-6799 or (202) 314-6551 Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2007-910403 from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605-6000 The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

iii Aircraft Accident Report Contents Abbreviations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

1. Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2. 1

History of Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.1.1 The Sister Ship History of Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1.2 Injuries to Persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.3 Damage to Aircraft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.4 Other Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.5 Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.5.1 The Captain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.5.2 The First Officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 1.6 Aircraft Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 1.6.1 General Aircraft Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 1.6.2 Stall Warning System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 1.6.3 Anti-Ice and Deice Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1.7 Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 1.7.1 National Weather Service Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 1.7.2 Airport Weather Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 1.7.3 Additional Icing Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 1.8 Aids to Navigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 1.9 Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 1.10 Airport Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 1.10.1 Air Traffic Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 1.10.2 Air Traffic Control Guidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 1.11 Flight Recorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 1.11.1 Cockpit Voice Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 1.11.1.1 Cockpit Voice Recorder Sound Spectrum Study . . . . . . . . . . . . . . . . . . . . . . . . 13 1.11.2 Flight Data Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 1.12 Wreckage and Impact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 1.13 Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 1.14 Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 1.15 Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 1.16 Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 1.16.1 Enhanced Ground Proximity Warning System Data Study . . . . . . . . . . . . . . . . . . 14 1.16.2 Airplane Performance Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1.17 Organizational and Management Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1.17.1 Operational Guidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 1.17.1.1 Normal Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 1.17.1.2 Operations in Icing Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 1.17.1.3 Anti-Ice and Deice Systems Usage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

iv Aircraft Accident Report 1.17.2 Flight Crew Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 1.17.2.1 Operations in Icing Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 1.17.2.2 Stall Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 1.18 Additional Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 1.18.1 Cessna 550 and 560 Airplanes Icing-Related Flight Testing and Subsequent Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 1.18.2 Previous Icing-Related Safety Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . 20 1.18.2.1 Deice Boot System Activation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 1.18.2.2 Certification Requirements for Flight into Icing Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 1.18.2.3 Stall Warning Margins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 1.18.3 Residual and Intercycle Ice and Automatic Deice Boot System Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

1. Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
2. 1

General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 2.2 Accident Sequence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 2.2.1 Descent Into Icing Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 2.2.2 Approach to Landing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 2.2.3 Final Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 2.2.4 Flight Crew Monitoring and Workload Management . . . . . . . . . . . . . . . . . . . . . . . 30 2.3 Deice Boot Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 2.4 Certification Requirements for Flight Into Icing Conditions . . . . . . . . . . . . . . . . . . . . . 34 2.5 Inadequate Stall Warning Margins in Icing Conditions . . . . . . . . . . . . . . . . . . . . . . . . 36

1. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
2. 1

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 3.2 Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

1. Safety Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
2. 1

New Safety Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 4.2 Previously Issued Safety Recommendations Reiterated in This Report . . . . . . . . . . . . 41

1. Appendixes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

A: Investigation and Public Hearing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 B: Cockpit Voice Recorder Transcript . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Contents

v Aircraft Accident Report Abbreviations agl above ground level AC advisory circular AD airworthiness directive AFM airplane flight manual AIRMET airmen’s meteorological information AOA angle-of-attack ARAC aviation rulemaking advisory committee ARTCC air route traffic control center ASOS automated surface observing system ASR-7 airport surveillance radar-7 ATC air traffic control ATIS automatic terminal information service ATP airline transport pilot BFU German Federal Bureau of Accidents Investigation C Celsius CAM cockpit area microphone CFR Code of Federal Regulations CG center of gravity COU Columbia Regional Airport CVR cockpit voice recorder EGPWS enhanced ground proximity warning system FAA Federal Aviation Administration fpm feet per minute FSS flight service station Hg mercury ILS instrument landing system

Abbreviations vi Aircraft Accident Report IMC instrument meteorological conditions IPHWG Ice Protection Harmonization Working Group METAR meteorological aerodrome report mm millimeter msl mean sea level NASA National Aeronautics and Space Administration NCAR National Center for Atmospheric Research nm nautical mile NPRM notice of proposed rulemaking NWS National Weather Service PIREP pilot report PUB Pueblo Memorial Airport PWC Pratt & Whitney Canada SB service bulletin SLD supercooled large droplet sm statute mile TCAS traffic alert and collision avoidance system UTC universal coordinated time

vii Aircraft Accident Report Executive Summary On February 16, 2005, about 0913 mountain standard time, a Cessna Citation 560, N500AT, operated by Martinair, Inc., for Circuit City Stores, Inc., crashed about 4 nautical miles east of Pueblo Memorial Airport, Pueblo, Colorado, while on an instrument landing system approach to runway 26R. The two pilots and six passengers on board were killed, and the airplane was destroyed by impact forces and postcrash fire. The flight was operating under the provisions of 14 Code of Federal Regulations Part 91 on an instrument flight rules flight plan. Instrument meteorological conditions prevailed at the time of the accident. The National Transportation Safety Board determines that the probable cause of this accident was the flight crew’s failure to effectively monitor and maintain airspeed and comply with procedures for deice boot activation on the approach, which caused an aerodynamic stall from which they did not recover. Contributing to the accident was the Federal Aviation Administration’s failure to establish adequate certification requirements for flight into icing conditions, which led to the inadequate stall warning margin provided by the airplane’s stall warning system. The safety issues discussed in this report include inadequate training on operations in icing conditions, inadequate deice boot system operational guidance, the need for automatic deice boot systems, inadequate certification requirements for flight into icing conditions, and inadequate stall warning margins in icing conditions. Safety recommendations concerning these issues are addressed to the Federal Aviation Administration.

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1 Aircraft Accident Report 1. Factual Information 1.1 History of Flight On February 16, 2005, about 0913 mountain standard time,1 a Cessna Citation 560, N500AT, operated by Martinair, Inc., for Circuit City Stores, Inc.,2 crashed about 4 nautical miles (nm) east of Pueblo Memorial Airport (PUB), Pueblo, Colorado, while on an instrument landing system (ILS) approach to runway 26R. The two pilots and six passengers on board were killed, and the airplane was destroyed by impact forces and postcrash fire. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 91 on an instrument flight rules flight plan. Instrument meteorological conditions (IMC) prevailed at the time of the accident. The accident flight and another Circuit City Stores Cessna 560 (N500FK, referred to in this report as the “sister ship”) were scheduled to transport Circuit City Stores employees from Richmond International Airport, Richmond, Virginia, to John Wayne Airport, Santa Ana, California, with scheduled fuel stops at Columbia Regional Airport (COU), Columbia, Missouri, and PUB. The accident flight departed Richmond about 0600 eastern standard time. The flight arrived at COU about 0736 central standard time and departed for PUB about 30 minutes later. At 0847:48, while descending through about flight level 370,3 the cockpit voice recorder (CVR)4 recorded the Denver Air Route Traffic Control Center (ARTCC) instructing the flight crew to descend to and maintain 13,000 feet. About 0851, the CVR recorded the flight crew start discussing the icing conditions. Specifically, at 0850:40, the captain stated, “I’m gonna heat ‘em up.”5 About 4 minutes later, the captain stated that he turned the windshield heat on, and he then asked the first officer to let him know if he saw any ice on the wing. The first officer replied that he saw ice “building a little bit right on 1 Unless otherwise indicated, all times in this report are mountain standard time based on a 24-hour clock. 2 Circuit City Stores owned the airplane. Martinair, an aircraft management and charter company, operated and managed the accident airplane for Circuit City Stores. See section 1.17 for more information. 3 Flight level 370 is an altitude of 37,000 feet mean sea level (msl) based on an altimeter setting of 29.92 inches of mercury (Hg). Unless otherwise indicated, all altitudes referenced in this report are reported as height above msl. 4 Correlation of the CVR recording to mountain standard time was established using times from the air traffic control (ATC) transcript prepared by the Federal Aviation Administration and PUB airport surveillance radar-7 radar. The time alignment of the CVR recording and radar revealed that the CVR clock was about 10 seconds ahead of the radar clock. As a result, the CVR times are presented with a 10-second offset to provide a consistent time base between the CVR and ATC sources. The airplane was not equipped with a flight data recorder. 5 The captain’s comment most likely refers to the activation of the engine anti-ice system, which heats the engine inlets and the inboard wing leading edges. For more information about the airplane’s anti-ice and deice systems and guidance on the usage of these systems, see sections 1.6.3 and 1.17.1.3, respectively.

Factual Information 2 Aircraft Accident Report the [wing] leading edge…it’s not the real white ice like we had yesterday. It’s more of a grayish.” The first officer then stated, “there’s a real thin line back there.” About 2 minutes later, the captain stated that it did not look like the airplane had accumulated any more ice. At 0858:20, as the airplane was descending through about 18,000 feet, the first officer suggested that the captain cycle the deice boots. After cycling the deice boots, the captain stated, “might’ve gotten rid of a little but not much.” At 0859:29, the first officer stated that the Vref was 96 knots. 6 About 3 1/2 minutes later, the captain told the first officer to “leave the heats on,” and the first officer replied, “okay. Got everything nice and warmed up.” At 0905:50, the first officer contacted PUB approach control and stated, “Pueblo approach…thirteen thousand with [automatic terminal information service] Juliet.”7 The PUB local controller instructed the flight crew to fly heading 240° for the ILS runway 26R final approach course and to descend to and maintain 7,000 feet. The first officer asked, “did you say two six right now?” The controller confirmed that runway 26R was in use. The controller also reported that a regional jet was in a holding pattern over PUB at 9,000 feet and asked the pilots to report when they had the airplane in sight.8 The first officer then told the captain that the controller had changed the landing runway from 8L to 26R. At 0907:36, the PUB local controller asked the pilots if they had the airplane in sight, and the first officer stated that he did not. The controller replied, “give me a best rate of descent through niner thousand or maintain one zero thousand. I’ll just turn you.” The first officer stated that they would descend to 7,000 feet. At 0908:25, the first officer reported to the controller that the flight was in IMC at an altitude of about 9,400 feet. The controller then instructed the flight to turn left to a heading of 170°. At 0908:55, the controller instructed the flight crew to turn right to a heading of 290° to intercept the localizer inbound. He then instructed the flight crew to maintain 7,000 feet and cleared the flight for the approach. 6 Vref is the landing reference airspeed with full flaps and landing gear down. In accordance with company guidance, if any amount of residual ice (that is, ice that remains on the deice surface after the deice boots have been cycled) is present, the Vref should be increased by 8 knots, which would have resulted in a Vref of 104 knots instead of the 96 knots reported by the first officer. For more information about guidance on operations in icing conditions, see section 1.17.1.2. 7 Automatic terminal information service (ATIS) information “Juliet,” which broadcast the 0753 weather, reported the following: wind 060° at 6 knots, visibility 10 statute miles, measured ceiling 1,400 feet overcast, temperature -3° Celsius (C), dew point -5° C, altimeter 30.16 inches of Hg. ATIS information “Juliet” also indicated that the landing runway in use was 8L. Altitudes referenced in this report from surface weather observations and terminal aerodrome forecasts are reported as height above ground level (agl). See section 1.7 for more meteorological information. 8 During postaccident interviews, the captain of the holding airplane stated that he had initially requested and received a holding pattern altitude of 8,000 feet. He stated that, although he was informed by ATC that icing conditions existed at that altitude, he decided to descend to 8,000 feet. As the airplane descended toward 8,000 feet into IMC, it began accumulating ice. He stated that he turned on the airplane’s wing anti-ice and immediately requested a climb to 9,000 feet to exit the icing conditions. He stated that, at 9,000 feet, the airplane was above the cloud layer and mostly in the clear. He characterized the icing as rime ice but did not know its accumulation rate or severity.

Factual Information 3 Aircraft Accident Report At 0909:19, the first officer stated, “you got a little different ice on there now. It’s clear.” The captain replied, “yeah,” and he then instructed the first officer to “open up those valves all the way.”9 The first officer replied, “all right, will do.” At 0909:41, the PUB local controller provided the flight crew with the current weather, which indicated the following: cloud ceilings broken at 900 feet and overcast at 1,400 feet, visibility 6 statute miles (sm) in mist, temperature -3° Celsius (C), dew point -4° C, wind 070° at 7 knots, and altimeter 30.16 inches of mercury (Hg). At 0910:22, the first officer stated, “ignition is on with the anti-ice, now it’s on for sure. Glideslope is alive.” At 0911:10, the captain stated, “[landing] gear’s down.” The PUB local controller cleared the flight to land on runway 26R and instructed the flight crew to maintain its present heading and altitude until established on the ILS localizer. At 0911:45, the CVR recorded the captain stating, “speed brakes coming back out.” The first officer replied, “okay…there’s your glideslope intercept.” The captain then called for full flaps. The first officer responded, “full flaps, here we go…full selected and indicated.” At 0912:00, the first officer briefed the missed approach. Four seconds later, he stated, “you are plus twenty five,”10 and the captain replied, “slowing.” At 0912:37, the first officer stated, “I don’t know if you want to run your ice a little bit. You got the Vref there.” Airplane performance calculations show that, about 0912:40, immediately after passing through about 6,100 feet,11 the airplane experienced an upset and the onset of a large roll to the left concurrent with a rapid decrease in pitch. The CVR recorded a short tone concurrent with the beginning of the upset. The frequency and the duration of the tone were consistent with the autopilot disconnect horn.12 At 0912:46, the CVR recorded the enhanced ground proximity warning system (EGPWS) “bank angle” aural warning alert.13 The last radar return was received at 0912:54 while the airplane was at an altitude of about 4,922 feet. One second later, the CVR stopped recording. According to the Federal Aviation Administration (FAA) air traffic control (ATC) transcript, at 0912:57, the PUB local controller issued an altitude alert to the accident flight, stating, “zero alpha tango altitude alert altitude indicates four thousand niner hundred over.” 1.1.1 The Sister Ship History of Flight During postaccident interviews, the sister ship captain indicated that, according to the airplane’s traffic alert and collision avoidance system (TCAS), the accident airplane was about 19 nm ahead of the sister ship en route to PUB. The flight crewmembers reported that, during the descent to PUB, the airplane was accreting rime ice;14 however, 9 The captain was most likely referring to the windshield anti-ice bleed air valves, which control the volume of engine bleed air to the windshield. The three-position (LOW, OFF, and HIGH) windshield bleed air switch controls the temperature of the air to the windshield. 10 The first officer’s comment “plus twenty five” refers to the Vref plus 25 knots. 11 The airplane was at an altitude of about 1,500 feet above ground level at the time of the upset. 12 The autopilot can be manually disconnected by the pilot or it can be automatically disconnected if certain conditions occur, such as a roll angle of more than 40° or a roll rate of more than 20° per second. 13 Analysis of the EGPWS data indicated that the bank angle at the time of the alert was about 50°.

Factual Information 4 Aircraft Accident Report they stated that no visible precipitation was present. The first officer estimated that the ice was less than 1/2-inch thick and stated that the deice boots effectively shed the ice. He stated that there was no ice on the heated inboard wing leading edge or on the top of the wing. The first officer stated that a little ice had formed on the windshield and that he selected the HIGH heat setting to deice and defog the windshield. The captain stated that they kept the airspeed up on the approach because of the icing conditions.15 The captain stated that they broke out of the clouds about 1,200 to 1,400 feet and that the visibility was about 6 nm with no precipitation. The captain stated that he heard the PUB controller clear the accident airplane to land and the flight crew acknowledge the clearance. He stated that, shortly afterward, he heard the controller issue a low-altitude warning of about 4,900 feet. He stated that the controller called for the accident flight three or four times but that the flight crew did not acknowledge. He stated that he then looked at the TCAS and saw that the accident airplane was no longer displayed. The sister ship landed on runway 8L about 0926 without incident. The flight crew and passengers reported that they observed some ice on the airplane after landing. A review of the sister ship’s CVR revealed that the pilots conducted several procedures to minimize any icing problems, including cycling the wing deice boots five times, turning the windshield heat to the HIGH position, using only approach flaps until close to the ground, and keeping the engine power and speed as high as possible until clear of the clouds and landing was assured. 1.2 Injuries to Persons Table 1. Injury chart. 14 Rime ice is an opaque, granular, and rough deposit of ice that usually forms on the airplane’s surfaces, including, in part, the wing leading edges, the horizontal stabilizers, and the engine inlets. 15 Airplane performance calculations revealed that the sister ship’s airspeed was more than 160 knots as the airplane descended through about 6,200 feet and that the airplane maintained an airspeed of about 120 knots until it was about 200 feet above airport elevation. Calculations revealed that the accident airplane’s airspeed was about 98 knots as it descended through about 6,200 feet. Injuries Flight Crew Cabin Crew Passengers Other Total Fatal 2 0 6 0 8 Serious 0 0 0 0 0 Minor 0 0 0 0 0 None 0 0 0 0 0 Total 2 0 6 0 8

Factual Information 5 Aircraft Accident Report 1.3 Damage to Aircraft The airplane was destroyed by impact forces and a postcrash fire. 1.4 Other Damage No other damage resulted from this accident. 1.5 Personnel Information 1.5.1 The Captain The captain, age 53, was hired by Martinair on February 1, 2002. He held a multiengine airline transport pilot (ATP) certificate, issued October 11, 1996, with type ratings in Beechcraft 300 and 1900, Cessna 500, and Dassault Falcon DA-10 series airplanes. The captain held a first-class FAA airman medical certificate, dated February 7, 2005, with the limitations that he “must wear lenses for distance” and “possess glasses for near vision.” According to the captain’s employment application for Martinair, from July 1989 to January 2001, he worked as a pilot in Cessna 560 airplanes at Southern States. From January 2001 to February 2002, he worked as a pilot in Cessna Citation Ultra airplanes at Chesapeake Corporation. Martinair records indicated that the captain had accumulated 8,577 total flight hours, including 2,735 hours in Cessna Citation airplanes, 1,500 hours of which were as pilot-in-command. He had flown about 113, 39, 12, and 3 hours in the 90, 30, and 7 days and 24 hours, respectively, before the accident. The captain’s last Cessna 500 series proficiency check occurred on November 1, 2004; his last recurrent ground training occurred on November 30, 2004; and his last line check occurred on January 4, 2005. A search of FAA records revealed no accident or incident history, enforcement action, or pilot certificate or rating failure or retest history. A search of the National Driver Register found no record of driver’s license suspension or revocation. According to the captain’s wife, he slept his normal sleep schedule16 at home in Richmond for several nights before February 15, 2005. On February 14, he flew a roundtrip to South Bend, Indiana, during the day (with the accident first officer). She stated that, on February 15, he left home by early afternoon, returned about 1500, and was awake in bed when she returned about 2030 to 2100. She stated that, on the morning of the accident, he awoke early; however, she did not know what time he departed for the airport. 16 According to the captain’s wife, he normally went to sleep about 2200 to 2300 and awoke by 0700 when he did not have to work. She stated that the captain sometimes had difficulty sleeping.

Factual Information 6 Aircraft Accident Report 1.5.2 The First Officer The first officer, age 42, was hired by Martinair in November 2004. He held a multiengine ATP certificate, issued March 3, 2004, with a type rating in Cessna 500 series airplanes. The first officer held a first-class FAA airman medical certificate, dated August 2, 2004, with no limitations. According to the first officer’s employment application for Martinair, from April 2002 to November 2004, he worked as a pilot in Cessna Citation airplanes for Commonwealth Aviation Services, Inc. Martinair records indicated that the first officer had accumulated 2,614 total flight hours, including 1,397 hours in Cessna Citation series airplanes, 322 hours of which were as pilot-in-command. He had flown about 127, 37, 11, and 3 hours in the 90, 30, and 7 days and 24 hours, respectively, before the accident. The first officer’s last Cessna Citation 500 series proficiency check and line check occurred on February 10, 2005, and his last recurrent ground training occurred on December 30, 2004. A search of FAA records revealed no accident or incident history, enforcement action, or pilot certificate or rating failure or retest history. A search of the National Driver Register found no record of driver’s license suspension or revocation. According to the first officer’s wife, he slept his normal sleep schedule17 at home in Richmond for several nights before February 15, 2005. She stated that, on February 14, he was still in bed when she left the house about 0730; he flew a roundtrip to South Bend that afternoon; and he went to bed about 2200 to 2300. On February 15, he flew another roundtrip to South Bend, and he went to bed about 2100 to 2130. On the morning of the accident, he awoke about 0300 and left the house about 0345 to 0400. 1.6 Aircraft Information 1.6.1 General Aircraft Information The accident airplane, serial number 0146, was manufactured by Cessna Aircraft Company on October 22, 1991, and was certified to 14 CFR Part 25 standards. At the time of the accident, the airplane had accumulated about 3,658 total flight hours. The airplane was equipped with two Pratt & Whitney Canada (PWC) JT15D-5A turbofan engines. The time since new for both engines was about 3,585 hours, and the time since overhaul for both engines was about 114 hours. Martinair provided National Transportation Safety Board investigators with estimated weight and balance information for the accident flight.18 According to these estimates, the accident airplane’s landing weight was about 13,040 pounds, including 17 According to the first officer’s wife, he normally went to sleep about 2200 and awoke by 0800 when he did not have to work. 18 The actual weight and balance information for the accident airplane was not found. Title 14 CFR Part 91 regulations do not require pilots to leave a manifest at the departure airport.

Factual Information 7 Aircraft Accident Report 2,000 pounds of fuel, 1,100 pounds of passenger weight, and 180 pounds of baggage, which was within the landing weight limit of 15,200 pounds. The estimates showed that the airplane’s landing center of gravity (CG) was 16.8 percent mean aerodynamic chord, which was within the landing CG limits of 16 to 28 percent. The airplane was equipped with speedbrakes, which are small panels that extend from the upper and lower surfaces of each wing to increase descent rates.19 After the accident, the left speedbrakes remained attached to the wing and were in the fully extended position. The right speedbrakes remained attached to the wing but were in an intermediate position. However, the speedbrake panels and hydraulic actuators on both wings were able to move freely. 1.6.2 Stall Warning System The accident airplane was equipped with a stall warning and angle-of-attack (AOA) system, which consisted of an AOA vane, indicator, indexer, and computer, and a stickshaker mounted on the forward side of the pilot’s control column. The AOA vane, which is located on the forward right side of the fuselage, streamlines with the relative airflow and transmits the sensed angle to the AOA system. Inputs from the AOA system are transmitted to the stickshaker, which has an electric motor with rotating weights that induce vibration to the control columns, providing a tactile warning to pilots of an impending stall. The stickshaker is designed to alert pilots of an impending stall about 7 percent above the actual stall speed when the airplane’s surfaces are not contaminated by ice.20 According to the Cessna Model 560 Citation V Operating Manual, the airplane was equipped with an upgraded, dual-mode AOA computer, which incorporated normal and ice modes. The ice mode is activated when either engine anti-ice switch is selected ON. In normal mode, stickshaker activation is referenced to standard airplane stall speeds, and, in ice mode, stickshaker activation is referenced to standard airplane stall speeds plus 5 knots to account for the increase in stall speed caused by airframe ice accumulation.21 According to the Cessna Model 560 Citation V Airplane Flight Manual (AFM), the accident airplane’s stall speed, with no ice on the wings and assuming an airplane weight of about 13,300 pounds and full flaps selected, should have been about 76 knots. The AFM states that, with ice on the wings, the stall speed increases by 5 knots; therefore, 19 The speedbrakes are electrically controlled and hydraulically actuated by a switch located on the throttle quadrant in the cockpit and may be selected to the fully extended or fully retracted (stowed) position. The speedbrakes are held in the stowed position by mechanical catches. A light illuminates in the cockpit when the speedbrakes are in transition and when they are fully extended. 20 According to Advisory Circular 25-7, “Flight Test Guide for Certification for Transport Category Airplanes,” “the stall warning should normally begin at a speed not less than 7 percent above the stall speed.” 21 During flight tests of Cessna 560 series airplanes, which were conducted by the FAA in 1996, it was determined that the stall speed increased from 3 to 5 knots in icing conditions. In early 1999, Cessna began installing stall warning systems that incorporated the ice mode. For more information about these tests and subsequent FAA and Cessna actions, see section 1.18.1.

Factual Information 8 Aircraft Accident Report the stall speed for the accident airplane should have been about 81 knots. As noted, the stickshaker is designed to alert pilots of an impending stall about 7 percent above the actual stall speed; therefore, the stickshaker should have activated at about 86 knots. The Cessna Model 560 Citation V AFM states that the stall warning system must be operable and a preflight check must be performed before takeoff. The sister ship captain, who flew the accident airplane the day before the accident, reported no pre- or in-flight stall warning system problems. Further, no discrepancies were noted during the last scheduled maintenance inspection of the stall warning system, which was completed on December 1, 2003. Postaccident examinations of the stall warning system components revealed that the AOA computer and vane electrical heating element exhibited heat and fire damage, which precluded functional checks. The AOA vane was able to move freely. The stall warning stickshaker and the vane heating elements were found to be functional during postaccident tests. 1.6.3 Anti-Ice and Deice Systems The Cessna 560 is certified to operate in known icing conditions and is equipped with anti-ice and deice systems to prevent ice accumulation on various exterior areas of the airplane.22 The engine anti-ice system uses engine bleed air to heat the engine inlets and the inboard wing leading edges, and the windshield anti-ice system uses engine bleed air to heat the windshield. The pitot static anti-ice system uses electrical heating elements to prevent ice buildup on the pitot tubes, static ports, and AOA vane. The anti-ice systems are activated by switches in the cockpit. Activation of the engine and windshield anti-ice systems and failures of the engine and pitot static anti-ice systems are annunciated by lights in the cockpit. The surface deice system consists of pneumatic boots on the outboard wing leading edges and the horizontal stabilizer. The deice system is typically activated by selecting the surface deice switch to the AUTO position. During the 18-second automatic deice boot cycle,23 pneumatic pressure from engine bleed air inflates the lower boots on the wing leading edges and the boot on the left horizontal stabilizer, then these boots completely deflate. The upper boots on the wing leading edges and the boot on the right horizontal stabilizer then inflate and deflate. After deflation of the upper deice boots, the cycle is terminated. Deice boot system activation is annunciated by lights in the cockpit. The deice boot system can also be operated manually by holding the deice surface control switch in the MANUAL position. As long as the control switch is held in the MANUAL position, all of the deice boots will inflate simultaneously and deflate when the 22 According to the Cessna Model 560 Citation V AFM, the airplane’s anti-ice and deice systems were not designed to protect against freezing rain or severe conditions of mixed or clear ice. 23 The AUTO mode automatically cycles the deice boots through one 18-second deice boot cycle. However, to activate another 18-second cycle, the pilot would have to move the surface deice switch to the AUTO position again.

Factual Information 9 Aircraft Accident Report switch is released. If the switch is placed and held in the MANUAL position during automatic cycle operation, the MANUAL will override the AUTO function, all of the deice boots will simultaneously inflate, and the automatic cycle will time out. CVR information indicated that the captain activated the deice boots and that the boots had removed some of the ice. Further, no discrepancies were noted during the last scheduled maintenance inspections of the anti-ice and deice systems, which were completed on December 1, 2003. After the accident, the engine anti-ice switches were found fractured, and their positions could not be determined. The windshield bleed air switches were missing. The left and right windshield bleed air valve positions could not be determined because the cables had been pulled out of both control mechanisms. The pitot static heat switch was found in the ON position. The surface deice switch was found spring-loaded to the neutral position. The deice control valves were found separated from the wreckage and damaged. On-scene disassembly revealed that the deice control valves were free of obstruction, and a functional test showed that the valves functioned properly. The left- and right-wing leading edge deice boots were severely damaged by impact and postcrash fire. The left and right horizontal stabilizer deice boots were damaged. The deice boot air supply lines from the tail section to the wings were damaged and/or consumed by fire. 1.7 Meteorological Information 1.7.1 National Weather Service Information A terminal aerodrome forecast prepared for PUB by the National Weather Service (NWS), which was issued at 0442 and was valid at the time of the accident, stated, in part, the following: winds 080° at 8 knots, visibility greater than 6 miles, skies scattered at 2,000 feet and overcast at 2,500 feet. Temporary condition between 1200Z[24] to 1600Z, visibility 3 miles in light freezing drizzle, mist, skies overcast at 1,000 feet. From 1600Z, winds 070° at 8 knots, visibility greater than 6 miles, skies scattered at 1,000 feet and overcast at 2,500 feet. The NWS also issued several winter weather advisories on the morning of the accident.25 The advisories issued at 0750 and 0934 warned that freezing drizzle existed along the accident flightpath through the midmorning hours. 24 Weather forecasts are transmitted in coordinated universal time (UTC). The “Z” designation that follows the time in the weather observation stands for Zulu, which indicates UTC time. Mountain standard time is 7 hours behind UTC time. 25 Although winter weather advisories are not aviation-related products, they provide additional information about atmospheric conditions.

Factual Information 10 Aircraft Accident Report About 0745, the NWS issued AIRMET [airmen’s meteorological information] Zulu, which covered the Pueblo area and was valid at the time of the accident. AIRMET Zulu warned of “occasional moderate rime or mixed icing in clouds and precipitation between freezing level and 22,000 feet, with the freezing level between the surface and 8,000 feet.” About 0830, the NWS issued AIRMET Sierra, which also covered the Pueblo area and was valid at the time of the accident. AIRMET Sierra warned of “occasional [cloud] ceilings below 1,000 feet and/or visibilities below 3 statute miles.” AIRMET Sierra also warned of obscured mountains caused by precipitation, clouds, mist, and/or fog. Base reflectivity image data were derived from the Weather Surveillance Radar-1988 Doppler system, which is located 15 nm northeast of the accident site. Data from the system’s 0911 atmospheric profile showed weak reflectivity values near the accident site, consistent with the presence of freezing drizzle atmospheric conditions. Geostationary Operational Environmental Satellite 10 data from the National Oceanic and Atmospheric Administration satellite indicated cloud top temperatures from -19° to -11° C and the presence of cloud layers in the area surrounding the airplane’s flightpath. The 0500 upper air sounding (that is, a vertical profile of atmospheric conditions) from Denver, Colorado (about 92 nm northeast of the site), showed temperatures below freezing from the surface to 30,000 feet. The sounding showed no layers in the atmosphere with temperatures above freezing. 1.7.2 Airport Weather Information Weather observations at PUB are made by an automated surface observing system (ASOS) located about 3 nm west of the accident site. The ASOS records continuous information on wind speed and direction, cloud cover, temperature, precipitation, and visibility and transmits an official meteorological aerodrome report (known as a METAR) each hour. The 0853 METAR indicated the following: wind 060° at 8 knots; visibility 8 miles; skies broken at 900 feet and overcast at 1,400 feet; temperature minus 3° C; dew point temperature minus 5° C…Remarks [cloud] ceiling varying between 700 to 1,100 feet. The 0944 METAR indicated the following: wind 070° at 7 knots; visibility 6 miles; skies overcast at 600 feet; temperature minus 3° C; dew point temperature minus 4° C…Remarks [cloud] ceiling varying between 400 and 900 feet. The PUB ASOS provides unofficial weather observations that are recorded every 5 minutes. At 0910, the PUB ASOS indicated the following: winds 070° at 7 knots and 6 sm in mist. At 0915, the PUB ASOS indicated the following: winds 060° and visibility 8 sm. Both reports reported the following: clouds broken at 900 feet and overcast at 1,400 feet, temperature -3° C, and dew point -4° C.

Factual Information 11 Aircraft Accident Report 1.7.3 Additional Icing Information Scientists from the National Center for Atmospheric Research (NCAR), Boulder, Colorado, conducted studies for the National Transportation Safety Board to determine whether the accident airplane encountered supercooled26 large droplet (SLD) conditions, which are more conducive to the accumulation of thin, rough ice on or aft of the protected surfaces, and to estimate the amount of airframe ice accumulation. NCAR reported that, on the basis of surface, radar, upper air, and satellite data, the airplane likely encountered SLD conditions from about 9,400 to 6,100 feet (the calculated altitude at which the upset occurred). NCAR indicated that, during the time that the airplane was in this cloud layer (about 4 1/2 minutes), from 1 to 4 millimeters (mm) (0.039 to 0.157 inch) of ice likely accumulated along the wing leading edges.27 Severe icing conditions are those in which 5 mm (0.195 inch) of ice accumulates in 5 minutes. Several pilot reports (PIREP) were provided around the time of the accident in the area over PUB. A PIREP received about 0646 from a pilot flying a Swearingen Merlin IV reported moderate mixed icing on final approach to runway 8. A PIREP received about 0809 from the pilot flying a Hawker jet who had landed on runway 8 about 1 minute earlier reported light to moderate and/or mixed icing and a “little” ice accumulation on the wing leading edges. A PIREP received about 1020 from a pilot flying a Learjet 31 reported light to moderate rime icing on final approach to runway 8. An urgent PIREP28 received about 1023 from a pilot flying a Beechcraft King Air 90 at an altitude of about 6,000 feet reported moderate mixed icing and ice accumulation from 1/4 to 1/2 inch on final approach to runway 8. 1.8 Aids to Navigation No problems with any navigational aids were reported. 1.9 Communications No communications problems between the pilots and any of the air traffic controllers who handled the accident flight were reported. 26 Supercooled is the liquid state of a substance that is below the normal freezing temperature for that substance. 27 The ice accumulation estimates do not account for all of the effects of SLD conditions, including the effect of the droplets’ running aft of the protected surfaces before freezing. 28 FAA Order 7210.3, “Facility Operation and Administration,” states that weather phenomena reported by a pilot that represents a hazard or a potential hazard to flight operations, including severe icing, should be disseminated as “urgent PIREPs.”

Factual Information 12 Aircraft Accident Report 1.10 Airport Information PUB is located about 5 nm southeast of Pueblo at an elevation of 4,726 feet. PUB has one set of parallel runways, 8L/26R and 8R/26L, and runway 17/35. 1.10.1 Air Traffic Control PUB has a combined tower and radar approach control facility. The tower is located on the south side of the airport, left of and about midway down runway 26R. PUB tower controllers use DBRITE (digital bright radar indicator tower equipment), which provides a visual display of the airport surveillance radar (ASR)-7 data and radar and beacon signals received from the PUB automated radar terminal system IIE radar processing system. 1.10.2 Air Traffic Control Guidance FAA Order 7110.65, “Air Traffic Control,” paragraph 2-6-3, “PIREP Information,” states that, when an air traffic controller receives a PIREP that involves icing, the controller should record the icing type and intensity and the air temperature in which the icing is occurring. The order states that controllers are required to “relay pertinent PIREP information to concerned aircraft in a timely manner” and the flight service station (FSS) “serving the area in which the report was obtained.” As noted previously, about 0809 (about 1 hour before the accident), the pilot of a Hawker jet, who had flown inbound to PUB from the southeast and had just landed, reported to the PUB local controller that a little bit of ice had accumulated on the airplane’s wing leading edges. The controller asked the pilot if the icing conditions were “moderate mixed,” and the pilot replied that the icing conditions were “light to moderate but it looks like it’s mixed.” The controller did not provide the PIREP to the accident flight crew or to the Denver FSS. In postaccident interviews, the controller stated that he had interpreted the pilot’s statement as “a trace or less” of ice and, therefore, not a reportable amount. FAA Order 7110.65, Section 9, “Automatic Terminal Information Service Procedures,” paragraph 2-9-1, “Application,” states that controllers should “use the ATIS information, where available, to provide advance non-control airport/terminal area and meteorological information to aircraft.” ATIS information includes the landing runway in use; however, air traffic controllers are allowed to amend the ATIS information at any time as situations change. ATIS information “Juliet,” which was effective at 0753, broadcast that the landing runway in use at PUB was 8L; however, at 0905:56, the PUB local controller instructed the flight crew to expect to land on runway 26R. During postaccident interviews, the controller stated that he was often asked by corporate pilots to use the runway opposite that being advertised on ATIS and that, as a service, he would provide the closest runway as a matter of course as long as the winds allowed it.

Factual Information 13 Aircraft Accident Report 1.11 Flight Recorders 1.11.1 Cockpit Voice Recorder The accident airplane was equipped with a B&D Instruments and Avionics CVR, serial number A01148. The exterior of the CVR exhibited slight structural damage. The CVR was sent to the Safety Board’s laboratory in Washington, D.C., for readout and evaluation. The tape was played back normally and without difficulty. The recording consisted of three separate channels of good quality audio information:29 the captain and first officer audio panels and the cockpit area microphone (CAM). A transcript was prepared of the entire 31-minute, 36-second recording (see appendix B). 1.11.1.1 Cockpit Voice Recorder Sound Spectrum Study The accident CVR recording was examined using computer signal and spectrum analyzers30 at the Safety Board’s laboratory to determine whether the stall warning system generated any aural alerts during the last 60 seconds of the flight. Specifically, the CAM channel was examined to determine whether any sounds could be identified that corresponded to the rotation rate of the stickshaker motor or weights. The study showed that the stall warning appears to have activated at 0912:44.5 (about 1 second after the loss of control) and continued to 0912:50.5. The stall warning appears to have reactivated at 0912:53.4 and continued to 0912:54.5 (the end of the recording). 1.11.2 Flight Data Recorder The airplane was not equipped with a flight data recorder nor was it required to be so equipped.31 1.12 Wreckage and Impact Information The airplane wreckage was located about 4 nm east of runway 26R at an elevation of about 4,600 feet. The debris field was about 550 feet long and extended along a 230° magnetic heading. All of the airplane’s major structures, including the cockpit, wings, 29 The Safety Board rates the quality of CVR recordings according to a five-category scale: excellent, good, fair, poor, and unusable. See appendix B for a description of these ratings. 30 The computer signal analyzer provides detailed analysis of the analog waveform and provides the specific frequency content of the signals and detailed timing information. The spectrum analyzer provides a visual presentation of the frequency content of the recorded signals. 31 On December 22, 2003, the Safety Board issued Safety Recommendation A-03-65, which recommended that the FAA require that all turbine-powered aircraft manufactured before January 1, 2007, being used for commercial or corporate purposes under Part 91 be retrofitted with a crash-protected image recording system by January 1, 2010. The Board reiterated Safety Recommendation A-03-65 on January 24,

1. For additional information, see National Transportation Safety Board, Collision with Trees and Crash

Short of Runway, Corporate Airlines Flight 5966, British Aerospace BAE-J3201, N875JX, Kirksville, Missouri, October 19, 2004, Aircraft Accident Report NTSB/AAR-06/01 (Washington, DC: NTSB, 2006).

Factual Information 14 Aircraft Accident Report fuselage, and empennage were found at the accident site. The main wreckage consisted of a section of the airframe from the aft pressure bulkhead to the cockpit. The cockpit was consumed by fire, and the instrument panel was crushed. The throttle quadrant was melted, and only stubs of the control handles were present. The left and right wings were found separated from the fuselage. The position of the landing gear actuators was consistent with the landing gear being in the down-and-locked position at impact. Evidence of a postcrash fire was found along the debris field, beginning about 55 feet after the initial impact marks. Both engines were found separated from the airplane. The engines showed no indications of uncontainment, case rupture, or in-flight fire. Both engines were disassembled at PWC’s facility in Bridgeport, West Virginia, under Safety Board supervision. Disassembly of the engines revealed no preexisting defects or malfunctions. 1.13 Medical and Pathological Information Fluid and tissue specimens obtained from the captain and a fluid specimen obtained from the first officer were transported to the FAA’s Civil Aerospace Medical Institute for toxicological analysis. The specimens tested negative for alcohol and a wide range of drugs, including drugs of abuse.32 1.14 Fire No evidence of an in-flight fire was found. 1.15 Survival Aspects According to the Pueblo County Coroner’s Office autopsy report, the cause of death for the captain, first officer, and six passengers was “multiple traumatic injuries.” 1.16 Tests and Research 1.16.1 Enhanced Ground Proximity Warning System Data Study The EGPWS computer, which contained two flash memory chips, was recovered on site. One of the memory chips exhibited several visible cracks to the package, and the other chip was found undamaged. The two memory chips were sent to Honeywell’s facility in Redmond, Washington, for examination and data recovery. 32 The drugs tested in the postaccident analysis include (but are not limited to) marijuana, cocaine, opiates, phencyclidine, amphetamines, benzodiazapines, barbiturates, antidepressants, antihistamines, meprobamate, and methaqualone.

Factual Information 15 Aircraft Accident Report Honeywell could only recover EGPWS data from the undamaged memory chip. EGPWS data from 12 flight parameters, including altitude, ground speed, descent rate, pitch, roll, and ground track, were available on the undamaged chip for about the last 30 seconds of the flight. A flight simulation conducted using the EGPWS data indicated that two EGPWS alerts had been recorded; however, the identification of the alert types was contained on the damaged chip and, therefore, the alert types could not be identified. Further, the EGPWS data were compared with the radar-data-based calculations and showed a good correlation with the calculations up to about 2 to 3 seconds into the loss of control, after which time the data were considered unreliable because of the large dynamic movements of the airplane. 1.16.2 Airplane Performance Study The Safety Board conducted an airplane performance study using EGPWS data, PUB ASR-7 radar data, manufacturer-provided aerodynamic data, and meteorological information to establish a time history of the airplane’s motions and to estimate the airplane’s performance parameters (including ground speed, airspeed, descent rate, and aircraft pitch and roll angles) for the final portion of the flight. Nominal error or uncertainty in the radar and wind data led to variables in the airplane performance parameters; therefore, the performance parameters should be considered approximations. According to the airplane performance study, the airplane started its final descent from 7,000 feet at an airspeed of about 155 knots about 0911:26. Over about the next 30 seconds, the descent rate was about 800 feet per minute (fpm). By about 0912:30, as the airplane was passing through about 6,200 feet, the descent rate had decreased to about 490 fpm, and the airspeed had decreased to about 98 knots. Over the next 10 seconds, the airspeed continued to decrease to about 90 knots. Immediately after passing through about 6,100 feet, the airplane experienced the onset of a large roll to the left concurrent with a sudden decrease in the pitch angle, consistent with the motion of an airplane that has experienced an aerodynamic stall. 1.17 Organizational and Management Information At the time of the accident, Circuit City Stores, Inc., which is headquartered in Richmond, Virginia, owned and maintained operational control of the accident airplane, another Cessna 560 airplane (the sister ship), and a Cessna Citation 650 airplane. Martinair, Inc., is a Part 135 aircraft charter and management company that began operations in July 1986. Martinair has provided pilots and maintenance support for Circuit City Stores airplanes through a management services agreement since 1993. At the time of the accident, Martinair managed 15 aircraft, operated 11 aircraft, and had 33 full- and part-time pilots and 8 aircraft mechanics. Martinair’s chief pilot stated that, although Circuit City Stores flights fell under 14 CFR Part 91 operating rules, company pilots generally adhered to Part 135 operating rules for these flights and used the same checklists and standard operating procedures used for Part 135 flights.

Factual Information 16 Aircraft Accident Report 1.17.1 Operational Guidance 1.17.1.1 Normal Operations According to the SimuFlite Cessna Citation V Technical Manual,33 a typical ILS approach should be flown, in part, as follows: When established on the localizer inbound to the FAF [final approach fix], ensure that flaps are set to T.O. [takeoff] and APPR [approach]. Maintain airspeed at Vref+20+wind factor and initiate the Before Landing checklist… At glideslope intercept, start timing, begin descent, and extend full flaps. Complete Before Landing checklist to the autopilot/yaw damper. Maintain airspeed at Vref+10+wind factor… Reduce power slightly to ensure crossing the runway threshold at Vref+wind factor. Martinair’s Operations Manual stated that, under normal circumstances, the airspeed on final must be held at Vref+10 ±5 knots and that the airspeed must be bled off to Vref at the runway threshold. 1.17.1.2 Operations in Icing Conditions The SimuFlite Cessna Citation V Technical Manual contains the following warning: “with any residual ice present do not attempt to fly uncorrected Vref/Vapp [34] speeds. Stall speeds increase and stall warning margins decrease.” The technical manual also contains the following caution: In icing conditions, a small amount of residual ice forms on unprotected areas. This is normal, but can cause an increase in stall speeds. When any amount of residual ice is visible, the stall speeds increase by 8 knots; the Vref/Vapp speeds and landing distances and the maximum landing weight permitted by brake energy must be corrected. Assuming some residual icing was present on the airplane’s surfaces during the accident flight, the corrected Vref would have been 104 knots. At 0859:29, the CVR recorded the first officer stating that the Vref was 96 knots. 33 The guidance for operating in icing conditions in the Simuflite Cessna Model 560 Citation V Technical Manual, which was used as the training manual for Martinair pilots, is in accordance with the guidance contained in the Cessna Model 560 Citation V AFM. 34 Vapp is the landing approach airspeed with approach flaps and landing gear up.

Factual Information 17 Aircraft Accident Report 1.17.1.3 Anti-Ice and Deice Systems Usage According to the SimuFlite Cessna Citation V Technical Manual, when operating in visible moisture and when the outside air temperature is between -30° and +10° C, the pitot static heat and engine anti-ice systems should be turned to ON. The manual also states that, if the temperature is above -18° C, the windshield bleed air switch should be turned to LOW, and, if the temperature is below -18° C, the windshield bleed air switch should be turned to HIGH. According to SimuFlite’s technical manual (and the Cessna AFM), the surface deice boots should be used when ice buildup is estimated to be between 1/4- to 1/2-inch thick. The manual further states, “Early activation of the boots may result in ice bridging[35] on the wing, rendering the boots ineffective. Late activation (if accumulation is more than 1/2-inch thick) may not clear the ice.” The manual also states the following: When reconfiguring for approach and landing…with any ice accretion visible on the wing leading edge, regardless of thickness, activate the surface deice system. Continue to monitor the wing leading edge for any reaccumulation. 1.17.2 Flight Crew Training Martinair provides initial in-house ground school training to company pilots. After the in-house training, pilots attend flight simulator training at CAE SimuFlite. 1.17.2.1 Operations in Icing Conditions During postaccident interviews, several SimuFlite instructors stated that guidance on operations in icing conditions is taught in initial and recurrent ground school. The training includes a review of the anti-ice and deice systems and their usage and anti-ice failure scenarios. The instructors also stated that icing operations in the simulator involved introducing ice on the wings. Pilots are taught to activate the deice boots after about 1/4 to 1/2 inch of ice has accumulated on the wings and to use the anti-ice systems when flying in visible moisture36 and when the outside air temperature is between -30° and +10° C. According to the SimuFlite instructors, the specific items to be covered during simulator training on operations in icing conditions are left to the discretion of the individual instructors. A review of SimuFlite’s training syllabus also revealed that no specific instruction exists to evaluate a pilot’s performance of the AFM procedures to increase the airspeed and operate the deice boots during approaches when ice is present on the wings. Further, one of the SimuFlite Cessna 560 instructors was unaware of these AFM procedures. Investigators also interviewed a Cessna 560 instructor from another 35 Ice bridging is a phenomenon in which ice in the shape of an inflated deice boot forms after the boot is cycled. Ice bridging had been known to occur on older deice boot designs that used larger tubes and lower pressures, resulting in slower inflation and deflation rates. 36 The manual indicates that visible moisture includes, but is not limited to, the following conditions: fog with visibility less than 1 mile, wet snow, and rain.

Factual Information 18 Aircraft Accident Report major flight training center, and he stated that, although he believed that each instructor emphasized the icing approach procedures during simulator training, the center’s syllabus contained no instruction to ensure that the instructors are evaluating the procedures. 1.17.2.2 Stall Recovery A SimuFlite instructor indicated that stalls in the clean, takeoff, and landing configurations are covered during training and checkrides. He stated that stall recovery in the Cessna 560 should be initiated at stickshaker activation and that recovery from an impending stall consisted of adding maximum power while conserving the altitude as much as possible. 1.18 Additional Information 1.18.1 Cessna 550 and 560 Airplanes Icing-Related Flight Testing and Subsequent Actions In early 1996, the FAA conducted preliminary evaluations of the Cessna 560 stall speeds and characteristics when operating in icing conditions. The evaluations were conducted partially as the result of the following icing-related Cessna 55037 and 560 accidents:38 • On December 30, 1995, a Cessna 560 crashed while circling to land in icing conditions in Eagle River, Wisconsin.39 The investigation revealed that about 1/8 inch of rime ice had accumulated on the left wing and horizontal stabilizer leading edges. • On January 2, 1996, a Cessna 560 crashed while on final approach in icing conditions in Augsburg, Germany.40 The pilots reported that the airplane started to buffet, entered a stall, and rolled right. No stall warnings were activated during the flight. The investigation by the German Federal Bureau of Accidents Investigation (BFU) revealed that about 2 mm (0.078 inch) of ice had accumulated along the wing leading edges. 37 The airfoil used on model 560 series airplanes is a modified version of the airfoil used on model 550 series airplanes. The main spar height is the same; however, the leading edge and the upper surface curvature have been changed to improve high airspeed performance. 38 The FAA also noted that several test pilots from its training academy had reported concerns about the Cessna 560’s stall handling characteristics. 39 The description of this accident, CHI96FA067, can be found on the Safety Board’s Web site at http://www.ntsb.gov. 40 For more information, see German Federal Bureau of Accidents Investigation, Report on the Accident to the Aircraft Cessna 560 on January 2, 1996, at Augsburg, File No. CX 001-0/96 (Braunschweig City, Germany: BFU, 1996).

Factual Information 19 Aircraft Accident Report • On February 19, 1996, a Cessna 550 crashed while on final approach in Salzburg, Austria.41 On the basis of radar recordings and witness testimony, the BFU determined that the airplane entered a stall, banked left, and became uncontrollable. The BFU stated that heavy icing at low altitudes prevailed during the approach and that the accident “happened because the minimum control airspeed was undershot during the final approach.” As a result of flight tests conducted in early 1996 with the Cessna 560, the FAA issued Priority Letter Airworthiness Directive (AD) 96-24-06, which was applicable to the Cessna 560, in November 1996. AD 96-24-06 required revising the Cessna Model 560 Citation V AFM to provide flight crews with airspeed limitations, deice system operational procedures, and landing performance information to be used during approach and landing when residual ice was present or expected to prevent the uncommanded roll of the airplane in such conditions. In late 1996, with Cessna participation, the FAA conducted additional flight tests with Cessna 550 and 560 series airplanes to assess the airplanes’ stall speeds, warnings, and characteristics. The FAA conducted the flight tests using airplanes with and without 1/2-inch-thick ice shapes installed on the protected (that is, those surfaces with deice boots) and unprotected surfaces of the wing.42 The flight tests of the Cessna 550 revealed that the airplane had an acceptable stall warning margin with and without the ice shapes installed. The flight tests of the Cessna 560 revealed that the stall warning margin was insufficient with and without ice shapes installed.43 Specifically, the flight tests of the Cessna 560 revealed that, even without ice shapes installed, the stall warning system activated only about 1 to 2 knots before a significant lateral roll tendency and subsequent stall occurred. The tests also showed that, with ice shapes installed, the stall warning system activated shortly after or concurrent with a stall and a subsequent significant lateral roll. The tests indicated that the stall speed increased from 3 to 5 knots with the ice shapes installed and that the stall warning system did not compensate for the increased stall speed. In early 1999, Cessna began incorporating modified stall warning systems on the Cessna 560 airplane (including the accident airplane) to provide a sufficient stall warning margin for operations in icing conditions. The modifications resulted in a stall warning margin increase of about 5 knots and were outlined in Cessna Service Bulletins (SB) SB560-34-69 and SB560-34-70. On April 3, 2000, the FAA issued AD 2000-03-09, 41 An English translation of the full accident report was not available; however, an English summary of the findings and the probable cause was provided to investigators by the BFU. 42 At the time of the Cessna 560 certification flight tests, artificial ice shapes were not required to be installed on the protected surfaces of the airplane. According to the original Cessna 560 flight testing certification, the flight tests were conducted in natural icing conditions and with artificial ice shapes installed on the unprotected surfaces of the airplane. According to the FAA, 1/2-inch ice shapes were used for the 1996 tests because these shapes represented the type of ice accumulated during the most likely encountered icing conditions and because the Cessna Model 560 Citation V AFM instructed pilots to activate the deice boots when ice accumulation was estimated to be from 1/4- to 1/2-inch thick. 43 Title 14 CFR 25.207 requires that the stall warning begin at a speed exceeding the stall speed by a margin of not less than 5 knots.

Factual Information 20 Aircraft Accident Report which superseded AD 96-24-06. AD 2000-03-69 retained the requirements contained in AD 96-24-06 and added a requirement to mandate the modifications outlined in Cessna SBs SB560-34-69 and SB560-34-70. The FAA indicated that the modified stall warning systems would also protect against the undesirable stall characteristics exhibited during the previous icing-related Cessna accidents and the 1996 ice shape tests. 1.18.2 Previous Icing-Related Safety Recommendations The Safety Board has previously issued numerous icing-related safety recommendations, several of which are on the Safety Board’s List of Most Wanted Transportation Safety Improvements. Five previously issued icing-related safety recommendations are relevant to the Pueblo accident and are detailed in this section. One of these recommendations was issued as a result of the investigation of the October 31, 1994, accident involving American Eagle flight 4184, which crashed during a rapid descent after an uncommanded roll excursion during icing conditions.44 The other four relevant recommendations were issued as a result of the investigation of the January 9, 1997, accident involving Comair Airlines, Inc., flight 3272, which experienced a loss of control while maneuvering with ice accumulation on the wings.45 1.18.2.1 Deice Boot System Activation During the Comair flight 3272 accident investigation, the Safety Board learned that the AFMs for many aircraft, including the Cessna 560, instructed pilots to delay initial deice boot activation until they observed 1/4- to 1/2-inch-thick ice accumulation on the wing surface. Further, the Cessna Model 560 Citation V AFM states, “early activation of the boots may result in ice bridging on the wing.” Additionally, Advisory Circular (AC) 25.1419-1A, “Certification of Transport Category Airplanes for Flight in Icing Conditions,” dated May 7, 2004, states, “many AFMs specify ice accumulation thickness prior to activation of the deicer boot system. The practice originates from a belief that a bridge of ice could form if boots are operated prematurely.” However, the AC further states the following: Although ice may not shed completely by one cycle of the boots, this residual ice will usually be removed during subsequent boot cycles and does not act as a foundation for a bridge to form. The AFM procedure for boot operations should be to operate the boots at the first sign of ice and not wait for a specific amount of ice to accumulate. 44 For additional information, see National Transportation Safety Board, In-flight Icing Encounter and Loss of Control, Simmons Airlines, d.b.a. American Eagle Flight 4184, Avions de Transport Regional (ATR) Model 72-212, N401AM, Roselawn, Indiana, October 31, 1994; Volume I Safety Board Report, Aircraft Accident Report NTSB/AAR-96/02 (Washington, DC: NTSB, 1996). 45 For additional information, see National Transportation Safety Board, In-Flight Icing Encounter and Uncontrolled Collision With Terrain, Comair Airlines, Inc., Flight 3272, Embraer EMB-120RT, N265CA, Monroe, Michigan, January 9, 1997, Aircraft Accident Report NTSB/AAR-98/04 (Washington, DC: NTSB, 1998).

Factual Information 21 Aircraft Accident Report Additionally, information gathered at a 1997 Airplane Deice Boot Bridging Workshop, which included participants from the FAA and the National Aeronautics and Space Administration (NASA); subsequent icing tunnel studies; and flight tests conducted as part of the Comair investigation revealed no evidence that modern turbine-powered airplanes (that is, airplanes equipped with high-pressure, segmented pneumatic deice boots that quickly inflate and deflate) were at risk for ice bridging. Further, a search of the Safety Board’s accident database revealed no accidents related to ice bridging. The icing tunnel tests, wind tunnel data, and existing icing research data revealed that thin (1/4 inch or less), rough ice accumulations on the wing leading edge deice boot surfaces could be, depending on distribution, as aerodynamically detrimental to an airplane’s performance as larger ice accumulations and that such ice could be difficult for pilots to perceive. As a result of these findings, the Safety Board issued Safety Recommendation A-98-91, which asked the FAA to do the following: Require manufacturers and operators of modern turbopropeller-driven airplanes in which ice bridging is not a concern to review and revise the guidance contained in their manuals and training programs to emphasize that leading edge deicing boots should be activated as soon as the airplane enters icing conditions. On July 16, 1999, the FAA issued Notice for Proposed Rulemaking (NPRM) 99-NM-136-AD, which was applicable to Cessna model 500, 501, 550, 551, and 560 series airplanes and proposed revising the applicable AFMs to include a requirement to activate the deice boots at the first sign of ice accumulation and to cycle the boots automatically, if the automatic mode was available, or to cycle the boots manually to minimize ice accumulation on the airframe. From July 1999 to March 2000, the FAA issued 18 similar NPRMs applicable to 14 CFR Part 23 airplanes and 21 NPRMs applicable to Part 23 and 25 airplanes equipped with pneumatic deice boots.46 In an August 12, 1999, letter to the FAA, Cessna requested that NPRM 99-NM-136-AD be withdrawn, contending that the affected airplanes’ service history in icing conditions, the modifications made to the airplanes’ stall warning systems, and the minimum airspeed in icing conditions guidance contained in its AFM validated that the airplanes could operate safely in icing conditions and that, therefore, the NPRM was not warranted. In a September 25, 2000, response letter to Safety Recommendation A-98-91, the FAA stated that it withdrew NPRM 99-NM-136-AD in November 1999 because manufacturer’s data indicated that the affected aircraft could operate safely with ice accretion on the protected surfaces. The FAA also withdrew six of the other NPRMs it issued from July 1999 to March 2000 for similar reasons. On May 19, 2003, the FAA informed the Safety Board about recommendations an Aviation Rulemaking Advisory Committee (ARAC) Ice Protection Harmonization Working Group (IPHWG) had made to revise Parts 25 and 121. The proposed revisions 46 In a March 12, 2000, response letter, the Safety Board expressed concern that the proposed ADs would require that the deice boot system be activated at the first sign of ice accumulation, not as soon as the airplane enters icing conditions.

Factual Information 22 Aircraft Accident Report would add a requirement that operators’ guidance state that the deice system be activated as soon as the airplane enters icing conditions.47 However, in the intervening 3 years, the FAA has taken no further action; therefore, on May 10, 2006, the Board classified Safety Recommendation A-98-91 “Open—Unacceptable Response,” pending issuance of a final rule adopting the regulatory changes proposed by the ARAC IPHWG. 1.18.2.2 Certification Requirements for Flight into Icing Conditions The Safety Board determined during the American Eagle flight 4184 accident investigation that SLD conditions can cause ice accretions that are more aerodynamically detrimental than those that were considered during the initial certification of many existing airplanes for flight in icing conditions (that is, those conditions that fell within the Part 25, Appendix C envelope).48 As a result, the Board issued Safety Recommendation A-96-54 (superseding Safety Recommendation A-81-116), which asked the FAA to do the following: Revise the icing criteria published in 14…CFR Parts 23 and 25, in light of both recent research into aircraft ice accretion under varying conditions of liquid water content, drop size distribution, and temperature, and recent developments in both the design and use of aircraft. Also, expand the Appendix C icing certification envelope to include freezing drizzle/freezing rain and mixed water/ice crystal conditions, as necessary. Safety Recommendation A-96-54 was reiterated in the Comair flight 3272 accident report and is currently on the Safety Board’s List of Most Wanted Transportation Safety Improvements. In a March 6, 2006, letter, the FAA stated that the ARAC IPHWG is continuing to develop a revision to Part 25 to require a demonstration that an airplane can safely operate in SLD conditions for an unrestricted time or can detect SLD and safely exit icing conditions. The Safety Board noted in its May 10, 2006, letter that, although the work of the IPHWG is responsive to this recommendation, the actions are proceeding at an unacceptably slow pace and that the FAA has not yet received the recommendations from the IPHWG, prepared regulatory analyses, issued an NPRM, analyzed comments, or completed the many other tasks involved in issuing new regulations. Pending development and issuance of regulatory requirements for both Part 23 and 25 airplanes to demonstrate that they can safely operate in SLD conditions for an unrestricted time or can detect the SLD and safely exit icing conditions, the Board classified Safety Recommendation A-96-54 “Open—Unacceptable Response.” The Safety Board also determined during the Comair flight 3272 accident investigation that the ice accretions and conditions considered during certification for 47 The ARAC IPHWG also stated that an operator’s guidance could only state that the deice system should be activated at the first sign of ice accumulation if the operator had demonstrated through additional flight tests that the airplane could operate safely with some ice accumulation. 48 Part 25, Appendix C specifies the kind of icing conditions in which an airplane’s ice protection system must be able to operate.

Factual Information 23 Aircraft Accident Report flight into icing conditions were not representative of all types of ice that could be encountered while operating in icing conditions, including rough ice accretions of less than 1/4 inch, which can severely degrade an airplane’s performance. Further, the effects of delayed anti-ice and deice system activation, intercycle ice accretions,49 or residual ice accretions were not addressed in the icing certification rules. Therefore, the Board issued Safety Recommendations A-98-92 and -100, both of which are currently on the Board’s List of Most Wanted Transportation Safety Improvements. Safety Recommendation A-98-92 asked the FAA to do the following: Conduct additional research to identify realistic ice accumulations, to include intercycle and residual ice accumulations and ice accumulations on unprotected surfaces aft of the deicing boots, and to determine the effects and criticality of such ice accumulations; further, the information developed through such research should be incorporated into aircraft certification requirements and pilot training programs at all levels. In a September 21, 2001, response letter, the FAA indicated that sufficient information and methods were not available at that time to provide additional guidance concerning the determination of critical ice shapes in aircraft certification and that, therefore, it would sponsor additional needed research. In an October 26, 2005, response letter, the FAA indicated that it had completed and would shortly issue a draft revision to AC 20-73, “Aircraft Ice Protection,” which included the certification guidance on determining critical ice shapes, descriptions of intercycle and residual ice accretions, and the aerodynamic penalties associated with these ice shapes. Although the FAA issued AC 20-73A on August 16, 2006, Safety Recommendation A-98-92 remains classified “Open—Unacceptable Response,” pending the receipt of information regarding any new research conducted in response to this recommendation. The Safety Board also issued a safety recommendation concerning the determination of critical ice shapes, A-98-100, to the FAA, which stated the following: When the revised icing certification standards [recommended in Safety Recommendation A-98-92] and criteria are complete, review the icing certification of all turbopropeller-driven airplanes that are currently certificated for operation in icing conditions and perform additional testing and take action as required to ensure that these airplanes fulfill the requirements of the revised icing certification standards. On November 4, 2005, in response to Safety Recommendation A-98-100, the FAA issued an NPRM titled, “Airplane Handling Characteristics in Icing Conditions,” which proposed to revise 14 CFR 25.143, “Proof of Compliance,” by adding a new paragraph, (i)(1), that specifies the certification requirements for airplane performance or handling qualities for flight in icing conditions and the type of ice accretions (including the size, shape, and location) that must be used to demonstrate compliance in each phase of flight. Specifically, the NPRM stated that thin, rough ice accretions must be considered to show 49 Intercycle ice is ice that has accreted on the deice surface between boot activation cycles.

Factual Information 24 Aircraft Accident Report compliance with proposed paragraph 25.143(i)(1). In its January 2006 comments on the NPRM, the Safety Board stated that it agreed with the intent of the NPRM and added that the ice used to demonstrate compliance with proposed paragraph 25.143(i)(1) should accurately represent thin, rough ice accretions, which can cause severe aerodynamic penalties. On November 4, 2005, the FAA also proposed AC 25-1X, “Performance and Handling Characteristics in the Icing Conditions Specified in Part 25, Appendix C,” which was intended to provide guidance for implementing the regulations proposed in the NPRM. In its January 2006 comments on the proposed AC, the Safety Board noted that the results of the research conducted as a part of the Comair flight 3272 accident investigation are currently included in Appendix R of draft AC 20-73, “Aircraft Ice Protection.” Appendix R, which is also referenced in Appendixes 1 and 2 of proposed AC 25.21-1X, includes guidance on determining critical ice shapes and their associated roughness, descriptions of intercycle and residual ice accretions, and the aerodynamic penalties associated with these ice shapes.50 Although the Safety Board agreed with the FAA’s proposed regulatory changes, in its May 10, 2006, response letter, the Board noted that the FAA has not applied the new information to all in-service turbopropeller-driven airplanes. Although the FAA indicated that no airplanes have an unsafe condition, the Board stated that it was concerned that the FAA reached this conclusion based on its belief that no accidents or serious incidents had occurred related to this issue. However, the Board stated that, during the 1990s, a number of accidents had occurred involving airplanes that had passed the certification standards and for which the FAA believed there was no unsafe condition requiring action and that these accidents generated new information that the FAA could now use. The Board stated that, to meet the intent of Safety Recommendation A-98-100, the FAA would need to formally evaluate (perhaps by conducting flight tests) all in-service turbopropeller-driven aircraft to ensure that these aircraft comply with all current icing certification criteria for new aircraft. The Board asked the FAA to provide a list of the aircraft that it had formally evaluated and a summary of the findings and resultant actions. Pending receipt of this information, Safety Recommendation A-98-100 was classified “Open—Unacceptable Response.” 51 1.18.2.3 Stall Warning Margins The Safety Board also determined during the Comair flight 3272 investigation that the stall warning did not activate until after the stall, as in this accident, because ice accumulation on the airplane had increased the stall speed and that the stall warning system was not designed to account for the increase caused by the type of ice that had 50 For more information about the testing conducted to determine the effects of residual and intercycle ice accretions, see section 1.18.3. 51 Safety Recommendation A-98-100 is on the Safety Board’s List of Most Wanted Transportation Safety Improvements. Accordingly, Safety Recommendation A-07-16, which supersedes Safety Recommendation A-98-100, will automatically be placed on the Most Wanted List.

Factual Information 25 Aircraft Accident Report accreted on the airplane. As a result, the Board issued Safety Recommendation A-98-96, which asked the FAA to do the following: Require manufacturers and operators of all airplanes that are certificated to operate in icing conditions to install stall warning/protection systems that provide a cockpit warning (aural warning and/or stick shaker) before the onset of stall when the airplane is operating in icing conditions. In a September 21, 2001, response letter, the FAA stated that it was pursuing regulatory development projects that would require both new and in-service airplanes to have stall warning systems installed that provide a cockpit warning before the onset of a stall when operating in icing conditions. However, in an October 26, 2005, response letter, the FAA stated that, after further review, it had determined that such a requirement for all in-service airplanes would impose a cost burden not commensurate with the potential safety benefits and that, therefore, it would take appropriate action on in-service airplane designs only if an unsafe condition were identified. The November 2005 NPRM proposed changes to 14 CFR 25.207 to require that newly type-certificated airplanes be equipped with stall warning systems that provide a stall warning before the onset of a stall when the airplane is operating in icing conditions. In its comments on the NPRM, the Safety Board stated that the proposed changes appear to address the intent of Safety Recommendation A-98-96 for newly type-certificated airplanes; however, the proposed changes do not address in-service airplanes. Further, in its May 2006 response letter, the Board stated that it was not acceptable for the FAA to wait until an accident or serious incident occurred to reveal that an unsafe condition existed on an in-service airplane. As a result, the Board classified Safety Recommendation A-98-96 “Open—Unacceptable Response,” pending issuance of a final rule associated with the November 2005 NPRM that includes a requirement that both newly type-certificated and in-service airplanes be equipped with stall warning systems that provide a cockpit warning before the onset of a stall in icing conditions. 1.18.3 Residual and Intercycle Ice and Automatic Deice Boot System Information In May 2002, as a result of additional testing conducted during the Comair flight 3272 investigation, the FAA published a report titled, Effect of Residual and Intercycle Ice Accretions on Airfoil Performance,52 which presented the results of testing designed to characterize and evaluate the aerodynamic performance effects of residual and intercycle ice accretions resulting from the cyclic operation of a typical aircraft deice boot system.53 The tests were conducted using a scaled version of the EMB-120 airfoil outboard wing section, which is similar to the Cessna Citation airfoil, and liquid water 52 Federal Aviation Administration, Office of Aviation Research, Effect of Residual and Intercycle Ice Accretions on Airfoil Performance, DOT/FAA/AR-02/68 (Washington, DC: 2002). 53 Some pneumatic deice boot systems can be turned on and activated automatically at either slow/low (3-minute) or fast/high (1-minute) cycle intervals. Cessna Citation series airplanes are not equipped with automatic deice boot recycling systems.

Factual Information 26 Aircraft Accident Report contents and mean volumetric diameters that fell within the current envelopes for known icing certification. During the tests, the deice boots were cycled at both 1- and 3-minute intervals. Results from the icing tests showed that the intercycle ice accretions were much larger in size and surface extent than residual ice accretions and that the intercycle ice shapes caused significant performance degradation. The testing showed that the deice boots generally removed the ice from the wing leading edge and left little residual ice. A single continuous maximum case was run with 1-minute boot cycles, which was found to be very effective in minimizing the size of the intercycle ice accretion. The tests also revealed that the deice boot system was equally effective at shedding ice when activated at the first sign of ice as when activated once a 1/4 inch of ice had accumulated. The FAA’s test report recommended the “early and often” approach to deicing (that is, activating the deice boots as soon as ice is detected and cycling the boots at 1-minute intervals) to limit the size of residual and intercycle ice accretions. On May 7, 2004, the FAA issued AC 25.1419-1A, which stated the following. The recommended AFM procedure for boot operation should be to operate the boots at the first sign of ice. … The boots should be operated until icing conditions are exited and ice no longer adheres to the airframe. On July 21, 2004, the FAA issued revised AC 23.1419-2C, “Certification of Part 23 Airplanes for Flight in Icing Conditions,” which reiterated the FAA’s technical report findings and added the following: For deicing systems that do not have a timer to cycle the system automatically once activated, the additional task of manually cycling deicing systems on pilot workload should be evaluated. A recent Part 23 applicant found that definition of airframe deicing boot intercycle and residual ice steered them toward one-minute boot cycles and the workload evaluation dictated an automatic timer for the boots.

27 Aircraft Accident Report 2. Analysis 2.1 General The captain and first officer were properly certificated and qualified under Federal regulations. No evidence indicated any preexisting medical or physical condition that might have adversely affected the flight crew’s performance during the accident flight. A review of the pilots’ 72-hour histories revealed that the pilots slept well in the days leading up to the accident flight and went to bed early in preparation for an early departure. No evidence was found that fatigue degraded the performance of either pilot on the day of the accident. The weight and balance of the airplane were within landing limits. The recovered components showed no evidence of any preexisting powerplant, structural, or system failures. The PUB local controller did not provide the accident flight crew or the Denver FSS with the PIREP reporting light to moderate icing; however, this was not a factor in the accident because CVR information indicated that the flight crew was aware of the icing conditions. During the approach, the flight crew of the sister ship, which was following the accident flight, cycled the deice boots numerous times and maintained a high airspeed and, subsequently, landed safely, indicating the importance of taking these actions to counteract the hazardous effects of icing. This analysis discusses the accident sequence, including the flight crew’s performance. This analysis also discusses inadequate training on operations in icing conditions, inadequate deice boot system operational guidance, the need for automatic deice boot systems, inadequate icing flight test certification requirements, and inadequate stall warning margins in icing conditions. 2.2 Accident Sequence 2.2.1 Descent Into Icing Conditions Surface observations and radar data indicated that freezing drizzle conditions existed in the PUB area around the time of the accident and that temperatures were below freezing from the surface to 30,000 feet. Several PIREPs and NWS products transmitted around the time of the accident, including winter weather advisories that warned of freezing drizzle, confirmed the presence of icing conditions in the PUB area. CVR

Analysis 28 Aircraft Accident Report evidence indicates that, starting about 0851, the flight crew began taking actions to minimize the icing’s hazardous effects, such as activating the airplane’s engine and windshield anti-ice systems. About 4 minutes later, the first officer stated that he saw a little bit of “grayish ice,” which is indicative of ice that has a rough surface, building up on the wing leading edges. He then stated that there was “a real thin line back there.” An analysis of the CVR and meteorological information indicated that mixed icing conditions existed from about 21,000 to 14,000 feet. Radar data and CVR information indicated that the airplane was in this icing layer for about 5 1/2 minutes. At 0858:20, as the airplane was descending through about 18,000 feet, the first officer suggested to the captain that he might want to cycle the deice boots.54 After cycling the deice boots, the captain indicated that the deice boots might have shed a little of the ice but that some ice remained on the wing, indicating the presence of residual ice. 2.2.2 Approach to Landing In accordance with the SimuFlite Cessna Citation V Technical Manual and the Cessna Model 560 Citation V AFM, pilots were trained that, when any residual ice is present or can be expected during approach and landing, Vref must be increased by 8 knots. The manuals also contained both a caution and a warning indicating that stall speeds increased during operations in icing conditions, and that, therefore, Vref must be increased. At 0859:29, the CVR recorded the first officer state that the Vref was 96 knots. In the case of this flight, the Vref should have been increased from 96 to 104 knots because of the icing conditions. The CVR did not record either pilot mention increasing the airspeed at any point during the approach. Therefore, the Safety Board concludes that the flight crew did not increase the Vref while operating in icing conditions, contrary to company procedures and manufacturer guidance. 2.2.3 Final Approach At 0908:25, while at an altitude of about 9,400 feet, the first officer reported that the flight was in IMC, and, about 1 minute later, while at an altitude of about 7,400 feet, he reported that clear ice had accumulated on the airplane’s wing. CVR and meteorological information indicated that the airplane likely encountered SLD conditions from 9,400 to 6,100 feet (the calculated altitude at the time of the upset) and that the airplane was likely in these conditions for about 4 1/2 minutes. During this time, about 1 to 4 mm (0.039 to 0.156 inch) of additional ice could have accumulated on the wing leading edges. The Safety Board concludes that the airplane encountered SLD conditions, which are most conducive to the formation of thin, rough ice on or aft of the protected surfaces, during about the last 4 1/2 minutes of the flight. The Safety Board further concludes that the airplane had residual ice on the wings after the deice boots were activated earlier in the 54 As noted, the pilots had been trained to wait until 1/4- to 1/2-inch-thick ice accumulation was visible on the wing leading edges before activating the deice boots.

Analysis 29 Aircraft Accident Report flight and that this ice would have affected the overall thickness, roughness, and distribution of the SLD ice accumulation. According to the airplane performance study, about 0910, the airplane started its final descent from 7,000 feet at an airspeed of about 155 knots. By about 0911:35, the airspeed had started to decrease. CVR evidence indicated that the landing gear was extended at 0911:10, followed by extension of the speedbrakes and selection of full flaps. At 0912:04, the first officer stated, “and you are plus twenty five,” to which the captain replied, “slowing.” On the basis of a Vref of 96 knots, the airspeed would have been about 121 knots at the time of the first officer’s statement. At 0912:37, when the airplane was at an altitude of about 6,100 feet, the first officer told the captain that he might want to run the deice boots and that they had the Vref. Company procedures for approach and landing in icing conditions stated that, when reconfiguring for approach and landing (extending landing gear and selecting full flaps), pilots should activate the deice boot system when any ice accumulation, regardless of thickness, is visible on the wing leading edges and continue to monitor the leading edges for any reaccumulation. Although the CVR recorded the first officer mention to the captain that they might want to activate the deice boots at 0912:37, there is no evidence that the deice system was activated during the approach. Therefore, the Safety Board concludes that the flight crew did not activate the deice boots when configuring for the approach and landing, which was contrary to company procedures and manufacturer guidance. The airplane performance calculations showed that, immediately after passing through about 6,100 feet, the airplane entered a large roll to the left concurrent with a sudden decrease in pitch, indicating the start of the loss of control and aerodynamic stall. No evidence exists indicating that the stall warning activated before or concurrent with the upset. In accordance with the Cessna Model 560 Citation V AFM and the design of the stall warning system, the accident airplane’s stall warning should have activated about 86 knots. Although it could not be determined at precisely what airspeed the loss of control occurred, airplane performance calculations indicated that the stall occurred at an airspeed of about 90 knots, which was well above the expected stall speed in icing conditions of 81 knots. According to company and manufacturer guidance on approach airspeeds in icing conditions, the airplane’s airspeed at the time of the upset should have been about 114 knots.55 The performance calculations and EGPWS ground speed data showed that the airspeed continued to decrease until the loss of control. The Safety Board concludes that the flight crew failed to maintain adequate airspeed during the final approach in icing conditions, which led to an aerodynamic stall from which they did not recover. 55 According to the guidance, the approach airspeed should be Vref+10 knots, in this case, 106 knots. Because the guidance requires that 8 knots be added to the approach airspeed in icing conditions, the approach airspeed should have been 114 knots.

Analysis 30 Aircraft Accident Report As noted, the flight crew did not increase the approach airspeed or activate the deice boots during the approach, which is required for the Cessna 560 when ice is present on the wing. Although it could not be determined precisely why the flight crew did not maintain adequate airspeed or activate the deice boots during the approach, the Safety Board discovered during the investigation that there may be insufficient training on operational procedures in icing conditions. For example, postaccident interviews with simulator flight instructors revealed that these procedures might not be getting emphasized during simulator training because the details of the training are left up to the individual instructors. Further, a review of two flight training centers’ syllabuses revealed that they do not state that instructors should emphasize these procedures. The Board is concerned that these operational procedures are not being consistently evaluated during simulator training. The Safety Board concludes that pilots could benefit from the reinforcement during training of the Cessna 560 AFM requirements to increase the airspeed and operate the deice boots during approaches when ice is present on the wings. Therefore, the Safety Board believes that the FAA should require that operational training in the Cessna 560 airplane emphasize the AFM requirements that pilots increase the airspeed and operate the deice boots during approaches when ice is present on the wings. 2.2.4 Flight Crew Monitoring and Workload Management The Safety Board examined the flight crew’s actions during the approach to determine the role of the timing of the approach briefing in the accident sequence. Although the flight crew had expected to land on runway 8L, based on the current ATIS information, at 0905:56, approach control issued vectors for the ILS to runway 26R. According to the CVR, the flight crew noted the change in the runway assignment and immediately tuned the radios and set the inbound course. However, subsequent discussion about the details of the runway 26R approach was not initiated until almost 5 minutes later, at 0910:47. During the remaining 2 minutes before the stall, the flight crew needed to intercept the localizer and glideslope and configure and slow the airplane for the approach. However, CVR evidence showed that, although these airplane-handling tasks were being performed, the flight crew was concurrently briefing the ILS 26R approach. Specifically, from 0912:17 to 0912:31, as the airspeed was decreasing, the flight crew briefed the missed approach procedure for runway 26R. It was only at the end of this discussion that the first officer recognized and called for the need to run the deice boots and indicated that the airplane had slowed to Vref. The Safety Board recognizes that a runway change can disrupt a flight crew’s planning and may affect the pilots’ ability to conduct an approach briefing during a relatively low workload phase of flight, such as the top of the descent. When the runway change occurs late in the approach, it is important for flight crews to determine how and when to conduct the briefing to ensure that the objectives of the briefing are achieved without compromising safety of flight.56 For the accident flight crew, the runway change occurred early enough for the briefing to have been completed before the pilots began to configure and slow the airplane for final approach. Literature on monitoring emphasizes

Analysis 31 Aircraft Accident Report that cockpit workload should be distributed to minimize conflicting task demands during critical phases of flight. In this case, the flight crew’s delayed approach briefing served to divert the pilots’ attention from handling the airplane, managing the deice boot system, and monitoring the tasks that had to be performed during that period. The Safety Board concludes that the briefing conducted late in the approach was a distraction that impeded the flight crew’s ability to monitor and maintain airspeed and manage the deice system. The Safety Board has long recognized the importance of flight crew monitoring skills in accident prevention. For example, the Board’s 1994 safety study of 37 major flight crew-involved accidents found that, for 31 of these accidents, inadequate monitoring and/or cross-checking had occurred.57 The study found that flight crewmembers frequently failed to recognize and effectively draw attention to critical cues that led to the accident sequence. As a result of this safety study, the Board issued Safety Recommendations A-94-3 and -4 to the FAA concerning the need for enhanced training of pilot monitoring skills. The recommendations stated, in part, that the FAA should require airlines operating under 14 CFR Part 121 to provide line operational simulation training that “allows flightcrews to practice, under realistic conditions, non-flying pilot functions, including monitoring and challenging errors made by other crewmembers” and that airlines’ initial operating experience programs should include training and experience for check airmen and pilots “in enhancing the monitoring and challenging functions.”58 In response to these recommendations, the FAA upgraded its written guidance to industry to enhance pilot training on monitoring. Specifically, on September 8, 1995, the FAA revised AC 120-51, “Crew Resource Management Training,” to emphasize monitoring issues. The guidance in AC 120-51 stated that “effective monitoring and cross-checking can be the last line of defense that prevents an accident” and that “the 56 Industry guidance states that crews should ask ATC for assistance, such as requesting to receive delayed vectors or enter a holding pattern, when they become rushed or otherwise behind on their duties as a result of unanticipated routings. 57 For additional information, see National Transportation Safety Board, A Review of Flightcrew-Involved, Major Accidents of U.S. Carriers, 1978 through 1990, Safety Study NTSB/SS-94/01 (Washington, DC: NTSB, 1994). 58 The complete text of Safety Recommendation A-94-3 to the FAA was as follows: “Require U.S. air carriers operating under 14 CFR Part 121 to provide, for flight crews not covered by the Advanced Qualification Program, line operational simulation training during each initial or upgrade qualification into the flight engineer, first officer, and captain position that (1) allows flight crews to practice, under realistic conditions, non-flying pilot functions, including monitoring and challenging errors made by other crewmembers; (2) attunes flight crews to the hazards of tactical decision errors that are errors of omission, especially when those errors are not challenged; and (3) includes practice in monitoring and challenging errors during taxi operations, specifically with respect to minimizing procedural errors involving inadequately performed checklists.” The complete text of Safety Recommendation A-94-4 to the FAA was as follows: “Require that U.S. air carriers operating under 14 CFR Part 121 structure their initial operating experience programs to include: (a) training for check airmen in enhancing the monitoring and challenging functions of captains and first officers; (b) sufficient experience for new first officers in performing the non-flying pilot role to establish a positive attitude toward monitoring and challenging errors made by the flying pilot; and (c) experience (during initial operating experience and annual line checks) for captains in giving and receiving challenges or errors.” On January 19, 1996, the Safety Board classified these recommendations “Closed—Acceptable Alternate Action” in response to the FAA’s upgrades of its training guidance.

Analysis 32 Aircraft Accident Report monitoring function is always essential, particularly during approach and landing.” Since that action, other FAA guidance on workload management and monitoring skills has been developed. For example, on February 27, 2003, the FAA expanded its guidance in this area in a revision of AC 120-71, “Standard Operating Procedures for Flight Deck Crewmembers,” to emphasize the importance of procedures, such as distributing cockpit workload to avoid interfering with pilot monitoring and assigning cockpit responsibilities so that one pilot can monitor continuously during high workload periods. With respect to conducting approach briefings and their impact on monitoring, the AC states that pilots should “when able, brief the anticipated approach prior to top-of-descent” to allow “greater attention to be devoted to properly monitoring … because the crew is not having to divide attention between reviewing the approach and monitoring the descent.” The guidance contained in both ACs is available to operators to support pilot training programs but is not mandatory. The Safety Board is aware of recent accidents in which inadequate pilot monitoring was a causal or contributing factor to the accident and in which pilots on approach to landing failed to observe critical and salient cues.59 These accidents demonstrate the importance of monitoring skills and effective workload management in ensuring safety of flight. Existing FAA guidance to operators addresses these skills but providing specific pilot training on effective monitoring and cockpit workload management would be a way for the aviation industry to effectively deliver and reinforce the importance of these skills to pilots. The Safety Board concludes that all operators would benefit from an increased focus on providing monitoring skills in their training programs, including those operating under 14 CFR Parts 121 and 135, as would pilots completing FAA-approved training programs for Part 91 operations.60 Therefore, the Safety Board believes that the FAA should require pilot training programs be modified to contain modules that teach and emphasize monitoring skills and workload management and include opportunities to practice and demonstrate proficiency in these areas. 2.3 Deice Boot Systems Company and manufacturer guidance states that the surface deice boots should be used when ice buildup is estimated to be between 1/4- to 1/2-inch thick and that “early activation of the boots may result in ice bridging on the wing.” During the Comair 59 For additional information, see National Transportation Safety Board, Collision With Trees on Final Approach, Federal Express Flight 1478, Boeing 727-232, N497FE, Tallahassee, Florida, July 26, 2002, Aviation Accident Report NTSB/AAR-04/02 (Washington, DC: NTSB, 2004); National Transportation Safety Board, Crash During Approach to Landing, Air Tahoma, Inc., Flight 185, Convair 580, N586P, Covington, Kentucky, August 13, 2004, Aviation Accident Report NTSB/AAR-06/03 (Washington, DC: NTSB, 2006); and National Transportation Safety Board, Crash During Approach to Landing, Business Jet Services Ltd., Gulfstream G-1159A (G-III), N85VT, Houston, Texas, November 22, 2004, Aviation Accident Brief NTSB/AAB-06/06 (Washington, DC: NTSB, 2006). 60 The Safety Board recognizes that many pilots engaged primarily in noncommercial flying under 14 CFR Part 91 do not complete formal training programs but believes that these pilots can benefit from the increased industry emphasis and specific training principles on monitoring.

Analysis 33 Aircraft Accident Report flight 3272 investigation, the Safety Board learned that many manufacturers and operators had similar deice boot operational guidance and concerns about ice bridging. However, AC 25.1419-1A states that, although ice may not be completely shed by one cycle of the boots, the residual ice will usually be removed by subsequent cycles and does not act as a foundation for a bridge of ice to form. Further, information gathered at a 1997 Airplane Deice Boot Bridging Workshop, subsequent icing tunnel tests, and flight tests conducted as part of the Comair investigation revealed that ice bridging did not occur on modern airplanes, which are equipped with deice boots that quickly inflate and deflate. The icing tunnel tests also revealed that thin (1/4 inch or less), rough ice accumulations on the wing leading edge deice boot surfaces could be, depending on distribution, as aerodynamically detrimental to an airplane’s performance as larger ice accumulations. A search of the Safety Board accident database revealed no accidents related to ice bridging. Conversely, the Board has investigated many icing accidents in which the airplane stalled prematurely and the stall warning system did not activate before the stall because of ice accumulation on the wing leading edges. This accident, previous accident investigations, Safety Board accident data, and existing icing information clearly show that delaying the activation of the deice boots can create unsafe operations. The Safety Board concludes that ice bridging does not occur on modern airplanes; therefore, it is not a reason for pilots to delay activation of the deice boots. As a result of its findings during the Comair flight 3272 investigation, the Safety Board issued Safety Recommendation A-98-91, which recommended that the FAA do the following: Require manufacturers and operators of modern turbopropeller-driven airplanes in which ice bridging is not a concern to review and revise the guidance contained in their manuals and training programs to emphasize that leading edge deicing boots should be activated as soon as the airplane enters icing conditions. In May 2002, the FAA issued an icing test report that recommended an “early and often” approach to deice boot usage to limit the size of residual and intercycle ice accretions. Further, in January 2003, an ARAC IPHWG recommended revisions to Parts 25 and 121 to require that deice systems be activated as soon as an airplane enters icing conditions. However, since that time, the FAA has taken no action to issue a final rule adopting the regulatory changes proposed by the ARAC IPHWG. Although the accident airplane most likely accumulated less than 1/4-inch-thick ice while operating in the lower cloud layer, the pilots’ failure to activate the deice boots during the approach led to the continued accumulation of thin, rough ice on the protected surfaces, which can severely degrade an airplane’s performance. The circumstances of this accident, information gathered during the Comair flight 3272 accident, and reports issued by the FAA and the ARAC IPHWG clearly demonstrate that existing guidance instructing pilots to delay activation of the deice boots until they observe 1/4- to 1/2-inch-thick ice accumulation is not adequate because it does not protect against the detrimental effects caused by thin, rough ice accumulation on or aft of the protected surfaces. If pilots

Analysis 34 Aircraft Accident Report continue to adhere to guidance about delaying deice boot activation, similar accidents could still occur. The Safety Board concludes that activating the deice boots as soon as an airplane enters icing conditions provides the greatest safety measure. On the basis of this accident and the Board’s continued concerns in this area, the Board believes that the FAA should require manufacturers and operators of pneumatic deice boot-equipped airplanes to revise the guidance contained in their manuals and training programs to emphasize that leading edge deice boots should be activated as soon as the airplane enters icing conditions. The new recommendation will supersede Safety Recommendation A-98-91 and will be classified “Open—Unacceptable Response.” The Safety Board is concerned that workload increases significantly when pilots of airplanes equipped with deice boots that do not cycle automatically operate in icing conditions because they must continuously monitor the ice accumulation on the airplane’s surfaces and determine when to reactivate the deice boots. This consideration is consistent with FAA concerns in AC 23.1419-2C.61 Having to operate the deice boot system manually is even more critical during the approach and landing phases of flight when pilot workload and monitoring demands are greatest. The Safety Board concludes that manual operation of the deice boot system increases pilot workload, which can result in distraction during critical phases of flight, such as approach and landing. Therefore, the Safety Board believes that the FAA should require that all pneumatic deice boot-equipped airplanes certified to fly in known icing conditions have a mode incorporated in the deice boot system that will automatically continue to cycle the deice boots once the system has been activated. 2.4 Certification Requirements for Flight Into Icing Conditions The Safety Board has previously identified concerns about inadequate flight test certification requirements. For example, the American Eagle flight 4184 accident investigation revealed that SLD conditions can cause ice accretions that are more aerodynamically detrimental than those accretions that fall within the Part 25, Appendix C envelope. As a result, the Safety Board issued Safety Recommendation A-96-54, which asked the FAA to do the following: Revise the icing criteria published in 14…CFR Parts 23 and 25, in light of both recent research into aircraft ice accretion under varying conditions of liquid water content, drop size distribution, and temperature, and recent developments in both the design and use of aircraft. Also, expand the Appendix C icing certification envelope to include freezing drizzle/freezing rain and mixed water/ice crystal conditions, as necessary. 61 AC 23.1419-2C stated that the effect on pilot workload of continuously cycling the deice boots should be evaluated.

Analysis 35 Aircraft Accident Report Further, icing tunnel tests conducted as part of the Comair flight 3272 accident investigation indicated that the effects of ice accretion on airplane performance could vary widely depending on the size, distribution, and type of ice accumulated on the airplane’s surfaces. However, the Board learned that manufacturers are not required to demonstrate an airplane’s flight handling characteristics or stall margins using thin, rough ice that can accrete on protected surfaces before the activation of the deice boot system or between activation cycles. As a result of its findings, the Board issued Safety Recommendation A-98-92, which asked the FAA (in cooperation with NASA and other interested aviation organizations) to do the following: [C]onduct additional research to identify realistic ice accumulations and … determine the effects and criticality of such ice accumulations … the information developed … should be incorporated into aircraft certification requirements. The Safety Board also issued Safety Recommendation A-98-100, which asked the FAA to review the icing certification of all turbopropeller-driven airplanes currently certificated for operation in icing conditions, perform additional testing, and take action as required to ensure that these airplanes fulfill the requirements of the revised icing certification standards asked for in Safety Recommendation A-98-92. The FAA indicated in a March 6, 2006, response to Safety Recommendation A-96-54 that the ARAC IPHWG is continuing to develop a revision to Part 25 to require a demonstration that an airplane can safely operate in SLD conditions for an unrestricted time or can detect SLD and safely exit icing conditions. However, the FAA has still not received the recommendations from the IPHWG, prepared regulatory analyses, issued the NPRM, analyzed comments, or completed the many other tasks involved in issuing new regulations. The FAA indicated in an October 26, 2005, response to Safety Recommendation A-98-92 that it had completed and would shortly issue a draft revision to AC 20-73, which included the certification guidance on determining critical ice shapes, descriptions of intercycle and residual ice accretions, and the aerodynamic penalties associated with these ice shapes. Although the FAA issued AC 20-73A on August 16, 2006, it has still not provided the Safety Board with information regarding any new research conducted in response to this recommendation. Regarding Safety Recommendation A-98-100, the FAA issued an NPRM in November 2005, which proposed to expand 14 CFR Part 25 to include specific certification requirements for airplane performance or handling qualities for flight in icing conditions and to specify the ice accumulations that must be considered for each phase of flight. Further, the FAA proposed changes to AC 25-1X, which intended to provide guidance for implementing the regulations proposed in the NPRM. In May 2006, the Safety Board expressed concern that, although it agreed with the proposed regulatory changes, the FAA had not applied the new standards to all in-service turbopropeller-driven aircraft. The FAA further indicated that no airplanes have an unsafe condition in icing environments despite a number of accidents in the 1990s that involved

Analysis 36 Aircraft Accident Report airplanes that had passed the certification standards. The Board stated that, to meet the intent of Safety Recommendation A-98-100, the FAA would need to formally evaluate (perhaps by conducting flight tests) all in-service turbopropeller-driven aircraft to ensure that these aircraft comply with all current icing certification criteria for new aircraft. The Board asked the FAA to provide a list of the aircraft that it had formally evaluated and a summary of the findings and resultant actions. To date, this information has not been received. The circumstances of the Comair flight 3272, American Eagle 4184, and Pueblo accidents and the icing tunnel test data show that the ice shapes used during initial certification flight tests were not adequate because the tests did not account for thin, rough ice on the wing. The 1996 ice shapes tests on the Cessna 560 were also inadequate because, although tests were conducted with ice shapes on the protected surfaces, tests were not conducted using thin, rough ice. Therefore, additional ice sizes, distribution patterns, and types need to be considered during flight testing to more adequately gauge an airplane’s performance in icing conditions. The Safety Board concludes that existing flight test certification requirements for flight into icing conditions do not test the effects of thin, rough ice on or aft of an airplane’s protected surfaces, which can cause severe aerodynamic penalties. The circumstances of this accident clearly show that the actions requested in Safety Recommendations A-96-54 and A-98-92 are needed to improve the safety of all airplanes operating in icing conditions. Therefore, the Safety Board reiterates Safety Recommendations A-96-54 and A-98-92. As noted, Safety Recommendation A-98-100 only addressed turbopropeller-driven airplanes. The circumstances of this accident clearly demonstrate that deice boot-equipped turbojet airplanes also require additional testing in an expanded Appendix C icing certification envelope, which would include thin, rough ice accumulations and intercycle and residual ice. Therefore, the Safety Board believes that the FAA should, when the revised icing certification standards and criteria are complete, review the icing certification of all pneumatic deice boot-equipped airplanes that are currently certificated for operation in icing conditions and perform additional testing and take action as required to ensure that these airplanes fulfill the requirements of the revised icing certification standards. The new recommendation (A-07-16) will supersede Safety Recommendation A-98-100 and will be classified “Open—Unacceptable Response.” 62 2.5 Inadequate Stall Warning Margins in Icing Conditions Stall warning systems are intended to provide flight crews with adequate warning of an impending stall to give them enough time to take necessary action to prevent a stall. 62 Safety Recommendation A-98-100 is on the Safety Board’s List of Most Wanted Transportation Safety Improvements. Accordingly, Safety Recommendation A-07-16 will automatically be placed on the Most Wanted List.

Analysis 37 Aircraft Accident Report The CVR sound spectrum study indicated that the accident airplane’s stall warning did not activate until after the stall. The Pueblo accident is not the first accident in which a stall has occurred before the stall warning activated. For example, the Safety Board determined during the Comair flight 3272 accident investigation that the airplane departed controlled flight before the stall warning activated and that stall warning systems “often do not provide adequate warning when the airplane is operating in icing conditions.” As a result of the Comair investigation, the Safety Board issued Safety Recommendation A-98-96, which recommended that the FAA require manufacturers and operators of all airplanes certificated to operate in icing conditions to install stall warning systems that provide a cockpit warning before the onset of a stall when the airplane is operating in icing conditions. The FAA stated in an October 26, 2005, response letter that it was pursuing rule changes to require only that newly certificated airplanes have stall warning systems installed that provide a cockpit warning before the onset of a stall when operating in icing conditions and that it would take appropriate action on in-service airplanes only if an unsafe condition were identified. The November 2005 NPRM proposed changes to 14 CFR 25.207 to require that only newly type-certificated airplanes be equipped with stall warning systems that provide a stall warning before the onset of a stall when the airplane is operating in icing conditions. In its comments on the proposed NPRM and in its May 2006 response letter to the FAA, the Safety Board stated that it was not acceptable for the FAA to wait until an accident or serious incident occurred to reveal that an unsafe condition existed on an in-service airplane and that, because the proposed changes did not address in-service airplanes, Safety Recommendation A-98-96 was classified “Open—Unacceptable Response.” The Board continues to believe that not requiring in-service airplanes to be equipped with improved stall warning systems until an unsafe condition is identified is unacceptable and encourages the FAA to expedite issuance of a final rule that contains such a requirement. Regarding the Cessna 560’s stall warning system, in 1996, the FAA conducted ice testing using 1/2-inch ice shapes installed on the protected surfaces. As a result of these tests, in early 1999, Cessna began incorporating a modified stall warning system on Cessna 560 airplanes (including the accident airplane) to provide a 5-knot increase in the stall warning margin for operations in icing conditions. However, as this accident has shown, these modifications were not adequate because they did not take into account the effects of thin, rough ice on the protected surfaces; therefore, additional modifications to the airplane’s stall warning system are necessary. The Safety Board concludes that the Cessna 560 airplane’s stall warning system did not provide a stall warning before the upset. The Safety Board further concludes that the Cessna 560 airplane’s stall warning system does not provide a warning in all icing conditions, including those conditions in which thin, rough ice can accumulate on the protected surfaces. Therefore, the Safety Board believes that the FAA should require modification of the Cessna 560 airplane’s stall warning system to provide a stall warning margin that takes into account the size, type, and distribution of ice, including thin, rough ice on or aft of the protected surfaces.

38 Aircraft Accident Report 3. Conclusions 3.1 Findings 1. The captain and first officer were properly certificated and qualified under Federal regulations. No evidence indicated any preexisting medical or physical condition that might have adversely affected the flight crew’s performance during the accident flight. A review of the pilots’ 72-hour histories revealed that they slept well in the days leading up to the accident flight and went to bed early in preparation for an early departure. No evidence was found that fatigue degraded the performance of either pilot on the day of the accident. 2. The weight and balance of the airplane were within landing limits. 3. The recovered components showed no evidence of preexisting powerplant, structural, or system failures. 4. The Pueblo Memorial Airport local controller did not provide the accident flight crew or the Denver Flight Service Station with the pilot report reporting light to moderate icing; however, this was not a factor in the accident because cockpit voice recorder information indicated that the flight crew was aware of the icing conditions. 5. During the approach, the flight crew of the sister ship, which was following the accident flight, cycled the deice boots numerous times and maintained a high airspeed and, subsequently, landed safely, indicating the importance of taking these actions to counteract the hazardous effects of icing. 6. The flight crew did not increase the landing reference airspeed while operating in icing conditions, contrary to company procedures and manufacturer guidance. 7. The airplane encountered supercooled large droplet (SLD) conditions, which are most conducive to the formation of thin, rough ice on or aft of the protected surfaces, during about the last 4 1/2 minutes of the flight. Further, the airplane had residual ice on the wings after the deice boots were activated earlier in the flight, and this ice would have affected the overall thickness, roughness, and distribution of the SLD ice accumulation. 8. The flight crew did not activate the deice boots when configuring for the approach and landing, which was contrary to company procedures and manufacturer guidance. 9. The flight crew failed to maintain adequate airspeed during the final approach in icing conditions, which led to an aerodynamic stall from which they did not recover.

Conclusions 39 Aircraft Accident Report

1. Pilots could benefit from the reinforcement during training of the Cessna Model 560

Citation V Airplane Flight Manual requirements to increase the airspeed and operate the deice boots during approaches when ice is present on the wings.

1. The briefing conducted late in the approach was a distraction that impeded the flight

crew’s ability to monitor and maintain airspeed and manage the deice system.

1. All operators would benefit from an increased focus on providing monitoring skills in

their training programs, including those operating under 14 Code of Federal Regulations Parts 121 and 135, as would pilots completing Federal Aviation Administration-approved training programs for Part 91 operations.

1. Ice bridging does not occur on modern airplanes; therefore, it is not a reason for pilots

to delay activation of the deice boots.

1. Activating the deice boots as soon as an airplane enters icing conditions provides the

greatest safety measure.

1. Manual operation of the deice boot system increases pilot workload, which can result

in distraction during critical phases of flight, such as approach and landing.

1. Existing flight test certification requirements for flight into icing conditions do not

test the effects of thin, rough ice on or aft of an airplane’s protected surfaces, which can cause severe aerodynamic penalties.

1. The Cessna 560 airplane’s stall warning system did not provide a stall warning before

the upset.

1. The Cessna 560 airplane’s stall warning system does not provide a warning in all

icing conditions, including those conditions in which thin, rough ice can accumulate on the protected surfaces. 3.2 Probable Cause The National Transportation Safety Board determines that the probable cause of this accident was the flight crew’s failure to effectively monitor and maintain airspeed and comply with procedures for deice boot activation on the approach, which caused an aerodynamic stall from which they did not recover. Contributing to the accident was the Federal Aviation Administration’s failure to establish adequate certification requirements for flight into icing conditions, which led to the inadequate stall warning margin provided by the airplane’s stall warning system.

40 Aircraft Accident Report 4. Safety Recommendations 4.1 New Safety Recommendations As a result of its investigation of the February 16, 2005, accident involving a Cessna Citation 560, the National Transportation Safety Board makes the following recommendations to the Federal Aviation Administration: Require that operational training in the Cessna 560 airplane emphasize the airplane flight manual requirements that pilots increase the airspeed and operate the deice boots during approaches when ice is present on the wings. (A-07-12) Require that all pilot training programs be modified to contain modules that teach and emphasize monitoring skills and workload management and include opportunities to practice and demonstrate proficiency in these areas. (A-07-13) Require manufacturers and operators of pneumatic deice boot-equipped airplanes to revise the guidance contained in their manuals and training programs to emphasize that leading edge deice boots should be activated as soon as the airplane enters icing conditions. (A-07-14) (This safety recommendation supersedes Safety Recommendation A-98-9163 and is classified “Open—Unacceptable Response.”) Require that all pneumatic deice boot-equipped airplanes certified to fly in known icing conditions have a mode incorporated in the deice boot system that will automatically continue to cycle the deice boots once the system has been activated. (A-07-15) When the revised icing certification standards (recommended in Safety Recommendations A-96-54 and A-98-92) and criteria are complete, review the icing certification of pneumatic deice boot-equipped airplanes that are currently certificated for operation in icing conditions and perform additional testing and take action as required to ensure that these airplanes fulfill the requirements of the revised icing certification standards. (A-07-16) (This safety recommendation supersedes Safety Recommendation A-98-10064 and is classified “Open—Unacceptable Response.”) 63 For more information about this recommendation, see sections 1.18.2.1 and 2.3. 64 For more information about this recommendation, see sections 1.18.2.2 and 2.4.

Safety Recommendations 41 Aircraft Accident Report Require modification of the Cessna 560 airplane’s stall warning system to provide a stall warning margin that takes into account the size, type, and distribution of ice, including thin, rough ice on or aft of the protected surfaces. (A-07-17) 4.2 Previously Issued Safety Recommendations Reiterated in This Report The Safety Board reiterates the following safety recommendations to the Federal Aviation Administration: Revise the icing criteria published in 14 Code of Federal Regulations Parts 23 and 25, in light of both recent research into aircraft ice accretion under varying conditions of liquid water content, drop size distribution, and temperature, and recent developments in both the design and use of aircraft. Also, expand the Appendix C icing certification envelope to include freezing drizzle/freezing rain and mixed water/ice crystal conditions, as necessary. (A-96-54)65 With the National Aeronautics and Space Administration and other interested avation organizations, conduct additional research to identify realistic ice accumulations, to include intercycle and residual ice accumulations and ice accumulations on unprotected surfaces aft of the deicing boots, and to determine the effects and criticality of such ice accumulations; further, the information developed through such research should be incorporated into aircraft certification requirements and pilot training programs at all levels. (A-98-92) For more information about these recommendations, see sections 1.18.2.2 and 2.4. 65 Safety Recommendation A-96-54 superseded Safety Recommendation A-81-116, which was issued in 1981. BY THE NATIONAL TRANSPORTATION SAFETY BOARD MARK V. ROSENKER Chairman ROBERT L. SUMWALT Vice Chairman DEBORAH A. P. HERSMAN Member KATHRYN O. HIGGINS Member STEVEN R. CHEALANDER Member Adopted: January 23, 2007

42 Aircraft Accident Report Board Member Statements Member Deborah A.P. Hersman’s Statement, Concurring in part and Dissenting in part:

While I agree with the general outcome of this report, I believe the probable cause ultimately approved by the Board is not entirely consistent with the rest of the report. As I asserted at the Board meeting on January 23, 2007, the inadequate guidance provided to aircraft operators regarding the operation of deice boots should have been cited as a contributing factor. Furthermore, the FAA’s inadequate certification requirements for flight into icing conditions should have been cited as one of the two primary causes of the accident, rather than as a contributing cause.

The final probable cause would lead one to believe that this was not an icing accident but simply an accident of pilot failures—failure to effectively monitor and maintain airspeed and failure to properly activate the deice boots. However, the rest of the report lays a foundation for finding that this accident was very much about ice and a lack of understanding among operators about whether an aircraft can safely operate in any type of ice and how to appropriately manage ice accumulation. FAA’s failure to establish proper certification requirements for aircraft flying in icing conditions should be cited as one of the primary causes of this accident. The Board has long been concerned about aircraft icing and inadequate certification standards. Following the Safety Board’s 1981 study on aircraft icing, numerous recommendations were issued to the FAA to revise certification standards regarding ice accretion under varying conditions. In over 25 years, the FAA has done little to address this issue and we have reiterated the original recommendations over and over and they remain on our Most Wanted List of Safety Improvements in an unacceptable status. According to the Cessna Model 560 Citation V AFM, the airplane’s anti-ice and de-ice systems were not designed to protect against freezing rain or severe conditions of mixed or clear ice. However, during the investigation of this accident, the National Center for Atmospheric Research determined that, on the basis of surface, radar, upper air, and satellite data, the airplane likely encountered Supercooled Large Droplet conditions, which are more conducive to the accumulation of thin, rough ice, between 9,400 to 6,100 feet (the altitude at which the upset occurred). The pilots were unaware that they were flying in conditions that the plane was not certificated for because there are no reliable methods for flight crews to differentiate, in flight, between water drop sizes that are outside the certification envelope. Furthermore, the Cessna 560 airplane’s stall warning system does not provide warning in this type of icing condition. In a recommendation in 1996, the Board recommended that FAA revise its icing criteria. That recommendation is being reiterated in this report. Another recommendation issued to FAA in 1996 is being revised and re-issued in this report, recommending that FAA revise icing certification requirements for airplanes equipped with pneumatic deice boots. Perhaps, if FAA had taken such measures 10 years ago, much more would have been understood by the pilots about flying in this type of icing

Board Member Statements 43 Aircraft Accident Report condition. For that reason, FAA has a place in the probable cause equal to that of the pilots who executed the errors in the conduct of this flight.

The narrative of the accident is clear that the pilots of this aircraft did not fail to monitor the icing conditions. The cockpit voice recorder revealed that they were aware of the icing conditions and they activated the de-ice boots at least once. The First Officer talked about the color of the ice, the rate of accumulation, and compared it to the ice accumulated on the previous day, and the Captain discussed the ice remaining on the wings after the initial activation of the deice boots. The probable cause faults the crew, not because they did not effectively monitor the icing conditions, but because they failed to activate the deice boots at the correct time. The report states that the manufacturer’s guidance and language in the AFM recommends that the deice boots be used when the ice buildup is between ¼ to ½ inches thick and that early activation of the boots could result in ice bridging. Despite information revealed during previous NTSB accident investigations (Comair Flight 3272, Monroe, Michigan, January 9, 1997), NASA published research on the topic, public information events such as the November 1997 Airplane Deicing Boot Ice Bridging Workshop, and various FAA publications, the ice bridging concept is still real to some pilots and operators. This concern about ice bridging was reinforced to this Board Member during a conversation earlier this month, with a well-respected pilot of a modern Cessna aircraft equipped with pneumatic boots, who repeatedly spoke of ice bridging and the guidance from the manual requiring a ¼ to ½ inch of ice accumulation before activating the boots. Regrettably, it appears that little has changed in the 10 years since the Board investigated the Monroe accident, the following language was contained in our November 30, 1998, recommendation letter to Administrator Garvey on recommendations A-98-88 through –106: “This illustrates how thoroughly ingrained the ice bridging concept was in pilots and operators and the importance of an ice bridging pilot education program. Therefore, a thin, yet performance-decreasing type of ice (similar to that likely accumulated by Comair flight 3272) can present a more hazardous situation that a 3-inch ram’s horn ice accumulation because it would not necessarily prompt the activation of the boots. Based on this information, the Safety Board concludes that the current operating procedures recommending that pilots wait until ice accumulates to an observable thickness before activating leading edge deicing boots results in unnecessary exposure to a significant risk… Based primarily on concerns about ice bridging, pilots continue to use procedures and practices that increase the likelihood of (potentially hazardous) degraded airplane performance resulting from small amounts of rough ice accumulated on the leading edges.” Yet in another part of the AFM, the direction to the crew is contradictory, “When configuring for approach and landing… with any ice accretion visible on the wing leading edge, regardless of thickness, activate the surface deice system. Continue to

Board Member Statements 44 Aircraft Accident Report monitor the wing leading edge for any accumulation.” Unfortunately, our investigators found that the SimuFlite training syllabus had no specific instruction to evaluate crew performance of the AFM procedures to increase the airspeed and operate the deice boots during approaches when ice is present on the wings. In addition, one of the instructors was unaware of these AFM procedures. Furthermore, this guidance about activating the deice boots on approach with any ice accretion seems to nullify the earlier guidance about waiting for a measurable ice build up prior to boot activation and de-bunking the myth of ice-bridging. Which leads me to question why Cessna requested, and the FAA agreed to withdraw NPRM 99-NM-136-AD, which was applicable to Cessna model 500, 501, 550, 551, and 560 series airplanes and proposed revising the applicable AFMs to include a requirement to activate the deice boots at the first sign of ice accumulation and to cycle the boots to minimize ice accumulation. When the NPRM was withdrawn, Cessna continued to publish the ¼ to ½ inch accumulation language. If it is safer to eliminate any visible ice from the wings during the approach phase of flight, then the same logic ought to apply to all phases of flight. FAA Advisory Circular AC 25.1419-1A states that residual ice does not act as a foundation for bridging ice. Furthermore, our report states, additional tests have shown that ice bridging does not occur on modern airplanes and deice boots should be activated as soon as an aircraft enters icing conditions. This contradiction between recent studies, the FAA Advisory Circular, and manufacturer guidance led the Board to include in this report a recommendation that FAA require manufacturers and operators of airplanes with deice boots to revise the guidance in their manuals to emphasize that deice boots should be activated as soon as the airplane enters icing conditions. Furthermore, the Board reiterated an older recommendation that FAA conduct additional research on the effects of residual ice accumulations behind the deicing boots and incorporate those new findings into the certification requirements and pilot training programs. I believe that in failing to cite the inadequate guidance as a contributing factor in the probable cause, and in relegating FAA’s failures to only a contributing cause, the Board is leaving a part of this investigation report undone. In our quest to make flying ever safer, we may never reach a time when pilots don’t sometimes make inexplicable errors. But in a case such as this one where we can piece the evidence together and spot plausible reasons why the pilots made the mistakes they made, we should do so emphatically. In almost 40 years of accident investigations, we have improved aviation safety and improved our process of accident investigations, but I believe we can and should reach further in our efforts. Simply citing the flight crew’s failure to monitor and maintain airspeed and de-ice the wings as required by the AFM is not going far enough. Until the AFMs fly the airplanes, we need to address the actions of the human beings who do fly the airplanes. In this accident, the reason the pilots failed in their critical tasks is because they did not have the benefit of proper guidance from the FAA and from the manufacturer about flying in the conditions they found themselves. While the Board articulated this issue very clearly in our conclusions and our recommendations, I believe the Board should have included this aspect in the probable cause as the best means of helping to prevent other pilots from making the same error in the future.

Board Member Statements 45 Aircraft Accident Report Member Higgins joined Member Hersman in this statement. [Original signed]

Deborah A. P. Hersman

January 30, 2007

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47 Aircraft Accident Report 5. Appendixes Appendix A Investigation and Public Hearing Investigation The National Transportation Safety Board was initially notified about this accident on the afternoon of February 16, 2005. A full go-team was assembled in Washington, D.C., and traveled to the accident scene. The go-team was accompanied by former Chairman Engleman Conners. The following investigative groups were formed: Operations, Meteorology, Air Traffic Control, Airworthiness, Maintenance Records, Powerplants, Aircraft Performance, Survival Factors, and Cockpit Voice Recorder. Parties to the investigation were the Federal Aviation Administration; Martinair, Inc.; and Cessna Aircraft Company. An accredited representative from the Transportation Safety Board of Canada and a technical advisor from Pratt and Whitney Canada also assisted in the investigation. Public Hearing No public hearing was held for this accident.

48 Aircraft Accident Report Appendix B Cockpit Voice Recorder Transcript The following is the transcript of the B&D Instruments and Avionics cockpit voice recorder, serial number A01148, installed on a Cessna 560 that crashed while on approach to Pueblo Memorial Airport, Pueblo, Colorado, on February 16, 2005. LEGEND HOT Crewmember hot microphone voice or sound source RDO Radio transmission from accident aircraft CTR1 Radio transmission from 1st Denver Center controller CTR2 Radio transmission from 2nd Denver Center controller APR Radio transmission from Pueblo approach control FBO Radio transmission from Pueblo fixed base operator TWR Radio transmission from Pueblo tower TWR Radio transmission from aircraft N500FK SW6431 Radio transmission from Skywest flight six four three one -1 Voice identified as Pilot-in-Command (PIC) -2 Voice identified as Co-Pilot (SIC) -3 Voice identified as aircraft mechanical voice -? Voice unidentified * Unintelligible word @ Non-pertinent word # Expletive

Break in continuity ( ) Questionable insertion [ ] Editorial insertion ... Pause Note 1: Times are expressed in mountain standard time (MST). Note 2: For ATC transmissions, generally only radio transmissions to and from the accident aircraft were tran- scribed.

Appendix B 49 Aircraft Accident Report 1 of 27 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (MST) TIME (MST) & SOURCE CONTENT & SOURCE CONTENT 0841:19 START of RECORDING START of TRANSCRIPT 0842:27 HOT-2 the secondary held in there pretty good on that little bit of de- scent. 0842:30 HOT-1 yeah. 0842:32 HOT-2 called standby I guess they call it. 0842:35 HOT-1 twenty feet. 0843:50 HOT-2 one thing I was thinking about, I'm surprised that Jepps didn't show that, as good as Jepps is. 0843:59 HOT-1 yeah, I would have thought it would have been on there. 0844:01 HOT-2 I mean that's not your every day departure procedure if you're an east coast flier. 0844:03 HOT-1 yeah.

Appendix B 50 Aircraft Accident Report 2 of 27 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (MST) TIME (MST) & SOURCE CONTENT & SOURCE CONTENT 0844:21 CTR1 Citation five hundred Alpha Tango, descend and maintain flight level two seven zero. 0844:25 RDO-2 five hundred Alpha Tango, three six oh for two seven oh. 0844:31 HOT-1 twenty seven. 0844:32 HOT-2 twenty seven. 0844:50 HOT-2 uh, no arrivals or nothing. they do have a uh, a radar, ASR if we had to have it. that's old as #. I reckon it's still in use. 0845:00 HOT-1 yeah. 0845:43 500FK Denver, good morning, Citation five zero zero Fox Kilo's with you out of thirty five and a half down to three four zero. 0845:49 CTR1 Citation five zero zero Foxtrot Kilo Denver center, roger. 0846:06 HOT-2 did you got number, well number one for me. 0846:07 HOT-1 I got one.

Appendix B 51 Aircraft Accident Report 3 of 27 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (MST) TIME (MST) & SOURCE CONTENT & SOURCE CONTENT 0846:13 RDO-2 Flower Aviation, Pueblo, Citation five hundred Alpha Tango. 0846:20 FBO good morning five hundred Alpha Tango, this is Flower Aviation in Pueblo, go ahead. 0846:25 RDO-2 yes ma'am, how you doing this morning? we'll be landing in about twenty minutes and we have uh, six passengers. be a uh, pit stop and a quick turn. and, gonna give you a fuel (order) here in just a second. 0846:43 FBO I understand that you're twenty minutes out. you have six pas- sengers for a pit stop and a quick turn and you'll give me the fuel in just a minute. 0846:51 HOT-2 you still want, you still want two hundred? 0846:54 HOT-1 uuh, yeah uh, have you already talked to 'em? 0846:58 HOT-2 no, I've got her on the radio. 0847:00 HOT-1 let's make it two ten a side. 0847:01 HOT-2 okay. that sounds good.

Appendix B 52 Aircraft Accident Report 4 of 27 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (MST) TIME (MST) & SOURCE CONTENT & SOURCE CONTENT 0847:06 RDO-2 and uh, young lady there at Flower Aviation for five hundred Al- pha Tango. we'll take two hundred and ten gallons a side, with Prist. 0847:16 FBO I understand that you're gonna want two one zero, two hundred and ten gallons a side and our Jet A is pre-mixed. 0847:23 RDO-2 okeydoke, and we'll, and we'll see you in just a little bit for the quick turn. and we have uh, just to let you know, we got com- pany traffic behind us uh, about ten minutes too. 0847:24 CTR1 Citation five hundred Alpha Tango contact Denver center one three three point four. 0847:28 RDO-1 thirty three four uh, Alpha Tango, so long. 0847:31 FBO okay, we'll see you in twenty minutes on the west end of the main terminal and we'll see your company in thirty minutes on the west end of the main terminal. 0847:39 RDO-2 okeydoke, thank you. 0847:40 RDO-1 and Denver center, Citation five hundred Alpha Tango's with you checking in three two zero for two seven zero.

Appendix B 53 Aircraft Accident Report 5 of 27 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (MST) TIME (MST) & SOURCE CONTENT & SOURCE CONTENT 0847:48 CTR2 Citation five hundred Alpha Tango Denver center, cross uh, change that to just descend and maintain one three, thirteen thousand. the Pueblo altimeter's three zero one six. 0847:57 RDO-1 thirty sixteen and one three thousand uh, Alpha Tango. 0848:02 HOT-2 all right, I'm back with you. 0848:04 HOT-1 all right. 0848:06 HOT-2 uh, down to thirteen thousand. 0848:07 HOT-1 I see that. 0848:08 HOT-2 uh.... what'd he say? three zero one six? 0848:14 HOT-1 think that's what he said. 0848:16 HOT-2 yeah, that's what I got. she says she'll be waiting at the main ramp.

Appendix B 54 Aircraft Accident Report 6 of 27 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (MST) TIME (MST) & SOURCE CONTENT & SOURCE CONTENT 0848:23 HOT-1 okay. I wonder what that means, she'll be waiting at the main ramp? 0848:37 HOT-2 the, the fueler will. 0848:38 HOT-1 uh, okay. 0848:41 HOT-2 I, I, I think, I think it's just one ramp there. 0848:42 HOT-1 okay. 0848:48 HOT-2 it appears, I think, I didn't quite understand kinda staticy, but she said they'd be waiting. 0850:47 HOT-1 okay. 0851:30 HOT-1

• interesting, I wonder how we got on heading?

0850:40 HOT-1 *, I'm gonna heat 'em up. 0850:48 HOT-2 all righty, sounds good.... you get these kind of descents out here too. just come right on down.... 0850:48 HOT-1 yeah.

Appendix B 55 Aircraft Accident Report 7 of 27 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (MST) TIME (MST) & SOURCE CONTENT & SOURCE CONTENT 0851:17 HOT-2 ... don't worry about all this leveling off stuff. 0851:23 HOT-2 I don't know how far out? seventeen miles seems like a long ways. uh, usually they do about ten, don't they? 0851:25 HOT-1 yeah. 0851:33 HOT-2 I don't know if there's a reason for that, but uh.... or it shows a procedure turn. they may bring you in right to the uh.... 0851:36 HOT-1 well, they've got approach control there don't they? 0851:38 HOT-2 yeah, we got Pueblo approach. 0851:39 HOT-1 yeah, they'll probably give us just radar vectors. 0852:18 HOT-2 now if you were on one engine, and you wanted to.... 0852:21 500FK Denver, five hundred Fox Kilo's uh, with you descending to two seven zero. 0852:24 HOT-2 ...heat that thing up. heat both edges. you would put your engine anti-ice switch down….

Appendix B 56 Aircraft Accident Report 8 of 27 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (MST) TIME (MST) & SOURCE CONTENT & SOURCE CONTENT 0852:26 CTR2 five hundred Foxtrot Kilo, Denver Center roger and uh, cleared to descend and *** descend and maintain one three, one three thousand. the uh, Pueblo altimeter is three zero one six. 0852:29 HOT-1 yeah transfer yeah.... 0852:29 HOT-2 on the engine that's running and that..... 0852:31 HOT-1 ...would then heat the opposite side. 0852:32 HOT-2 that would bleed both of 'em. 0852:33 HOT-1 yeah. 0852:39 500FK thirty sixteen. down to one three thousand. Foxtrot Kilo. 0852:39 HOT-1 I guess I'm trying to remember is the two that way. 0852:40 HOT-2 no. 0852:41 HOT-1 no? 0852:42 HOT-2 no. it does not have cr... 'cause it's electric.

Appendix B 57 Aircraft Accident Report 9 of 27 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (MST) TIME (MST) & SOURCE CONTENT & SOURCE CONTENT 0852:45 HOT-1 that's right, that's right. 0852:46 HOT-2 the, the front of the wing is electric. 0852:57 HOT-2 and why would you need the heat on a dead engine, just to keep the ice from flying back into it? 0853:02 HOT-1 yeah. yeah, just keeps everything clean. 0853:10 HOT-2 oh, not so much engine protection, just the wing.... 0853:11 HOT-1 it's the wing yeah. 0853:13 HOT-2 ...itself. 0853:14 HOT-1 aah. 0853:17 HOT-2 you want me to ask them if we can slow down a little bit? 0853:19 HOT-1 yeah. 0853:57 HOT-2 they got the white knuckle guy on the other airplane, right?

Appendix B 58 Aircraft Accident Report 10 of 27 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (MST) TIME (MST) & SOURCE CONTENT & SOURCE CONTENT 0854:00 HOT-1 yeah. oh, ** I don't know if any of these are or not but I know that @ is on theirs. 0854:16 HOT-1 all right, windshield heat's comin' on. 0854:18 HOT-2 okay. 0854:19 HOT-1 you got 'em cracked. 0854:24 HOT-2 yeah. 0854:35 HOT-1 I really can't see lookin' into the sun. you'll have to let me know if you see anything. 0854:39 HOT-2 okay, it's building a little bit right on the leading edge. 0854:43 HOT-1 all right. 0855:07 HOT-2 it's not the real white ice like we had yesterday. it's more of a grayish. 0855:10 HOT-1 all right. 0856:18 HOT-2 there's a real thin line back there.

Appendix B 59 Aircraft Accident Report 11 of 27 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (MST) TIME (MST) & SOURCE CONTENT & SOURCE CONTENT 0856:19 HOT-1 okay, I can see now yeah. couldn't see b', when on top of those clouds, so bright. 0856:39 HOT-2 and, just a little positional awareness, that's direct to Pueblo there too. 0856:44 HOT-1 all right. 0856:46 HOT-2 anything west of it, the terrain starts rising. 0857:13 HOT-1 uh, too bad it's not a clear day, it'd be right pretty. 0857:16 HOT-2 yeah, I imagine it would. 0858:00 HOT-2 uh, one eight oh, three zero one six. 0858:03 HOT-1 sixteen is set twice. recogs are coming on. 0858:05 HOT-2 all right. transition check complete. 0858:15 HOT-1 uh, doesn't look like we picked up any more. 0858:17 HOT-2 nope.

Appendix B 60 Aircraft Accident Report 12 of 27 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (MST) TIME (MST) & SOURCE CONTENT & SOURCE CONTENT 0858:20 HOT-2 I don't know if you want to cycle it one time. it ain't gonna, at mi- nus three it ain't gonna melt much on the ground. 0858:25 HOT-1 naw, it isn't.... might've gotten rid of a little but not much. 0858:45 HOT-2 little sticky ice today. 0858:46 HOT-1 yeah. 0858:58 HOT-2 okay belts and harness, good on my side. 0859:00 HOT-1 good on the left. 0859:02 HOT-2 passenger seats. everybody still looks okay. exits are clear. avionics, flight instruments. I've got Pueblo on hold. localizer, one oh nine five and we set the inbound oh seven seven. 0859:15 HOT-1 set up. 0859:17 HOT-2 crossfeed? 0859:17 HOT-1 is normal. 0859:18 HOT-2 passenger lights are on. anti-skids?

Appendix B 61 Aircraft Accident Report 13 of 27 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (MST) TIME (MST) & SOURCE CONTENT & SOURCE CONTENT 0859:20 HOT-1 is on. 0859:23 HOT-2 ground idle? 0859:24 HOT-1 is normal. 0859:25 HOT-2 I'll hold there on the sync. 0859:28 HOT-1 all righty. 0859:29 HOT-2 ninety six on your ref. 0859:32 HOT-1 that's set. 0859:32 HOT-2 and crew brief we've talked about. I'll hold right there. 0859:53 HOT-2 the descent accumulation comes a little bit different than the climb accumulation. 0859:57 HOT-1 yeah. a whole lot faster in the descent than in the climb. 0900:30 RDO [sound Morse code identification similar to pilot identifying navi- gation station]

Appendix B 62 Aircraft Accident Report 14 of 27 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (MST) TIME (MST) & SOURCE CONTENT & SOURCE CONTENT 0901:09 HOT-2 yeah I bet this would be really pretty if it was clear. 0901:11 HOT-1 oh yeah. 0901:23 HOT-2 so Pueblo's just a little south of Denver still on the east side of the front range. 0901:27 HOT-1 yeah, yeah and it's south also of uh, of Colorado Springs.... 0901:32 HOT-2 uh huh. 0901:32 CAM [sound similar to altitude alerter] 0901:33 HOT-1 ...Colorado Springs sits in the middle, one to go. 0901:38 HOT-2 one to go. got clear air for a little bit. 0902:14 HOT-2 this is kinda equivalent of being down to eight thousand to hand off to Potomac. 0902:20 HOT-1 yeah. 0902:52 HOT-1 just leave the heats on.

Appendix B 63 Aircraft Accident Report 15 of 27 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (MST) TIME (MST) & SOURCE CONTENT & SOURCE CONTENT 0902:55 HOT-2 okay. got everything nice and warmed up. 0903:01 HOT-1 yeah. 0903:08 HOT-1 yeah, there's uh.... 0903:09 HOT-2 am I seeing clouds or am I possibly seeing Pikes Peak? 0903:12 HOT-1 eeeh, that's probably Pikes Peak. 0903:14 HOT-2 all that range. 0903:15 HOT-1 yeah, well they're clouds I think behind it, but uh, I think what you're seeing on this side of it, the dark ridges, that's, that's the mountains. it looks like it could be clouds on the uh, west side of that, though. 0903:36 HOT-2 very deceiving illusional up here with the clouds an.... 0903:37 HOT-1 yeah. 0903:38 HOT-2 ...when they slope and everything. 0903:50 HOT-2 I got one little static wick back there on the aileron just....

Appendix B 64 Aircraft Accident Report 16 of 27 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (MST) TIME (MST) & SOURCE CONTENT & SOURCE CONTENT 0903:54 HOT-1 vibrating. 0903:55 HOT-2 ...flapping like devil. the three right beside it are dead still. 0904:02 HOT-1 the one that's vibrating, is it out on the tip? 0904:04 HOT-2 nope. in, inboard of the aileron. 0904:07 HOT-1 okay. 0905:24 HOT-2 seems like they should be handing us down to the approach, huh? 0905:26 HOT-1 yeah, you might want to check with 'em. 0905:30 HOT-2 only thing is we got to go past * a little. 0905:32 CTR2 Citation zero Alpha Tango, contact Pueblo approach one two zero point one. we'll see you. 0905:39 RDO-2 okay, one twenty dot one and we'll see you in just a little bit.

Appendix B 65 Aircraft Accident Report 17 of 27 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (MST) TIME (MST) & SOURCE CONTENT & SOURCE CONTENT 0905:43 CTR2 all right. 0905:50 RDO-2 and Pueblo approach, Citation five hundred Alpha Tango thirteen thousand with Juliet. 0905:56 APR Citation five hundred Alpha Tango, Pueblo approach. fly heading two four zero vectors ILS runway two six right final approach course. descend and maintain seven thousand. 0906:05 RDO-2 'kay, two four zero on the heading and down to seven thousand and did you say two six right now? 0906:13 APR Citation zero Alpha Tango, affirmative, runway two six right for the ILS. traffic holding over the airport is a regional jet at niner thousand. report if you get him in sight. 0906:23 RDO-2 okay, I'll be looking and uh, looking for the ILS two six right. 0906:27 HOT-2 changed up on us. 0906:28 HOT-1 yeah. 0906:29 HOT-2 he did a change on us here. 0906:30 HOT-1 yeah, yeah.

Appendix B 66 Aircraft Accident Report 18 of 27 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (MST) TIME (MST) & SOURCE CONTENT & SOURCE CONTENT 0906:40 HOT-2 'kay, one oh eight point three.... inbound's gonna be a little bit different this time. 0906:51 HOT-1 right. 0906:52 HOT-2 it's gonna be inbound two five seven. 0906:54 HOT-1 all right. two five seven. you still holding Pueblo? 0906:58 HOT-2 I'm still holding Pueblo. 0906:59 HOT-1 all right. 0907:00 HOT-2 two five seven. the regional is holding. 0907:02 HOT-1 all right. 0907:03 HOT-2 do you want me to ask him if he is holding for, or is he climbing out or is.... 0907:05 HOT-1 I, I.... 0907:07 HOT-2 ...holding for the missed?

Appendix B 67 Aircraft Accident Report 19 of 27 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (MST) TIME (MST) & SOURCE CONTENT & SOURCE CONTENT 0907:07 HOT-1 I suspect, oh no, it couldn't be for a miss. I'm sure he, he's either climbing out or.... I mean you can ask him but uh, he didn't say anything about us to expect any holding. 0907:30 RDO-2 and Pueblo, just a little heads up for Alpha Tango. is a holding expected or is that fellow climbing out in a holding pattern? 0907:36 APR Citation zero Alpha Tango, that aircraft is holding in the uh, traffic uh, pattern. he needs to burn off some fuel. do you have him in sight, twelve o'clock and uh, one zero miles? 0907:46 HOT-1 naw. 0907:47 RDO-2 uh, no sir. what's his altitude? 0907:51 APR roger, he's holding at niner thousand. why don't you go ahead and uh, give me a best rate of descent through niner thousand or maintain one zero thousand. I'll just turn you. 0908:01 RDO-2 okay, we'll head on down to seven thousand and through nine. 0908:05 HOT-2 so we don't have.... 0908:06 APR Citation zero Alpha Tango roger, that traffic eleven moving twelve o'clock and niner miles turning northbound at niner thousand.

Appendix B 68 Aircraft Accident Report 20 of 27 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (MST) TIME (MST) & SOURCE CONTENT & SOURCE CONTENT 0908:14 RDO-2 okay, we're out of ten now hurrying on down to seven. he must be IMC. 0908:20 APR negative, he's just on top. 0908:24 HOT-1 aah, we're well.... 0908:25 RDO-2 okay but we're IMC now at ninety four hundred ah, Alpha Tango. 0908:29 APR Citation zero Alpha Tango roger. turn left heading of one seven zero. 0908:35 RDO-2 left turn one seven zero, Alpha Tango. 0908:40 APR Skywest sixty four thirty one, are you IMC? 0908:43 SW6431 yeah, we're just at the top here. it's pretty darn hazy though. get- tin' a little ice here and there. and uh, we have them on TCAS. ** passing behind us now. 0908:49 APR regional jet or correction Skywest sixty four thirty one, Roger. 0908:55 HOT-2 all right, comin' up on, one to go.

Appendix B 69 Aircraft Accident Report 21 of 27 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (MST) TIME (MST) & SOURCE CONTENT & SOURCE CONTENT 0908:55 APR Citation zero Alpha Tango, turn right heading of two niner zero in- tercept the localizer inbound. traffic five miles.... 0909:02 CAM [sound similar to altitude alert signal] 0909:03 APR ...west your position level at niner thousand. maintain seven thousand until established, you're cleared approach. 0909:07 RDO-2 okay, that's a right turn to two niner zero to intercept and cleared for the approach uh, five hundred Alpha Tango at seven thou- sand. 0909:16 APR Citation zero Alpha Tango, affirmative. 0909:19 HOT-2 you got a little different ice on there now. it's clear. 0909:22 HOT-1 yeah. 0909:26 HOT-1 and open up those valves all the way. 0909:28 HOT-2 all right, will do.... okay, you're cleared for the approach. do you want the uh.... 0909:38 HOT-1 yeah, I want to keep that out 'til we slow down and we can get some flaps out.

Appendix B 70 Aircraft Accident Report 22 of 27 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (MST) TIME (MST) & SOURCE CONTENT & SOURCE CONTENT 0909:41 APR Citation zero Alpha Tango, measured ceiling niner hundred bro- ken, one thousand four hundred overcast. visibility six, mist. temperature minus three, dew point minus four. wind currently zero seven zero at seven. and altimeter's three zero one six. 0909:59 RDO-2 okay, copy that on the weather for Alpha Tango. 0910:03 HOT-1 we're cleared, we're cleared for the approach? 0910:05 HOT-2 yeah, we have been. 0910:08 RDO-2 Alpha Tango, just want to verify. we are cleared for the ap- proach. 0910:11 APR Citation zero Alpha Tango, affirmative you are cleared approach. 0910:22 HOT-2 'kay, ignition is on with the anti-ice, now it's on for sure. glideslope is alive. 0910:30 500FK five hundred Fox Kilo's uh, with you, one three thousand, Juliet.

Appendix B 71 Aircraft Accident Report 23 of 27 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (MST) TIME (MST) & SOURCE CONTENT & SOURCE CONTENT 0910:35 APR Citation five hundred Foxtrot Kilo, Pueblo approach. descend and maintain eight thousand. expect ILS runway two six right fi- nal approach course. reduce your speed to two one zero knots and then descend and maintain uh, seven thousand or correction eight thousand. 0910:47 HOT-2 it's two hundred decision height and three quarters of a mile. 0910:47 500FK back to two ten, down to eight thousand and uh, are you aware Juliet's advertising the eight left ILS? 0910:51 HOT-1 all right. 0910:55 APR affirmative, just kinda trying to save you a little bit of flight time. if you'd like runway eight left, I can certainly provide that. 0911:01 500FK no that's fine. we were just double checking you knew what was going on here and we're down to uh, eight thousand now and two hundred and ten knots for Alpha Tango. 0911:06 HOT-2 localizer's got it. 0911:09 CAM [sound of tone]

Appendix B 72 Aircraft Accident Report 24 of 27 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (MST) TIME (MST) & SOURCE CONTENT & SOURCE CONTENT 0911:09 APR Citation zero Foxtrot uh.... 0911:10 HOT-1 all right, gear's coming down. 0911:12 HOT-2 there's your gear. 0911:13 APR ...or correction uh, Cita, correction Citation zero Alpha Tango, you're cleared approach. just remain with me runway two six right. cleared to land. 0911:19 RDO-2 okay, five hundred Alpha Tango, cleared to land with you, at seven thousand. intercepting the glide slope. 0911:26 APR Citation zero Foxtrot Kilo, intercept the localizer inbound your present heading. maintain seven thousand 'til established. you're cleared ILS runway two six right approach. 0911:27 HOT-1 all right, this, this time it'll be what a, left turn off, or right turn off. uuuuuh. left turn off. 0911:34 HOT-2 two six'll be a left turn off Hotel or Fox. 0911:37 HOT-1 all right, all right.

Appendix B 73 Aircraft Accident Report 25 of 27 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (MST) TIME (MST) & SOURCE CONTENT & SOURCE CONTENT 0911:37 500FK 'kay uh, we are cleared for the approach now for five hundred Foxtrot Kilo. 0911:44 CAM [sound similar to altitude alerter] 0911:45 HOT-1 and speed brakes coming back out again. 0911:46 HOT-2 okay. and standing, there's your glide slope intercept. 0911:48 HOT-1 full flaps. 0911:49 HOT-2 full flaps, here we go. 0911:53 APR Citation zero Foxtrot Kilo, you picking up the localizer okay? 0911:57 500FK uh, yes sir. we're coming left to intercept it a little bit and we'll be right on it here in a second. 0912:00 HOT-2 full, full selected and indicated. 0912:01 HOT-1 all right. 0912:04 HOT-2 and you are plus twenty five.

Appendix B 74 Aircraft Accident Report 26 of 27 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (MST) TIME (MST) & SOURCE CONTENT & SOURCE CONTENT 0912:07 HOT-1 slowing. 0912:08 HOT-2 slowing, sinking seven. captured the localizer and the glideslope. I've got some ground but stay on them gauges. 0912:16 HOT-1 all right. 0912:17 HOT-2 just a brief on the missed if we have to. it's climb to seven thou- sand, direct to the Pueblo localizer. 0912:23 HOT-1 all right. 0912:24 HOT-2 uh, Pueblo outer marker. 0912:28 HOT-1 right turn or left turn? 0912:29 HOT-2 it doesn't say. it says direct to it uh.... 0912:30 HOT-1 all right. 0912:31 HOT-2 ...straight ahead on the other side.

Appendix B 75 Aircraft Accident Report 27 of 27 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (MST) TIME (MST) & SOURCE CONTENT & SOURCE CONTENT 0912:37 HOT-2 I don't know if you want to run your ice a little bit. you got the, Vref there. 0912:40 APR Citation Foxtrot Kilo uh, traffic.... 0912:42 CAM [sound of high pitch tone for one second] 0912:44 HOT-1 #. 0912:46 CAM-3 bank angle, bank angle... bank angle. 0912:49 HOT-1 oh #. 0912:50 HOT-1 [groaning sound to end of recording] 0912:55 END of RECORDING END of TRANSCRIPT

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FD07330 ｜ 2007_美国_AAR0703.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2007 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

aviation Weather Encounter and Subsequent Collision into Terrain Bali Hai Helicopter Tours, Inc. Bell 206B, N16849 Kalaheo, Hawaii September 24, 2004 ACCIDENT REPORT NTSB/AAR-07/03 PB2007-910404

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Aircraft Accident Report Weather Encounter and Subsequent Collision into Terrain Bali Hai Helicopter Tours, Inc. Bell 206B, N16849 Kalaheo, Hawaii September 24, 2004 NTSB/AAR-07/03 PB2007-910404 National Transportation Safety Board Notation 7862A 490 L’Enfant Plaza, S.W. Adopted February 13, 2007 Washington, D.C. 20594 E

P L U R IB US UN U M

N A T I O N A L

T R A S P O R T A T I O N

B O A R D S A FE T Y N

National Transportation Safety Board. 2007. Weather Encounter and Subsequent Collision into Terrain, Bali Hai Helicopter Tours, Inc., Bell 206B, N16849, Kalaheo, Hawaii, September 24, 2004. Aircraft Accident Report NTSB/AAR-07/03. Washington, DC. Abstract: This report explains the accident involving a Bell 206B helicopter, N16849, registered to and operated by Bali Hai Helicopter Tours, Inc., of Hanapepe, Hawaii, which impacted mountainous terrain in Kalaheo, Hawaii, on the island of Kauai, 8.4 miles northeast of Port Allen Airport, in Hanapepe. The safety issues discussed in this report include the influence of pilot experience and operator scheduling on in-flight decision-making; the lack of Federal Aviation Administration (FAA) oversight of 14 Code of Federal Regulations Part 91 air tour operators; the need for national air tour safety standards; and the lack of direct FAA surveillance of commercial air tour operators in Hawaii. The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Web at http://www.ntsb.gov. Other information about available publications also may be obtained from the Web site or by contacting: National Transportation Safety Board Records Management, CIO-40 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (800) 877-6799 or (202) 314-6551 Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2007-910404 from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605-6000 The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

iii Aircraft Accident Report Contents Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii

1. Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2. 1

History of Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.2 Injuries to Persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.3 Damage to Helicopter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.4 Other Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.5 Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.5.1 The Pilot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.5.1.1 Flight Time and Duty Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.5.1.2 72-hour History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 1.6 Helicopter Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1.6.1 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1.6.2 Maintenance Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1.7 Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 1.7.1 Federal Aviation Administration Weather Radar Data . . . . . . . . . . . . . . . . . . . . . . . 9 1.7.2 Airmen’s Advisories and Area Forecast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 1.7.3 Witness Weather Observations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 1.7.4 Local Weather Information Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 1.7.5 Hawaii-Specific Weather Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 1.8 Aids to Navigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 1.9 Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 1.10 Airport Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 1.11 Flight Recorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1.12 Wreckage and Impact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1.13 Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 1.14 Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 1.15 Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 1.16 Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 1.17 Organizational and Management Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 1.17.1 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 1.17.2 Pilot Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 1.17.3 Pilot-Scheduling Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 1.17.3.1 Daily Tour Schedules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 1.17.3.2 Pilot Lunch and Rest Breaks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 1.17.4 Weather-Related Tour Cancellations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 1.17.5 Ridge-Crossing Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 1.17.6 Federal Aviation Administration Surveillance – Honolulu Flight Standards District Office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

iv Aircraft Accident Report 1.17.6.1 Staffing Levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 1.17.6.2 Geographical Surveillance Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 1.18 Additional Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 1.18.1 Helicopter Operations in Reduced Visibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 1.18.2 Spatial Disorientation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 1.18.3 Helicopter Pilot Fatigue Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 1.18.4 Flight Time and Duty Period Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 1.18.5 Special Federal Aviation Regulation 71 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 1.18.5.1 Certificate of Waiver or Authorization to Deviate from Special Federal Aviation Regulation 71 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 1.18.5.2 Formal Air Tour Safety Meetings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 1.18.6 Automatic Dependent Surveillance-Broadcast Program . . . . . . . . . . . . . . . . . . . . . 30 1.18.7 Previous Related Safety Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 1.18.8 National Air Tour Safety Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 1.18.8.1 Notice of Proposed Rulemaking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 1.18.8.2 Final Rule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 1.18.9 Requirements for Part 135 Air Tour Operators . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

1. Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
2. 1

General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 2.2 Accident Sequence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 2.3 Human Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 2.3.1 Spatial Disorientation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 2.3.2 Pilot’s Decision-making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 2.3.2.1 Inexperience with Local Weather Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 2.3.2.2 Overconfidence and Decision Bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 2.3.2.3 Bali Hai’s Pilot-Scheduling Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 2.3.2.4 Management Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 2.4 Federal Aviation Administration Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 2.4.1 Oversight of Part 91 Air Tour Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 2.4.2 Honolulu Flight Standards District Office Surveillance of Bali Hai . . . . . . . . . . . 43 2.4.3 Honolulu Flight Standards District Office Staffing Issues . . . . . . . . . . . . . . . . . . . 44 2.4.4 Air Tour Safety Meeting Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 2.5 Safety Impact of Special Federal Aviation Regulation 71 . . . . . . . . . . . . . . . . . . . . . . 46 2.6 Need for National Air Tour Safety Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 2.7 Implementing Automatic Dependent Surveillance-Broadcast in Hawaii . . . . . . . . . . . 48

1. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
2. 1

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 3.2 Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

1. Safety Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
2. Appendixes

A: Investigation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Contents

v Aircraft Accident Report Figures

1. Map of Kauai, showing accident site and some of

Bali Hai’s site-specific locations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

1. Radar data for the last 2 minutes of the accident flight

plotted over a topographical map . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

1. Weather radar at 1634 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2. Weather radar at 1639 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3. Weather radar at 1645 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

vi Aircraft Accident Report Abbreviations ADS-B automatic dependent surveillance-broadcast agl above ground level AIRMET airmen’s meteorological information ASI aviation safety inspector ATC air traffic control ATIS automated terminal information service CERAP air route traffic control center and radar approach control CFR Code of Federal Regulations dBZ decibels DOT Department of Transportation DUATS direct user access terminal system FAA Federal Aviation Administration FSDO Flight Standards District Office FSS flight service station GAATA General Aviation and Air Taxi Activity GSU geographical surveillance unit IFR instrument flight rules IMC instrument meteorological conditions IOE initial operating experience LIH Lihue Airport, Lihue, Hawaii LOA letter of authorization McIDAS Man computer Interactive Data Access System msl mean sea level NOE nap of the Earth or nape of the Earth NPG National Flight Standards Work Program Guidelines NPRM notice of proposed rulemaking

Abbreviations vii Aircraft Accident Report NWS National Weather Service PAK Port Allen Airport, Hanapepe, Hawaii PIC pilot-in-command POI principal operations inspector S/N serial number SIC second-in-command SFAR Special Federal Aviation Regulation UTC coordinated universal time VFR visual flight rules VMC visual meteorological conditions WSR-88D Weather Surveillance Radar-1988 Doppler

viii Aircraft Accident Report Executive Summary On September 24, 2004, about 1642 Hawaiian standard time, a Bell 206B helicopter, N16849, registered to and operated by Bali Hai Helicopter Tours, Inc., of Hanapepe, Hawaii, impacted mountainous terrain in Kalaheo, Hawaii, on the island of Kauai, 8.4 miles northeast of Port Allen Airport, in Hanapepe. The commercial pilot and the four passengers were killed, and the helicopter was destroyed by impact forces and postimpact fire. The nonstop sightseeing air tour flight was operated under the provisions of 14 Code of Federal Regulations Part 91 and visual flight rules with no flight plan filed. Instrument meteorological conditions prevailed near the accident site. The National Transportation Safety Board determines that the probable cause of this accident was the pilot’s decision to continue flight under visual flight rules into an area of turbulent, reduced visibility weather conditions, which resulted in the pilot’s spatial disorientation and loss of control of the helicopter. Contributing to this accident was the pilot’s inexperience in assessing local weather conditions, inadequate Federal Aviation Administration (FAA) surveillance of Special Federal Aviation Regulation 71 operating restrictions, and the operator’s pilot-scheduling practices that likely had an adverse impact on pilot decision-making and performance. The safety issues discussed in this report include the influence of pilot experience and operator scheduling on in-flight decision-making; the lack of FAA oversight of Part 91 air tour operators; the need for national air tour safety standards; and the lack of direct FAA surveillance of commercial air tour operators in Hawaii. Nine safety recommendations are addressed to the FAA regarding local weather-training programs for newly hired Hawaii air tour pilots; evaluation of operational practices for commercial air tour helicopter pilots; Honolulu Flight Standards District Office control of the annual safety meetings, as required under approved certificates of waiver or authorization; evaluation of the safety impact of the altitude restrictions in the State of Hawaii; national air tour safety standards; and the potential benefits of automatic dependent surveillance-broadcast technology for Hawaii air tour operators.

1 Aircraft Accident Report 1. Factual Information 1.1 History of Flight On September 24, 2004, about 1642 Hawaiian standard time,1 a Bell 206B helicopter, N16849, registered to and operated by Bali Hai Helicopter Tours, Inc., of Hanapepe, Hawaii, impacted mountainous terrain in Kalaheo, Hawaii, on the island of Kauai, 8.4 miles northeast of Port Allen Airport (PAK) in Hanapepe. The commercial pilot and the four passengers were killed, and the helicopter was destroyed by impact forces and postimpact fire. The nonstop sightseeing air tour flight was operated under the provisions of 14 Code of Federal Regulations (CFR) Part 912 and visual flight rules (VFR) with no flight plan filed.3 Instrument meteorological conditions (IMC) prevailed near the accident site. The air tour flight was conducted under Special Federal Aviation Regulation (SFAR) 71, “Special Operating Rules for Air Tour Operators in the State of Hawaii,” and in accordance with a certificate of waiver or authorization approved for Bali Hai by the Federal Aviation Administration’s (FAA) flight standards district office (FSDO) in Honolulu, Hawaii. The minimum altitude for tour flights specified in SFAR 71 is 1,500 feet above ground level (agl) and no closer than 1,500 feet to any person or property, unless otherwise authorized. Bali Hai’s certificate of waiver or authorization allowed its pilots to deviate from the minimum altitude requirement and to fly transition segments4 at 1,000 feet agl, cross ridgelines at 500 feet agl, and cross razorback ridgelines5 at 200 feet agl. The flight, which was the pilot’s eighth and final tour flight for the day, was scheduled to depart PAK about 1600 and fly clockwise around the island of Kauai for a 45-minute sightseeing tour over a number of site-specific locations,6 including Waimea Canyon, the Na Pali Coast, Waialeale Crater, and Manawaipuna Falls (see figure 1). 1 Hawaiian standard time is coordinated universal time minus 10 hours. Unless otherwise indicated, all times are Hawaiian standard time based on a 24-hour clock. 2 According to Federal Aviation Regulations, 14 CFR Part 91 commercial air tour flights are authorized as long as they are conducted as “nonstop sightseeing operations in non-common carriage” in accordance with 14 CFR 119.1(e)(2) and 135.1(a)(5), which specify that the flights must begin and end at the same airport and must be conducted within a 25-statute-mile radius of that airport. 3 Personnel at the company office logged tour departure times and knew the usual tour routes, but they did not track the flights or perform flight-following services. 4 Bali Hai’s FAA-approved transition segments were established with the Honolulu FSDO and were outlined in the certificate of waiver or authorization. 5 The certificate of waiver or authorization does not define razorback ridgeline. Generally, the description refers to a sharp, narrow ridge. 6 Bali Hai’s site-specific locations were approved by the Honolulu FSDO, which maintained a master map that identified the locations for the operators. Bali Hai’s certificate of waiver or authorization allowed its pilots to descend to 500 feet agl over site-specific locations.

Factual Information 2 Aircraft Accident Report Digital, time-stamped still images recovered from a passenger’s camera showed that, when the helicopter departed, the weather near PAK appeared sunny with good visibility. Subsequent images taken during the tour showed low clouds and precipitation near some site-specific locations. Figure 1. Map of Kauai, showing accident site and some of Bali Hai’s site-specific locations. A review of air traffic control (ATC) radar data from the FAA’s air route traffic control center and radar approach control (CERAP) facility in Honolulu showed the helicopter’s ground track entered the area north of Mount Waialeale about 1635;7 however, the helicopter’s flight altitudes could not be determined.8 The radar data showed that, about 1641, the helicopter crossed a 2,000-foot ridge that extended east from Kahili Ridge (see figure 2), the main ridgeline 3,000 feet south of Waialeale Crater. Shortly 7 Radar coverage on the island of Kauai was limited due to the location of the radar station and the high terrain in the center of the island; the CERAP facility had no radar data for the helicopter before 1635. 8 The helicopter was equipped with a mode C transponder, which is designed to transmit the helicopter’s identification code and altitude information in response to interrogation signals received from ground-based radar equipment. During the accident flight, however, the helicopter’s transponder transmitted only a constant altitude of 1,000 feet mean sea level; thus, the helicopter’s actual flight altitudes before the accident could not be determined. 0 7.5 15 Miles 3.75 N 11.25 Lihue Airport Accident Site Port Allen Airport Kahili Ridge Hanapepe Valley Manawaipuna Falls Mount Waialeale Waimea Canyon Na Pali Coast Hanalei Valley Princeville Hanapepe Kalaheo Waialeale Crater Hanalei

Factual Information 3 Aircraft Accident Report thereafter, the helicopter tracked west toward a pass at the top of Kahili Ridge, then crossed Kahili Ridge. About 1642, the radar track depicted the helicopter on the west side of Kahili Ridge as it turned toward the north. The helicopter’s ground track then made a 180º clockwise turn toward the south and crossed back to the east side of the Kahili Ridge in a zigzag pattern before it was lost from radar at 1642:46. The wreckage was located on the east side of Kahili Ridge about 200 feet below the top of the ridgeline and southeast of the last radar return.9 Figure 2. Radar data for the last 2 minutes of the accident flight plotted over a topographical map. When the helicopter failed to return to PAK as scheduled, Bali Hai personnel notified the tower controllers at Lihue Airport (LIH) in Lihue, on the island of Kauai, and the U.S. Coast Guard that the flight was overdue. Bali Hai, other air tour companies, and the Coast Guard conducted visual aerial searches, but clouds obscured the location of the crash site. The Coast Guard located the wreckage about 1420 on September 25, 2004. Recovery of the victims and the wreckage took 10 days because of the terrain and weather conditions. According to recovery personnel, heavy downdraft wind conditions and low cloud cover affected the area. 9 The wreckage debris was scattered in a west-southwest direction. The duration and directions of the helicopter’s ground track between the location of the last radar return and the accident site are not known. For more information about the wreckage debris path, see section 1.12.

Factual Information 4 Aircraft Accident Report 1.2 Injuries to Persons Table 1. Injury chart. 1.3 Damage to Helicopter The helicopter was destroyed by impact forces and a postcrash fire. 1.4 Other Damage Trees and other vegetation at the accident site were damaged as a result of the accident. 1.5 Personnel Information 1.5.1 The Pilot The pilot, age 39, held a commercial pilot certificate with a rating for rotorcraft helicopter issued on May 6, 2004. His most recent FAA first-class airman medical certificate was issued on October 20, 2003, with no restrictions. The pilot was a citizen of India and was retired from the Indian Air Force, in which he served from 1986 to 2003. He received his initial helicopter training at an Indian Air Force training school in Hyderabad, India. During his military career, he acquired a military helicopter pilot certificate with an instrument rating; was qualified as a rotorcraft instructor, instrument instructor, and pilot examiner in single- and twin-turbine helicopters; and was trained in military flying profiles, including nap-of-the-Earth (NOE) flight.10 In a résumé dated June 3, 2004, the pilot reported he had accumulated 4,005 total Injuries Flight Crew Cabin Crew Passengers Other Total Fatal 1 0 4 0 5 Serious 0 0 0 0 0 Minor 0 0 0 0 0 None 0 0 0 0 0 Total 1 0 4 0 5 10 NOE flight (sometimes also referred to as “nape” of the Earth) is low-level, military tactical flying that is intended to increase stealth and mission security. NOE flight requires the pilot to make continuous changes in the helicopter’s speed, altitude, and heading to fly close to the ground and among obstacles.

Factual Information 5 Aircraft Accident Report flight hours, which included 3,900 hours in turbine-powered helicopters, 2,820 hours pilot-in-command (PIC), 1,350 hours second-in-command (SIC), and 800 hours as an instructor pilot. The pilot moved to Michigan in November 2003. The FAA issued him a U.S. private pilot certificate with a rating for rotorcraft helicopter in February 2004 on the basis of his foreign pilot license.11 The pilot logged no flight time from February 2003 to March 2004. Between March and April 2004, the pilot accumulated 20 hours of civilian flight experience in Enstrom F28C2 helicopters while preparing for the FAA practical test for his commercial pilot certificate. The pilot was hired by Bali Hai in July 2004, and he moved to Hawaii to begin work. It was his first civilian pilot job, and he had no previous Bell 206 helicopter experience. According to Bali Hai personnel, they provided the pilot 22 hours of ground instruction, 5 hours of flight instruction, and 1.7 hours of supervised PIC flight time between July 8 and July 31, 2004. Bali Hai’s owner stated that the pilot demonstrated very good skills and controlled the helicopter well during training. The pilot passed an FAA SFAR 71 checkride12 on July 22, 2004. Company records indicated that the pilot accumulated 120 hours of flight experience in the company’s helicopters between August 1, 2004, and the accident date. A search of driver history records in Hawaii found no history of driver’s license revocations or suspensions. 1.5.1.1 Flight Time and Duty Period Bali Hai did not maintain, and was not required to maintain, records of pilot flight time or duty periods.13 Bali Hai personnel stated that they kept records of only scheduled revenue flight hours. On the day of the accident, the pilot arrived at the company office about 0800, performed a preflight inspection of the helicopter, washed the turbine engine compressor, and helped the line service technician transport the helicopter to the airport. He was scheduled to fly eight tours consisting of five 45-minute tours and three 55-minute tours departing every hour, on the hour. During tours, the pilot’s duties, in addition to flying, included narrating the tour for the passengers. During the 5 to 15 minutes of ground time between the tours, the pilot sat in the cockpit and monitored the fuel gauge while the line service technician added fuel to the 11 According to 14 CFR 61.75, a person who holds a current foreign pilot license may apply for and be issued a U.S. private pilot certificate with the appropriate ratings on the basis of the foreign pilot license if the requirements of the regulation are met. Under this provision, a pilot who meets the requirements would not have to demonstrate proficiency to be issued the U.S. private pilot certificate. 12 The SFAR 71 checkride is administered by the FAA and is required for Hawaii air tour pilots who fly for an operator that holds a certificate of waiver or authorization to deviate from SFAR 71. The checkride was designed to evaluate the pilot’s knowledge of SFAR 71 regulations and the company’s approved deviations, among other criteria. 13 Part 91 air tour operators, unlike Part 135 and Part 121 operators, are not subject to any pilot flight time and duty period limitations or any pilot rest requirements.

Factual Information 6 Aircraft Accident Report helicopter, and he did not leave the helicopter to take a lunch break.14 Interviews with company personnel and an examination of company scheduling records indicated that, on the day of the accident, the pilot had been on duty about 8.7 hours, had been at the controls of the helicopter with the rotors turning for at least 7.7 consecutive hours, and had flown about 6.5 revenue flight hours15 by the time the accident occurred (see table 2). Table 2. Revenue hours flown by the pilot on the day of the accident.a a All flight times are based on scheduled tour times, not actual tour times. The duration of the last flight is based on the estimated time of the accident. With the exception of a continuous 9-day leave of absence from September 5 to September 13, 2004,16 company scheduling records indicated that the pilot was on duty each week for the 6 weeks from August 1, 2004, to the day of the accident.17 The pilot’s average daily revenue flight time, recorded in a company spreadsheet, was 3.5 hours. According to the spreadsheet, the day before and the day of the accident were the pilot’s longest days of flying, and the pilot was credited with 6.7 and 6.45 revenue flight hours, respectively. 14 For more information about Bali Hai’s pilot-scheduling practices, see section 1.17.3. 15 Revenue flight hours include only the time that the helicopter was in use during tour flights. Additional flight time would have been required for the pilot to start the helicopter, maneuver it off the trailer, and land it nearby at the company’s loading/unloading area. Tour Number of Passengers Start Time Stop Time Duration (minutes) Turnaround (minutes) 1 3 0900 0955 0:55 0:05 2 4 1000 1045 0:45 0:15 3 4 1100 1155 0:55 0:05 4 4 1200 1245 0:45 0:15 5 4 1300 1345 0:45 0:15 6 4 1400 1455 0:55 0:05 7 3 1500 1545 0:45 0:15 8 4 1600 1642

0:42

Totals

30

6:27 1:15 16 During his leave, the pilot traveled to Michigan to visit his family and obtained a permanent resident card. 17 During that time, the pilot had three 6-day workweeks, two 5-day workweeks, and one 4-day workweek. In late August, the pilot worked 7 days in a row.

Factual Information 7 Aircraft Accident Report 1.5.1.2 72-hour History The pilot lived alone, and little information was available regarding his nonwork activities in the 72 hours before the accident. The pilot’s wife still resided in Michigan with their child but planned to join the pilot in Hawaii in October 2004. She last spoke with him by telephone about 1700 on September 21, 2004, 3 days before the accident. She stated that the pilot sounded “normal” and “very happy.” He told her that he had been going to bed early, getting up early, and going for morning walks. Based on the pilot’s recent sleeping schedule, his wife estimated that he might have gone to bed between 2100 and 2130 that evening. Two acquaintances of the pilot told investigators that they visited with the pilot for about an hour as he walked to his apartment after work 2 or 3 days before the crash. They reported that the pilot was very friendly during their discussion and told them he was looking forward to reuniting with his family. The day of the accident was the pilot’s fourth consecutive day of work after a 2-day weekend. According to the company’s scheduling records and interviews, on September 22, 2004, the pilot flew two 45-minute tours and one 55-minute tour between 1300 and 1600.18 On September 23, 2004, the pilot flew four 45-minute tours, three 55-minute tours, and one 60-minute tour between 0900 and 1700.19 On the day of the accident, the pilot was the only pilot on duty at Bali Hai, and the customer service representative stated that the pilot appeared “fine” when he arrived at the office. The pilot’s first tour began at 0900, and the line service technician stated that the pilot appeared “fine” between his tours. A passenger on the fourth tour stated that the pilot was “very nice” and “professional” and appeared relaxed as he narrated the tour. The passenger stated that he never saw the pilot get out of the helicopter and that he could not tell if the pilot was tired. The line service technician stated that, before departing on the sixth tour, the pilot asked how many tours he had left. Passengers on the seventh tour stated that the pilot looked “extremely tired” before their flight and that he got out of the helicopter to stretch and walk around. When the line service technician boarded the four passengers for the eighth tour, he reminded the pilot that this was his last tour for the day. He stated that the pilot looked “fine” but was wearing sunglasses and that he couldn’t see the pilot’s eyes or determine if he looked tired. 18 Company records indicate that the pilot was credited with 2.37 hours of flight pay, rather than the 2.42 hours he was scheduled to fly. 19 Company records indicate that the pilot was credited with 6.7 hours of flight pay, rather than the 6.75 hours he was scheduled to fly.

Factual Information 8 Aircraft Accident Report 1.6 Helicopter Information 1.6.1 General The helicopter, serial number (S/N) 2355, was manufactured in 1978 and was equipped with a 420 shaft-horsepower Rolls-Royce 250-C20B engine, S/N CAE 832474. The helicopter’s flight instruments included an airspeed indicator, attitude indicator, and heading indicator; the helicopter was not certificated for instrument flight rules (IFR) operations. The pilot’s seat was positioned at the front right, a passenger seat was positioned at the front left, and a bench seat in the back accommodated three passengers. The pilot’s seat was equipped with a four-point restraining system, and each passenger seat was equipped with a lapbelt restraining system. The helicopter’s second set of cockpit flight controls, normally located at the front left seat, was removed, except for the antitorque pedals.20 1.6.2 Maintenance Information The helicopter was used only for Part 91 operations and was required to undergo annual and 100-hour inspections.21 Also, the operator was required to maintain records, in accordance with 14 CFR 91.417, and to adhere to the replacement times for life-limited parts, as specified in the helicopter’s specifications, type certificate data sheets, or other documents approved by the FAA.22 According to the helicopter’s airframe and engine maintenance logbooks, the helicopter’s most recent 100-hour inspection was completed on September 16, 2004, at an airframe total time of 15,963.1 hours and an engine total time of 13,281.5 hours. According to the logbooks, the helicopter’s most recent annual inspection was completed on March 2, 2004, at an airframe total time of 15,392.6 hours and an engine total time of 12,711.0 hours. A review of Bali Hai’s records revealed numerous discrepancies between the airframe total time and engine total time recorded in the respective logbooks and the times recorded in the airframe and engine component status reports.23 Other records, including component historical service records, also showed discrepancies. The discrepancies in various maintenance records included conflicting airframe and engine total times, 20 Antitorque pedals are foot-pedal controls for the tail rotor system. 21 A Part 91 operator must comply with 100-hour and annual inspections unless the operator elects to participate in a progressive inspection program, the manufacturer’s approved maintenance/inspection program, or an FAA-approved continuous airworthiness inspection program. 22 Some records that the operator was required to maintain, according to 14 CFR 91.417, included records of maintenance, preventive maintenance, alteration, 100-hour inspection, annual inspection, progressive inspection, and other required or approved inspections for each aircraft, engine, rotor, and appliance; records of total time in service of the airframe, engine, and each rotor; records of the current status of life-limited parts of each airframe, engine, rotor, and appliance; records of the time since last overhaul for each installed item that is required to be overhauled on a specified basis; and copies of the forms required for each major alteration to the airframe, engine, rotors, and appliances.

Factual Information 9 Aircraft Accident Report component times, types of maintenance or overhaul, installation and/or maintenance dates, and S/Ns. Further, the records indicated no evidence of compliance with a number of mandatory inspections, including special retorque inspections. Bali Hai’s mechanic stated that the company did not use daily discrepancy records and that, instead, the pilots relayed airworthiness issues to him verbally at the end of each day. He stated that, if he noted any issues, he would fix them and would make a maintenance logbook endorsement only when he believed the repair to be a “safety factor.” Review of the maintenance records for the year before the accident revealed no record of any minor discrepancies having been reported or repaired. The mechanic stated that he did not use the helicopter’s Hobbs hour meter24 to track airframe and engine time because it was unreliable. He stated that he, instead, tracked these times by calling the sales office each day to obtain the total scheduled trip times for the tours flown that day.25 Review of various records revealed no evidence that time accumulated on the helicopter during nonrevenue operations, such as any flight before, between, and after tours, or during training and maintenance flights, were recorded at all for maintenance purposes as required.26 A review of historical correspondence between Bali Hai and the FAA revealed that, as far back as 1996, the accident helicopter was deemed unairworthy on at least two occasions because of improper maintenance practices and record-keeping. 1.7 Meteorological Information 1.7.1 Federal Aviation Administration Weather Radar Data The FAA’s Weather Surveillance Radar-1988 Doppler (WSR-88D) located on the island of Kauai provides a three-dimensional volume scan of the atmosphere at varying degrees of elevation. Figures 3 through 5 display the WSR-88D images generated from data downloaded from Unidata and displayed using the Man computer Interactive Data Access System (McIDAS)27 and depict the base reflectivity images at 1634, 1639, and 1645.28 At the accident site, the radar beam center is about 2,800 feet above mean sea level 23 Bali Hai’s airframe and engine component status report dated September 29, 2004, listed the airframe total time as 15,982.3 hours and the engine total time as 10,862.3 hours; this recorded engine time was about 2,000 hours less than what was recorded in the engine logbook for the annual and 100-hour inspection entries dated about 6 months and 2 weeks earlier, respectively. 24 A Hobbs hour meter is a time-recording device that activates by sensing such things as aircraft electrical power “on,” oil pressure, or other criteria. According to FAA Advisory Circular 43-9C, such a recording device can be helpful in determining time in service for maintenance purposes. 25 Sales office personnel did not record the helicopter’s actual time in service; they logged how many 45- and 55-minute tours were flown each day and provided those totals to the mechanic. 26 For example, the accident pilot’s training record showed he received 1.5 hours of flight instruction on July 13, 2004, and flew 1.5 hours with the owner on July 14, 2004, however, company flight schedules showed only revenue flights were logged, and there was no indication that the time accumulated on the helicopter during these training flights had been recorded at all for maintenance purposes.

Factual Information 10 Aircraft Accident Report (msl). The weather radar echo intensities are represented in decibels (dBZ) (see color bar on the right side of each figure). In the figures, the ground track of the accident flight from 1635:11 to 1642:46 is plotted in white, and selected radar plot times are noted in blue. Figure 3. Weather radar at 1634. 27 WSR-88D Doppler Weather Radar Level III products were acquired using tools made available to the research and education communities through the University Corporation for Atmospheric Research’s Unidata Program, funded by the National Science Foundation. These data originated in the U.S. National Weather Service McIDAS. McIDAS is an interactive meteorological analysis and data management computer system and is administered by personnel at the Space Science and Engineering Center at the University of Wisconsin at Madison. Data are accessed and reviewed on a Hewlett-Packard 9000/C360 workstation running McIDAS-X software. 28 The weather radar product images display time in coordinated universal time, or Zulu, as denoted by the designator “Z.” The times in the figure captions have been converted to Hawaiian standard time.

Factual Information 11 Aircraft Accident Report Figure 4. Weather radar at 1639. Figure 5. Weather radar at 1645.

Factual Information 12 Aircraft Accident Report 1.7.2 Airmen’s Advisories and Area Forecast At 120029 on the day of the accident, the National Weather Service (NWS) Forecast Office in Honolulu issued an airmen’s meteorological information (AIRMET) advisory for turbulence. AIRMET Tango Update 3 was valid until 1800, and it reported, “over and immediately south through west of mountains, all islands temporary moderate turbulence below 5,000 feet.” The area forecast, issued September 24, 2004, at 1140 and valid until midnight, contained the following information: North through east coastal and mountain sections and adjacent waters of the remaining islands, including central Oahu (includes Kauai), scattered clouds at 2,500 feet, broken to overcast at 4,500 feet, tops to 8,000 feet, temporary 2,500 feet broken, isolated 1,500 feet broken, tops 12,000 to 15,000 feet, visibility 3 to 5 miles, and moderate rain showers. 1.7.3 Witness Weather Observations According to a tour pilot for another company conducting operations from PAK on the day of the accident, the weather was “really nice” in the morning but deteriorated later in the day. He also reported that he flew by Kahili Ridge about 1 hour after the accident and that the ridgeline was obscured by clouds. A passenger on the accident pilot’s fourth tour on the day of the accident stated that skies were clear when the tour departed the airport but that the flight encountered turbulence and rain along the Na Pali Coast and in Hanapepe Valley. Passengers from the accident pilot’s tour before the accident tour stated that, when the helicopter crossed Kahili Ridge (near the accident site), it encountered strong winds and rain in that area. They also stated that the helicopter encountered rain, mist, and clouds inside Waialeale Crater and that clouds sometimes completely obscured ground references. Time-stamped digital images recovered from a passenger’s camera showed clouds and precipitation were at some locations along the accident tour, including areas along the Na Pali Coast, in the mountains south of Hanalei, and over the foothills east of Mount Waialeale. The last photograph recorded by the camera, which was taken about 5 minutes before the accident, showed a location about 4 miles from the accident site. The photograph showed that a broken layer of clouds appeared to be in front of the helicopter with some cloud bases below the horizon. The visibility below some clouds appeared to be degraded by mist and/or rain, and areas of coastline behind the line of clouds appeared to be brighter than the land in the foreground. 29 Airmen’s weather information products are transmitted in coordinated universal time. However, the times in this section have been converted to Hawaiian standard time.

Factual Information 13 Aircraft Accident Report 1.7.4 Local Weather Information Sources According to Bali Hai personnel, weather information was available from local television broadcasts, the Internet, and the FAA’s flight service station (FSS) in Honolulu, but they did not know what resources, if any, the pilot used the day of the accident. There was no record that the pilot obtained a weather briefing from the local FSS. Bali Hai did not have a direct user access terminal system (DUATS) at its office. There were no weather information update capabilities at Bali Hai’s ramp area at PAK. After a pilot left the company office, he or she could visually assess the weather from the airport or during tour flights, or the pilot could request reports from other tour pilots using the helicopter’s communications radios or by cellular telephone. A pilot would also have the option of contacting other Kauai airports at Princeville, Barking Sands military airfield, or LIH by cellular telephone. 1.7.5 Hawaii-Specific Weather Challenges Many local air tour pilots,30 some with several years’ flying experience on the island of Kauai, stated that helicopter operations there could be particularly challenging because of the terrain, mountain winds, and rapidly changing cloud conditions. They also stated that conditions were more challenging in winter. Many reported that, because weather conditions on Kauai changed so rapidly, traditional sources of pilot weather information, such as automated reporting stations, automated terminal information service (ATIS), and FSS briefings, were not very useful for flight planning. Of the eight weather-related31 air tour accidents that occurred in Hawaii since SFAR 71 was implemented, four involved pilots, including the accident pilot, who were relatively new to air tour operations in Hawaii, three of whom had been flying in the islands for less than 2 months.32 For example, on September 23, 2005, an Aerospatiale AS350BA air tour helicopter crashed off the northern coast of Kauai after encountering heavy rain and other adverse weather conditions, killing three of the five passengers.33 The pilot had been conducting tour flights in Kauai since August 8, 2005. The pilot survived and reported to investigators that he obtained a weather printout from a DUATS before his first flight that morning. He also stated that he listened to the LIH ATIS before he departed from LIH on the accident flight and that he observed good weather and visibility at the airport. One surviving passenger reported that, when the tour began, the visibility was 30 Air tour pilots contacted during the investigation included former Bali Hai pilots and pilots who had flown or were flying for other air tour operators in Hawaii. 31 When these data were compiled, some accidents remained under investigation, and the classification “weather-related” was derived from collected factual information. For completed investigations, the classification was derived from published probable causes and factors. 32 The four accidents are this accident, LAX98FA211, LAX04FA190, and SEA05MA199. 33 The description of this accident, SEA05MA199, can be found on the Safety Board’s Web site at http://www.ntsb.gov.

Factual Information 14 Aircraft Accident Report good, but, as the tour progressed, the helicopter entered thick clouds and encountered heavy rain and reduced visibility. Another pilot, who was involved in the April 18, 2004, accident on the island of Hawaii, had been employed by the tour company for 11 days and was conducting her first 14 CFR Part 135 revenue tour flight.34 Interviews with Honolulu FSDO inspectors revealed that, after that accident, they discussed whether initial operating experience (IOE)35 should be required for all local new-hire tour pilots to familiarize them with not only the tour routes, but also the changing weather patterns in the islands. The FSDO inspectors stated that they believed IOE would be the best way to provide guided experience to new air tour pilots, but a requirement for IOE was not implemented. The experienced Kauai air tour pilots interviewed stated that they believed that a pilot’s ability to assess local weather-related changes and to anticipate the effect of such changes on flying conditions improved as the pilot’s local flying experience increased. During its investigation of the previously mentioned September 23, 2005, air tour accident, the National Transportation Safety Board identified three relatively experienced Kauai air tour pilots who encountered the same storm as the accident pilot. Of the three, one pilot chose to cancel his tour and return to base rather than attempt to enter the storm. The other two pilots chose to enter the storm and, although neither flight resulted in an accident, both pilots encountered visibility conditions below what is allowed under SFAR 71. 1.8 Aids to Navigation Not applicable. 1.9 Communications There were no known radio communications between the accident flight and any ATC facilities or other aircraft. 1.10 Airport Information Bali Hai operated its tour flights from PAK, a general aviation airport 1 mile southwest of Hanapepe on the southwest side of Kauai. Located on a flat peninsula, PAK 34 The accident involved a Piper PA-28-161 airplane. The description for this accident, LAX04FA190, can be found at the Safety Board’s Web site at http://www.ntsb.gov. 35 IOE is described as the initial actual aircraft flying experience a pilot performs after completing simulator training and ground school. IOE is usually performed under the oversight of an instructor or check airman, and a minimum number of IOE hours are typically required before a pilot is allowed to fly as part of a crew during a revenue flight. This type of oversight of flights is most commonly encountered in 14 CFR Part 121 operations, though some Part 135 operators choose to use this training method.

Factual Information 15 Aircraft Accident Report has one paved 2,400-foot runway and an adjacent, unpaved helicopter-parking apron that has no buildings or shelters. 1.11 Flight Recorders Not applicable. 1.12 Wreckage and Impact Information The helicopter’s wreckage was located on the east side of Kahili Ridge about 200 feet below the crest of the ridge at an elevation of 2,850 feet. According to Kauai Fire Department personnel, who were the first to reach the accident site, the wreckage was located on a 75º slope covered by thick vegetation. The wreckage was oriented west-southwest, and the debris field remained within a 50-foot radius of the main impact area with the main concentration of debris scattered to the southwest up the steep slope. Nearly all the wreckage was recovered and transported to a hangar at LIH for examination. Most of the fuselage structure was destroyed by impact and fire damage. The landing skids and crossover tubes were fragmented into numerous pieces. The top of the cockpit and cabin structure was crushed and was deformed upward. The left side cabin and cockpit doors were deformed; the right side cabin and cockpit doors were significantly more fragmented and deformed than the left side doors. Cockpit flight controls were found in the wreckage debris, but damage prevented investigators from determining control continuity. The tail boom was separated from the fuselage at the fuselage junction area, was not fire-damaged, and was deformed downward. The transmission and the main rotor mast remained intact and were attached to the roof structure. Examination of the airframe, flight control system components, main rotor system, transmission components, and the tail rotor system components revealed no evidence of a precrash mechanical malfunction. Examination of the main rotor mast revealed no evidence of a mast-bumping event.36 The engine was separated from the airframe attach mounts, and the oil, air, and fuel lines showed impact and/or fire damage. From November 2 to 3, 2004, the engine was examined at the Rolls-Royce Corporation facility in Indianapolis, Indiana, under Safety Board supervision. Examination revealed that the compressor impeller shroud displayed rotational scoring and gouging throughout the entire circumference of the shroud, heavy rub damage was evident within the turbine section, and the engine fuel control unit’s 36 According to the FAA’s Rotorcraft Flying Handbook, Chapter 11, “Helicopter Emergencies,” a mast-bumping event occurs when the main rotor hub comes in contact with the rotor mast, which could result in severe damage to the rotor mast or the separation of the main rotor system from the helicopter. Mast-bumping events typically result from improper pilot control inputs or from turbulence that can subject the helicopter to low-gravity conditions.

Factual Information 16 Aircraft Accident Report pointer indicated the throttle was full open. No evidence of precrash engine malfunction was observed. On May 13, 2005, the attitude indicator from the cockpit instrument panel was disassembled and was examined at the Safety Board’s materials laboratory. Visual and microscopic examination of the internal rotor and its housing revealed that each showed circumferential scoring consistent with rotor rotation at impact. Damage precluded testing of the helicopter’s mode C transponder. 1.13 Medical and Pathological Information Tissue and fluid specimens from the pilot were sent to the FAA’s Civil Aerospace Medical Institute in Oklahoma City, Oklahoma, for toxicological testing. According to the toxicology report, the specimens tested negative for carbon monoxide, cyanide, and a wide range of legal and illegal drugs.37 Traces of pseudoephedrine, a drug found in common, over-the-counter decongestants, were found in the pilot’s liver. Quantities of ethanol were detected in the brain, muscle, and blood; however, the report noted, “the ethanol found in this case may be the result of postmortem ethanol production.” 1.14 Fire A fuel-fed fire erupted after the helicopter impacted the ground. 1.15 Survival Aspects An autopsy was performed on the pilot on September 29, 2004, by the Wilcox Memorial Hospital Department of Pathology, Lihue. According to the autopsy report, the cause of death for the pilot was “multiple traumatic injuries.” According to the autopsy reports for the passengers, the cause of death for each was “multiple traumatic injuries sustained in a helicopter crash and fire.” 1.16 Tests and Research None. 37 The drugs tested for included the following: amphetamine, opiates, marijuana, cocaine, phencyclidine, benzodiazepine, barbiturates, antidepressants, antihistamines, meprobamate, methaqualone, and nicotine.

Factual Information 17 Aircraft Accident Report 1.17 Organizational and Management Information 1.17.1 General Bali Hai began conducting its Part 91 sightseeing operations in 1986. Its office included an enclosed garage, which served as the company’s maintenance facility. The company had two Bell 206B helicopters that operated from PAK, which was about 1 mile from the office. The helicopters were transported each day from the office to the airport on a flatbed trailer pulled by the company’s fuel truck and were returned each evening in the same manner. The company operated tours 7 days per week. Company personnel stated that the summer season and the Christmas and New Year’s holidays were the company’s busiest tour periods. Bali Hai did not record operating statistics, but the owner estimated that the company flew 1,000 to 1,200 flight hours and carried about 4,500 passengers per year. Review of company scheduling records for the 60 days preceding the accident indicated that the company flew 410 tours, 335 revenue flight hours, and 1,479 passengers during that time period. At the time of the accident, Bali Hai was the only Part 91 helicopter air tour company on Kauai; the other helicopter air tour companies on the island were certificated and operated under Part 135. Bali Hai was a family-operated business in which the owner himself was pilot-certificated, his son was the company’s sole mechanic,38 his daughter was the office manager, and his son-in-law served as a customer service representative.39 Nonfamily employees included the senior pilot, the accident pilot, and the line service technician. The pilots received a flat monthly salary plus flight-hour pay, which was an hourly rate applied to the number of revenue flight hours flown. 1.17.2 Pilot Training Bali Hai’s owner, mechanic, and other company pilots40 provided the accident pilot some initial company training, as their tour schedule permitted. Bali Hai was not required to have company-specific initial training;41 the owner stated that each pilot received as much training as the owner felt was needed for the pilot to fly safely and to 38 The mechanic held an aviation mechanic’s certificate with airframe and powerplant ratings. He stated that he gained his helicopter knowledge through on-the-job training at Bali Hai. 39 The customer service representative’s duties included providing the passenger safety briefing and providing a calculated weight and balance sheet in the form of a “boarding pass” to the passengers while they were at the company’s office. After the passengers arrived at the helicopter staging area at PAK, they would give the weight and balance sheet to the line service technician, who would give it to the pilot before the flight. 40 Besides the senior pilot, Bali Hai had one other pilot when the accident pilot was hired. That pilot was no longer with the company on the date of the accident. 41 Part 91 air tour operators, unlike Part 135 and Part 121 operators, are not subject to any initial pilot-training requirements.

Factual Information 18 Aircraft Accident Report pass the initial SFAR 71 checkride. Because Bali Hai held a certificate of waiver or authorization to deviate from SFAR 71, its pilots were required by the FAA to pass an SFAR 71 checkride every 12 calendar months. The owner stated that, whenever a pilot required a biennial flight review,42 the company would pay a certificated flight instructor and supply a helicopter so that the pilot could complete the required ground and flight training. Bali Hai did not provide, and was not required to provide, recurrent flight training.43 According to the owner, he believed the required SFAR 71 checkrides and annual air tour safety meetings44 provided an opportunity for the pilots to refresh their knowledge of SFAR 71 and Bali Hai’s deviation authorization. The accident pilot had not been employed with Bali Hai long enough to have attended one of the air tour safety meetings. 1.17.3 Pilot-Scheduling Practices 1.17.3.1 Daily Tour Schedules According to company personnel, unless there was a gap in the tour schedule, the helicopter would be kept running with its rotors turning continuously all day, to reduce engine wear associated with engine start cycles. On the day of the accident, the pilot did not shut down the helicopter. The customer service representative stated that the pilots typically flew no more than seven or eight tours per day. A review of scheduling records for the 3-month period before the accident showed that the senior pilot and the accident pilot averaged six tours per day when serving as primary pilot.45 During that timeframe, the accident pilot flew as many as 8 tours per day, and the senior pilot flew as many as 10 tours per day. Former Bali Hai pilots stated that the company sometimes added tours to the end of the day’s schedule, which would depart at 1700 or later, and that they sometimes felt too tired to fly these tours. Some former pilots reported flying as many as 13 tours per day. One former pilot stated, “There are only so many flights you can do where you feel strong enough.” 42 According to 14 CFR 61.56, a flight review requires ground and flight training from a certificated flight instructor. 43 Part 91 air tour operators, unlike Part 135 and Part 121 operators, are not subject to any recurrent pilot-training requirements. 44 For air tour pilots who are approved to deviate from SFAR 71, the FAA requires, in addition to the SFAR 71 checkride, that pilots participate in at least one formal air tour safety meeting each year. For more information about the meetings, see section 1.18.5.2. 45 Company personnel stated that Bali Hai typically scheduled pilots each week to fly 2 full days and 2 half-days, plus 1 additional full or half-day, depending on the demand for tours. The pilot scheduled to work a full day was considered the primary pilot.

Factual Information 19 Aircraft Accident Report 1.17.3.2 Pilot Lunch and Rest Breaks According to Bali Hai’s Policies and Procedures Manual, employees could take a 30-minute lunch break “provided all flight line ... needs are met.” However, former Bali Hai pilots stated that they either ate lunch while sitting in the helicopter between tours or did not eat lunch at all. One former pilot stated, “I would have appreciated a half-hour [break], but that’s just the way it was. I wasn’t overly fatigued by that, as long as I got something to eat.” Another former pilot stated, “[Bali Hai’s management] simply pushed the flights out. Pilots were just a cog in the wheel to make sure it happened. There was disregard for any fatigue or lunches or long hours, they just wanted pilots to keep flying.” Former pilots reported that management strongly encouraged them to return from tours on time. According to the line service technician, on the day of the accident, the pilot told him about 1200 that he was getting hungry and that the pilot asked him to buy a sandwich for him at a nearby store. According to the technician, the pilot ate the sandwich, while sitting in the helicopter, after returning from his fifth tour about 1345. Bali Hai did not provide shelter or restroom facilities at the airport for its employees or customers. Former company pilots stated that, when they needed to go to the bathroom, they would ask the line service technician to hold the helicopter’s flight controls so they could exit the helicopter to go relieve themselves on the ground behind the fuel truck or in nearby bushes. 1.17.4 Weather-Related Tour Cancellations Bali Hai’s owner stated that the minimum visibility requirement for tours was 3 miles. He said that he told each pilot to assess the weather conditions and his own personal safety limits and make a go/no-go decision about flying in marginal weather. The company’s senior pilot said that the company tried to abide by the Part 91 minimum VFR weather requirements and the more restrictive minimums outlined in the company’s SFAR 71 operations specifications document.46 Bali Hai’s senior pilot said that, because the accident pilot was new to Kauai, he and the owner “kept [an] eye on him” and briefed him numerous times about avoiding areas of poor weather. He stated that he had taken the pilot off the tour schedule for weather-related reasons on more than one occasion, even when conditions exceeded the company’s minimums. A review of Bali Hai’s flight-scheduling records indicated that, during the 8 weeks before the accident, one or more tours were canceled because of weather on 7 days that the accident pilot was working. On September 21, 2004, for example, the accident pilot’s 1200 and 1400 tours were rescheduled “due to [weather].” 46 As a Part 91 operator, Bali Hai was not required to have an operations specifications document. The Honolulu FSDO issued this document to Bali Hai after the owner applied for the authorization to deviate from SFAR 71.

Factual Information 20 Aircraft Accident Report The senior pilot stated that the accident pilot had informed him that he had avoided the Hanalei Valley and Waialeale Crater on more than one occasion when he had become uncomfortable about the weather conditions there. The senior pilot described the accident pilot’s flying as, “conservative,” “very controlled,” and “he tended to avoid weather at all costs.” The FAA inspector who administered the pilot’s SFAR 71 checkride stated that the pilot demonstrated good decision-making during the checkride by choosing not to enter Waialeale Crater during marginal weather conditions. A passenger on the accident pilot’s fourth tour on the day of the accident stated that the helicopter did not enter clouds. Passengers from another tour that day stated that the pilot maneuvered the helicopter carefully around clouds to show them Manawaipuna Falls. A professional helicopter pilot who rode as a tour passenger with the accident pilot on August 17, 2004, stated that the pilot crossed some ridges approximately 50 feet above terrain. The passenger stated that, while crossing a ridge during the latter portion of the tour, the pilot flew the helicopter into thin, light clouds. The passenger stated that he told the pilot that he did not want to fly in clouds and that the pilot replied that it was “OK” because he could “see through them.” The senior pilot stated that he had not experienced pressure to fly in marginal weather conditions. However, six of seven former Bali Hai pilots reported feeling at least some pressure from the company to fly in marginal weather conditions. One former pilot told investigators that the company’s go/no-go criteria for winds, clouds, and visibility were, “None. Put together whatever tour you can, fly in a little corner of the island if you have to.” He stated, “There was always implied pressure to fly.” Some former pilots reported that Bali Hai’s owner came out to the airport and yelled at them when they refused to fly because of poor weather. However, Bali Hai’s owner and office manager were out of town the week of the accident, and they were not on Kauai when the accident occurred. The accident pilot’s wife said that she had asked him how the flying was in Hawaii and that he told her that he enjoyed it but that he had expressed concern about challenging weather conditions. She said that he told her that it was more difficult to cancel his flights at Bali Hai than it had been in the military because Bali Hai was a commercial operation. She stated that he told her, “If it’s too bad, we won’t go, but if it’s just OK, we’ll go,” and that, “[the senior pilot] goes and comes back.” The pilot’s wife also stated, however, that he had not told her of any instances of being pressured by management to fly in poor weather. 1.17.5 Ridge-Crossing Practices Bali Hai’s certificate of waiver or authorization to deviate from SFAR 71 included a transition segment that crossed the south end of Kahili Ridge at a landmark called the billboard. According to the transition segment approval, ridge crossings at this location could be executed as low as 500 feet agl. The ridge pass near the accident site was more

Factual Information 21 Aircraft Accident Report than 1 mile from the centerline of the company’s approved transition segment; therefore, any crossing at that location would have to be performed in compliance with the SFAR 71 minimum altitude of 1,500 feet agl. The FAA inspector who administered the pilot’s SFAR 71 checkride stated that, during the checkride, he and the pilot discussed the rules for crossing Kahili Ridge near the accident site. He stated that he told the pilot that he was not permitted to cross there at low altitudes, and the pilot stated that he understood. Bali Hai’s owner stated that his pilots were allowed to cross the ridge at that location, but he incorrectly thought that a crossing could be performed there at 500 feet agl. Bali Hai’s senior pilot correctly stated the crossing altitude for that location. Interviews with five former Bali Hai pilots indicated that they varied in their understanding of the regulations and company practices for ridge-crossing locations and altitudes. The senior pilot estimated that 10 percent or less of the company’s tours crossed the ridge at the location near the accident site. He stated that a pilot might choose to cross there if the weather near the billboard was bad or for “scenic reasons.” A former Bali Hai pilot stated that he had often crossed the ridge where the accident occurred because passengers liked taking photographs there and because it reduced flight time by 2 to 3 minutes, which he considered helpful if the tour was running long. The chief pilot for another helicopter tour company stated that he had observed the accident pilot cross Kahili Ridge near the accident site on previous days and twice on the day of the accident. He considered this crossing location unsafe because it brought helicopters closer to clouds and challenging winds. Passengers from the pilot’s seventh tour stated that the pilot crossed Kahili Ridge near the accident site and that the helicopter encountered strong wind and rain in that area. One passenger stated that he was worried at times that the helicopter might not clear a ridge because the pilot would descend before crossing a ridge, then pull up to clear it. 1.17.6 Federal Aviation Administration Surveillance – Honolulu Flight Standards District Office Bali Hai’s operations and its certificate of waiver or authorization were under the jurisdiction of the Honolulu FSDO. The FSDO manager stated that oversight of a Part 91 air tour operator47 would only occur during random ramp inspections, during an SFAR 71 checkride conducted on the operator’s pilots, or in response to a customer complaint. The FSDO manager stated that the only complaints about Bali Hai that he could recall involved homeowners’ complaints about low-flying aircraft, and he said that he received similar complaints about other operators. He stated that he followed up on the complaints but that none resulted in any enforcement action against Bali Hai. One Honolulu FSDO 47 FAA Order 1800.56D, “National Flight Standards Work Program Guidelines (NPG),” lists the required surveillance items that inspectors must perform for Part 135 and Part 121 commercial air tour operators; however, the NPG does not contain any provisions that mandate inspector surveillance of Part 91 air tour operators.

Factual Information 22 Aircraft Accident Report inspector recalled receiving past complaints from Bali Hai pilots about maintenance-related issues, and he stated that one such complaint resulted in enforcement action after inspectors found deficiencies with the life vests on board Bali Hai’s helicopters. The Honolulu FSDO inspectors stated that, when they were at PAK conducting their mandatory inspections of a Part 135 air tour operator based at that airport, they would occasionally also conduct ramp inspections of Bali Hai’s helicopters and/or pilots. Review of the Program Tracking and Reporting Subsystem database revealed that the last maintenance-related ramp inspection of Bali Hai took place in 2002 and revealed a few mechanical discrepancies.48 According to the inspectors, because Part 91 surveillance was not mandatory and because Bali Hai had not been involved in an accident or incident since its inception in 1986, no emphasis was placed on monitoring its operations. 1.17.6.1 Staffing Levels As of February 22, 2005,49 the Honolulu FSDO employed 45 inspectors (22 operations inspectors, 18 airworthiness inspectors, and 5 avionics inspectors) and 6 managers (4 for the operations unit and 2 for the airworthiness unit). As of March 2005, the Honolulu FSDO was responsible for the oversight of 6 Part 121 operators, 46 Part 135 operators, 14 Part 133 operators, 6 Part 137 operators, and 5 Part 141 flight schools. Also, as of March 2005, the FSDO had 22 current approvals for Part 135 operator certificate of waiver or authorization for SFAR 71 deviations and 2 current approvals for Part 91 operator SFAR 71 deviations.50 The FAA estimates that there are about 400,000 air tour flights per year in Hawaii. Since 1990, Honolulu FSDO staffing issues and their potential impact on safety have been the subject of numerous Safety Board recommendations.51 Although the FAA has taken action in response, Honolulu FSDO staffing has remained below its authorized level.52 According to the Honolulu FSDO manager, at the time of the Bali Hai accident, the FSDO was about 10 inspectors short.53 The FSDO manager stated he was not authorized to hire more inspectors to fill those positions because the FAA’s Western-Pacific Region as a whole was overstaffed, and a hiring freeze was in effect. 48 These discrepancies included screws missing in the top engine cowling, safety wire missing for cannon plug for fuel filter assembly, and rubber boot missing for oil chip plug assembly. 49 On February 22, 2005, Safety Board and FAA investigators met with Honolulu FSDO personnel to conduct interviews about the FSDO’s staffing situation, work requirements, work scheduling, and budget issues, among others. The interviewees attending the meeting included the Honolulu FSDO manager, the operations unit managers, and the airworthiness unit managers. 50 One Part 91 approval was for Bali Hai, and the other was for an air tour company that was in the process of obtaining a Part 135 operating certificate. 51 For more information about the safety recommendations, see section 1.18.7. 52 According to the Honolulu FSDO manager, the FSDO has historically experienced staffing problems because it is not easy to recruit qualified personnel willing to relocate to Honolulu due to the cost-of-living expenses associated with the area. Over the years, some inspectors retired or transferred to other FSDOs or other areas in the FAA.

Factual Information 23 Aircraft Accident Report During interviews, Honolulu FSDO inspectors stated that they were time-constrained in trying to complete their mandatory inspections. They stated that, because of the staffing situation that existed at the time of the Bali Hai accident, the Part 135 operations inspectors focused on Part 135 surveillance and certification oversight and had little or no time for nonmandatory oversight duties, such as Part 91 oversight and/or surveillance. 1.17.6.2 Geographical Surveillance Unit In October 1995, the Honolulu FSDO formed a geographical surveillance unit (GSU), which provided direct oversight of all air tour operators in Hawaii, regardless of whether they operated under Part 135 or Part 91, and was responsible for ensuring compliance with SFAR 71.54 The GSU was originally established with eight inspectors, one clerical assistant, and one supervisor. All inspectors used in surveillance operations were trained to recognize standoff distances55 and elevations above terrain. The GSU was equipped with surveillance cameras, binoculars, video cameras, and other equipment that the inspectors used to monitor operations and to ensure that pilots and tour companies were complying with cloud and terrain clearance requirements. The GSU used a number of innovative surveillance methods, such as monitoring air tour activity from remote locations and sending inspectors posing as tourists on revenue flights.56 These methods resulted in some pilots being cited for violating cloud and terrain clearance restrictions. As part of its duties, the GSU primarily focused its surveillance on operators that were the subject of air tour customer complaints. A former GSU inspector recalled at least one instance in which a passenger complaint, combined with the passenger’s photographic evidence, resulted in FAA enforcement action against an operator. Former GSU inspectors recalled that the unit had performed some surveillance of Bali Hai that resulted 53 According to the FSDO manager, he completed a 2004 staffing allocation model, and it indicated that the FSDO was 13 inspectors short. By September 2006, FSDO personnel reported that the total FSDO staffing level was similar to that at the time of the accident; however, due to retirements and transfers, fewer inspectors were dedicated to Part 121 oversight and five more inspectors, including the newly hired ones, were dedicated to Part 135 oversight. The newly hired inspectors were not expected to be fully trained and able to resume full responsibilities until the end of fiscal year 2007. 54 The “Geographical Surveillance Unit – SFAR Manual” contains the guidelines for the Honolulu FSDO’s GSU program and lists GSU inspectors’ duties, which include traveling to all airports, heliports, landing sites, remote locations, and tour routes frequented by the air tour/sightseeing industry; performing ramp inspections, en route inspections, maintenance functions, and any other surveillance to ensure compliance with SFAR 71; investigating accidents, incidents, and complaints in regards to air tour/sightseeing; and reviewing and making recommendations about problem areas or improvement of the SFAR 71 deviation process/approval, among other duties. 55 Standoff distance refers to a defined horizontal radius to be maintained between the aircraft and any person, structure, vehicle, vessel, or raw terrain. 56 The GSU also used inspectors from mainland FSDOs to help conduct this type of en route oversight; using non-Honolulu FSDO inspectors reduced the likelihood that the tour pilots would recognize the inspectors. This provided the FAA the opportunity to observe typical flight operations.

Factual Information 24 Aircraft Accident Report in the correction of minor discrepancies, but they did not recall that any in-depth inspections had been performed or any violations issued. According to Honolulu FSDO personnel, the GSU was highly successful at performing surveillance of air tour operations. However, by late 2003, the FSDO needed to fill operations and airworthiness inspector positions, and, because the National Flight Standards Work Program Guidelines stated that oversight of certificated operators was the priority, inspectors from the GSU were reallocated to fill those positions instead. In May 2004, the GSU was officially disbanded. After the GSU disbanded, there were no inspectors dedicated to providing direct surveillance of air tour flights in Hawaii. 1.18 Additional Information 1.18.1 Helicopter Operations in Reduced Visibility Reduced visibility conditions pose a significant challenge for helicopter operations for multiple reasons. Helicopters are usually flown at lower altitudes than fixed-wing aircraft, which imposes high visual demands on helicopter pilots to maintain obstacle and terrain clearance. When visual references are obscured, such as by fog or clouds, the risk of a collision with obstacles or terrain increases. Helicopters are more maneuverable, but less stable, than fixed-wing aircraft, and require relatively continuous pilot control inputs unless equipped with stability augmentation systems. Most helicopters that are certificated for single-pilot flight under IFR are equipped with stability augmentation systems, such as control stabilization and autopilot systems, which are designed to reduce pilot workload.57 However, most older helicopters, including the accident helicopter (which was not certificated for IFR operations), do not have this equipment; research has shown that these helicopters can impose a high workload on pilots who attempt to fly them in reduced visibility conditions by reference to flight instruments alone. Accidents that occur in reduced visibility conditions after a pilot has attempted VFR flight into IMC are much more likely to be fatal than accidents that occur in visual meteorological conditions (VMC). In a 2005 study,58 the Safety Board reported that, in 2004, only 6 percent of all general aviation accidents occurred in IMC, but 70 percent of those accidents were fatal.59 A review of Safety Board helicopter accident data indicated that, from 1995 to 2004, about 20 percent of fatal helicopter general aviation accidents and 52 percent of fatal helicopter air taxi accidents occurred in either IMC or dark night VMC. None of the pilots who experienced fatal accidents in those conditions had activated an IFR flight plan. 57 S.G. Hart, “Helicopter Human Factors,” Human Factors in Aviation (1988): 591-638. 58 National Transportation Safety Board, Risk Factors Associated with Weather-Related General Aviation Accidents, Safety Study NTSB/SS-05/01 (Washington, DC: NTSB, 2005). 59 In 2004, there were 103 general aviation accidents that occurred in IMC, resulting in 143 deaths.

Factual Information 25 Aircraft Accident Report Reduced visibility conditions, such as IMC or dark night VMC, also greatly increase the risk of spatial disorientation. One recent study of U.S. Army rotary-wing operations found that sudden loss of visual cues preceded about 25 percent of helicopter accidents attributed to spatial disorientation.60 1.18.2 Spatial Disorientation Spatial disorientation occurs when a pilot develops an incorrect perception of aircraft attitude, altitude, or motion relative to the Earth’s surface. It results when a pilot’s normal visual cues to aircraft attitude are inaccurate, unavailable, or inadequately monitored, and the pilot, instead, relies on other cues to aircraft attitude that may be misleading. These cues are provided by the motion-sensing vestibular organs in each inner ear. The sensory organs of the inner ear detect angular accelerations in the pitch, yaw, and roll axes, as well as gravity and linear accelerations. The vestibular system provides useful sensory information under conditions of self-locomotion on the ground but provides misleading sensations in the flight environment. Vestibular sensations are easily ignored when pilots have a clear view of the horizon, but they become compelling illusions when external visual references are not available. Instrument-rated pilots are taught to ignore misleading vestibular sensations in favor of the visual cues from flight instrumentation when operating in IMC. However, even experienced, instrument-rated pilots can experience episodes of spatial disorientation in reduced-visibility conditions. Situational risk factors for spatial disorientation include false surface planes created by sloping clouds or terrain, transitions between VMC and IMC that require the shifting of visual attention between external visual references and cockpit flight instruments, sustained turns, and high workload.61 Spatially disoriented pilots are at risk of making inappropriate control inputs that can result in loss of aircraft control. A survey examining disorientation phenomena among naval helicopter pilots found that the most common form of pilot disorientation involved illusions of the helicopter banking.62 In fact, most surveys examining the incidence of in-flight spatial disorientation among pilots have produced similar findings. For example, in one survey of Indian Air Force pilots, 55 percent of helicopter pilots reported having experienced a false sensation of “one wing low,” and 45 percent reported having felt as if they were banking in the opposite direction. Also, 54 percent of helicopter pilots reported having experienced spatial disorientation illusions in clouds, and 32 percent reported experiencing such illusions in poor visibility conditions. The average duration of spatial disorientation 60 M.G. Braithwaite, S.J. Durnford, J.S. Crowley, N.R. Rosado, and J.P. Albano, “Spatial Disorientation in U.S. Army Rotary-wing Operations,” Aviation, Space, and Environmental Medicine, Vol. 69 (1998): 1031-1037. 61 (a) F.H. Previc, “Visual Illusions in Flight,” Spatial Disorientation in Aviation (2004): 283-323; and (b) L.R. Young, “Spatial Orientation,” Human Factors in Aviation (2003). 62 F.R. Tormes and F.E. Guedry, “Disorientation Phenomena in Naval Helicopter Pilots,” Aviation, Space, and Environmental Medicine, Vol. 46, No. 4 (1975): 387-393.

Factual Information 26 Aircraft Accident Report illusions experienced by Indian Air Force pilots flying fixed- and rotary-wing aircraft was 46 seconds.63 1.18.3 Helicopter Pilot Fatigue Issues Little research has examined the unique effect of time-on-task as a cause of fatigue and an influence on performance among helicopter pilots. One such study64 examined the effect of a vibrating, noisy, helicopter cockpit environment and continuous flying activity on subjective fatigue and pilot performance. Flight legs were designed to simulate repetitive circular, helicopter air taxi flights conducted under IFR in a metropolitan area, with complete circuits lasting about 1 hour and including three approaches and landings. Pilots flew either 3-, 4-, 6-, or 8-hour flight periods.65 Rest breaks were permitted during the 4- and 8-hour flight periods but not during the 3- and 6-hour flight periods. Pilot performance was measured, and the pilots also provided ratings of subjective fatigue each hour. Time-on-task and subjective fatigue were found to have no effect on some basic aspects of flying performance, but they were associated with increased “lapses” in performance, such as navigational errors, which were excluded from the performance analysis. The study found that subjective fatigue increased with time-on-task, peaking during the last hour of flight, but scheduled breaks delayed the onset of subjective fatigue. The 6-hour flight period without breaks was the most fatiguing condition (more fatiguing than the 8-hour flight period with scheduled breaks). During the last hour of the 6-hour period, average subjective fatigue ratings were between “looking forward to a rest period” and “just hanging on till [sic] end of period.” Some pilots who participated in the study stated that they would not feel safe to fly an actual helicopter by the end of the 6-hour period with no breaks. 1.18.4 Flight Time and Duty Period Limitations Title 14 CFR 1.1 defines “flight time” as “pilot time that commences when an aircraft moves under its own power for the purpose of flight and ends when the aircraft comes to rest after landing.” This definition is the same for helicopters and airplanes. By comparison, U.S. Army flight regulations provide a unique definition of flight time for helicopters, stating that flight time begins when a helicopter lifts off the ground and ends when it lands and either the engines are stopped or the flight crew changes. Federal regulations do not impose maximum flight time or duty period limitations on Part 91 air tour pilots, but they do impose flight time limits for Part 135 operations. 63 P.D. Navathe and B. Singh, “Prevalence of Spatial Disorientation in Indian Air Force Aircrew,” Aviation, Space, and Environmental Medicine, Vol. 65 (1994): 1082-5. 64 A.M. Stave, “The Effects of Cockpit Environment on Long-Term Pilot Performance,” Human Factors, Vol. 19 (1977). 65 Sleep was not intentionally restricted for this study; however, flight periods were conducted between 1700 and 0100, after the pilots had already performed 8 hours of office work.

Factual Information 27 Aircraft Accident Report Under 14 CFR 135.267, pilots flying nonscheduled Part 135 flights are limited to 8 hours of flight time per consecutive 24-hour period for single-pilot operations and 10 hours of flight time per consecutive 24-hour period for two-pilot crews. More flight time is permitted as long as the anticipated duty period will not exceed 14 hours and is preceded and followed by rest periods of at least 10 hours. These flight time limits for nonscheduled Part 135 flights are the same for helicopter and airplane pilots. Army flight regulations66 allow local commanders flexibility in developing flight time limitations for helicopter pilots, but they recommend that flight time be limited to 8 hours per 24-hour period, 15 hours per 48-hour period, and 37 hours per week. Army regulations also recommend that maximum helicopter pilot flight times be reduced by factors of 1.3 for day contour or low-level flight and 1.6 for day, NOE flight. These recommendations were developed after questionnaire data from Army pilots gathered in 1980 indicated that low-altitude flight profiles following terrain contours and lower-altitude, terrain-hugging flights were more fatiguing for pilots than higher-altitude flights.67 1.18.5 Special Federal Aviation Regulation 71 After two helicopter air tour accidents occurred on the same day in Hawaii on July 14, 1994, the FAA issued SFAR 71 in the form of an emergency final rule on September 26, 1994, to establish certain procedural, operational, altitude, and equipment requirements for air tour operations in Hawaii.68 The final rule became effective on October 26, 1994. FAA headquarters personnel indicated that the 1,500-foot altitude restriction in SFAR 71 was not based on specific accident or incident data but was arbitrarily selected based on the rationale that operating at a higher altitude would provide more time for decision-making action in the event of a loss of engine power or other in-flight emergency. In a letter to the FAA dated October 27, 1994, the Safety Board commented that it was pleased to recognize the FAA’s initiative to improve the safety of air tour operations in Hawaii but that it was also concerned that the SFAR 71 altitude restriction could result in unintended degradation of the existing level of safety because of increased compression of traffic at the 1,500-foot limit. The Board urged the FAA to review the SFAR 71 altitude restriction “to [ensure] that there is no increase in the potential for in-flight collisions or inadvertent encounters with cloud layers.” The Hawaii Helicopter Operators Association, Air Line Pilots Association, air tour operators, and other groups also expressed concerns 66 Headquarters Department of the Army, Aviation Flight Regulations, U.S. Army Regulation 95-1 (Washington, DC: HQDA, 1997). 67 U.S. Army Aeromedical Research Laboratory, Evaluation of Army Aviator Human Factors (Fatigue) in a High-Threat Environment, USAARL Report No. 80-8 (Fort Rucker, AL: USAARL, 1980). 68 In addition to the minimum altitude requirements, other rules specified in SFAR 71 include flotation equipment for certain helicopter tour flights (external helicopter floats were required only for single-engine helicopter flights conducted beyond the shore of any island); a helicopter performance plan; operations suited to the helicopter’s operating limitations; and a passenger briefing on the use of flotation equipment, water-ditching procedures, and emergency-egress procedures.

Factual Information 28 Aircraft Accident Report that SFAR 71 could result in an increased likelihood of midair collisions and encounters with cloud layers. The FAA attempted to lessen these concerns by developing a means to allow air tour operators to request FAA approval to deviate below the SFAR 71 minimum altitude at specified locations. Such approvals are granted in a certificate of waiver or authorization, which, according to the FAA, provide separation between the fixed-wing aircraft and helicopters around the scenic areas where the air tour traffic is most dense. At the time of the accident, almost every helicopter tour operator conducting business in Hawaii held an authorization to deviate below the specified SFAR 71 minimum altitude along transition routes and at site-specific locations. A comparison of Hawaii air tour accident data69 for the 10-year period before SFAR 71 was implemented with data for the 10-year period after SFAR 71’s implementation revealed that 40 air tour accidents occurred between 1986 and 1995, resulting in 41 fatalities and that 22 air tour accidents occurred between 1996 and 2005, resulting in 43 fatalities. Because the FAA does not collect air tour passenger and flight hour data, accident rates for these two periods are not known.70 In the 10-year period before SFAR 71 was implemented, only 5 percent of Hawaii air tour accidents (2 of 40 accidents, resulting in 16 fatalities) involved encounters with weather. In the 10-year period after SFAR 71, 36 percent of the accidents (8 of 22 accidents) involved adverse weather and accounted for most of the fatalities (31 of 43 fatalities).71 1.18.5.1 Certificate of Waiver or Authorization to Deviate from Special Federal Aviation Regulation 71 To obtain a certificate of waiver or authorization to deviate from the SFAR 71 minimum altitude, operators were required to demonstrate to the FAA that they would be able to provide a level of safety equivalent to that provided by operating at the higher altitude. Operators did this by adding other safety measures to their operations. An October 30, 1997, FAA document supporting the extension of SFAR 71 stated that the FAA grants deviations case by case after scrutinizing each air tour operation to determine whether the deviation will achieve the desired safety goals.72 According to Honolulu FSDO management, as part of obtaining the deviation approval, the operator’s pilots must demonstrate knowledge of the site-specific locations during annual FAA checkrides, and helicopter pilots must demonstrate the ability to autorotate73 the helicopter successfully to an alternate emergency landing area at each site-specific location.74 69 These data were compiled from the National Transportation Safety Board accident database and its special investigation report: National Transportation Safety Board, Safety of the Air Tour Industry in the United States, Special Investigation Report NTSB/SIR-95/01 (Washington, DC: NTSB, 1995). 70 The Safety Board has issued several safety recommendations to the FAA requesting that the FAA obtain improved data. For more information about some of the recommendations, see section 1.18.7. 71 When these data were compiled, some accidents remained under investigation, and the classification “weather-related” was derived from collected factual information. For completed investigations, the classification was derived from published probable causes and factors.

Factual Information 29 Aircraft Accident Report The FAA has the ability to revise an operator’s certificate of waiver or authorization to require any safety enhancements that it feels are necessary, or it can revoke an authorization at any time. During interviews, Honolulu FSDO inspectors showed differences in their understanding of what they could require of operators seeking an approval to deviate from SFAR 71. Some inspectors indicated that they could require anything they deemed necessary to ensure operational safety, while others believed they were restricted as to how much they could demand on the basis of set precedent. Interviews conducted with Kauai air tour pilots after the accident indicated that pilots showed differences in their understanding of their respective companies’ FAA-approved ridgeline crossing requirements. As mentioned previously, present and former Bali Hai pilots provided various answers for permissible crossing altitudes, and a number of pilots not associated with Bali Hai believed that they were permitted to cross any ridgeline at 200 feet agl, even if it were not on a transition segment. Some pilots also did not realize that, when flying outside of a transition segment, they were required to maintain the SFAR 71 minimum altitude of 1,500 feet agl. 1.18.5.2 Formal Air Tour Safety Meetings The SFAR 71 deviation authorizations for all operators require that air tour pilots must “participate in at least one formal air tour safety meeting each 12 calendar months to review SFAR 71 and sightseeing/air tour issues and procedures.” Although the Honolulu FSDO requires air tour pilots to attend the annual safety meetings, the FSDO does not run the meetings or propose the agenda, and FSDO personnel do not always attend.75 Instead, individual air tour industry participants host each meeting as they see fit. A FSDO inspector who attended some meetings stated that some had disintegrated rapidly into a complaint session about SFAR 71. The most recent safety meeting for the island of Kauai before the accident took place in January 2004. Bali Hai’s senior pilot headed that meeting, and he stated that it concentrated mostly on concerns surrounding the FAA’s proposed revisions to 14 CFR Part 136.76 72 Air tour operators seeking approval for an SFAR 71 deviation were required to identify their selected site-specific locations on the FSDO’s master map, document the suitable emergency landing areas for each site, and provide the FAA with ingress and egress descriptions and minimum altitudes in their selected site-specific locations. Operators seeking approval to deviate from the 1,500-foot transition segment altitude were also required to provide the FAA information on their intended transition segments and the minimum altitude along that transition segment. The FAA stated that each deviation is site-specific and allows operation only over areas of raw terrain (devoid of any persons, vessels, vehicles, or structures). 73 Autorotation is a rotorcraft flight condition in which the lifting rotor is driven entirely by the action of the air when the rotorcraft is in motion. In the event of a loss of engine power, a helicopter pilot would have to perform an autorotation to land the helicopter. During training scenarios and checkrides, autorotations are typically performed with a simulated loss of engine power. 74 Pilots of fixed-wing aircraft who are authorized to deviate from the SFAR 71 minimum altitudes and conduct air tour operations at 1,000 feet agl are not required to demonstrate the aircraft’s ability to reach a suitable landing site. 75 The Honolulu FSDO kept the attendance sheets for each meeting. For meetings not attended by FSDO personnel, the host operator would forward the attendance sheets to the FSDO, and FSDO personnel had no knowledge of what safety topics, if any, may have been covered.

Factual Information 30 Aircraft Accident Report 1.18.6 Automatic Dependent Surveillance-Broadcast Program In 1998, the FAA developed an initiative for implementing the National Automatic Dependent Surveillance-Broadcast (ADS-B) Program to support the next-generation air transportation system. The program, which includes ground-based stations, satellites, and aircraft avionics, among other technologies, is designed to provide pilots with radarlike information in the cockpit and to enable air traffic controllers to monitor low-flying aircraft in those areas with limited or no radar coverage. For Hawaii air tour pilots, who are faced with challenging local weather conditions, high-density air tour traffic, and island geography that makes large areas of low-altitude airspace invisible to FAA radar systems, an ADS-B system could provide enhanced in-flight navigation, air traffic, terrain, and weather information, and, through data-link, provide the same information to ground-equipped personnel, such as operator dispatchers, air traffic controllers, or other FAA personnel. In 1999, the FAA began to test ADS-B program applications in some regions of Alaska, including high-volume air tour areas, such as southeast Alaska. The FAA also worked with the Cargo Airline Association and installed transceivers and tested ADS-B program applications in the Ohio River Valley. These and other tests have been highly successful. The FAA has stated that the National ADS-B Program ground infrastructure will be in place nationwide by 2013. The FAA has stepped up the implementation timeframe for the Gulf of Mexico and plans to have the infrastructure in place by 2010.77 Louisville, Kentucky; Philadelphia, Pennsylvania; and Juneau, Alaska, are also scheduled for completion by 2010. Hawaii is not singled out for early attention as part of this plan, however; its ADS-B ground infrastructure is scheduled to be installed by 2013, with the rest of the national airspace system. In a recent communication,78 the FAA indicated that the surveillance services and broadcast program planned to award a contract in July 2007 for the installation of ADS-B ground infrastructure covering all the areas in which there are now surveillance services for national airspace users and air traffic controllers. The FAA also indicated that, once the new infrastructure is in place, the program office and its vendors will explore options for providing surveillance services to other areas. 76 At the time of the meeting, Part 136 pertained to National Parks Air Tour Management. However, in an October 22, 2003, notice of proposed rulemaking, the FAA proposed a new subpart A in Part 136 that would establish general safety regulations for all commercial air tours. 77 Safety Recommendation A-06-21, issued March 24, 2006, asked the FAA to “ensure that the infrastructure for the National Automatic Dependent Surveillance-Broadcast Program in the Gulf of Mexico is operational by fiscal year 2010.” On July 17, 2006, the Board classified A-06-21, “Open—Response Received,” after the FAA surveillance and broadcast services program manager provided a June 15, 2006, briefing on the ADS-B program to the Board Members and staff, which included a discussion of the progress of the program for the Gulf of Mexico. 78 The Safety Board received an electronic communication from Vincent Capezzuto, FAA Air Traffic Organization (ATO)-E surveillance and broadcast services program manager, on October 25, 2006.

Factual Information 31 Aircraft Accident Report 1.18.7 Previous Related Safety Recommendations From October 1, 1988, to April 1, 1995, the Safety Board investigated 139 air tour accidents and incidents and issued numerous safety recommendations to the FAA and the Honolulu FSDO about air tours and FSDO staffing. During its investigation of the October 28, 1989, accident in Hawaii involving a de Havilland DHC-6 operated by Aloha IslandAir as a scheduled Part 135 passenger-carrying flight,79 the Board noted specific deficiencies with Honolulu FSDO staffing and oversight of general aviation and Part 135 operators and concluded that “at least three accidents in the Hawaiian Islands might have been prevented if [Honolulu] FSDO-13 had personnel and guidance to maintain adequate surveillance of its assigned … Part 135 operators.”80 As a result, among several recommendations, the Safety Board issued Safety Recommendation A-90-136, which asked the FAA to do the following: Perform a special study of the adequacy of Flight Standards District Office staffing considering the availability of work hours, the geographic area of responsibility, and the size and complexity of the assigned operations. On February 8, 1991, the FAA responded that it had procured a contractor to develop the required analyses and revalidated staffing standard. On May 11, 1993, the FAA reported that, among other improvements, it updated the safety inspector staffing standards, that the standards were developed at the regional level and were applied using the most current data providing regional staffing estimates, and that field office staffing estimates were generated and were being analyzed against current on-board employment for accuracy. In a June 7, 1994, response, the Safety Board noted that the FAA also reviewed aviation safety inspector (ASI) job tasks and elements, analyzed ASI job tasks by time and frequency, and planned a means to identify needed workforce distribution adjustments by option, specialty, and location. As a result, the Board classified Safety Recommendation A-90-136 “Closed—Acceptable Action.” After the April 22, 1992, accident on the island of Maui involving a Beech Model E18S operated by Tomy International, Inc. (doing business as Scenic Air Tours),81 the 79 National Transportation Safety Board, Aloha IslandAir, Inc., Flight 1712, de Havilland Twin Otter, DHC-6-300, N707PV, Halawa Point, Molokai, Hawaii, October 28, 1989, Aviation Accident Report NTSB/AAR-90/05 (Washington, DC: NTSB, 1990). 80 In its report, the Safety Board also concluded, “Inadequate surveillance [was] a result of the POI’s [principal operations inspector] heavy workload and insufficient qualitative guidance from FAA headquarters. … Turnover of personnel and the lack of experienced personnel resulted in only two POIs having responsibility for all the general aviation and Part 135 surveillance activities for FSDO-13 from June until August 1989.” 81 National Transportation Safety Board, Tomy International, Inc., d/b/a Scenic Air Tours, Flight 22, Beech Model E18S, N342E, In-flight Collision with Terrain, Mount Haleakala, Maui, Hawaii, April 22, 1992, Aviation Accident Report NTSB/AAR-93/01 (Washington, DC: NTSB, 1993).

Factual Information 32 Aircraft Accident Report Safety Board issued Safety Recommendation A-93-11, among others, to request that the FAA do the following: Ensure that the regulatory basis and surveillance resources are in place to oversee the operations, equipment, airmen, and airspace associated with any selective attention directed toward commercial air tour operations. Safety Recommendation A-93-11 was classified, “Closed—Acceptable Action” on February 22, 1994, after the FAA responded that it was considering rulemaking action and that it had taken action to provide better oversight of air tour operators in Hawaii and over the Grand Canyon. The Safety Board’s 1995 air tour special investigation report82 contained 11 safety recommendations; four of which are described below. Safety Recommendation A-95-57 asked the Department of Transportation (DOT) to do the following: Establish and maintain a database of all air tour operators that would provide data for use in determining the scope of air tour operations and accident rates that can be used to assess the safety of the air tour industry. On July 14, 1999, the Safety Board classified A-95-57 “Closed—Unacceptable Action” due to the DOT’s failure to take action in a timely manner. The other three recommendations, Safety Recommendations A-95-58, -61, and -64, respectively, asked that the FAA do the following: Develop and implement national standards by December 31, 1995, within 14 CFR Part 135, or equivalent regulations, for all air tour operations with powered airplanes and rotorcraft to bring them under one set of standards with operations specifications and eliminate the exception currently contained in 14 CFR Part 135.1. Use the data for air tour operators as recommended in A-95-57 to the Department of Transportation to provide adequate staffing at all FSDOs that have air tour operations within their geographic boundary. As soon as possible, conduct meetings with interested parties in Hawaii to resolve the issues of optimum flight altitudes and stand-off distances for air tour flights. These discussions should consider any positive or negative effects on safety of the current provisions of SFAR 71. The FAA responded to Safety Recommendation A-95-58 on September 15, 1995, stating that it was considering a notice of proposed rulemaking (NPRM) to address the issues in the recommendation. On June 18, 2001, the Safety Board concluded that the 82 National Transportation Safety Board, NTSB/SIR-95/01 (1995).

Factual Information 33 Aircraft Accident Report delays were unacceptable, and it classified A-95-58 “Open—Unacceptable Response,” pending issuance of the NPRM and the final rule. The NPRM, “National Air Tour Safety Standards,”83 was issued on October 22, 2003; the final rule was issued February 13, 2007. The Board notes that the final rule differs substantially from the NPRM and has not yet issued a response to the FAA.84 In a July 25, 2001, response, the Safety Board classified A-95-61 “Closed— Acceptable Alternate Action,” noting that, although the DOT failed to take the action on which the recommendation was dependent, the FAA created an alternative system to acquire data on air tour operators and use these data to provide adequate staffing at all FSDOs that have air tour operations in their geographic boundary. The FAA gathers the data through its mandatory drug-testing program for all air tour pilots.85 On October 29, 1996, the Safety Board classified A-95-64 “Closed—Acceptable Action” after the FAA responded on July 8, 1996, that it met with helicopter operators in Hawaii and decided to grant deviations from SFAR 71 to individual operators. As a result of the Safety Board’s analysis of the FAA’s procedures for collecting and reporting general aviation activity, on May 12, 2005, the Safety Board issued Safety Recommendation A-05-13 to supersede Safety Recommendation A-03-3886 and to ask the FAA to do the following: Develop, validate, and document an unbiased method for generating and revising activity estimates based on surveys or reporting of general aviation operations. On August 2, 2005, the FAA responded that it agreed that credible data on flight hours and flight characteristics are among the most basic requirements of safety analysis. The FAA stated that it would focus on improving the General Aviation and Air Taxi Activity (GAATA) survey distribution to include a larger portion of the general aviation fleet. On January 4, 2006, the Safety Board classified A-05-13 “Open—Acceptable Response” due to the FAA’s anticipated improvements to the GAATA survey process. 83 The NPRM was issued on October 22, 2003, in 68 Federal Register 60572. For more information, see section 1.18.8.1. 84 The final rule was issued on February 13, 2007, in 72 Federal Register 6884. For more information, see section 1.18.8.2. 85 Part 91, Part 135, and Part 121 operators must participate in the program. The information gathered through the testing program enables the FAA to monitor the number of air tour operators throughout the country, but it does not provide the FAA any flight-hour or passenger data for each operator for use in determining the scope of air tour operations and accident rates. 86 Safety Recommendation A-03-38 had been issued August 20, 2003, as a result of the Safety Board’s previous analysis of the FAA’s accident data and activity data.

Factual Information 34 Aircraft Accident Report 1.18.8 National Air Tour Safety Standards 1.18.8.1 Notice of Proposed Rulemaking The FAA’s original NPRM for national air tour safety standards sought to increase the safety of commercial air tours nationally by proposing requirements for the certification of air tour operators and establishing new safety requirements. The NPRM proposed to create a new Subpart A in Part 136 that would establish the general safety regulations for all air tours. The proposed Subpart A of Part 136 included a uniform definition for all commercial air tours and defined the terms “air tour operator,” “raw terrain,” “suitable landing area,” and “shoreline.” The NPRM also proposed that, in addition to the provisions of Part 136, air tour operators would still have to comply with Part 91, Part 135, or Part 121, however, Part 91 air tour flights would be limited to charitable or community events. The 14 CFR 119.1(e)(2) and 135.1(a)(5) exception, which currently allows for air tour operators like Bali Hai to conduct business under Part 91, would be amended to allow only flights that are conducted as part of infrequent functions that enable the general aviation community to contribute in a positive way to charitable and local causes.87 These events would be limited to a 3-day timespan and limited to four or fewer events per calendar year. According to the NPRM, the Part 91 air tour operators that were operating under the 14 CFR 119.1(e)(2) and 135.1(a)(5) exception, such as Bali Hai, would have to begin the process of obtaining a Part 135 or Part 121 operating certificate. The Safety Board responded to the NPRM on January 22, 2004, by supporting the proposed rule and by indicating that its implementation would establish safety requirements for commercial air tours that were long overdue. The Board also noted that the NPRM attributed a decrease in air tour accidents in Hawaii to the issuance of SFAR 71. However, the Board commented that it does not believe that there is a reliable basis for this conclusion because of the current lack of an accurate, verifiable method of collecting and tracking flight-hour activity data for specific segments of nonscheduled Part 135 flight operations. The Board also commented that these data-collection deficiencies hinder the Board’s and the FAA’s ability to calculate safety statistics. In addition to the Safety Board’s response, however, the FAA received thousands of complaints from within the air tour industry indicating that, if the proposals under the NPRM are implemented, a number of businesses, such as single-aircraft, single-pilot, Part 91 air tour operators (for example, operators who sell rides in open-cockpit, antique biplanes), would go out of business if required to comply with Part 135 regulations. The FAA responded by substantially revising several aspects of the NPRM before releasing the final rule. 87 According to the NPRM, to qualify for an exception under 14 CFR 119.1(e)(2), a charitable or community event must be conducted to raise funds for either of the following: a charity identified by the U.S. Department of Treasury; a nonprofit entity, with one of the entities’ purposes being the promotion of aviation safety; or a local community cause not covered by the first two exceptions. The sponsor of the charitable or community flight(s) would also be required to provide the local FSDO with at least 7 days advance notice.

Factual Information 35 Aircraft Accident Report 1.18.8.2 Final Rule On February 8, 2007, the FAA issued the final rule for National Air Tour Safety Standards. Among the final rule’s provisions, Subpart A of Part 136, as proposed under the NPRM, provides definitions for the terms “commercial air tours,” “air tour operator,” “raw terrain,” “suitable landing area,” and “shoreline.” The final rule also permanently establishes the requirements outlined under SFAR 71 by including those requirements in Part 136 of Appendix A. In contrast to what the NPRM proposed, the final rule allows most Part 91 air tour operators to still operate under the 14 CFR 119.1(e)(2) and 135.1(a)(5) exception;88 however, these operators must also comply with the safety requirements of Part 136, Subpart A, and must also apply for, receive, and comply with a letter of authorization (LOA) from the FAA in accordance with 14 CFR 91.147. The LOA requirements include the operator’s name; principal business address; principal place of business; the name of the person responsible for management; the name of the person responsible for aircraft maintenance; the make, model, and series of each aircraft; and the registration number of each aircraft. According to the FAA, the LOAs will enable the FAA to develop a database of all air tour operators, and the LOAs will be maintained in the same database as the operations specifications for certificated air tour operators. The final rule does not require operations specifications for Part 91 air tour operators, and it does not require air tour activity data reporting. 1.18.9 Requirements for Part 135 Air Tour Operators In addition to the mandatory FAA oversight requirements for Part 135 air tour operators, in general, operators that hold Part 135 operating certificates are required to do the following: prepare operating, maintenance, and training manuals and have them accepted or approved by the Administrator; acquire and install any equipment required for their operations under Part 135, as appropriate; train and test their crewmembers to show that those crewmembers are qualified to serve under Part 135, as appropriate; maintain flight-locating or dispatch procedures; and develop record-keeping systems to show that they can comply with Part 135 crewmember and maintenance requirements on an ongoing basis. In addition, all Part 135 certificated air tour operators have specific authority in their operations specifications to conduct commercial air tours. The operations specifications also list any special authority or deviations granted to the operator. Part 135 regulations, which were originally established for nonscheduled air taxi operations, also include restrictions and training requirements that are pertinent for air-taxi related operations, such as cargo handling, hazardous material carriage, hazardous material training programs, and international operations, among others. Air tour operators that hold Part 135 operating certificates must comply with these requirements, even though their daily operations may never involve such activities. 88 According to the final rule, an operator may not conduct tour flights over the Grand Canyon National Park under the exception.

36 Aircraft Accident Report 2. Analysis 2.1 General The pilot was properly certificated and qualified under Federal regulations to conduct the Part 91 nonstop sightseeing air tour flight. No evidence indicated any preexisting medical condition that might have adversely affected his performance during the flight. Although the operator inaccurately tracked the helicopter’s hours and kept inadequate maintenance records, examination of the wreckage revealed no evidence that powerplant, system, or structural failures of the helicopter contributed to the accident. The helicopter’s weight and balance were within limits for the duration of the flight. The accident was not survivable for any of the occupants because they were subjected to impact forces that exceeded the limits of human tolerance. This analysis discusses numerous human performance issues that contributed to this accident, including the role of spatial disorientation, the pilot’s inexperience with local weather patterns, his decision-making, and the effect that the operator’s pilot-scheduling practices and other cognitive factors had on the pilot’s ability to assess risks and make decisions. This analysis also discusses the lack of FAA oversight of Part 91 air tour operators, FAA oversight of commercial air tour operations, the inability of the Honolulu FSDO to provide direct surveillance of air tour operations in Hawaii, and the benefits of ADS-B in Hawaii. 2.2 Accident Sequence The air tour flight was conducted under VFR and collided with mountainous terrain during IMC. The pilot had encountered deteriorating visibility and cloud conditions during his previous tour, and those conditions were also present several minutes before the accident. Moderate turbulence was forecast, and passengers from previous tours reported that the helicopter encountered some turbulence, rain, and high winds. Weather radar data indicated that a line of weather echoes containing rain showers was converging on the ridge near the accident location about the time of the accident. This line of echoes was associated with a lowering of cloud bases below 2,400 feet msl and obscuration of the higher terrain in the area where the accident occurred. ATC radar data indicate that the helicopter passed over terrain elevations as high as 3,000 feet; thus, the pilot likely encountered areas of restricted visibility as he attempted to cross the ridge.

Analysis 37 Aircraft Accident Report ATC radar data was of limited use in helping investigators understand the helicopter’s movements because the helicopter’s mode C transponder was not functioning properly and transmitted erroneous altitude data; damage precluded postaccident testing of the unit. As a result, the available data provided only a two-dimensional ground track for the flight. The data showed that, as the helicopter crossed the top of the ridge, it entered a clockwise, spiral pattern for the remaining 47 seconds of flight. This spiral track grew increasingly erratic before ending near the location of the aircraft wreckage, which suggests that the pilot was unable to maintain a stable heading. Without accurate altitude data, however, it is impossible to know what changes in altitude may have accompanied these changes in ground track. The accident site was on a 75º slope, and the wreckage debris was scattered up the slope. Observed wreckage damage included fragmented skids and cross tubes, heavier crush damage on the right side of the cabin than the left, downward deformation of the tail boom, and evidence of a high engine-power setting. These damage characteristics and the wreckage debris distribution suggest that, when the helicopter struck the sloping terrain, it was in an extreme nose-high attitude with a high engine-power setting, neither of which are consistent with what would be expected for controlled cruise or maneuvering flight. Although it is possible that the pilot may have seen the terrain through the clouds moments before impact and added control inputs in an attempt to avoid it, the erratic, zigzagging ground track that preceded the impact suggests that the pilot lost control of the helicopter before the collision. 2.3 Human Performance 2.3.1 Spatial Disorientation Spatial disorientation has contributed to many accidents involving loss of control. In these cases, loss of control follows the pilot’s inappropriate control resulting from confusion about the aircraft’s attitude. Major situational risk factors for spatial disorientation include sustained turns, high workload, false surface planes created by sloping clouds or terrain, and transitions between VMC and IMC that require shifting visual attention between external visual references and cockpit flight instruments. All of these risk factors were present for the pilot during the last minute of the accident flight. Attempts to continue visual flight into IMC may be even more problematic for helicopter pilots than for pilots of fixed-wing aircraft because helicopters are inherently less stable and require near continuous control inputs from the pilot. Helicopters, like the accident helicopter, that are not equipped for IFR flight and do not have control stabilization or autopilot systems can impose high perceptual and motor demands on the pilot. These helicopters can make it very challenging for pilots to maintain stable flight by referring to flight instruments alone. When the accident pilot attempted to continue visual flight into IMC, he would have been subjected to a high workload in order to maintain control of the helicopter. Moreover, the extent of the weather echoes and the duration of the sustained turn captured by the radar track suggest that the encounter with IMC was

Analysis 38 Aircraft Accident Report prolonged. This would have further complicated the pilot’s workload and increased the potential for spatial disorientation resulting from hazardous illusions, thereby, increasing the potential for inappropriate control input responses. In the absence of evidence indicating a mechanical malfunction, severe turbulence,89 or some other factor that would explain the accident pilot’s apparent loss of control of the helicopter, spatial disorientation is the most likely explanation. The Safety Board concludes that the helicopter’s descending spiral flightpath, which became increasingly erratic in the final seconds of the flight, was consistent with pilot spatial disorientation. 2.3.2 Pilot’s Decision-making Although the pilot likely encountered areas of deteriorating weather and IMC near the accident site, photographs recovered from a passenger’s camera showed areas of clearer weather along the coastline, east of the helicopter’s position, as it exited Waialeale Crater. The lower terrain between the helicopter and the coastline and the height of the clouds would have permitted a safe deviation in that direction. Furthermore, Bali Hai pilots were authorized to fly as low as 1,000 feet agl from the crater toward the coast; thus, the pilot could have flown in the direction of better weather, while remaining in compliance with SFAR 71 and the certificate of waiver or authorization requirements. Rather than deviate to the east, however, the pilot chose to fly south, along his usual tour route adjacent to Kahili Ridge, as the advancing line of clouds closed in on the high terrain. The pilot’s decision to fly into an area of deteriorating weather and high terrain, despite the availability of a safer route to the east, was an error that played an important causal role in this accident, and the Safety Board considered many factors that may have influenced that decision. 2.3.2.1 Inexperience with Local Weather Patterns The accident pilot had been flying commercial air tours for Bali Hai on Kauai for less than 2 months. Nearly all of his previous flight experience had been gained as a military pilot with the Indian Air Force. Though the pilot was experienced in helicopter operations and claimed previous mountain and coastal flying experience, he had few flight hours as a commercial air tour pilot and had limited knowledge of Kauai’s weather patterns. The pilot had no previous experience flying in Hawaii before he was hired by Bali Hai, and he began conducting tour flights after accruing just 6.7 hours of flight training from company personnel, none of which included specific training on Kauai weather. Many experienced local air tour pilots interviewed after the accident stated that VFR helicopter operations on Kauai were unusually challenging because of the rugged terrain, mountain winds, and rapidly changing visibility and cloud conditions. They stated 89 The forecast included only moderate turbulence, and the weather study found no evidence to indicate a likelihood of severe turbulence.

Analysis 39 Aircraft Accident Report that these conditions rendered traditional sources of pilot weather information, such as automated reporting stations and FSS briefings, not very useful, and that this heightened the importance of a pilot’s skill in visually assessing changes in weather conditions during tour flights. The experienced pilots indicated that a pilot’s skill in assessing changing weather conditions and anticipating the effect of any changes on flying conditions was critical for effective decision-making. They stated that such skills improved as local flying experience increased. This raises concern about the impact of local inexperience on the safety of pilot decision-making. A review of the eight weather-related air tour accidents that have occurred in Hawaii since SFAR 71’s implementation revealed that four of the accidents involved pilots who had relatively low experience flying air tours in Hawaii. In fact, three of the accidents involved pilots who had flown there for less than 2 months. It is highly unlikely that the accident pilot would have decided to continue into the area of deteriorating weather conditions and attempted to cross in the vicinity of the accident site if he had accurately assessed the changing weather and had appreciated how it would likely affect flight visibility in those areas. Therefore, the pilot’s decision to fly in the vicinity of the accident site indicates that he was unable to accurately assess how rapidly or to what extent the weather was deteriorating in that area. As described earlier in this report, the pilot had previously told a passenger that he had flown through thin clouds during a ridge crossing because he could see through the clouds. The pilot may have expected that this would be the case during the accident flight; however, visibility was dramatically reduced along the top of the ridge as the incoming line of weather reached the high terrain. The Safety Board concludes that the pilot’s inexperience with Hawaii weather conditions affected his ability to make appropriate in-flight decisions when faced with deteriorating weather. The Board also concludes that other pilots who are inexperienced with Hawaii weather conditions may also be hindered in their ability to make appropriate in-flight decisions when faced with deteriorating weather. FAA-sponsored, human-factors research conducted by aviation psychologists suggests that cue-based training programs can improve pilots’ weather-related decision-making during VFR flights.90 The Safety Board concludes that cue-based training, tailored to the dynamic local island climate conditions of Hawaii, could provide an important safety benefit to pilots who are new to flying in the state. There are currently no FAA guidance materials providing specialized training on the recognition of local weather cues that are critical for in-flight decision-making in the Hawaiian Islands. Therefore, the Board believes that the FAA, in cooperation with Hawaii commercial air tour operators, aviation psychologists, and meteorologists, among others, should develop a cue-based training program for commercial air tour pilots in Hawaii that specifically addresses hazardous aspects of local weather phenomena and in-flight decision-making. The Board also believes that, once a cue-based training program that specifically addresses hazardous aspects of local weather phenomena and weather-related, decision-making issues is developed, as requested in 90 M. Wiggins and D. O’Hare, “Weatherwise: Evaluation of a Cue-Based Training Approach for the Recognition of Deteriorating Weather Conditions During Flight,” Human Factors. Human Factors and Ergonomics Society, Vol., No. 2 (2003): 337-345.

Analysis 40 Aircraft Accident Report Safety Recommendation A-07-18, the FAA should require all commercial air tour operators in Hawaii to provide this training to newly hired pilots. 2.3.2.2 Overconfidence and Decision Bias FAA-sponsored research indicates that pilots who demonstrate a willingness to fly under VFR into IMC in a simulated context tend to be more confident in their own abilities and less concerned about the associated risks.91 The pilot had expressed concerns to his family about flying in the challenging weather conditions on Kauai. However, passengers on tour flights he conducted before the accident flight reported that the pilot was willing to fly into areas of clouds and reduced visibility. Digital photographs taken during the accident flight showed that the pilot flew through at least two such areas before reaching the Kahili Ridge. These decisions had not previously resulted in an accident. This may have increased the pilot’s confidence in his own abilities and decreased his estimation of the risk associated with such decisions. The pilot’s decision to continue flying into deteriorating weather may also have been influenced by a cognitive bias. Deviating east toward the coastline would have required the pilot to disappoint his passengers by eliminating the last major scenic area on his tour and would have resulted in a late return to the airport. These outcomes represented certain inconveniences for the pilot. However, the pilot had the option of avoiding these inconveniences by continuing along his usual flightpath adjacent to the Kahili Ridge and attempting to cross the ridge at the high pass. Although the pilot may have recognized the increased safety risk associated with this option, the decision to accept a riskier choice to avoid a certain set of inconveniences would be consistent with a human decision bias that is often observed when people weigh potential decision outcomes in terms of the potential losses associated with each choice.92 Although it is possible that the pilot’s decision was influenced by overconfidence or decision-making bias, the extent to which either of these factors might have influenced his decision to continue flying into the area of deteriorating weather could not be determined. 2.3.2.3 Bali Hai’s Pilot-Scheduling Practices Bali Hai’s pilots remained at the helicopters’ flight controls nearly continuously for up to 8 hours per day because of the company practice of keeping the helicopters running between tour flights. The pilots did not have scheduled breaks, and they ate lunch while sitting in the helicopter between tours, if at all. There was no shelter at Bali Hai’s staging area, nor were there any restroom facilities. The lack of scheduled breaks, the short turnaround times between flights, and the unavailability of private restroom facilities probably discouraged consumption of food and liquids during the workday because there 91 Human Factors and Ergonomics Society, “An Investigation of the Factors that Contribute to Pilots’ Decisions to Continue Visual Flight Rules into Adverse Weather,” (Santa Monica, CA: 2001). 92 D. O’Hare and T. Smitheram, “Pressing On Into Deteriorating Conditions: An Application of Behavioral Decision Theory to Pilot Decision-Making,” International Journal of Aviation Psychology, Vol. 5 (1995): 351-370.

Analysis 41 Aircraft Accident Report was little opportunity to go to the bathroom. This increased the risk of dehydration and other physiological problems, which could have degraded performance. These working conditions were also conducive to fatigue. Research on pilot fatigue in a noisy, vibrating helicopter simulator found considerable increases in subjective fatigue after 6 hours of short repetitive flights. At the end of this period, some helicopter pilots who participated in the study said they were so fatigued that they did not feel safe to fly a real helicopter. As subjective fatigue increased, study pilots demonstrated increasingly frequent “lapses” in performance. The study also found that routine, hourly rest breaks outside the cockpit reduced the buildup of pilot fatigue to manageable levels, even when flight periods were extended to 8 hours.93 The day of the accident was the pilot’s second-longest day of flying since he began working for Bali Hai. By the time of the accident, he had been at the controls of the helicopter with the rotors turning for about 7.7 hours and had been observed to leave the cockpit briefly only once, about 1500. Passengers waiting to board the pilot’s 1500 flight later described him as appearing fatigued at that time. This evidence suggests that the pilot was likely to have been fatigued during the accident flight. Bali Hai operated under Part 91 and was, therefore, not subject to flight time, duty period, or rest requirements. However, the pilot’s cumulative flight time of approximately 6.5 hours did not exceed single-pilot limitations specified under Part 135. Part 135 allows a maximum of 8 hours of flight time per consecutive 24-hour period, with additional flight time permitted when the anticipated duty period will not exceed 14 hours and is preceded and followed by rest periods of at least 10 hours. By comparison, U.S. Army flight regulations94 also recommend that helicopter pilot flight time be limited to 8 hours per 24-hour period. However, the Army has recognized the stresses associated with helicopter flying, and its regulations recommend that maximum flight times be reduced to 6.15 hours for day contour flight or low-level flight at or below 200 feet agl. Army regulations also contain a broader definition of flight time. Army regulations consider a pilot’s flight time to begin when a helicopter lifts off the ground and ends when it lands and either its engines are stopped or the flight crew changes. The accident pilot’s air tours included a combination of low-level ridge crossings and higher-altitude flying. Although not subject to Army regulations, depending on how this flying was classified, the accident pilot’s cumulative time at the controls might have exceeded Army safety limitations. It is difficult to evaluate the relative extent to which dehydration, unmet physiological needs, or fatigue might have contributed to the accident pilot’s decision to continue flying into an area of deteriorating weather rather than deviate around the weather and risk a delayed return. However, it is likely that one or more of these factors was affecting the pilot at the time of the accident, any one of which would have negatively affected the pilot’s concentration and decision-making. The Safety Board concludes that Bali Hai’s pilot-scheduling practices, although permitted under Federal aviation 93 Stave (1977): 503-514. 94 U.S. Army Regulation 95-1 (1997).

Analysis 42 Aircraft Accident Report regulations, likely had an adverse impact on pilot decision-making and performance. The Board also concludes that existing Federal aviation regulations do not adequately address the pilot fatigue issues associated with the continuous, repetitive, high-frequency flight operations that are unique to commercial air tour helicopter operations. Therefore, the Safety Board believes that the FAA should establish operational practices for commercial air tour helicopter pilots that include rest breaks and that will ensure acceptable pilot performance and safety, and require commercial air tour helicopter operators to adhere to these practices. 2.3.2.4 Management Pressure Several pilots who had previously been employed by Bali Hai stated that the company owner and office manager had inappropriately pressured them to conduct tour flights in poor weather conditions on multiple occasions, and some reported being told it was unacceptable to allow tours to exceed scheduled times. In addition, the accident pilot’s wife stated that the pilot had expressed concern about the commercial pressure to continue flying when weather conditions were “just OK.” Despite these statements, the influence of management pressure on the accident pilot’s decision-making during the accident flight is uncertain. The pilot’s wife stated that he had not told her of being directly pressured by company managers to fly in poor weather, and both the company’s senior pilot and a pilot who left the company in August 2004 stated that they had not been pressured. Also, Bali Hai’s owner and office manager were out of town the week of the accident and were not on Kauai when the accident occurred; thus, their physical absence likely diminished their ability to monitor and directly influence the pilot’s activities on the day of the accident. The Safety Board concludes that, although there is evidence that Bali Hai managers had inappropriately pressured some pilots to fly in poor weather conditions and to avoid late returns, the extent to which management pressure might have influenced the pilot’s decision-making during the accident flight could not be determined. 2.4 Federal Aviation Administration Surveillance 2.4.1 Oversight of Part 91 Air Tour Operations Bali Hai was able to conduct its 45- and 55-minute commercial air tour flights under Part 91 because of the exception listed under 14 CFR 119.1(e)(2) and 135.1(a)(5) for nonstop flights within a 25-mile radius of the departure and arrival airport. The island of Kauai offers a unique opportunity in that its small size and large number of seasonal tourists enable an air tour operator to conduct tours of the entire island without exceeding the distance limit. Although the exception does not stipulate any operator flight-hour or passenger limitations, the intent behind the exception was likely to enable provisions for small operations, such as single-aircraft, single-pilot operators. It likely did not consider that an operator like Bali Hai could keep two helicopters running continuously daily to

Analysis 43 Aircraft Accident Report transport an estimated annual passenger load of about 4,500 to 8,50095 people under the relatively lenient regulations of Part 91. For example, in the NPRM titled “National Air Tour Safety Standards,” issued on October 22, 2003, the FAA acknowledged that “commercial air tours conducted in accordance with Part 121 or Part 135 are subject to a higher level of safety than those conducted in accordance with Part 91 because of the number of passengers they carry, the type of aircraft used … and the frequency of operations.” This assertion implies that the FAA expects that an air tour operator that carries a large number of passengers should be subject to a higher level of safety, yet Bali Hai was subject to no pilot training requirements, no pilot duty time limitations, relatively fewer aircraft maintenance requirements, and minimal FAA oversight and surveillance requirements. 2.4.2 Honolulu Flight Standards District Office Surveillance of Bali Hai Bali Hai conducted its sightseeing air tours since 1986 and, before this accident, did not receive any FAA national, regional, or office inspections or focused, multiperson, team inspections because such inspections are not required for Part 91 operators. According to FAA Order 1800.56D, the National Flight Standards Work Program Guidelines for FAA inspectors, “surveillance is one of the most important functions performed by AFS [Flight Standards Service] field office personnel to ensure safety and regulatory compliance in the aviation system.” The FSDO manager stated that oversight of a Part 91 operator would only be performed as needed, such as during an SFAR 71 checkride or in response to a customer complaint. With the exception of SFAR 71 pilot checkrides, the FAA performed no meaningful oversight of Bali Hai since 2002. During the Safety Board’s investigation of this accident, the FAA inspected Bali Hai and noted numerous maintenance-records discrepancies for the accident helicopter, such as the failure to record all operating hours on the helicopter and its components; the failure to maintain consistent records of component times; and the failure to record daily discrepancies, repairs, and replacements. These record-keeping discrepancies represent careless maintenance practices in which Bali Hai systematically underreported the hours on the helicopter and its components. Although maintenance issues were not a factor in this accident, proper record-keeping and proper tracking of the time that components are in use are crucial elements in any aircraft maintenance program, and, when not performed properly, they pose a serious threat to the safety of operations. If the FAA had required and had performed any systematic oversight of Bali Hai’s maintenance programs and operations, it likely would have detected the maintenance discrepancies and would have required that the operator correct these issues before any flights, revenue or otherwise, could resume. 95 The owner estimated that the company flew 4,500 passengers annually. However, in the 60 days before the accident, the company flew 1,479 passengers, and that time period was not part of the company’s busiest season.

Analysis 44 Aircraft Accident Report 2.4.3 Honolulu Flight Standards District Office Staffing Issues FSDO staffing issues and their effect on safety have been subjects of Safety Board concern for years. In 1990, staffing deficiencies at the Honolulu FSDO, in particular, led the Board to conclude that “at least three accidents in the Hawaiian Islands might have been prevented if [Honolulu] FSDO-13 had personnel and guidance to maintain adequate surveillance of its assigned … Part 135 operators.” The Board subsequently issued Safety Recommendation A-90-136, which asked the FAA to “perform a special study of the adequacy of Flight Standards District Office staffing considering the availability of work hours, the geographic area of responsibility, and the size and complexity of the assigned operations.” Five years later, Safety Recommendation A-95-61 was issued, asking the FAA to use data collected for air tour operations to provide adequate staffing at all FSDOs that have air tour operations in their geographic boundary. The FAA’s actions in response to Safety Recommendations A-90-136 and A-95-61, which included plans for a means to identify needed adjustments to workforce distribution by option, specialty, and location, have resulted in these recommendations being classified as “Closed—Acceptable Action” and “Closed—Acceptable Alternate Action,” respectively. However, the continued staffing deficiencies at the Honolulu FSDO clearly show that the FAA has not effectively implemented its plans. At the time of the accident, the FSDO manager estimated he was about 10 inspectors short but stated he was not authorized to hire any new inspectors. At the time of the Bali Hai accident, FSDO inspectors reported they were time-constrained in performing even the minimum required oversight for their Part 135 operator—a problem the Safety Board noted in its recommendation some 15 years earlier. Without FAA enforcement, repeated noncompliance with SFAR 71 and the certificates of waiver or authorization has persisted, some of which is likely unintentional. Interviews revealed that some Kauai air tour pilots differed in their understanding of their respective companies’ existing approvals and incorrectly identified their authorized ridge-crossing altitudes. Thus, these pilots likely crossed ridgelines in some locations during tour flights at altitudes lower than permitted under SFAR 71 or their respective authorizations, and, without FAA surveillance and intervention, they likely believed that such practices were permissible and safe. Because the FAA is not enforcing SFAR 71 and the deviation authorizations for all air tour operators, some pilots may be intentionally disregarding the rules with no consequences, thus, fostering hazardous in-flight decision-making practices and placing passenger safety at risk. For example, photographic evidence from the accident flight and passengers’ descriptions of flight conditions during previous tours indicate that the accident pilot had repeatedly flown the helicopter into clouds and areas of highly degraded in-flight visibility. Moreover, a Safety Board investigation of another air tour accident on Kauai found that, in addition to that accident’s pilot, two other air tour pilots chose to enter areas of highly degraded in-flight visibility. Thus, the Safety Board concludes that, because the Honolulu FSDO is not providing direct surveillance and enforcement of SFAR 71, pilots continue to violate SFAR 71 and the certificate of waiver or authorization

Analysis 45 Aircraft Accident Report requirements, either intentionally or unintentionally, thus, placing themselves and their passengers at unnecessary risk for accidents, particularly in marginal weather conditions. Between October 1995 and May 2004, the Honolulu FSDO’s GSU had been tasked to enforce SFAR 71 by monitoring all air tour operators, including those operating under Part 91. The GSU performed periodic, direct surveillance of the flight operations of air tour operators, and this resulted in the identification of a number of in-flight violations of SFAR 71 operating requirements. Before it was disbanded, the GSU also performed some surveillance of Bali Hai that resulted in the correction of some discrepancies, but the GSU had not performed in-depth inspections of the company. Although FSDO personnel considered the GSU to be highly effective, the FSDO had to disband the GSU to reallocate the unit’s personnel to fill operations and airworthiness inspector positions. The Safety Board concludes that the FAA has not provided sufficient resources for the Honolulu FSDO to implement air tour surveillance. Such surveillance, in the months before the accident, may have detected and corrected the accident pilot’s risky flying practices, such as low-altitude, off-route ridge crossings, and flight into clouds and reduced visibility. Therefore, the Board believes that the FAA should develop a permanent mechanism to provide direct surveillance of commercial air tour operations in the State of Hawaii and to enforce commercial air tour regulations. 2.4.4 Air Tour Safety Meeting Requirements In addition to the required FAA-administered initial and annual knowledge tests and checkrides, operators approved to deviate from SFAR 71 were required to ensure that their tour pilots participate in at least one formal air tour safety meeting annually. The FAA stated that the purpose of the safety meetings was to review SFAR 71 and sightseeing/air tour issues and procedures, and Bali Hai’s owner stated that he believed that the meetings provided his pilots an opportunity to refresh their knowledge of SFAR 71 and the SFAR 71 deviation requirements. Safety Board interviews with meeting attendees, however, revealed disparity between the intent of these meetings and the actual discussion topics and followup discussions that occurred. Although the Honolulu FSDO requires meeting attendance, it does not run the meetings or dictate the agenda. A FSDO inspector stated that some past meetings disintegrated rapidly into a complaint session or strayed into other topics. As mentioned previously, many Kauai air tour pilots demonstrated a lack of understanding of their respective companies’ minimum altitudes for ridge crossings. Improved refresher training may increase their knowledge of these issues. In addition, the annual safety meeting could be used to discuss pertinent safety issues, such as lessons learned, hazardous and/or consistent weather phenomena, and hazards related to site-specific areas, among other topics. Therefore, the Safety Board concludes that the annual SFAR 71 safety meetings have not been effective because the Honolulu FSDO has not ensured that the meetings are focused on safety trends and SFAR 71 procedures. Therefore, the Board believes that the FAA should direct the Honolulu FSDO to ensure that the annual safety meetings, as required under approved certificates of waiver or

Analysis 46 Aircraft Accident Report authorization, focus on pertinent and timely commercial air tour safety issues, including, but not limited to, reviews of Hawaii air tour accidents, local weather phenomena, and SFAR 71 procedures. 2.5 Safety Impact of Special Federal Aviation Regulation 71 In its air tour safety NPRM, the FAA attributed a decrease in the number of air tour accidents in Hawaii to the issuance of SFAR 71. The FAA also stated that the benefits associated with minimum altitude, visibility, and cloud clearance requirements “can be attributed to: (1) Increased time available for the pilot to react in an emergency, (2) prevention of situations in which the pilot unexpectedly encounters IMC, and (3) avoidance of adverse weather conditions.” Because of the current lack of an accurate, verifiable method of collecting and tracking flight-activity data for specific segments of nonscheduled Part 135 and Part 91 flight operations, the Safety Board concluded in a January 22, 2004, letter to the FAA about the NPRM, that, without the required safety and accident rate data, there is not a reliable basis for the FAA’s assertion that SFAR 71 has resulted in a decrease in air tour accidents. Safety Board review of Hawaii air tour accident data for the 10-year periods before and after SFAR 71’s implementation showed that, although the total number of air tour accidents decreased after SFAR 71’s implementation, the proportion of weather-related accidents increased and was responsible for 31 of the 43 total fatalities. While the rising trend in weather-related accidents appears to support the Board’s concerns that SFAR 71 altitude restrictions may increase the potential for inadvertent encounters with cloud layers, the Board acknowledges that there is not enough data to determine its significance. Therefore, the Safety Board concludes that the safety impact of SFAR 71, in terms of a potential decrease in the Hawaii air tour accident rate or a potential increase in the rate of weather-related accidents, cannot be established with the current data. Therefore, the Board believes that the FAA should reevaluate the altitude restrictions in the State of Hawaii to determine if they may have resulted in any unintended degradation of safety with regard to weather-related accidents and fatalities. 2.6 Need for National Air Tour Safety Standards In its 1995 special investigation report, the Safety Board expressed concern that the provisions of Part 91 were inadequate to ensure sufficient FAA oversight of air tour companies to identify and correct important safety deficiencies that could expose the traveling public to unacceptable safety risks. To address this concern, the Board issued Safety Recommendation A-95-58, which asked the FAA to “develop and implement national standards by December 31, 1995, within 14 CFR Part 135, or equivalent regulations, for all air tour operators … to bring them under one set of standards with

Analysis 47 Aircraft Accident Report operations specifications and eliminate the exception currently contained in 14 CFR Part 135.1.” This accident, involving a Part 91 air tour operator that carried a large number of passengers annually yet had numerous safety deficiencies and lacked FAA oversight, serves to illustrate the very scenario the Board’s recommendation sought to prevent. The FAA shared the Board’s concern. In its 2003 NPRM, “National Air Tour Safety Standards,” the FAA recognized that Part 91 air tour operators do not have the equivalent safety measures that are implemented by Part 135 operators and that action was needed. The FAA also indicated that it agreed that the same safety standard should be applied to all commercial air tours, wherever they are conducted. In the NPRM, the FAA proposed to require that all commercial air tour operators be certificated under Part 135 or Part 121 and that Part 91 air tour operations be limited to infrequent, charitable events. In response to the NPRM, however, the FAA received an overwhelming number of complaints from air tour operators that conduct business under Part 91, indicating that a number of businesses (such as single-aircraft, single-pilot operations) would go out of business if required to comply with Part 135 regulations. As a result, the FAA made substantial revisions to the proposed rule. The final rule, which was released February 8, 2007, still allows for Part 91 air tour operations under the 14 CFR 119.1(e)(2) and 135.1(a)(5) exception. The final rule also requires these operators to obtain an LOA from the FAA and abide by the new commercial air tour safety regulations defined in Subpart A of Part 136. Although the NPRM had proposed to place all commercial air tour operations under Part 135, the Safety Board acknowledges that Part 135 is an air taxi rule with which smaller air tour operators would have difficulties complying. Part 135 regulations were originally established for nonscheduled air taxi operations, which focused on the transport of passengers or cargo from one location to another. These regulations specify restrictions and training requirements for additional issues that would not usually be associated with air tour operations, such as cargo handling, hazardous material carriage, hazardous material training programs, and international operations. In the final rule, the FAA effectively withdraws its proposal to place all air tours under Part 135, and the Safety Board agrees that, though a number of the regulations under Part 135 enhance safety when compared to the requirements for Part 91 operations, the additional and unrelated rules would burden the smaller air tour operators with additional training and operational requirements that do not necessarily relate to their daily operations. Additionally, there may be some requirements under Part 135 that may not be stringent enough for the air tour industry, such as flight time and duty period limitations. However, the Board concludes that the public would benefit from air tour regulations that provide increased oversight and additional safety requirements for Part 91 air tour operators that carry large numbers of passengers annually, such as Bali Hai. The Safety Board acknowledges that, although the final rule establishes some national air tour safety standards in the form of Part 136, Subpart A, the regulation still does not contain provisions that would prevent the types of deficiencies highlighted by this accident. Specifically, for Part 91 air tour operations, the new LOA and Part 136

Analysis 48 Aircraft Accident Report requirements do not provide for mandatory FAA oversight. And, for all air tour operations, the final rule does not incorporate any initial and recurrent pilot training programs that address local geography and meteorological hazards and special airspace restrictions; maintenance policies and procedures; flight scheduling that fosters adequate breaks and flight periods; and operations specifications that address management, procedures, route specifications, and altitude restrictions, as necessary. The Safety Board concludes that a regulation specific to commercial air tour operations would be more appropriate than an air taxi regulation, and it would allow the FAA inspectors responsible for air tour operators to focus on the daily safety requirements unique to those operations. Therefore, the Board believes that the FAA should develop and enforce safety standards for all commercial air tour operations that include, at a minimum, initial and recurrent pilot training programs that address local geography and meteorological hazards and special airspace restrictions; maintenance policies and procedures; flight scheduling that fosters adequate breaks and flight periods, as established by the implementation of Safety Recommendation A-07-20; and operations specifications that address management, procedures, route specifications, and altitude restrictions, as necessary. 2.7 Implementing Automatic Dependent Surveillance-Broadcast in Hawaii The Safety Board commends the FAA for recognizing the safety benefits of ADS-B for oil industry operators in the Gulf of Mexico and for taking action in response to Safety Recommendation A-06-21 to advance the timeline for installing ADS-B system infrastructure there by 2010. According to a 2006 proposed schedule for deploying of ADS-B services nationwide, the FAA plans to install ADS-B infrastructure in the state of Hawaii by 2013. Hawaii’s mountainous landscape, limited ATC radar coverage, challenging weather, and high-density air tour traffic make it a prime candidate for the National ADS-B Program.96 ADS-B will support avionics features that enable pilots to see the location, extent, and movement of weather systems; thus, improving pilot awareness and helping pilots make safer decisions in flight. For example, if the accident helicopter had been equipped with avionics capable of displaying ground-based, weather-radar information transmitted via ADS-B infrastructure, the pilot would have been able to see the full extent of the weather converging on the Kahili Ridge, and his decision to continue into the weather may have been different. In addition to providing in-flight weather information to pilots, ADS-B also has the potential to reduce the risk of midair collisions, a concern commonly cited by air tour helicopter operators and their pilots. As Hawaii’s air tour industry continues to grow, 96 Initial ADS-B program testing was originally slated to take place in Alaska and Hawaii, but, due to the lack of funding in the Hawaii area, the initial testing was instead conducted in Alaska and Ohio.

Analysis 49 Aircraft Accident Report increasing numbers of aircraft will be flying over rugged, scenic terrain in a finite airspace, and some of these flights will occur in conditions of reduced visibility. ADS-B will support cockpit displays of traffic information that could improve pilot awareness of the position and movement of other aircraft in high-density tour areas. ADS-B services will also allow operators to remotely monitor the progress of their own tour flights. Operators could use this information to identify pilot excursions from company tour routes or below prescribed altitudes. The detection of such events would provide an opportunity for operators to discuss such events with the pilots involved and would allow operators to evaluate the need for any changes to their pilot training, standard operating procedures, or SFAR 71 deviation authorizations. The Safety Board concludes that the National ADS-B Program technology could help Hawaii air tour operators reduce operational risks. In October 2006, the FAA surveillance and broadcast services program manager indicated that the FAA planned to award a contract in July 2007 for the installation of ADS-B ground infrastructure covering all the areas in which there are now surveillance services for national airspace users and air traffic controllers. The FAA also indicated that, once the new infrastructure is in place, the program office and its vendors will explore options for providing surveillance services to other areas. The Safety Board notes, however, that major portions of the tour routes normally flown by Bali Hai and other air tour helicopter operators throughout Hawaii do not currently receive air traffic surveillance services. Thus, the Board concludes that, under the FAA’s current plan for installing the National ADS-B Program infrastructure in Hawaii, only limited services would be provided to the Hawaii air tour operators that could achieve significant safety benefits from the technology. Therefore, the Safety Board believes that the FAA should accelerate the implementation of ADS-B infrastructure in the State of Hawaii to include high-quality ADS-B services to low-flying aircraft along heavily traveled commercial air tour routes. In order to receive enhanced services that will be supported under the National ADS-B Program, Hawaii tour operators will first have to equip their aircraft with compatible avionics to benefit from planned ADS-B infrastructure. The FAA’s proposed schedule indicates that aircraft operators will have until 2020 to ensure that aircraft utilizing air traffic services are so equipped. The ADS-B program office has stated that it has not yet been established whether low-flying aircraft throughout the State of Hawaii will be required to have ADS-B-compatible avionics installed by 2020.97 The Safety Board concludes that commercial air tour operators operating under VFR may not be required to install ADS-B compatible avionics, even after ADS-B infrastructure is installed, which could lessen the safety-related benefit of these new services on Hawaii air tour flight operations. Therefore, the Board believes that the FAA should require that Hawaii air tour operators equip tour aircraft with compatible ADS-B technology within 1 year of the installation of a functional National ADS-B Program infrastructure in Hawaii. 97 The FAA stated that it intends to release an NPRM in September 2007 that will define the avionics that will be required to operate in different classes of airspace.

50 Aircraft Accident Report 3. Conclusions 3.1 Findings 1. The pilot was properly certificated and qualified under Federal regulations to conduct the 14 Code of Federal Regulations Part 91 nonstop sightseeing air tour flight. No evidence indicated any preexisting medical condition that might have adversely affected his performance during the flight. 2. There was no evidence that powerplant, system, or structural failures of the helicopter contributed to the accident. The helicopter’s weight and balance were within limits for the duration of the flight. 3. The accident was not survivable for any of the occupants because they were subjected to impact forces that exceeded the limits of human tolerance. 4. The helicopter’s descending spiral flightpath, which became increasingly erratic in the final seconds of the flight, was consistent with pilot spatial disorientation. 5. The pilot’s inexperience with Hawaii weather conditions affected his ability to make appropriate in-flight decisions when faced with deteriorating weather. 6. Other pilots who are inexperienced with Hawaii weather conditions may also be hindered in their ability to make appropriate in-flight decisions when faced with deteriorating weather. 7. Cue-based training, tailored to the dynamic local island climate conditions of Hawaii, could provide an important safety benefit to pilots who are new to flying in the state. 8. Bali Hai’s pilot-scheduling practices, although permitted under Federal aviation regulations, likely had an adverse impact on pilot decision-making and performance. 9. Existing Federal aviation regulations do not adequately address the pilot fatigue issues associated with the continuous, repetitive, high-frequency flight operations that are unique to commercial air tour helicopter operations.

1. Although there is evidence that Bali Hai managers had inappropriately pressured

some pilots to fly in poor weather conditions and to avoid late returns, the extent to which management pressure might have influenced the pilot’s decision-making during the accident flight could not be determined.

Conclusions 51 Aircraft Accident Report

1. Because the Honolulu Flight Standards District Office is not providing direct

surveillance and enforcement of Special Federal Aviation Regulation (SFAR) 71, pilots continue to violate SFAR 71 and the certificate of waiver or authorization requirements, either intentionally or unintentionally, thus, placing themselves and their passengers at unnecessary risk for accidents, particularly in marginal weather conditions.

1. The Federal Aviation Administration has not provided sufficient resources for the

Honolulu Flight Standards District Office to implement air tour surveillance. Such surveillance, in the months before the accident, may have detected and corrected the accident pilot’s risky flying practices, such as low-altitude, off-route ridge crossings, and flight into clouds and reduced visibility.

1. The annual Special Federal Aviation Regulation (SFAR) 71 safety meetings have not

been effective because the Honolulu Flight Standards District Office has not ensured that the meetings are focused on safety trends and SFAR 71 procedures.

1. The safety impact of Special Federal Aviation Regulation 71, in terms of a potential

decrease in the Hawaii air tour accident rate or a potential increase in the rate of weather-related accidents, cannot be established with the current data.

1. The public would benefit from air tour regulations that provide increased oversight

and additional safety requirements for 14 Code of Federal Regulations Part 91 air tour operators that carry large numbers of passengers annually, such as Bali Hai.

1. A regulation specific to commercial air tour operations would be more appropriate

than an air taxi regulation, and it would allow the Federal Aviation Administration inspectors responsible for air tour operators to focus on the daily safety requirements unique to those operations.

1. The National Automatic Dependent Surveillance-Broadcast Program technology

could help Hawaii air tour operators reduce operational risks.

1. Under the Federal Aviation Administration’s current plan for installing the National

Automatic Dependent Surveillance-Broadcast Program infrastructure in Hawaii, only limited services would be provided to Hawaii air tour operators that could achieve significant safety benefits from the technology.

1. Commercial air tour operators operating under visual flight rules may not be required

to install automatic dependent surveillance-broadcast (ADS-B) compatible avionics, even after ADS-B infrastructure is installed, which could lessen the safety-related benefit of these new services on Hawaii air tour flight operations.

Conclusions 52 Aircraft Accident Report 3.2 Probable Cause The National Transportation Safety Board determines that the probable cause of this accident was the pilot’s decision to continue flight under visual flight rules into an area of turbulent, reduced visibility weather conditions, which resulted in the pilot’s spatial disorientation and loss of control of the helicopter. Contributing to this accident was the pilot’s inexperience in assessing local weather conditions, inadequate Federal Aviation Administration surveillance of Special Federal Aviation Regulation 71 operating restrictions, and the operator’s pilot-scheduling practices that likely had an adverse impact on pilot decision-making and performance.

53 Aircraft Accident Report 4. Safety Recommendations As a result of the investigation of this accident, the National Transportation Safety Board makes the following recommendations to the Federal Aviation Administration: In cooperation with Hawaii commercial air tour operators, aviation psychologists, and meteorologists, among others, develop a cue-based training program for commercial air tour pilots in Hawaii that specifically addresses hazardous aspects of local weather phenomena and in-flight decision-making. (A-07-18) Once a cue-based training program that specifically addresses hazardous aspects of local weather phenomena and weather-related, decision-making issues is developed, as requested in Safety Recommendation A-07-18, require all commercial air tour operators in Hawaii to provide this training to newly hired pilots. (A-07-19) Establish operational practices for commercial air tour helicopter pilots that include rest breaks and that will ensure acceptable pilot performance and safety, and require commercial air tour helicopter operators to adhere to these practices. (A-07-20) Develop a permanent mechanism to provide direct surveillance of commercial air tour operations in the State of Hawaii and to enforce commercial air tour regulations. (A-07-21) Direct the Honolulu Flight Standards District Office to ensure that the annual safety meetings, as required under approved certificates of waiver or authorization, focus on pertinent and timely commercial air tour safety issues, including, but not limited to, reviews of Hawaii air tour accidents, local weather phenomena, and SFAR 71 procedures. (A-07-22) Reevaluate the altitude restrictions in the State of Hawaii to determine if they may have resulted in any unintended degradation of safety with regard to weather-related accidents and fatalities. (A-07-23) Develop and enforce safety standards for all commercial air tour operations that include, at a minimum, initial and recurrent pilot training programs that address local geography and meteorological hazards and special airspace restrictions; maintenance policies and procedures; flight scheduling that fosters adequate breaks and flight periods, as established by the implementation of Safety Recommendation A-07-20; and operations specifications that address management, procedures, route specifications, and altitude restrictions, as necessary. (A-07-24)

Safety Recommendations 54 Aircraft Accident Report Accelerate the implementation of automatic dependent surveillance-broadcast (ADS-B) infrastructure in the State of Hawaii to include high-quality ADS-B services to low-flying aircraft along heavily traveled commercial air tour routes. (A-07-25) Require that Hawaii air tour operators equip tour aircraft with compatible automatic dependent surveillance-broadcast (ADS-B) technology within 1 year of the installation of a functional National ADS-B Program infrastructure in Hawaii. (A-07-26) BY THE NATIONAL TRANSPORTATION SAFETY BOARD MARK V. ROSENKER Chairman ROBERT L. SUMWALT Vice Chairman DEBORAH A. P. HERSMAN Member KATHRYN O. HIGGINS Member STEVEN R. CHEALANDER Member Adopted: February 13, 2007

55 Aircraft Accident Report

1. Appendixes

Appendix A Investigation and Public Hearing Investigation The National Transportation Safety Board was initially notified of this accident on September 24, 2004. An investigator-in-charge (IIC) traveled to the area on September 25, 2004, but was unable to access the accident site due to hazardous terrain and adverse weather. The IIC was flown over the accident site on October 2, 2004, and subsequently examined the wreckage as it was recovered to a hangar. The following areas were assigned to specialists during the course of this investigation: Meteorology, Operations, and Human Performance. Parties to the investigation were the Federal Aviation Administration and Rolls-Royce Corporation. In accordance with Annex 13 to the Convention on International Civil Aviation, a nontraveling accredited representative from the Transportation Safety Board of Canada was assigned, and Bell Helicopter Textron, Inc., served as technical advisor. Public Hearing No public hearing was held for this accident.

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FD07331 ｜ 2007_美国_AAR0704.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2007 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

aviation In-flight Separation of Right Wing Flying Boat, Inc. (doing business as Chalk’s Ocean Airways) Flight 101 Grumman Turbo Mallard (G-73T), N2969 Port of Miami, Florida December 19, 2005 ACCIDENT REPORT NTSB/AAR-07/04 PB2007-910405

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Aircraft Accident Report In-flight Separation of Right Wing Flying Boat, Inc. (doing business as Chalk's Ocean Airways) Flight 101 Grumman Turbo Mallard (G-73T), N2969 Port of Miami, Florida December 19, 2005 NTSB/AAR-07/04 PB2007-910405 National Transportation Safety Board Notation 7756D 490 L’Enfant Plaza, S.W. Adopted May 30, 2007 Washington, D.C. 20594 E

P L U R IB US UN U M

N A T I O N A L

T R A S P O R T A T I O N

B O A R D S A FE T Y N

National Transportation Safety Board. 2007. In-flight Separation of Right Wing, Flying Boat, Inc. (doing business as Chalk's Ocean Airways) Flight 101, Grumman Turbo Mallard (G-73T), N2969, Port of Miami, Florida, December 19, 2005. Aircraft Accident Report NTSB/AAR-07/04. Washington, DC. Abstract: This report explains the accident involving Flying Boat, Inc. (doing business as Chalk’s Ocean Airways) Flight 101, a Grumman Turbo Mallard (G-73T) amphibious airplane, which crashed into a shipping channel adjacent to the Port of Miami, Florida, shortly after takeoff from the Miami Seaplane Base. Safety issues discussed in this report focus on air carrier maintenance programs and practices and Federal Aviation Administration (FAA) oversight procedures for air carrier maintenance programs. Safety recommendations concerning these issues are addressed to the FAA. The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Web at http://www.ntsb.gov. Other information about available publications also may be obtained from the Web site or by contacting: National Transportation Safety Board Public Inquiries Section, RE-51 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (800) 877-6799 or (202) 314-6551 Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2007-910405 from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605-6000

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

iii Aircraft Accident Report Contents Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Abbreviations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi Executive Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

1. Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2. 1

History of Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.2 Injuries to Persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1.3 Damage to Airplane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1.4 Other Damage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1.5 Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1.5.1 The Captain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1.5.2 The First Officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.6 Airplane Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.6.1 Wing Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 1.6.2 Maintenance Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1.6.2.1 Company Records of Right Wing Repairs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1.6.2.2 Major Repairs and Alterations of the Wing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 1.6.2.3 Continuous Airworthiness Maintenance Program . . . . . . . . . . . . . . . . . . . . . . . 11 1.6.2.4 Continuing Analysis and Surveillance System Program . . . . . . . . . . . . . . . . . . 11 1.6.2.5 Aging Airplane Inspection and Records Review . . . . . . . . . . . . . . . . . . . . . . . . 12 1.7 Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 1.8 Aids to Navigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 1.9 Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 1.10 Airport Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 1.11 Flight Recorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 1.11.1 Cockpit Voice Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 1.11.2 Flight Data Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1.12 Wreckage and Impact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1.13 Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 1.14 Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 1.15 Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 1.16 Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 1.16.1 Additional Grumman G-73T Examinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 1.16.2 Video and Image Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 1.16.3 Examination for Explosives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 1.17 Organizational and Management Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 1.17.1 Maintenance Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 1.17.1.1 Additional Maintenance Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 1.17.2 Postaccident Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 1.17.3 Federal Aviation Administration Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 1.18 Additional Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 1.18.1 Applicable Federal Aviation Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

iv Aircraft Accident Report 1.18.2 Previous Related Safety Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 1.18.2.1 Supplemental Inspections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 1.18.2.2 Cockpit Voice Recorder Functionality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 1.18.3 Postaccident Interviews Regarding Maintenance of Chalk’s Ocean Airways’ Airplanes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 1.18.3.1 Former and Current Company Pilots . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 1.18.3.2 Director of Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 1.18.3.3 Maintenance Supervisor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 1.18.3.4 Designated Engineering Representatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 1.18.4 Grumman Customer Service Bulletin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 1.18.5 Department of Transportation Concerns About the Economic Fitness of Chalk’s Ocean Airways . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

1. Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
2. 1

General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 2.2 In-flight Breakup Sequence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 2.2.1 Fracture Scenario . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 2.3 Chalk’s Ocean Airways Maintenance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 2.3.1 Ineffective Repairs on the Accident Airplane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 2.3.2 Recurring Discrepancies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 2.3.3 Other Fleet Maintenance Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 2.4 Federal Aviation Administration Oversight of the Chalk’s Ocean Airways Maintenance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 2.4.1 Importance of Program Oversight for Aircraft With Limited Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 2.4.2 Continuing Analysis and Surveillance System Program Guidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 2.4.3 Other Indicators of Potential Safety Deficiencies . . . . . . . . . . . . . . . . . . . . . . . . . . 49 2.5 Certification Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

1. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
2. 1

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 3.2 Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

1. Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
2. 1

New Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 4.2 Previously Issued Recommendation Reiterated and Classified in This Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 4.2.1 Previously Issued Recommendation Resulting From This Accident Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Board Member Statements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

1. Appendixes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

A: Investigation and Hearing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Contents

v Aircraft Accident Report Figures

1. G-73/G-73T Wing Box Components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2. Locations of Fractures Near Right Wing Station 34 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3. External Doubler Adjacent to Right

Wing Station 34 (Before Removal) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

1. Lower Skin Crack in the Area That Was Covered

by the Doublers Adjacent to Right Wing Station 34 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

1. Right Wing Rear Z-Stringer Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2. Right Wing Rear Spar Lower Spar Cap Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . 20

vi Aircraft Accident Report Abbreviations AC advisory circular AD airworthiness directive ASOS automated surface observing system CAMI Civil Aeromedical Institute CAMP Continuous Airworthiness Maintenance Program CASS Continuing Analysis and Surveillance System CFR Code of Federal Regulations c.g. center of gravity CVR cockpit voice recorder DER designated engineering representative DOT Department of Transportation FAA Federal Aviation Administration FAR Federal Aviation Regulation FLL Fort Lauderdale/Hollywood International Airport, Fort Lauderdale, Florida FSAW flight standards information bulletin for airworthiness GMM general maintenance manual METAR meteorological aerodrome report MIA Miami International Airport PMI principal maintenance inspector POI principal operations inspector S/N serial number SAIB special airworthiness information bulletin SAFO safety alert for operators STC supplemental type certificate WS wing station X44 Miami Seaplane Base, Miami, Florida

vii Aircraft Accident Report Executive Summary On December 19, 2005, about 1439 eastern standard time, a Grumman Turbo Mallard (G-73T) amphibious airplane, N2969, operated by Flying Boat, Inc., doing business as Chalk’s Ocean Airways flight 101, crashed into a shipping channel adjacent to the Port of Miami, Florida, shortly after takeoff from the Miami Seaplane Base. Flight 101 was a regularly scheduled passenger flight to Bimini, Bahamas, with 2 flight crewmembers and 18 passengers on board. The airplane’s right wing separated during flight. All 20 people aboard the airplane were killed, and the airplane was destroyed by impact forces. Flight 101 was operating under the provisions of 14 Code of Federal Regulations Part 121 on a visual flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident. The National Transportation Safety Board determines that the probable cause of this accident was the in-flight failure and separation of the right wing during normal flight, which resulted from (1) the failure of the Chalk’s Ocean Airways maintenance program to identify and properly repair fatigue cracks in the right wing and (2) the failure of the Federal Aviation Administration (FAA) to detect and correct deficiencies in the company’s maintenance program. The safety issues discussed in this report focus on air carrier maintenance programs and practices and FAA oversight procedures for air carrier maintenance programs. Safety recommendations concerning these issues are addressed to the FAA.

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1 Aircraft Accident Report 1. Factual Information 1.1 History of Flight On December 19, 2005, about 1439 eastern standard time,1 a Grumman Turbo Mallard (G-73T) amphibious airplane, N2969, operated by Flying Boat, Inc., doing business as Chalk’s Ocean Airways flight 101, crashed into a shipping channel adjacent to the Port of Miami, Florida, shortly after takeoff from the Miami Seaplane Base (X44). Flight 101 was a regularly scheduled passenger flight to Bimini, Bahamas, with 2 flight crewmembers and 18 passengers2 on board. The airplane’s right wing separated during flight.3 All 20 people aboard the airplane were killed, and the airplane was destroyed. Flight 101 was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 on a visual flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident. On the day of the accident, the accident flight crew flew the airplane from Fort Lauderdale/Hollywood International Airport (FLL) in Fort Lauderdale, Florida, to X44 as Chalk’s Ocean Airways flight 110. According to the flight log, the airplane departed FLL about 1305 and landed at X44 about 1321.4 The airplane departed X44 on the accident flight about 1438 and crashed into the water about 1 minute later. Of about 15 witnesses interviewed, most reported that the airplane’s right wing separated from the rest of the airplane in flight, that smoke or fire came from the wing or a fireball in the sky, and that the airplane subsequently descended into the water.5 About one-half of these witnesses reported that they heard an explosion associated with the wing separation.6 Most of the wreckage was located in about 30 feet of water. Lifeguards who patrolled Miami Beach on foot and on jet skis were the first to respond to the accident scene. Miami emergency dispatch notified the Miami Coast Guard and the Miami Beach Police Department by telephone about the accident. The Miami Coast Guard log showed 1 Unless otherwise noted, all times in this report are eastern standard time, based on a 24-hour clock. 2 Of the 18 passengers, 3 were lap-held infants. Eleven of the passengers were citizens of the Bahamas; the seven other passengers and the flight crew were U.S. citizens. 3 The G-73T technically has one wing structure. For the purpose of this report, “right wing” generally refers to any wing area on the right side of the airplane’s fuselage, and “left wing” generally refers to any wing area on the left side of the airplane’s fuselage. 4 During a postaccident interview, the chief pilot of Chalk’s Ocean Airways stated that the accident airplane had been scheduled to depart from FLL about 0815 but had been delayed because of weather. 5 Some witnesses provided video and digital still images that captured segments of the accident sequence. For more information, see section 1.16.2. 6 An explosives examination performed on the wreckage found no evidence of explosives. For more information, see section 1.16.3.

Factual Information 2 Aircraft Accident Report that the Miami Coast Guard launched an HH-65 helicopter to the accident scene about 7 minutes after receiving notification of the accident and began recovery efforts about 6 minutes afterward. 1.2 Injuries to Persons Table 1. Injury chart. Injuries Flight Crew Cabin Crew Passengers Other Total Fatal 2 0 18 0 20 Serious 0 0 0 0 0 Minor 0 0 0 0 0 None 0 0 0 0 0 Total 2 0 18 0 20 1.3 Damage to Airplane The airplane was destroyed by impact forces. 1.4 Other Damage No other damage was noted. 1.5 Personnel Information 1.5.1 The Captain The captain, age 37, held an airline transport pilot certificate with ratings for airplane multiengine land and sea. She held a Federal Aviation Administration (FAA) first-class medical certificate dated September 27, 2005, with a limitation that required her to wear corrective lenses while exercising the privileges of this certificate. The captain received a type rating for the G-73T in May 2005. FAA records indicated no accident or incident history or enforcement action, and a search of records at the National Driver Register found no history of driver’s license revocation or suspension.

Factual Information 3 Aircraft Accident Report The captain was hired by Chalk’s Ocean Airways in March 2003.7 The captain’s most recent line check occurred on August 14, 2005, and her most recent G-73T proficiency check was on May 10, 2005. Company records indicated that the captain had accumulated 2,820 hours of total flying time, including 1,330 hours as a pilot-in-command, 1,630 hours in the G-73T, and 430 hours as a G-73T pilot-in-command. She had flown 723, 203, and 85 hours in the 12 months, 90 days, and 30 days, respectively, before the accident. In the 24 hours before the accident, the captain had flown about 2.5 hours. On the day of the accident, the captain was scheduled to fly seven flight segments for a total of 4.1 hours of flying time. (The accident occurred on the second flight segment.) The captain’s first flight was scheduled to depart from FLL about 0815 but was delayed by a low fog layer that prevented flying. The captain had to wait in the airport terminal. According to the chief pilot, who had also waited at FLL to depart, the captain seemed to be upbeat, friendly, smiling, and alert. According to company flight logs, on the day before the accident (December 18), the captain’s first flight segment began about 0635 and was a repositioning flight to return the airplane to FLL. The captain then flew seven additional flight segments, with the last one ending about 1730. She accumulated a total of 6.9 hours for the day. On December 17, the captain was on duty and flew the accident airplane on 10 flight segments. The first officer who flew with the captain during those trips stated that the captain appeared to be in a good mood. The first officer also stated that, after a layover at a hotel, the captain appeared rested when flying resumed early on the morning of December 18. Company records indicated that the captain was off duty from December 12 to 16,

1. According to her husband, the captain slept all day on December 16 because they

had arrived home from a personal trip the night before (December 15), and she was exhausted. In addition to her flying duties, in August 2005, the captain was appointed as the company’s director of safety.8 According to a company representative, the captain spent about 2 days per month accomplishing her director of safety activities, which involved attending meetings, performing safety audits, and reporting safety concerns directly to the general manager. According to the captain’s husband, on days when the captain was on duty, she awoke about 0430. During the winter, she returned home from work between 2030 and 7 The captain flew the G-73T as a first officer until receiving her type rating on the airplane. 8 According to 14 CFR 119.65(a)(1), a Part 121 certificate holder must have a qualified person “serving full-time” as director of safety. However, according to FAA Order 8400.10, “Air Transportation Operations Inspector’s Handbook,” “in a small Part 121 operation, the director of safety functions may be an additional function of a current manager. Any request for a management deviation involving a director of safety position must be approved by AFS-200.” The company’s FAA-approved operations specifications listed the captain as the director of safety.

Factual Information 4 Aircraft Accident Report 2100 and went to bed by 2230. He stated that she was healthy and strong but that, during the year before the accident, her health had been affected by the stress of work demands. He also stated that, although she felt loyal to the airline and liked the company’s director of operations, she had begun applying for another flying job because she was becoming physically exhausted, was not enjoying the job any longer, and was interested in a higher salary.9 Her husband added that, despite the situation at work, she had a positive frame of mind. Before the captain’s employment with Chalk’s Ocean Airways, she was a flight instructor10 for Angel Air Flight Training, Chandler, Arizona, from May 2002 to February 2003 and a charter coordinator for Scottsdale Flyers, Scottsdale, Arizona, from March 2000 to March 2002. 1.5.2 The First Officer The first officer, age 34, held a commercial pilot certificate with ratings for airplane single- and multiengine land and sea and an FAA first-class medical certificate dated January 31, 2005, with no limitations. FAA records indicated no accident or incident history or enforcement action, and a search of records at the National Driver Register found no history of driver’s license revocation or suspension. The first officer was hired by Chalk’s Ocean Airways in April 2005. He received company ground school training from April to mid-June 2005 then took a 3-month break.11 He received company flight training from September to October 2005 and completed a G-73T proficiency check on October 19, 2005. He completed his company’s initial operating experience on November 21, 2005. Company records indicated that the first officer had accumulated 1,420 hours total flying time, including 1,200 hours as a pilot-in-command, 100 hours as second-in-command, and 71 hours in the G-73T. He had flown 71, 58, and 1.1 hours in the 90 days, 30 days, and 24 hours, respectively, before the accident. Company records indicated that the first officer had been on duty from December 15, 2005, to the day of the accident. On the day of the accident, he was scheduled to fly seven flight segments for a total of 4.1 hours of flying time. A company maintenance manager at FLL observed the first officer about 0620 on the morning of the accident as he conducted a preflight inspection of the accident airplane. The maintenance manager stated that the first officer looked normal and energetic. The maintenance manager also saw the first officer about 1300 and described him as being friendly and happy. 9 According to the captain’s husband, she also voiced concerns about the company’s maintenance of its airplanes. Additional information from interviews with the captain’s husband and with other company personnel regarding the company’s maintenance program appears in section 1.18.3. 10 The captain received her flight instructor certificate with a rating for airplane single-engine land in February 2002. 11 According to Chalk’s Ocean Airways personnel, in April 2005, the company hired more first officers than it needed and had to postpone the flight training for some because of aircraft availability issues.

Factual Information 5 Aircraft Accident Report The accident flight was the first officer’s first pairing with the captain. Company pilots described the first officer as a likable and helpful person who was happy working for the company and who had good piloting skills for his experience. Before his employment with Chalk’s Ocean Airways, the first officer was a line service technician for Reading Flite Academy, Reading, Pennsylvania, from April to August 2002 and was pilot/dispatcher for Quest Diagnostics in Reading from June 2002 to April 2005. 1.6 Airplane Information The accident airplane, a Grumman Turbo Mallard (G-73T), serial number (S/N) J-27, was a turbine-conversion amphibious airplane equipped with two Pratt & Whitney PT6A-34 turbopropeller engines12 and Hartzell HC-B3TN-3D constant-speed, three-bladed propellers. The airplane was manufactured by Grumman Aircraft Engineering Corporation in May 1947 and was originally certificated as a G-73 model equipped with Pratt & Whitney radial piston engines.13 At the time of original certification, the airplane’s maximum gross weight was 12,750 pounds, and it was configured to carry 2 flight crewmembers and 10 passengers. Chalks Ocean Airways acquired the airplane in 1980 and modified it to a G-73T model in July 1981 by replacing its piston engines with turbopropeller engines in accordance with FAA-approved supplemental type certificate (STC) SA2323WE.14 The modification to the G-73T model included an increase in the airplane’s maximum gross weight to 14,000 pounds. Also, in July 1981, the airplane’s cabin was modified to a 17-seat passenger configuration in accordance with STC SA4410SW, and its avionics were upgraded. At the time of the accident, the airplane had accumulated 31,226 total flight hours and 39,743 total cycles.15 Information about the hours for the powerplants and propellers appears in table 2. 12 One engine was a PT6A-34AG model, which has identical specifications and limitations as the PT6A-34. “AG” denotes it was originally configured for agricultural aviation. 13 Grumman ended production of the G-73 airplane in 1951. 14 For more information about the STC, see section 1.18.1. 15 An aircraft cycle is one complete takeoff and landing sequence.

Factual Information 6 Aircraft Accident Report Table 2. Powerplant and Propeller Information for the Accident Airplane Powerplant Time since new Date of last overhaul Time since last overhaul Engine No. 1 (left) 7,515 hours March 2005 1,154 hours No. 2 (right) 9,036 hours July 2004 3,037 hours Propeller No. 1 (left) 11,117 hours March 2005 1,154 hours No. 2 (right) 17,995 hours October 2003 2,657 hours According to the weight-and-balance manifest form for the accident flight, the airplane’s takeoff weight was 13,828 pounds,16 which was less than the maximum takeoff weight of 14,000 pounds. The takeoff center of gravity (c.g.) was 21.8 percent mean aerodynamic chord, which was within the c.g. limits of 17.7 to 26.0 percent. The zero fuel weight was 12,488 pounds, which was less than the maximum zero fuel weight of 12,800 pounds. The accident captain and another first officer had flown the accident airplane on December 17, 2005 (2 days before the accident) for 10 trip segments. According to that first officer, the airplane flew normally. He stated that the airplane underwent maintenance before these trips and that he and the accident captain conducted a 15- to 20-minute operational check flight before beginning passenger service that day. He stated that the captain commented that the airplane came out of maintenance in good shape and that, during passenger service, he felt no unusual vibrations and observed no fuel, oil, or hydraulic fluid leaks. 1.6.1 Wing Structure The wing structure of G-73 and G-73T airplanes includes a center wing box that spans the center of the wing from left wing station (WS) 125 to right WS 125.17 The fuselage walls intersect the wing box at left and right WS 34. Portions of the wing box structure serve as the left and right fuel tanks. 16 Chalk’s Ocean Airways did not allow carry-on baggage. The manifest form listed the total passenger weight as 2,475 pounds, which was derived from taking the number of noninfant passengers (15) and multiplying it by 165 pounds in accordance with the company’s average weight program. The FAA approved the program’s 165-pound-per-passenger estimate on the basis of a company survey of actual passenger weights. Although Chalk’s Ocean Airways’ operations specifications had been amended to require that the company should use only actual passenger weights, on September 7, 2005, the company petitioned the FAA to reconsider this requirement. In a letter dated September 26, 2005, the FAA notified the company that the effective date of the actual weight requirement was postponed pending the FAA’s review and final response to the petition. 17 Each WS is designated “right” or “left,” depending on its location in relation to the airplane’s centerline, and WS numbers correspond to the distance in inches outboard from the airplane’s centerline.

Factual Information 7 Aircraft Accident Report The structural components of the wing box include the front spar, the rear spar, the stringers, the ribs, the upper skin, and the lower skin.18 The skin panels are attached by fasteners to stringers; the three stringers for the lower skin panel are known as Z-stringers because of their shape.19 The vertical surface of each Z-stringer, called a web, has two slosh holes20 located just outboard of the wing ribs at WS 34 and WS 48. Figure 1 shows a general diagram of some wing box components. The accident airplane’s wing structure was certificated in accordance with the requirements in Part 4aT of the Civil Air Regulations, dated November 1, 1943, and amended March 8, 1944. The certification requirements included a static strength analysis, which is performed using loads that do not vary with time and have a constant magnitude, such as a steady 1 G flight condition.21 No requirements for a fatigue analysis existed at the time the G-73T was originally certificated as a G-73. A fatigue analysis is performed using loads that vary in amplitude and frequency; these loads are referred to as dynamic, cyclic, or repetitive loads. Examples of these loads include taxiing on a rough runway, taxiing on rough water, taking off and landing, and encountering turbulence during flight.22 18 Spars are beam-like structures that are the principal structural members of the wing. The spars are oriented parallel to the airplane’s lateral axis, which runs wingtip to wingtip. The vertical surfaces of each spar are called webs, and the top and bottom of each spar are called spar caps. Wing ribs are the structural crosspieces of the wing that are oriented forward to aft. Ribs give the wing its cambered shape. Ribs for the wing box are located at the centerline and at 18 wing stations (9 on the right and 9 on the left). Skin is the smooth outer covering of an aircraft. The skin panels discussed in this section are sheet metal panels that make up the upper and lower surfaces of the wing and wing box structure. 19 Stringers are also structural components of the wing but are much smaller than spars. The wing box stringers are oriented parallel to the airplane’s lateral axis, and, like spars, their vertical surfaces are called webs. The top and bottom of each Z-stringer’s web have horizontal flanges that face in opposite directions. Thus, in cross-section, the stringer has the shape of the letter “Z.” 20 The slosh holes are the round openings in the vertical surface of each Z-stringer that allow fuel inside the tank area of the wing to move forward and aft. 21 G is a unit of measurement that is equivalent to the acceleration caused by the earth’s gravity (32.174 feet/second2). A 1 G flight condition is represented by wings-level, steady-state flight. 22 Fatigue failure is the sudden and catastrophic separation of a part into two or more pieces under normal operating loads as a result of a crack that grows due to repeated variations in load over a period of time. Failure takes place after a fatigue crack reaches a critical length then propagates suddenly.

Skin Ribs Stringers Front spar Web Rear spar lower spar cap Rear spar Wing station 34 Wing station 125 Factual Information 8 Aircraft Accident Report Figure 1. G-73/G-73T Wing Box Components Note: For illustrative purposes only. For figure clarity, some components are shown not to scale, and others are not depicted. 1.6.2 Maintenance Information 1.6.2.1 Company Records of Right Wing Repairs National Transportation Safety Board investigators reviewed Chalk’s Ocean Airways’ flight log sheets for the accident airplane from January 1995 to December 1999 and February 2001 to December 18, 2005 (the day before the accident); Chalk’s Ocean

Factual Information 9 Aircraft Accident Report Airways could not provide the flight log sheets from January 2000 to January 2001. No open maintenance items appeared on the log sheets that were reviewed. During July 2005, three flight log maintenance record entries for fuel leaks in the right wing root area were recorded. These entries stated the following: “fuel leak right wing root,” “fuel leaking in … right wing root,” and “fuel leaking from … right aft bottom.” Also, during September 2005, three flight log maintenance record entries noted a “fuel leak from right [wing] dry bay.”23 Maintenance records indicated that the July and September 2005 fuel leak discrepancies were corrected by removing the existing sealant and applying new sealant.24 Safety Board investigators also reviewed routine and nonroutine work cards25 for the accident airplane’s C checks26 from 2001 to 2005 and found eight references to fuel leaks on the right wing. A nonroutine work card from an August 2005 check indicated “fuel leak … lt [left] & rt [right] wing tanks …” and a corrective action of “cleaned lt & rt fuel tanks, repaired as req’d [required] and sealed … re-fueled … no leaks noted at this time.” Also, while the airplane was undergoing its December 2005 C1 check, a fuel leak discrepancy was noted, and the nonroutine work card indicated “rt fuel tank bottom aft corner has leak” and a corrective action of “rt wing fuel tank bottom aft corner leak repair and sealed.” 1.6.2.2 Major Repairs and Alterations of the Wing A review of FAA records for the accident airplane indicated that an FAA form 337, “Major Repair and Alteration,”27 was on file for a major repair that was made on April 13, 1992, to the rear spar upper spar cap at right WS 34. According to the engineering information submitted with the form, this repair was made because of structural corrosion under the skin and popped rivets that were discovered during inspections on the right wing at WS 34. The information indicated that, when the skin was removed, light-to-moderate corrosion was also found on the top aft spar. 23 The dry bay is a compartment that contains electronic, hydraulic, and mechanical components. The dry bay for the G-73T is located inside the center wing box between left and right WS 34 and is adjacent to the wing fuel tanks. 24 The flight logs also documented numerous discrepancies regarding elevator flutter, elevator vibration, and elevator trim. For some of these discrepancies, the flight logs showed that maintenance personnel tried to resolve the problem several times before it was eventually corrected. 25 According to FAA Advisory Circular 120-16D, work cards, although not required by regulations, are often used in air carrier maintenance programs to comply with regulations for performing maintenance and for maintenance recordkeeping. 26 C checks are scheduled maintenance visits designed to ensure a complete inspection of the airplane over the course of 20 calendar months. The C checks are divided into six categories of work, C1 through C6, to be performed at 80-day intervals. For more information, see section 1.6.2.3. 27 According to FAA Order 8300.10, “Airworthiness Inspector’s Handbook,” a major repair is a repair that “might appreciably affect weight, balance, structural strength, performance, powerplant operation, flight characteristics, or other qualities affecting airworthiness” or a repair that “is not done according to accepted practices or cannot be done by elementary operations.”

Factual Information 10 Aircraft Accident Report Another FAA form 337 showed that a major repair to the rear Z-stringer at right WS 50.5 was made on July 6, 2000. Chalk’s Ocean Airways could not provide the Safety Board with corresponding company maintenance records or a description of the discrepancy that resulted in this repair. During visual examination of the airplane wreckage, investigators observed that the rivets used in the repair were not installed in accordance with Advisory Circular (AC) 43.13-1B, section 4, figure 4-6, “Riveting Practice and Rivet Imperfections.”28 Specifically, some rivets used in the repair had undersized shop heads and were overdriven, and one rivet through the skin and stringer flange at the slosh hole was of a larger size and different head type than specified. Evidence of additional maintenance work, which involved the use of angles and blind rivet fasteners at the rib-to-stringer interface, was observed; however, this type of work was not documented in the engineering drawing or on FAA form 337. Examination of the wreckage also discovered evidence that a major repair was made to the lower right wing skin at the location where the wing separated from the fuselage. Maintenance records provided by Chalk’s Ocean Airways did not contain any entry for this major repair, which consisted of one external and three internal doublers29 applied in the area of a long chordwise skin crack just outboard of right WS 34. Company maintenance records contained an entry indicating that, on May 6, 1992, the lower wing skin at left WS 34 received a major repair; examination of the wreckage showed that this repair had characteristics similar to the repairs observed near right WS 34. The areas with the repair doublers observed during the examinations would not have been visible on the exterior of the airplane because a fairing30 between the wing and fuselage covered each area. The fairings also covered a fuel sump drain on each wing. Examination of both the repair to right WS 34 (date of repair unknown) and the May 6, 1992, repair to left WS 34 revealed evidence that the rivet installation for each was not in accordance with AC 43.13-1B, section 4, paragraph 4-57c, “Rivet Edge Distance”; figure 4-5, “Rivet Hole Spacing for Single-Lap Sheet Splices”; figure 4-6, “Riveting Practice and Rivet Imperfections”; and figure 8, “Holes.” Specifically, some fastener holes were observed at edge distances less than specified, rivet-hole spacing was less than specified, and some holes did not meet specifications because they were double-drilled.31 28 The engineering drawing for this repair indicated that the riveting needed to be performed in accordance with AC 43.13-1B. Technical data referenced in such drawings become approved data. 29 A doubler is material that is intended to relieve load in the structural element to which it is attached. 30 Fairings are shaped and rounded panels on the exterior of the airplane that are typically installed in areas where the wing or other structural units meet the fuselage at angles. The purpose of fairings is to smooth out the airflow in these areas during flight. 31 A double-drilled hole is a hole consisting of two intersecting, nonconcentric-drilled holes in which a portion of the hole from the first drilling remains after the second hole is drilled.

Factual Information 11 Aircraft Accident Report 1.6.2.3 Continuous Airworthiness Maintenance Program The Flying Boat, Inc., operations specifications for Chalk’s Ocean Airways indicated that the air carrier was authorized to use a continuous airworthiness maintenance program (CAMP),32 the latest revision of which was approved by the FAA on November 21, 2005. Basic CAMP requirements include aircraft inspection, scheduled and unscheduled maintenance, overhaul and repair, structural inspection, required inspection items, a continuing analysis and surveillance system (CASS) program,33 and outsourcing maintenance. The company’s CAMP included the following maintenance items: • Transit service, which was to be performed overnight every 48 hours or less at bases where maintenance personnel are available. Company records showed the last transit service on the accident airplane was performed on December 19, 2005 (the day of the accident). • Engine service, which was to be performed every 250 flight hours. Company records showed the last engine service on the accident airplane was performed on October 19, 2005 (No. 1 engine) and November 12, 2005 (No. 2 engine); both occurred within the 250-hour requirement. • C checks, which were divided into six scheduled maintenance visits, C1 through C6. These visits, which were to be completed at 80-day intervals, were designed to completely inspect the airframe, components, systems, and appliances within 20 calendar months. Company records showed the airplane’s most recent C check was completed December 17, 2005.34 In accordance with the Grumman Service Manual, the airplane’s external components were washed with fresh water during each of the C checks to minimize the effects of corrosion on those components.35 1.6.2.4 Continuing Analysis and Surveillance System Program As part of its FAA-approved CAMP, Chalk’s Ocean Airways was required to maintain a CASS program that identified and corrected deficiencies in the company’s maintenance program. As part of a CASS, operators are required to monitor the mechanical performance of the flying fleet by collecting and analyzing operational data. This includes the day-to-day monitoring and long-term monitoring of each airplane. To accomplish this task, operators typically set repair thresholds by establishing the number of times a discrepancy may reoccur in a given period, usually specified in days or hours. If 32 A CAMP combines the maintenance and inspection functions used to fulfill an operator’s total maintenance needs. 33 For more information about the company’s CASS program, see section 1.6.2.4. 34 The most recent C check for the right wing, which was maintenance visit C3, was completed March 23, 2005. According to the C3 checklist, the inspection covered right WS 34 to 400 and included preliminary inspection/corrosion control, lubrication, avionics check/inspection, and main landing gear inspection. 35 Company maintenance personnel stated that the airplane’s external components were also washed with fresh water during transit service maintenance, but the transit service cards did not show this task.

Factual Information 12 Aircraft Accident Report a discrepancy recurs within the established repair threshold, further troubleshooting, such as maintenance and/or engineering, would be needed, and, at times, grounding of the airplane would be necessary. Chalk’s Ocean Airways conducted monthly CASS meetings to review the previous month’s maintenance discrepancies. Records indicated that FAA representatives, including the air carrier’s principal maintenance inspector (PMI), attended the January, October, and November 2005 meetings.36 Minutes from the CASS meetings for January through November 2005 included mechanical interruption reports, logbook information, airplane discrepancies, and minimum equipment list information for each company airplane.37 The minutes for the July and September 2005 CASS meetings referenced fuel leaks on the accident airplane. The July 2005 minutes referenced six fuel leaks on either the accident airplane’s left or right wing during a 5-day period; the September 2005 CASS meeting minutes referenced a fuel leak from the accident airplane’s right wing dry bay area for 3 consecutive days.38 None of the 2005 CASS meeting minutes directly referenced any of the accident airplane’s wing box structural fractures. 1.6.2.5 Aging Airplane Inspection and Records Review The operations specifications for Chalk’s Ocean Airways also indicated that the air carrier must have an aging aircraft inspection and records review. Title 14 CFR 121.368, “Aging Airplane Inspections and Records Reviews,” paragraph (b)(1), requires initial and repetitive inspections and records review of airplanes operating under Part 121 (except for those airplanes operating entirely within the state of Alaska) and exceeding 24 years of service on December 8, 2003. The regulation requires that the initial inspection and records review take place no later than December 5, 2007, and that the repetitive inspections occur at intervals thereafter not to exceed 7 years. According to 14 CFR 121.368(b), the purpose of the regulation is for the operator to demonstrate to the FAA that “the maintenance of age-sensitive parts and components of the airplane has been adequate and timely enough to ensure the highest degree of safety.” On October 7, 2005, Chalk’s Ocean Airways’ PMI conducted the company’s aging airplane inspection and records review. At the time, the accident airplane had accumulated 31,012 flight hours and 39,404 flight cycles. The review included the April 13, 1992, major repair to the rear spar upper spar cap at right WS 34 and the May 6, 1992, major repair to the lower wing skin at left WS 34. The review found that no further action was required for these repairs. The review did not include the doubler repair that was observed on the chordwise skin crack just outboard of right WS 34 and for which Chalk’s Ocean Airways did not have records. On November 4, 2005, the PMI sent a letter to Chalk’s Ocean Airways indicating that the aging airplane inspection and records review had been 36 Chalk’s Ocean Airways could not provide CASS meeting attendance records for March and May 2005, so there was no record of whether FAA representatives attended those meetings. 37 The December 2005 CASS meeting had not been held at the time of the accident. 38 As mentioned previously, maintenance records showed that the repair methods used to address these fuel leaks involved removing and replacing the sealant in the fuel tank.

Factual Information 13 Aircraft Accident Report completed. The PMI noted that paperwork discrepancies found during the review were corrected by the air carrier during the C5 and C6 inspections. The accident airplane, because of its size and the date of its type certificate, would not be subject to the additional inspection requirements of 14 CFR 121.370a, “Supplemental Inspections,” which apply to transport-category, turbine-powered airplanes (except for those airplanes operating entirely within the state of Alaska) that were type certificated after January 1, 1958, and had a maximum passenger seating capacity of 30 or more or a maximum payload of 7,500 pounds. Title 14 CFR 121.370a(c) requires that, after December 20, 2010, the maintenance programs of the affected airplanes must include “FAA-approved damage-tolerance-based inspections and procedures for airplane structure susceptible to fatigue cracking that could contribute to a catastrophic failure. These inspections and procedures must take into account the adverse affects repairs, alterations, and modifications may have on fatigue cracking and the inspection of this airplane structure.” On July 24, 2006, the Safety Board issued Safety Recommendation A-06-52 to address the exemptions contained in this regulation; see section 1.18.2.1 for more information. 1.7 Meteorological Information The nearest weather reporting station is located at Miami International Airport (MIA), Miami, Florida, which is about 8 nautical miles from X44. MIA has an automated surface observing system (ASOS) that is maintained by the National Weather Service and records continuous information on wind speed and direction, cloud cover, temperature, precipitation, and visibility.39 The ASOS transmits an official meteorological aerodrome report (METAR) each hour. A METAR at 1443 on the day of the accident indicated the following: wind from 340º at 7 knots, visibility 4 miles, ceiling overcast at 1,200 feet, temperature 23º C, dew point 18º C, and altimeter 30.09 inches of mercury. 1.8 Aids to Navigation No problems with any navigational aids were reported. 1.9 Communications No communications problems were reported. 39 Cloud cover is expressed in feet above ground level. Visibility is expressed in statute miles.

Factual Information 14 Aircraft Accident Report 1.10 Airport Information X44 is located on Watson Island and about 2 miles east of Miami. X44 has a water runway that is 15,000 feet long and 600 feet wide and is oriented northwest/southeast. The water runway has an elevation of 0 feet mean sea level. X44 has no published instrument procedures. Chalk’s Ocean Airways’ terminal was built in 1926. 1.11 Flight Recorders 1.11.1 Cockpit Voice Recorder The airplane was equipped with a Fairchild model A-100A solid-state cockpit voice recorder (CVR), S/N 52969. The CVR did not sustain any heat or structural damage, but the recorder was wet because of its immersion in the water. The tape was removed from the recorder and was cleaned and dried. The audio information was extracted without difficulty. The CVR recording contained channels of audio data for the pilot and copilot stations and the cockpit area microphone.40 Although audio was recorded on each of these channels, the audio was unintelligible. The Safety Board noted, specifically, that the characteristics of the audio were similar to that of the tape having been recorded over multiple times without being erased between recordings. The CVR chassis was sent to L3 Communications41 for evaluation of its functionality. According to the L3 Communications evaluation report, testing revealed a failure of the electronic circuit card for the erase head. The evaluation report indicated that this condition was most likely the reason for the failure of the erase-head functionality of the recorder and that, on the basis of the Safety Board’s finding of multiple overwriting on the CVR-recorded channels, this failure most likely occurred sometime before the accident. The evaluation report further indicated that the CVR “push to test” operation would not likely identify a failure of the erase head because the recorded test tone amplitude would be detected despite the presence of previously recorded audio.42 On March 24, 2006, the Safety Board issued Safety Recommendation A-06-23, which addressed this and other issues related to CVR functionality. Section 1.18.2.2 provides information about this recommendation. 40 The CVR was equipped with another channel for a third flight crewmember. Because the G-73T was not configured for a three-person flight crew, that CVR channel was unconnected. 41 L3 Communications is the owner of Fairchild model CVRs. 42 L3 Communications stated that one way to ensure correct operation of the erase-head function was a service check of the CVR. With regard to the accident airplane, Chalk’s Ocean Airways’ operations specifications did not require CVR service checks.

Factual Information 15 Aircraft Accident Report 1.11.2 Flight Data Recorder The airplane was not equipped with a flight data recorder (FDR). The FAA stated that 14 CFR 121.344a, “Digital Flight Data Recorders for 10-19 Seat Airplanes,” applied to the accident airplane and that the regulation excludes 10-to-19 seat, turbine-powered airplanes that were brought onto the U.S. registry on or before October 11, 1991. 1.12 Wreckage and Impact Information The right wing separated from the fuselage in flight, and the remainder of the airplane broke up on impact with the water. Most of the main wreckage was scattered within a debris field of about 200 feet by 200 feet and was oriented along a 122º magnetic heading. The fuselage, left wing, left engine, landing gear, and empennage were located within the main debris field. All of this wreckage was submerged in the water along a rock jetty. The separated right wing with the right engine attached was located about 160 feet northwest of the main debris field. The center wing box structures were fractured where the wing intersected the fuselage at right WS 34, allowing the right wing to separate. Examination of the wreckage found that the right wing fuel tank was breached and that fire damage was evident on the right wing. Fire damage and soot were also present on fuselage skins and empennage skins aft of the right wing. The left wing showed no evidence of fire damage. Safety Board investigators documented and reconstructed the airplane’s center wing box. The reconstruction consisted of locating and identifying the right and left wing front and rear spars and upper and lower stringers and skins from about right WS 60 to left WS 60. Detailed examination of the wreckage fractures revealed areas of fatigue on multiple elements of the wing box structure, including the lower skin panel aft Z-stringers at right and left WS 34 (emanating from the fuel slosh holes), the skin at the edge of the doubler repairs at right and left WS 34, the rear spar lower spar cap at right WS 34, and the forward spar lower spar cap near left WS 53. The recovered fracture surfaces from the wing box were sent to the Safety Board’s Materials Laboratory in Washington, D.C., for visual and fractographic examinations. To facilitate the examination, the internal and external repair doublers that were located near right and left WS 34 were removed from the lower skin. The upper part of figure 2 shows an overall view of right WS 34, including the locations of the rear spar lower spar cap, rear Z-stringer, the chordwise fracture in the lower skin, the crack (approximately parallel to and outboard of the chordwise lower skin fracture) in the lower skin, and the external and internal doublers. The lower part of

Factual Information 16 Aircraft Accident Report figure 2 shows a view with the doublers detached. Fatigue fracture features were found in the rear spar lower spar cap, rear Z-stringer, skin fracture (inboard), and skin crack (outboard).43 Figure 2. Locations of Fractures Near Right Wing Station 34 43 Overstress fracture features were found on the entire fracture surfaces of the middle Z-stringer, forward Z-stringer, and forward spar lower spar cap at right WS 34.

Factual Information 17 Aircraft Accident Report Figure 3 shows a photograph of the external doubler that was adjacent to right WS 34 before it was removed from the lower skin for examination. The lower skin crack that was observed in the area that had been covered by this external doubler was about 16 inches long. The aft end of the crack extended from the skin trailing edge to a point near the aft side of the middle Z-stringer lower flange. Figure 3. External Doubler Adjacent to Right Wing Station 34 (Before Removal) The skin crack under the doublers at right WS 34 (see figure 4) intersected three unfilled machined holes in the skin that exhibited features consistent with stop drill holes.44 These holes were located about 7, 9, and 16 inches forward of the skin trailing edge. Several fasteners at the inboard end of the doubler were inserted through hard green sealant around the fuel sump drain. 44 A stop drill hole is made at the tip of a fatigue crack to temporarily retard the propagation of a fatigue crack until a more permanent repair can be made.

Factual Information 18 Aircraft Accident Report Figure 4. Lower Skin Crack in the Area That Was Covered by the Doublers Adjacent to Right Wing Station 34 Note: The yellow arrows show the direction that each segment of the crack propagated. The fractographic examination at right WS 34 found that fatigue in the rear Z-stringer initiated from the slosh hole in the Z-stringer located about 1.5 inches outboard of right WS 34, as shown in figure 5. Sanding marks were observed under the sealant around the edge of the slosh hole, and sealant was observed on the fracture surface. In the sanded area, deformed material was observed curled over onto the edges of the fracture surface.

Factual Information 19 Aircraft Accident Report Figure 5. Right Wing Rear Z-Stringer Fracture The skin crack under the doublers at right WS 34 had an aft segment with fatigue features emanating from the area of corrosion around the fuel sump drain and a longer forward segment with fatigue features that initiated from a fastener hole adjacent to the rear Z-stringer fracture. The lower skin chordwise fracture (inboard of the skin crack) at the separated area intersected the fastener holes at the inboard edge of the doublers. Regions of fatigue emanated from several of the fastener holes. Sliding contact marks consistent with repeated opening and closing of the chordwise skin fracture were observed on the surface of the external doubler between several fastener locations in the inboard fastener row for the doubler. Fatigue in the rear spar lower spar cap initiated from a double-drilled hole for a threaded fastener in the horizontal flange of the spar cap located about 1 inch inboard of right WS 34, as shown in figure 6. Multiple fatigue origins were observed along the double-drilled hole through the thickness of the horizontal flange. Relatively flat regions with large numbers of crack arrest positions, indicating slower growth fatigue cracking, emanated from the fatigue origin areas both forward and aft of the hole. The remainder of the fatigue regions had a mixture of curving flat regions (indicating areas of relatively slow crack growth) with crack arrest positions separated by rougher regions without crack arrest positions (indicating relatively fast crack growth or overstress regions). The portion

Factual Information 20 Aircraft Accident Report of the crack aft of the hole propagated from a length of 0.07 to 0.44 inch in about 11 increments of rapid crack growth. Figure 6. Right Wing Rear Spar Lower Spar Cap Fracture Examination of the left wing indicated that fatigue fracture features were found in the rear Z-stringer, middle Z-stringer, front spar lower spar cap, and lower skin fractures near left WS 34. One external and two internal doublers were attached to the lower skin panel at the aft side of the wing box at left WS 34. The lower surface of the external doubler showed evidence around the fuel sump drain that was consistent with corrosion in that area.

Factual Information 21 Aircraft Accident Report The left wing front spar lower spar cap had a transverse fracture about 5 inches outboard of left WS 34. This area had not been repaired and did not have adjacent structural element failures. A portion of the horizontal flange of the spar cap had fatigue features that emanated from a hole for a threaded fastener to attach a wing leading edge panel. The aft portion of the fatigue region contained multiple relatively rough regions, which was indicative of an overstress fracture that was progressing fairly rapidly. These fracture regions were interspersed between regions with crack arrest positions. 1.13 Medical and Pathological Information Toxicology tests were performed by the FAA’s Civil Aeromedical Institute (CAMI) on specimens from the captain and first officer. The specimens were tested for ethanol and a wide range of drugs, including major drugs of abuse. All specimens tested negative, except that diphenhydramine was detected in urine specimens from the captain and quinine was detected in tissue specimens from the first officer.45 1.14 Fire Postcrash examination of the wreckage indicated the occurrence of an in-flight fire on the separated right wing and on exterior skin surfaces of the fuselage and empennage aft of the right wing. The left wing showed no evidence of fire damage. 1.15 Survival Aspects The Miami medical examiner performed autopsies of the airplane occupants, and the autopsy reports indicated the cause of death for each was “plane crash.” A review of the reports revealed the main pathologic findings for each occupant were multiple blunt force injuries. 1.16 Tests and Research 1.16.1 Additional Grumman G-73T Examinations Safety Board investigators examined other G-73T airplanes following the accident. One airplane, N142PA, was also owned by Chalk’s Ocean Airways and was used for passenger service at the time of the accident. Like the accident airplane, N142PA was built in 1947 as a G-73 model and was subsequently modified to a G-73T. Also, N142PA 45 Diphenhydramine, commonly known by the trade name Benadryl, is an over-the-counter antihistamine with sedative effects, often used to treat allergy symptoms or as a nighttime sedative. It is not quantified in CAMI results unless a substantial quantity is present. Diphenhydramine was not detected in the captain’s blood specimens. Quinine is found in tonic water and is not quantified in CAMI results, unless a substantial quantity is present.

Factual Information 22 Aircraft Accident Report had a similar number of flight hours and cycles as the accident airplane. The left wing aft spar attachment point on N142PA showed evidence of grinding in some areas, and the right wing aft spar attachment point had corrosion. Extensive corrosion was present on other areas of the airplane. In August 2005, N142PA’s right wing lower skin was replaced from the centerline to the nacelle. The designated engineering representative (DER)46 who provided engineering approval for this major repair stated that Chalk’s Ocean Airways informed him in June 2005 that fuel was leaking from the right wing-to-body fairing. The DER also stated that his subsequent inspection47 found that fuel was leaking out of a lower skin crack on the right wing and that his analysis showed that the crack, which was about 22 inches in length, had reduced the load-carrying capacity of the right wing box by about 50 percent.48 The DER stated that he recommended that the wing be removed for repair but that Chalk’s Ocean Airways did not want to remove the wing. As a result, the fuselage skin was pulled away from the area of the skin crack so that the lower wing skin could be replaced. The DER stated that, when the skin was removed, he noticed that all of the stringers were corroded and cracked, so they were removed and replaced. He also noticed that many of the repairs that had previously been made on the rest of the wing appeared to be “quite old.” Although fatigue- and damage-tolerance requirements were not part of the G-73’s original certification (which was the certification basis for the G-73T), a fatigue- and damage-tolerance-based approach was employed in the August 2005 repair to the right wing on N142PA. The repair included instructions for continued airworthiness,49 which indicated that the repair should be inspected every 24 months or 6,020 flight hours, whichever occurred first. These inspections were intended to detect cracks before they reached their critical crack length (that is, the point at which fracture occurs rapidly without increased load). In July 1999, a repair was made to N142PA’s lower left wing skin, which extended across the wing-to-fuselage junction. According to the structures DER who designed this repair for Chalk’s Ocean Airways, an area of corrosion around the fuel sump drain was removed, a 14-inch crack (emanating from the forward edge of the corrosion to a point 46 A DER is a qualified technical person who is authorized by the FAA to perform certain examinations, testing, and inspections necessary to determine compliance with applicable airworthiness standards and who offers technical expertise with state-of-the-art knowledge. A DER completes FAA form 8110-3, “Statement of Compliance with the Federal Aviation Regulations,” to indicate that the engineering changes are in accordance with regulations. The company is responsible for implementing the changes stated on the form and completing FAA form 337 after the repair has been accomplished. 47 During this inspection, the DER noticed a doubler on the left wing lower skin with a 17-inch crack. (The DER provided the Safety Board with a photograph showing this crack.) According to the DER, he asked Chalk’s Ocean Airways if he should provide the engineering for the repair of the left wing, but the company indicated that it would take care of the repair. 48 The DER’s analysis showed that the skin and stringers carried about 70 percent of the load and that the spar caps carried 30 percent of the load. 49 Instructions for continued airworthiness are a series of maintenance actions that help to ensure the continued airworthiness of a repair. DERs can include these instructions as part of FAA form 8110-3.

Factual Information 23 Aircraft Accident Report that was 9 inches forward) was stop-drilled and slotted, and a doubler was placed over the top of the wing skin in this area. This repair was designed with a static strength analysis only. Safety Board investigators also examined a privately owned G-73T airplane, N632SS. That airplane was undergoing restoration at Mirabella Aviation, Jupiter, Florida. Chalk’s Ocean Airways had owned the airplane briefly beginning in November 2005 and had maintained it as a spare parts airframe before selling it. Like the accident airplane, N632SS was built in 1947 and was subsequently modified to a G-73T. N632SS had fewer flight hours (about 16,000) and cycles (about 30,000) than the accident airplane. In July 1977, N632SS was substantially damaged when it crashed and sank during an attempted takeoff from Great Bear Lake in Canada. The airplane was recovered, rebuilt, and used during the 1980s for revenue operations. According to Mirabella staff, the airplane was again damaged in 1989 when it was subjected to flooding during a hurricane. At the time of the examination of the airplane, the left wing had been removed, the outboard wing sections had been separated from the center wing box, and the lower wing skin was removed from the center wing box. Investigators found that, although corrosion was present on the wing structure, the corrosion was generally not as severe as that found on the airplanes in the Chalk’s Ocean Airways fleet and that only one rear Z-stringer had a similar amount of corrosion. The rear Z-stringer was sent to the Safety Board’s Materials Laboratory for examination. The examination found that the rear Z-stringer had a fatigue crack that was located about 1.5 inches outboard of the rib at left WS 48. The examination also found that the fatigue emanated from the slosh hole in the web of the Z-stringer. In addition, the examination found that the corrosion was particularly severe in the web and flange areas above the slosh hole. 1.16.2 Video and Image Study Segments of the accident flight were captured by witnesses with personal video and still cameras and by a U.S. Coast Guard video surveillance security camera. Copies of the video and still images were submitted to the Safety Board’s Vehicle Recorder Division, Washington, D.C., for review. One video from a personal video camera was recorded by a witness on the deck of a cruise ship that was located across the main channel from X44. The video does not show the accident but contains footage of the accident airplane arriving and departing from X44. The only noise heard on the video that is associated with the airplane is that of the powerplants after the airplane’s departure. Another video from a personal video camera was recorded by a witness on a beach north of the accident site. The video does not show the right wing separating but captures

Factual Information 24 Aircraft Accident Report the airplane in a nose-down attitude of between 35º and 45º after the separation. The video shows no obvious smoke or debris coming from the airplane, but, in the upper right corner of view, a cloud of fire and black smoke appears behind the airplane. The airplane and the cloud of fire and smoke follow a similar trajectory and impact the water behind a rock jetty. The digital surveillance video was recorded by a U.S. Coast Guard station camera located near the east end of the main channel. The video shows the accident airplane passing over Miami Harbor toward the ocean and traveling away from the camera. About the time that the airplane moves into the center of the camera’s view, it has become too small to be seen. About 9 seconds after the airplane disappears, a bright flash appears in the area where the airplane was last seen. Black smoke then begins emanating from the flash, and the trail of smoke falls toward the water. A digital still image taken by a witness in a vehicle traveling on a nearby causeway shows the accident airplane in the water during its takeoff roll. Both propellers appear to be in motion. A bright streak located outboard of the right engine appears to be a flashing light. A second digital image, which was taken by a witness in a vehicle traveling on the same causeway, shows the airplane shortly after liftoff above the main channel. 1.16.3 Examination for Explosives Specimens from the accident airplane were sent to the Federal Bureau of Investigation’s laboratory in Quantico, Virginia, to determine whether explosives or explosive residues were present. None of the explosives or explosive residues for which the laboratory screens was found on the specimens. 1.17 Organizational and Management Information Flying Boat, Inc., held an air carrier certificate to conduct Part 121 passenger operations originally issued on December 10, 1990, and reissued on March 19, 1997, by the FAA Southern Region. The company’s operating certificate was managed by the FAA South Florida Certificate Management Office, and the Miami, Florida, Flight Standards District Office was responsible for oversight. Flying Boat began operating passenger service under the business name Chalk’s Ocean Airways in July 1999, in reference to the original airline, Chalk’s Flying Service, which was founded in 1919. Since 1919, Chalk’s Flying Service was owned and operated by various owners under various business names.50 At the time of the accident, Chalks Ocean Airways had 82 employees, including 10 pilots, 12 mechanics, and 5 mechanic assistants.51 50 Chalks Flying Service was purchased in the 1980s by a hotel and casino development company. That company then sold the airline to several south Florida business investors, who operated the airline under the name Pan Am Air Bridge. In July 1999, the airline was bought by a Florida businessman and began operating on the Flying Boat certificate as Chalk’s Ocean Airways. 51 According to a company representative, the other employees represented functions such as reservations, dispatch, and station personnel.

Factual Information 25 Aircraft Accident Report Also, at the time of the accident, Chalk’s Ocean Airways’ flights were based at X44 and flew to destinations in the Bahamas. Most of the flights were over open water, and most of the destination airports were seaplane bases. Chalk’s Ocean Airways operated three G-73T airplanes for revenue service, all of which had the same configuration.52 The airplanes would typically fly six to eight cycles each day. On the day after the accident, Chalk’s Ocean Airways flew one more scheduled flight (in N142PA) from Bimini to Fort Lauderdale. Afterward, the airline ceased flight operations. 1.17.1 Maintenance Organization Flying Boat, Inc., also held a Part 145 repair station certificate issued on August 24, 1993. The Chalk’s Ocean Airways General Maintenance Manual (GMM) contained an organizational chart of the maintenance organization and described the duties of company maintenance and inspection personnel. As outlined in the GMM, the general manager was in charge of the entire maintenance organization. The director of maintenance and the chief inspector/director of quality control reported to the general manager. According to the GMM, the director of maintenance was responsible for “maintaining Company aircraft in an airworthy condition at all times, including all maintenance, repairs, and modifications performed.” The director of maintenance was also responsible for reviewing daily status sheets to ensure efficient and smooth coordination of maintenance tasks, verifying that assigned work packages were completed, ensuring that parts were ordered, overseeing the scheduling of airplanes to ensure dispatch reliability, and serving as the vice chairman at the monthly CASS meetings. In addition, the production manager (also referred to as the maintenance supervisor), lead mechanics, and mechanics reported directly to the director of maintenance. The chief inspector/director of quality control was responsible for the inspection of all work performed. The chief inspector/director of quality control was also responsible for ensuring that maintenance, inspections, airworthiness directives (AD), repairs, and modifications were conducted according to FAA and company policy; accepting or rejecting all work that was accomplished on company airplanes by company shops, maintenance contractors, or vendors; inspecting all incoming parts; maintaining training records of all company inspection and maintenance personnel; maintaining all company manuals; and serving as the chairman during the monthly CASS meetings. The inspectors 52 At the time of the accident, one revenue service airplane, N130FB, was not operable because its engines had been removed for maintenance. In addition, Flying Boat, Inc., had another G-73T, N2974, and a G-73, N1208, listed on its certificate that were not airworthy at the time of the accident. Besides the airplanes in Chalk’s Ocean Airways’ fleet, only three other G-73/G-73T airplanes were in revenue service at the time of the accident and were being operated as sightseeing airplanes in Australia. The remaining airplanes in the G-73/G-73T fleet were operated by personal or corporate owners, most of whom maintained their airplanes as showpieces.

Factual Information 26 Aircraft Accident Report (including those designated as required inspection item inspectors) and the CASS/aircraft records technician reported directly to the chief inspector/director of quality control. Chalk’s Ocean Airways did not have an engineering department to oversee structural airplane issues. As a result, the company contracted with DERs for major repairs of the airplane’s structure. Section 3 of Chalk’s Ocean Airways GMM, volume 5 (dated May 24, 2005), contained the maintenance policies and procedures used to ensure the airworthiness of company airplanes. Page 53006, paragraph a, stated that each corrective action was to include “a reference to FAA approved data, such as repaired in accordance with GMM, chapter, sec[tion], page or any other FAA approved document applicable to corrective action signoff.” 1.17.1.1 Additional Maintenance Information In March 1981, Frakes Aviation in Cleburne, Texas, purchased the G-73 type certificate from Grumman. As a result, Chalk’s Ocean Airways did not have engineering, maintenance, and operating support from the original aircraft manufacturer. Also, a structural repair manual was not issued for the G-73 because it was not required at the time the airplane was manufactured.53 According to Frakes Aviation personnel, the company had no involvement with G-73/G-73T repairs and no formal interaction with Chalk’s Ocean Airways for at least the 15 years that preceded the accident. 1.17.2 Postaccident Actions In December 2005, after the accident, the Department of Transportation’s (DOT) Air Carrier Fitness Division suspended Chalk Ocean Airways’ economic authority to operate under the Flying Boat, Inc., Part 121 certificate.54 The DOT stated that the air carrier had 1 year to “prove to [the DOT] that the public interest is best served if they [Chalk’s Ocean Airways] re-start their operation.” As of the 1-year target date, Chalk’s Ocean Airways was not operating its own airplanes; the Part 121 certificate remained suspended, and the company had entered into a wet lease55 arrangement with another certificated carrier to provide transportation. Flying Boat, Inc., retained its Part 145 repair station authorization for Chalk’s Ocean Airways; however, according to an FAA inspection on December 14, 2006, there was little activity. 53 For operators of airplanes for which no structural repair manual was issued, AC 43-13 provides information on typical structural repairs that have been approved by the FAA. The AC contains methods, techniques, and practices “for the inspection and repair of … civil aircraft, only when there are no manufacturer repair or maintenance instructions.” 54 For more information about the history of the DOT’s concerns about the economic fitness of Chalk’s Ocean Airways, see section 1.18.5. 55 According to the FAA, a wet lease is a leasing agreement whereby a certificate holder agrees to provide an aircraft and at least one crewmember to another direct air carrier.

Factual Information 27 Aircraft Accident Report On December 23, 2005, the FAA issued Special Airworthiness Information Bulletin (SAIB)56 NM-06-18, which advised G-73 and G-73T operators of the circumstances of this accident. The SAIB stated, in part, the following: “FAA is considering the need for mandatory detailed inspections of parts or all of the wing structure on the fleet of G-73 airplanes. If FAA determines that the accident airplane wing’s pre-separation condition is potentially manifest in other G-73 airplanes, the FAA will take appropriate action.” On December 30, 2005, the FAA issued Emergency AD 2006-01-51, which directed operators of G-73 and G-73T airplanes to do the following: Before further flight, perform a detailed visual inspection to detect repairs, cracking, or corrosion of the wings from wing station (WS) 77L to WS 77R, front spar to rear (main) spar; remove any repair that is found, to allow for inspection of the wing structure underneath the repairs; and remove the sealant from the interior of the wet bays to allow for inspection of the skins, stringers, and both spars. This visual inspection was to be performed in accordance with a method that has been approved by the FAA. Because no such method existed at the time that the AD was issued, the AD effectively grounded all G-73/G-73T airplanes. At the time, there were 31 U.S.-registered G-73/G-73T airplanes, about 15 of which were considered airworthy. The AD also required that an FAA aircraft certification office approve reports of any findings, repairs performed, or alternate methods of compliance. Since the time that the AD was issued, the FAA approved, on a case-by-case basis, six privately owned G-73/G-73T airplanes to fly for an interim period of 200 flight hours. At least two other privately owned airplanes were undergoing evaluation. Also, the FAA recently approved a private owner’s alternate means of compliance for the AD, and work has begun on the airframe of that airplane. That airplane and the rest of the G-73/G-73T fleet remain prohibited from further flight until individually approved by the FAA to be in compliance with AD 2006-01-51 or an approved alternate method. 1.17.3 Federal Aviation Administration Oversight As stated previously, the Flying Boat, Inc., operating certificate for Chalk’s Ocean Airways was managed by the FAA’s South Florida certificate management office. At the time of the accident, the Chalk’s Ocean Airways PMI had been in that position for about 5 years. He was also responsible for overseeing two other Part 121 air carriers. During a postaccident interview, the Chalk’s Ocean Airways PMI stated that the number of times he visited the company each month varied depending on his workload and that he attempted to be at each monthly CASS meeting. The PMI also stated that his work included inspections of the maintenance facility, vendors, and airplane records; ramp inspections; and the aging aircraft inspection and records review program. The PMI indicated that he was “comfortable” with the maintenance being conducted on the 56 SAIBs are informational in nature and are not mandatory.

Factual Information 28 Aircraft Accident Report company’s airplanes. He added that the maintenance program met all Federal Aviation Regulation (FAR) requirements. 1.18 Additional Information 1.18.1 Applicable Federal Aviation Regulations As stated previously, the accident airplane was modified from a G-73 model to a G-73T model in accordance with STC SA2323WE, and its seating configuration was modified in accordance with STC SA4410SW. A review of the STCs showed that both were held by Frakes Aviation. In August 1968, Frakes Aviation applied to the FAA for the STC to replace the piston engines with turbopropeller engines and to increase its maximum gross weight from 12,750 to 14,000 pounds. The FAA issued STC SA2323WE to Frakes Aviation in April 1971. In October 1979, Frakes Aviation applied to the FAA for an STC to increase the number of passenger seats in the cabin from 10 to 17. The FAA issued STC SA4410SW to Frakes Aviation in July 1981. Title 14 CFR 21.19, “Changes Requiring a New Type Certificate,” had been in effect since February 1965, more than 3 years before Frakes Aviation applied for the engine modification STC. The version of the regulation that was current at the time of the STC application stated in paragraph (b)(2) that a new application for a type certificate was required for transport-category airplanes if the proposed change included engines using different principles of propulsion. However, the FAA granted Frakes Aviation the option to use the airplane’s original type certificate (which was issued in September 1947) as the basis for the analysis required for the modifications, instead of requiring Frakes to apply for a new type certificate for the G-73T airplane.57 The practice of applying former regulations instead of new regulations is known as grandfathering. As a result of the FAA’s decision, Frakes Aviation performed the analysis for the engine modifications58 in accordance with Part 4aT of the Civil Air Regulations, dated November 1, 1943, and amended March 8, 1944. As mentioned previously, this regulation required a static strength analysis, which is performed using loads that do not vary with time and that have a constant magnitude. The regulation did not include any provisions for a fatigue strength analysis for an expected service life for the airplane’s structural components. Because the FAA allowed Frakes Aviation to perform the analysis per the airplane’s original type certificate, the G-73T airplane was not made subject to 14 CFR 25.571, “Fatigue Evaluation of Flight Structure,” which had been in effect since 57 An STC applicant can request to negotiate the certification basis with the applicable FAA aircraft certification office, and all decisions are made at the discretion of the FAA Administrator. 58 Frakes Aviation used STRATO Engineering Company, Inc., of California to perform the engineering analysis.

Factual Information 29 Aircraft Accident Report February 1965. The version of 14 CFR 25.571 that was in effect at the time that Frakes applied for the STC was dated October 1966 and required, in part, the following: (a) Strength, detail design, and fabrication. Those parts of the structure (including wings, fixed and movable control surfaces, the fuselage, and their related primary attachments), whose failure could result in catastrophic failure of the airplane, must be evaluated under the provisions of either paragraph (b) or (c) of this section. (b) Fatigue strength. The structure must be shown by analysis, tests, or both, to be able to withstand the repeated loads of variable magnitude expected in service. (c) Fail safe strength. It must be shown by analysis, tests, or both, that catastrophic failure or excessive structural deformation, that could adversely affect the flight characteristics of the airplane, are not probable after fatigue failure or obvious partial failure of a single principal structural element. 1.18.2 Previous Related Safety Recommendations 1.18.2.1 Supplemental Inspections According to 14 CFR 121.370a, “Supplemental Inspections,” the maintenance programs of certain airplanes are required to include damage-tolerance-based supplemental inspections and procedures in addition to the aging airplane inspection and records review required by 14 CFR 121.368. The FAA issued the final rule for 14 CFR 121.370a in February 2005; however, the final rule differed substantially from the December 2002 interim final rule by exempting certain airplanes from the supplemental inspection requirements. The supplemental inspection requirements in the final rule for 14 CFR 121.370a apply only to transport-category, turbine-powered airplanes that were type-certificated after January 1, 1958, and that have a maximum passenger seating capacity of 30 or more seats or a maximum payload of 7,500 pounds.59 The final rule also changed the compliance date from December 5, 2007, to December 10, 2010. In addition, both the December 2002 interim final rule and the February 2005 final rule exempted airplanes that are operated entirely within the state of Alaska. In a July 24, 2006, letter to the FAA, the Safety Board referenced this accident and stated that it was concerned that the exemptions allowed certain airplanes, including the G-73T airplane, to carry passengers under Part 121 without having to undergo 59 The December 2002 interim final rule required supplemental inspections for all airplanes operated under 14 CFR Part 121, all U.S.-registered multiengine airplanes operated under 14 CFR Part 129, and all multiengine airplanes used in scheduled operations under 14 CFR Part 135 (with the exception of certain Alaska and smaller airplane operations mentioned later in this section).

Factual Information 30 Aircraft Accident Report supplemental inspections. Because of these concerns, the Board issued Safety Recommendation A-06-52 on July 24, 2006, which asked the FAA to do the following: Require records reviews, aging airplane inspections, and supplemental inspections for all airplanes operated under 14 Code of Federal Regulations (CFR) Part 121, all U.S.-registered airplanes operated under 14 CFR Part 129, and all airplanes used in scheduled operations under 14 CFR Part 135. This would include those airplanes operated under 14 CFR Part 135 that carry nine or fewer passengers and those that are operated in scheduled cargo service. On November 20, 2006, the FAA stated that airplanes that were type-certificated before 1958 and that had a maximum passenger seating capacity of less than 30 seats were not included in the final rule requiring damage tolerance-based supplemental inspections because it would be cost prohibitive to do so. The FAA estimated that fewer than 80 aircraft operated under Part 135 would be in scheduled operation in 2010, the compliance date for the supplemental inspections. The FAA stated that it would address the discovery of any age-related problems or unsafe conditions for these airplanes through continued operational safety programs and ADs. The FAA further stated that, if operators of small airplanes wanted to voluntarily develop supplemental inspections programs, they could refer to AC 91-60, which was being revised and would be completed in 2007. On March 21, 2007, the Safety Board issued a response letter and asked that the FAA reconsider its position regarding the exemption of aircraft from the supplemental inspection requirements. In the letter, the Board stated that, until such reconsideration, Safety Recommendation A-06-52 is classified “Open—Unacceptable Response.” 1.18.2.2 Cockpit Voice Recorder Functionality During its investigation of the March 23, 2004, accident involving a helicopter that crashed into the Gulf of Mexico,60 the Safety Board found that the CVR data recovered during that investigation were of limited use because of a CVR anomaly that was not detected during the functional check of the CVR after installation. As a result, on March 24, 2006, the Board issued Safety Recommendation A-06-23, which asked the FAA to do the following: Require all operators of aircraft equipped with a cockpit voice recorder (CVR) to (1) test the functionality of the CVR before the first flight of each day as part of an appoved aircraft checklist and (2) perform a periodic maintenance check of the CVR as part of an approved maintenance check of the aircraft. The CVR preflight test should be performed according to procedures provided by the CVR manufacturer and should include listening to the recorded signals on each channel to verify that the audio is being recorded properly, is intelligible, and is free from 60 National Transportation Safety Board, Controlled Flight into Terrain, Era Aviation, Sikorsky S-76A++, N579EH, Gulf of Mexico, About 70 Nautical Miles South-Southeast of Scholes International Airport, Galveston, Texas, March 23, 2004, Aviation Accident Report NTSB/AAR-06/02 (Washington, DC: NTSB, 2006).

Factual Information 31 Aircraft Accident Report electrical noise or other interference. The periodic maintenance check of the CVR should include an audio test followed by a download and review of each channel of recorded audio. The downloaded recording should be checked for overall audio quality, CVR functionality, and intelligibility. In response, the FAA issued Safety Alert for Operators (SAFO) 06019 on November 8, 2006, advising operators to test CVR functionality before the first flight of the day and to add this test to their approved checklists. The SAFO emphasizes the importance of operators ensuring they have procedures and training for the functional test of the CVR. The SAFO also recommends that operators ensure that training requirements for testing of CVRs are emphasized during initial and recurrent training and that all pilots of aircraft equipped with a CVR test the function of the CVR before the first flight of each day as part of an approved aircraft checklist. According to the FAA, the release of the SAFO was to be accompanied by a flight standards information bulletin for airworthiness (FSAW) that would instruct airworthiness aviation safety inspectors to ensure that operators perform periodic CVR maintenance checks, including checks of all possible combinations of intercom and microphone audio selections. These checks would ensure that all permutations of these selections were connected to the appropriate CVR channels and did not inhibit normal selectable functions or create loss in fidelity or intelligibility. As of April 2007, the FAA had not yet issued the FSAW. In a letter to the FAA dated April 12, 2007, the Safety Board noted that the SAFO did not provide the specific guidance for the CVR preflight test included in the recommendation. The Board also reminded the FAA that the FSAW should include sufficient detail to ensure that nonfunctional CVR systems are identified and repaired as quickly as possible. On April 12, 2007, the Board classified Safety Recommendation A-06-23 “Open—Unacceptable Response,” pending the FAA’s revision of the SAFO and issuance of an appropriate FSAW. 1.18.3 Postaccident Interviews Regarding Maintenance of Chalk’s Ocean Airways’ Airplanes The Safety Board interviewed Chalk’s Ocean Airways pilots, the husband of the accident captain, the company’s director of operations, the company’s maintenance supervisor, and two DERs regarding Chalk’s Ocean Airways’ maintenance policies and practices. Their interviews are summarized in sections 1.18.3.1 through 1.18.3.4, respectively. 1.18.3.1 Former and Current Company Pilots The Safety Board interviewed four pilots who were employed by Chalk’s Ocean Airways at the time of the accident, the husband of the accident captain, and three pilots who had left the company before the accident. According to some pilots, in August 2004, all of the company captains had met with their director of operations to discuss shared

Factual Information 32 Aircraft Accident Report pilot concerns about the maintenance of company airplanes, including concerns about visible cracks and degraded rivets on some airplanes. Some pilots recalled that, during the meeting, the pilots had stated that they wanted to know that actions would be taken to ensure their safety and that the director of operations seemed to be concerned and told them that the airplanes would be examined.61 Some of the pilots stated that they were concerned about the amount of time maintenance items on company airplanes were deferred and that the director of maintenance and the maintenance supervisor told them that that skin cracks in the airplanes were superficial. Some of the pilots stated that they voiced concerns about fuel leaks, most of which occurred near the location where the wing meets the fuselage, and that the company told them that the leaks involved sealant in the fuel tanks and that the tanks would be resealed. One current company captain stated that fuel leaks had to be written up multiple times before they were fixed and that, in 2004, the same fuel leak was written up between 10 and 15 times. Two current company first officers stated that company maintenance was “great” and that, when any problems were found with the airplanes, they would be fixed or grounded. One former captain stated that, in November 2004, he experienced an in-flight emergency when he lost elevator control of the airplane during climbout because of an elevator cable that failed. He stated that he landed the airplane without incident using elevator trim. This captain stated he resigned from his job at Chalk’s Ocean Airways on the day of the event because he had a job offer from another company. Another former captain stated that he experienced loss-of-engine-power events during flights in January and February 2005. The flight crews were able to land the airplane each time without incident. This captain stated he resigned after the February 2005 engine failure because of his concerns with company maintenance issues. Another captain stated that he resigned from the company solely because of his concerns with maintenance issues. This captain stated that, just before submitting his resignation letter (dated January 28, 2005) to the company, he provided the company’s director of maintenance with a five-page letter (dated January 13, 2005) outlining his concerns.62 The captain’s letter stated that the most common reaction to a maintenance problem that could not be fixed quickly was for the mechanic to ask the captain of that airplane if he would fly it anyway; the letter stated that the second most common reaction was for the mechanic to sign off that the airplane was fixed when it actually was not fixed. The letter further indicated that “delayed maintenance, ignored maintenance, and lack of maintenance on our aircraft has caused an alarming trend to develop that has been all but 61 The accident captain’s husband stated that the captain was concerned that company airplanes were not well maintained and that she would speak daily about problems with the airplanes. 62 This captain stated that he submitted this letter and tendered his resignation after being informed by the director of maintenance that he would be receiving disciplinary action (either a downgrade to first officer or time off) because of his difficulties in dealing with maintenance personnel.

Factual Information 33 Aircraft Accident Report ignored by the maintenance department and management altogether.” In addition, in the letter, the captain suggested that the company “fix the aircraft when they do break, and improve our preventative maintenance, which is obviously sadly lacking.” 1.18.3.2 Director of Operations The Chalk’s Ocean Airways director of operations has been in that position since August 2001.63 He was an active pilot who conducted most acceptance flights after maintenance because he wanted to personally confirm that the airplanes were safe before other pilots flew them.64 He stated that the company responded seriously to the comments expressed by its former captain by systematically checking airplane logbooks to confirm that all of his maintenance concerns had been addressed and fixed. The director stated that he was satisfied that these issues had been resolved and that the airplanes were safe to fly. The director of operations stated that he did not agree with the former captain’s assertion that, among pilots, there was a general concern with airplane maintenance. The director pointed out that only two captains left the company because of maintenance concerns and that several other captains could provide a more favorable view of the company. He also pointed to the company’s 86-year “unblemished” safety record before the time of the accident.65 The director of operations stated that fuel leak concerns raised by pilots were “always a company concern” and that they were addressed before a flight was released. He also stated that every crack reported by pilots was corrected. He stated that the accident captain, as director of safety, was responsible for the safety aspect of flight and ground operations. He indicated that she discussed routine items during monthly meetings. He stated that he did not recall any time during these meetings in which she raised a concern about maintenance. The director further indicated that each captain could decide not to fly an airplane if a problem, including maintenance, existed. 63 The director of operations has also been the company’s general manager since February 2005. 64 The director of operations stated that he had to limit his flying after August 2005 because of medical issues. 65 A review of Safety Board accident and incident data revealed that on March 18, 1994, two Chalk’s Ocean Airways crewmembers were killed when the G-73T they were piloting crashed on takeoff. The Board determined that the probable cause of the accident was the “failure of the pilot-in-command to assure that the bilges were adequately pumped free of water (adequately preflighted), which resulted in the aft center of gravity limit to be exceeded, and the failure of the aircrew to follow the checklist. A factor related to the accident was the water leak.” For more information about this accident, see MIA94FA097 on the Board’s web site at http://ntsb.gov. Other Chalk’s Ocean Airways accidents and incidents include a hard landing in 2002; a landing-gear fatigue failure in 2001 due to unserviceable parts installed on an airplane; a control yoke overload separation in 2000; a nose landing-gear failure in 1984; and an elevator-trim actuator failure in 1984. For more information about these events, see MIA02WA063, MIA01IA144, MIA00IA186, MIA84IA147, and MIA84IA077, respectively. Also, the previously mentioned November 29, 2004, event, in which a pilot reported he lost elevator control due to a broken elevator cable but landed the airplane safely, is reflected in a service difficulty report that Chalk’s Ocean Airways submitted to the FAA.

Factual Information 34 Aircraft Accident Report 1.18.3.3 Maintenance Supervisor The Chalk’s Ocean Airways maintenance supervisor at the time of the accident had been employed with the company for about 28 years and had been in that position for 26 years. He stated that he attended the yearly recurrent training on the company’s GMM and the Grumman service manual66 and was present at most of the monthly CASS meetings. The maintenance supervisor stated that Chalk’s Ocean Airways management gave him all of the resources, including airplane parts and personnel, to maintain the airplanes in an airworthy condition and that he did not sense “any pressure from upper management to keep the airplanes flying no matter what.” He also stated that sometimes it took several attempts to determine the cause of a discrepancy and implement a fix to solve the problem. The maintenance supervisor further stated that he was not involved with any of the DER structural repairs.67 The maintenance supervisor did not recall accomplishing, or instructing one of the company’s mechanics to accomplish, the doubler repair at right WS 34 on the accident airplane. He recalled seeing the repair several times during the C3 (right wing) inspection but thought that the repair “must have been done prior to Chalk’s getting the airplane.” The maintenance supervisor stated that he did not recall seeing any paperwork for this repair. During the postaccident interview, the Safety Board showed the maintenance supervisor a picture of stop drill holes in the area of the doubler repair at right WS 34 on the accident airplane. The maintenance supervisor stated that he had not previously seen the stop drill holes and that he did not recollect instructing any of the mechanics to accomplish a stop drill repair in the area. He further stated that the repair was not accomplished using best maintenance practices.68 1.18.3.4 Designated Engineering Representatives A structures DER stated that he worked with Chalk’s Ocean Airways during the 5 to 6 years that preceded the accident. He indicated that most of the work performed for the company was the reverse engineering69 of parts that were affected by corrosion. To accomplish this work, he prepared a design drawing and a stress report, along with FAA form 8110; this form provided approval for the replacement parts, which were made of modern materials whose design properties were equivalent to those of the former 66 The chief inspector provided this and all other recurrent training at the company. 67 Either a company mechanic or an outside mechanic recommended by the DER would accomplish these repairs. 68 As mentioned in section 1.6.2.2, several characteristics of the repair were not in accordance with AC 43.13-1B. 69 Reverse engineering is the process of recreating a drawing or specification for a component by analyzing a manufactured product for which a drawing or specification is unavailable.

Factual Information 35 Aircraft Accident Report materials. The DER stated that the August 2005 right wing repair on N142PA was the first time he had worked on the wing structure of an airplane in Chalk’s Ocean Airways’ fleet. Another structures DER stated that he had worked with Chalk’s Ocean Airways on four or five repairs since 1999, including the July 1999 lower left skin repair to N142PA. He also worked with the company on the July 2000 rear Z-stringer repair (right WS 50.5) to the accident airplane. The DER stated that this repair, which was needed because of a fatigue crack in one of the slosh holes, consisted of nesting two angles on the stringer in the region of the crack. The DER further stated that this repair was accomplished when the airplane was having major maintenance performed and that he did not recall any other damage or corrosion on the rest of the airplane at that time. 1.18.4 Grumman Customer Service Bulletin Grumman issued Customer Service Bulletin No. 89 in May 1963. The bulletin stated that corrosion was the “greatest maintenance problem” for watercraft and that, for G-73 airplanes operating in a saltwater environment for most of their service life, corrosion might occur in the lower skin of the wings in the fuel tank areas. The bulletin also stated that corrosion might be occurring if one or all of the following conditions were present: chronic leakage of fuel; looseness of sealant in the tanks; and/or blisters, swelling, or visible corrosion in the skin in the tank areas. The bulletin further stated that local repairs would probably correct the corrosion, but, if the aircraft had much saltwater operation in the past or if extended saltwater operations were anticipated in the future, the lower wing skin should be completely removed for a thorough cleaning, inspection, and resealing. In addition, the bulletin stated that wing skin removal and resealing of the fuel tanks would improve the fuel tightness and corrosion resistance of the tanks. 1.18.5 Department of Transportation Concerns About the Economic Fitness of Chalk’s Ocean Airways As part of the DOT’s informal continuing fitness review of Chalk’s Ocean Airways, the Air Carrier Fitness Division sent the company a letter dated April 14, 2004, that expressed its concerns about the company’s “weak” financial position and what it considered to be excessive subservicing.70 The DOT notified the FAA of its concerns by sending copies of the correspondence to the principal operations inspector (POI) assigned to Chalk’s Ocean Airways. In a four-page attachment to the fitness review letter, the DOT also noted that, during discussions with the POI, the POI indicated that “his overall impression of the air carrier’s operations was that it seems to be run more like a Part 135 air taxi operation rather than the Part 121 operator it is.” The DOT review also indicated that the POI expressed concerns “that the management team may be too busy with their 70 Subservicing is the practice of transferring passengers to other carriers.

Factual Information 36 Aircraft Accident Report flight duties to effectively attend to their administrative and oversight duties on the ground.” In a follow-up e-mail on August 11, 2004, the DOT asked the POI, “Aside from the subservice issue, do you have any concerns with the carrier’s operations and/or management?” In an e-mail reply that day, the POI stated, “I do not.” In a letter dated November 4, 2004, Chalk’s Ocean Airways responded to the DOT that it used subservicing when fleet maintenance requirements prevented it from using its own airplanes. These maintenance events included both scheduled and unscheduled maintenance items. In a January 5, 2005, letter to the company’s general manager, the DOT reiterated its concerns about the company’s economic viability and its subservicing arrangements.

37 Aircraft Accident Report 2. Analysis 2.1 General The captain and the first officer were properly certificated and qualified under Federal regulations. No evidence indicated any medical or behavioral conditions that might have adversely affected their performance during the accident flight. There was no evidence of flight crew fatigue. The accident airplane was certificated and equipped in accordance with Federal regulations. The recovered components showed no evidence of any system or powerplant failures but showed evidence of multiple failures of wing structural components. The fire damage to the fuselage and empennage was a result of the failure of the right wing and the subsequent breach in the wing fuel tank. The accident was not survivable. The emergency response was timely. This analysis discusses the in-flight separation of the accident airplane’s right wing, Chalk’s Ocean Airways’ maintenance of the accident airplane and other airplanes in its fleet, the FAA’s oversight of the Chalk’s Ocean Airways maintenance program, and certification issues pertaining to aging aircraft. 2.2 In-flight Breakup Sequence On the basis of the accident airplane’s takeoff weight and airspeed, the wing structure developed normal aerodynamic loads during takeoff, and these loads, in turn, created normal internal loads. However, the right wing separated from the airplane at WS 34 while the airplane was operated within its certificated design envelope, rendering the airplane uncontrollable. The airplane departed on the accident flight with preexisting damage to some wing structural components, however, the damaged components were not visible to the flight crew. The Safety Board concludes that there was no evidence from the performance or appearance of the airplane that would have provided warning to the flight crew of the right wing’s imminent failure and that there was nothing that the crew could have done to regain control of the airplane after the in-flight separation of the right wing. Section 2.2.1 discusses the fracture scenario and the right wing’s structural performance. 2.2.1 Fracture Scenario Examination of the right wing revealed preexisting fatigue fractures and cracks in the rear Z-stringer, lower skin, and rear spar lower spar cap, each of which contributed to reducing the wing structure’s ability to carry load. An analysis of each component’s fracture characteristics, rub evidence and other characteristics observed on some

Analysis 38 Aircraft Accident Report components and on some maintenance repairs, and evaluation of the typical load-bearing characteristics of the wing structure design were performed to produce a general timeline and likely sequence for the respective failure of each fractured component. Section 2.3 discusses the importance of this sequence as it relates to opportunities for repairing each damaged component before they cumulatively resulted in wing failure. The analysis revealed that the airplane’s right rear Z-stringer (as shown in figure 5) likely fractured first. Several features indicated that the right rear Z-stringer had been fractured for some time, most likely years, before the accident.71 Fatigue initiated at the slosh hole in the web of the Z-stringer just outboard of right WS 34. No anomalies, such as material defects, mechanical damage, or corrosion, were identified as factors to cause fatigue initiation at the slosh hole. It is likely that fatigue initiated at the slosh hole because the number of load cycles on the stringer exceeded its fatigue life.72 After the right rear Z-stringer fractured, the lower skin developed a fatigue crack (as shown in figure 4). Because of the load-bearing characteristics of the wing structure design, initiation of a skin-fatigue crack in this location would be unlikely unless the rear Z-stringer was already fractured.73 The skin crack, which was about 16 inches in length, consisted of two segments that initiated from two areas. Both segments of the skin crack propagated forward and aft of the initiation sites. The aft segment of the crack initiated from an area of corrosion and missing skin material around the fuel sump drain near right WS 34. The forward segment of the skin crack (the longer of the two segments) initiated from a rear Z-stringer fastener hole (the first fastener hole outboard of the fracture). Several features observed on this crack and on maintenance repairs associated with the crack suggest that the crack also likely developed over a period of months to years. For example, three stop drill holes were observed in the crack path forward of the initiation site at the rear Z-stringer fastener hole (about 7, 9, and 16 inches forward of the skin trailing edge), indicating that the skin crack was detected by maintenance personnel on at least three occasions, likely over the course of months to years, and that crack extension beyond the previous stop drill hole was detected at least twice. The external and internal doublers were likely applied after the third stop drill hole had been drilled and after the skin crack propagated forward up to the middle Z-stringer. Missing skin material replaced with hard green sealant was observed between the doublers around the fuel sump drain. In this area, several fasteners at the inboard edge of the doublers went through the 71 These features included the following: the overstress region on the upper flange was worn, which was consistent with rubbing of mating fracture surfaces over time; sanding marks were observed around the slosh hole that deformed the edges of the fracture face, and sealant was present in the fracture surface, indicating that the flange was cracked or fractured at the time the sanding and sealant procedures were performed; and one of the three internal doublers was covering the lower flange of the Z-stringer at the fracture location. 72 Fatigue life is the number of load cycles that a component experiences before failure is expected due to fatigue fracture. 73 If the rear Z-stringer were intact, it would carry most of the load, thereby reducing the load on the skin at the stringer fastener row. However, the right rear Z-stringer on the accident airplane was broken, causing the load to shed to the skin and leading to fatigue of the skin emanating from a fastener hole adjacent to the fracture.

Analysis 39 Aircraft Accident Report sealant instead of skin material and, thus, would not provide load transfer across the skin crack in that area. Multiple-site fatigue damage was observed on the skin fracture surface (inboard of the stop-drilled crack) at the inboard fastener row for the external doubler adjacent to right WS 34. At some time before the accident, several of these sites linked up in overstress to form a fracture through the skin at the rear Z-stringer and, most likely, several inches forward and aft of the Z-stringer.74 After the lower skin fractured, fatigue cracks initiated in the rear spar lower spar cap (as shown in figure 6). The initiation of these fatigue cracks was likely late in the overall sequence of events because the fracture features indicated relatively rapid growth under relatively high stresses. Fatigue in the rear spar lower spar cap initiated from a double-drilled hole in the horizontal flange of the spar cap for a threaded fastener attaching the wing to the fuselage.75 Although a double-drilled hole could be considered an initiating defect in many cases, in this case, fatigue initiated from multiple sites through the thickness of the horizontal flange (including both the narrow and wide areas of the double-drilled hole) indicating that stresses in the spar cap were high enough to cause fatigue initiation from any fastener hole in the area, with relatively few load cycles. Further, fatigue in the rear spar progressed rapidly from a relatively small, slow growth region. The portion of the crack aft of the hole propagated from a length of 0.07 to 0.44 inch in about 11 increments of rapid crack growth; each increment was most likely associated with an individual flight cycle. Also, more than one-half of the rear spar lower spar cap fractured in overstress. The relatively small size of the slow growth region and the limited overall size of the fatigue region indicated that stresses on the rear spar lower spar cap were relatively high as the crack propagated under normal flight loads, and the high stresses were most likely a result of the shedding of load from the fatigue-fractured and cracked rear Z-stringer and lower skin. The Safety Board’s residual strength and fatigue analyses76 of the right wing structure revealed that the fatigue cracks grew to their critical crack length and that the remaining wing structure could no longer sustain the applied loads. The Safety Board 74 Evidence of relative movement between the inboard side of the skin fracture and the doubler at its inboard fastener row, which was consistent with the fracture opening and closing, was observed on the surface of the doubler between several fastener locations, including the fastener for the right rear stringer and the adjacent two fasteners aft of the stringer. 75 The age of the double-drilled hole could not be determined. It is possible that both holes could have been drilled at the time the airplane was manufactured, and it is also possible that the second hole was drilled during maintenance. 76 The residual strength and fatigue analyses assumed 1 G flight loads that were obtained with and without fuel and were applied to the wing structure. The resulting reaction forces and associated stresses were computed for the undamaged wing. The stresses were then recomputed with certain elements either completely removed or their cross-sectional areas reduced, based on the amount of fatigue damage present in the wing structure. Stress concentration factors were then applied, and new stresses were computed and compared with the material yield and ultimate stresses. A crack-growth analysis was performed for the spar cap and the wing skin to determine the number of cycles required for the fatigue fractures to reach their critical crack length.

Analysis 40 Aircraft Accident Report concludes that the right wing separated from the accident airplane at WS 34 because of preexisting fatigue fractures and cracks in the rear Z-stringer, lower skin, and rear spar lower spar cap and that this multiple-element fatigue damage reduced the residual strength capability of the wing structure and caused the fatigue failure of the wing during normal flight operations. 2.3 Chalk’s Ocean Airways Maintenance Program The Chalk’s Ocean Airways maintenance program was ineffective in identifying and correcting the longstanding structural problems that led to the in-flight separation of the accident airplane’s right wing near WS 34. Because several of these problems occurred over months and years, company maintenance and inspection personnel had multiple opportunities to identify and correct the individual damaged components and, thus, could have prevented the wing failure. 2.3.1 Ineffective Repairs on the Accident Airplane Although maintenance personnel detected some problems and attempted repairs, many of the repairs were ineffective in that they did not properly restore the load-carrying capability of the wing structure. Ineffective repairs observed on the accident airplane included documented repairs performed by company maintenance personnel and some undocumented repairs. Also, company inspection personnel failed to identify that the repairs were ineffective. The ineffective repairs observed on the accident airplane included the following: • Sanding marks were observed around the rear Z-stringer slosh hole and fracture lips at right WS 34, suggesting that the sanding was an attempt to remove cracking that had been detected in the Z-stringer. The cracking, however, was not completely removed, and the crack continued to propagate over time. • One of the three internal doublers at right WS 34 had a portion that covered the lower flange of the rear Z-stringer, suggesting that the portion of the doubler covering the Z-stringer was an attempt to reinforce the fractured Z-stringer. Doubling only the lower flange did not restore the strength of the fractured Z-stringer. • Multiple-site fatigue damage at the inboard fastener row for the doublers at right WS 34 linked up in the area of the rear Z-stringer before the wing separated, indicating that repairs in this area did not restore the strength of the rear Z-stringer.

Analysis 41 Aircraft Accident Report • Several fasteners in the inboard row of fasteners for the doubler repair at right WS 34 were inserted through sealant near the fuel sump drain instead of the lower skin.77 This resulted in ineffective load transfer between the skin and the doublers in that area. • Three stop drill holes were located in the area of the doubler repair to the lower skin at right WS 34. The stop drill holes showed that the skin crack was detected at least three times before the doublers were applied and that the crack had extended twice from the location of a previous stop drill hole. Continued crack growth from a stop drill hole is indicative of an underlying structural problem that was not properly addressed in previous maintenance actions. On July 6, 2000, a major repair to the accident airplane’s rear Z-stringer was performed at right WS 50.5 using a DER drawing that indicated that the riveting was to be performed in accordance with AC 43.13.78 This repair was not part of the fracture scenario but was, nonetheless, ineffective because the rivets used in the repair did not meet the standards described in the AC. Some rivets had undersized shop heads and were overdriven, and a rivet through the skin and stringer flange at the slosh hole was of a larger size and different head type than specified, which was not in compliance with the engineering drawing for the repair. A fatigue crack in the skin emanated from the hole with the large rivet. In addition, flight logs documented numerous fuel leak discrepancies involving the accident airplane that occurred over several months before the accident. Many of these discrepancies occurred near the area where the right wing separated from the airplane. The Chalk’s Ocean Airways director of maintenance stated that fuel leaks reported by pilots were addressed before a flight was released. However, the flight logs showed that the fuel leak discrepancies often took several attempts to resolve but would then recur. Because the wing skin and other wing box structures make up the wing fuel tanks, wing fuel leaks can be indicative of discrepancies with the wing box structure. The Safety Board concludes that the repetitive fuel leaks near the area where the accident airplane’s right wing separated from the fuselage were indicators of structural damage inside the right wing. This issue is further discussed in section 2.3.2. Other maintenance-related problems existed with the accident airplane. For example, during postaccident metallurgical examinations, corrosion was observed in many locations throughout the airplane’s structure,79 with some areas showing significant pitting and thinning. Also, the metallurgical examinations showed significant fatigue 77 AC 43.13 shows typical structural repair methods for aluminum structure, but the repairs described in this and the preceding two bulleted items were not included as examples of typical structural repair methods. Also, AC 43.13 does not include any reference to indicate that cracks can be removed by sanding, as described in the first bulleted item. 78 Technical data referenced in engineering drawings are considered to be approved data, and Chalk’s Ocean Airways GMM requires that all maintenance be performed in accordance with approved data. 79 The Safety Board could not determine whether Chalk’s Ocean Airways had received and implemented Grumman Service Bulletin No. 89, which addressed the problem of corrosion for airplanes that operated in a saltwater environment (see section 1.18.4).

Analysis 42 Aircraft Accident Report cracks on the left wing, including one crack on the left wing front spar lower spar cap that had extended from an area of corrosion damage and had begun to progress fairly rapidly. The crack was located in an area that had not been repaired and did not have adjacent structural element failures. If the accident airplane had not experienced a catastrophic failure at right WS 34, the crack in the left wing front spar lower spar cap likely would have eventually led to a catastrophic failure. In addition, Chalk’s Ocean Airways’ maintenance records did not contain any entry for the doubler repair to the accident airplane’s lower skin at right WS 34. During a postaccident interview, the company’s maintenance supervisor stated that he did not recall accomplishing, or instructing one of the company’s mechanics to accomplish, the repair. The maintenance supervisor stated that he recalled seeing the repair several times during the C3 (right wing) inspection but thought that the repair “must have been done prior to Chalk’s getting the airplane.” The company’s maintenance records showed that, on May 6, 1992, a doubler repair was made to the accident airplane’s lower skin at left WS 34. Metallurgical examination showed a substantially greater amount of corrosion damage in the left wing doubler repair compared to corrosion damage in the right wing doubler repair. Thus, the right wing repair appeared to be more recent than the May 1992 left wing repair. As a result, the Safety Board concludes that Chalk’s Ocean Airways most likely performed the doubler repair to the accident airplane’s lower skin at right WS 34 and that this repair should have been reflected in the company’s maintenance records. It is possible that this repair was accomplished between January 2000 and January 2001, the time period for which the company was unable to provide flight log sheets. The Safety Board further concludes that the doubler repair to the accident airplane’s lower wing skin at right WS 34 was ineffective because the doublers did not restore the load-carrying capability of the skin in the area of the fuel sump drain and the repair did not properly address the underlying cause of the skin cracking, which was the cracked or fractured rear Z-stringer. 2.3.2 Recurring Discrepancies As previously stated, Chalk’s Ocean Airways’ flight logs documented numerous fuel leak discrepancies involving the accident airplane. Minutes from the July 2005 CASS meeting showed that the accident airplane had a fuel leak from either the left or right wing near the fuel tank six times during a 5-day period. Also, the minutes from the September 2005 CASS meeting showed that the accident airplane had a fuel leak in its right wing dry bay for 3 consecutive days. The repair methods used to address these fuel leaks involved removing and replacing the sealant on the fuel tank. As mentioned previously, the Chalk’s Ocean Airways’ repair methods to resolve the fuel leak discrepancies were not effective, as demonstrated by the recurring leaks in the same areas. As part of its CAMP and CASS program, Chalk’s Ocean Airways was required to monitor the mechanical performance of the flying fleet by collecting and analyzing operational data. However, the company’s evaluation of the recurring leaks was inadequate because it failed to recognize that the leaks were repeated indicators of

Analysis 43 Aircraft Accident Report structural damage inside the right wing. A thorough evaluation of the leaks should have recognized that, because the leaks recurred after repeated skin repairs, the skin repairs were not effective. This should have prompted further evaluation to determine a more effective repair; in the case of the accident airplane, further evaluation should have detected the structural damage inside the wing that led to skin cracks and the recurring leaks. Correction of that structural damage not only would have corrected the leaks but also would have prevented the accident. If Chalk’s Ocean Airways had established a repair threshold that limited the number of times such a discrepancy may recur in a given period, the recurrence of the leaks following multiple repairs may have prompted further troubleshooting, maintenance, engineering, and/or grounding of the airplane. The Safety Board concludes that the establishment of repair thresholds in all maintenance programs would help ensure that repeated occurrences of a specific discrepancy are sufficiently evaluated. Therefore, the Safety Board believes that the FAA should verify that the maintenance programs of commercial aircraft operators include stringent criteria to address recurring or systemic discrepancies to include, if necessary, further analysis of the discrepancies through a comprehensive engineering evaluation. 2.3.3 Other Fleet Maintenance Issues Maintenance-related problems also existed with another G-73T airplane in Chalk’s Ocean Airways’ fleet, N142PA. According to the structures DER who provided engineering approval for the August 2005 major repair to the lower right wing skin of that airplane, Chalk’s Ocean Airways informed him 2 months earlier that fuel was leaking from the right wing-to-body fairing. The DER inspected the airplane and found that fuel was leaking from a 22-inch crack in the right wing lower skin; the crack was covered by the fairing and reduced the load-carrying capacity of the right wing box by about 50 percent. The DER also found that all of the stringers on the right wing were corroded and cracked and that many of the other repairs visible on the rest of the wing appeared to be “quite old.”80 As a result of the DER’s findings, the wing repairs involved replacing all of the stringers (including lower Z-stringers) and the lower wing skin from the centerline to the nacelle. The Safety Board concludes that, on the basis of the repetitive nature of the fuel leaks on the accident airplane and the structural damage that was found during the fuel leak inspection of another company airplane that led to the August 2005 replacement of that airplane’s lower right wing skin and stringers, Chalk’s Ocean Airways should have performed a comprehensive inspection of and maintenance on the wing structures of the airplanes in its fleet. 80 In addition, the DER noticed that a doubler on the left lower wing skin had a 17-inch crack. The Safety Board confirmed the existence of the right wing lower skin crack and the left wing lower skin doubler crack in photographs provided by the DER. In addition, the DER who designed the July 1999 major repair to N142PA’s lower left wing skin stated that N142PA had an area of corrosion around the fuel sump drain and a 14-inch crack that emanated from the forward edge of the corrosion to a point that was 9 inches forward. He also stated that the left wing aft spar attachment point showed evidence of grinding in some areas, the right wing aft spar attachment point had corrosion, and extensive corrosion was present on other areas of the airplane.

Analysis 44 Aircraft Accident Report Even though the airplanes in Chalk’s Ocean Airways’ fleet were not subject to the fatigue evaluation requirements in 14 CFR 25.571,81 and the aging aircraft inspection and records review performed under 14 CFR 121.368 was not designed to detect fatigue cracking, the company was still responsible for maintaining its airplanes in an airworthy condition. The Chalk’s Ocean Airways maintenance supervisor stated that he was given all of the resources (parts and personnel) that he needed to maintain the company’s airplanes in an airworthy condition and that he did not sense “any pressure from upper management to keep the airplanes flying no matter what.” However, in a January 2005 letter to the company’s director of maintenance, a former company captain stated that the most common reaction to a maintenance problem that could not be quickly fixed was for the mechanic to ask the captain of that airplane if he would fly it anyway and that the second most common reaction was for the mechanic to sign off that the airplane was fixed when it was not actually fixed. The Safety Board concludes that the failure of Chalk’s Ocean Airways to identify and properly repair fatigue cracks in the accident airplane’s wing structure and the numerous maintenance-related problems found on the accident airplane and another company airplane demonstrate that the company’s maintenance program and practices were deficient, and these deficiencies were causal to the accident. 2.4 Federal Aviation Administration Oversight of the Chalk’s Ocean Airways Maintenance Program The Chalk’s Ocean Airways PMI was responsible for overseeing the company’s maintenance program plan and the maintenance performed on the airplanes in the company’s fleet. During a postaccident interview, the PMI stated that he was “comfortable” with the maintenance being conducted on Chalk’s Ocean Airways’ airplanes, and he did not convey any concerns about the quality of the maintenance program. The PMI also noted that the company’s maintenance program plan met all FAR requirements. As part of his oversight duties, the PMI conducted the 14 CFR 121.368 aging aircraft inspection and records review for Chalk’s Ocean Airways on October 7, 2005. A review of the paperwork for the PMI’s aging aircraft inspection and records review indicated that, for the accident airplane, major repairs to the rear spar upper spar cap at right WS 34 and to the lower wing skin at left WS 34 were accomplished on April 13 and May 6, 1992, respectively. However, the paperwork did not include the July 6, 2000, major repair to the rear Z-stringer at right WS 50.5, even though maintenance records for this repair were available. Also, the paperwork did not include the major repair to the lower wing skin at right WS 34. 81 As mentioned in section 1.16.1, the Safety Board notes that Chalk’s Ocean Airways electively employed a fatigue- and damage-tolerance-based approach for the August 2005 repair to the right wing on N142PA.

Analysis 45 Aircraft Accident Report Because 14 CFR 121.368 does not specifically include requirements for inspecting airplane structures that are susceptible to fatigue cracking, a thorough aging aircraft inspection alone would not likely detect the multiple-element fatigue cracking on the accident airplane’s right wing and the significant fatigue crack on the airplane’s left wing front spar lower spar cap. However, the Safety Board is concerned that the PMI’s aging aircraft inspection and records review for Chalk’s Ocean Airways did not include a repair that was undocumented in the maintenance records but was known to company maintenance personnel. As previously discussed, the purpose of Chalk’s Ocean Airways’ CASS program was to identify and correct deficiencies in the company’s maintenance program plan, and the PMI was responsible for monitoring the company’s CASS program. Records showed that the Chalk’s Ocean Airways PMI did not attend the July and September 2005 CASS meetings, each of which included discussions of fuel leak issues on the accident airplane. However, according to the PMI’s annual work plan, he was responsible for reviewing all information related to the company’s CASS program, including the CASS meeting minutes, so he should have been aware of the repetitive fuel leaks on the accident airplane. As stated previously, the fuel leak discrepancies on the accident airplane were repeated indicators of wing structural damage issues that the Chalk’s Ocean Airways maintenance program did not effectively address. Because the PMI had information that the fuel leaks were recurring and that a DER’s evaluation of leaks on N142PA led to extensive structural repairs of that airplane’s wing structure in August 2005, the PMI should have realized that the skin and sealant repair methods being applied to the accident airplane were not sufficient. However, no evidence indicated that the PMI investigated the cause of the repetitive fuel leaks or discussed these issues with company management. 2.4.1 Importance of Program Oversight for Aircraft With Limited Support The Safety Board has long recognized that effective FAA oversight of air carriers serves as an important safety function to help prevent accidents. For example, during its investigations of the May 11, 1996, ValuJet Airlines accident82 and the August 7, 1997, Fine Airlines accident,83 the Board noted that FAA oversight activities did not detect systemic deficiencies at each airline that were related to the circumstances of each accident. As a result, the Board issued Safety Recommendation A-98-51 on July 10, 1998, which asked the FAA to determine why certain oversight procedures failed to detect 82 National Transportation Safety Board, In-flight Fire and Impact With Terrain, ValuJet Airlines Flight 592, DC-9-32, N904VJ, Everglades, Near Miami, Florida, May 11, 1996, Aircraft Accident Report NTSB/AAR-97/06 (Washington, DC: NTSB, 1997). 83 National Transportation Safety Board, Uncontrolled Impact With Terrain, Fine Airlines Flight 101, Douglas DC-8-61, N27UA, Miami, Florida, August 7, 1997, Aircraft Accident Report NTSB/AAR-98/02 (Washington, DC: NTSB, 1998).

Analysis 46 Aircraft Accident Report systemic safety problems at ValuJet Airlines and Fine Airlines and to modify those procedures.84 The Safety Board has also long recognized the value of engineering services in assisting operators to periodically evaluate and improve their maintenance practices. For example, on July 21, 1989, the Board issued Safety Recommendation A-89-61,85 which asked the FAA to require that air carrier maintenance departments use the engineering services available from the manufacturer or other sources to periodically evaluate their maintenance practices.86 In response to the recommendation, the FAA stated, “present association between the manufacturers’ engineering organizations and the air carriers’ maintenance organizations is adequate,” and “air carrier engineering departments maintain a close liaison with their counterparts in the manufacturers’ organizations and their maintenance department liaison with the manufacturers’ service representatives.” However, in the case of Chalk’s Ocean Airways, neither the airplane’s manufacturer nor the current type certificate holder provided engineering services, and Chalk’s Ocean Airways did not have an engineering department. Engineering support for Chalk’s Ocean Airways was provided by individual contracts with multiple DERs. This type of support does not provide the comprehensive understanding of the operator’s fleet that sole-source engineering support could provide. In addition, a structural repair manual was not issued for the G-73 because one was not required at the time the airplane was manufactured. The Safety Board notes that, because of the limited availability of engineering services and manufacturer support for the G-73T airplanes, effective FAA oversight of the Chalk’s Ocean Airways maintenance program plan was important to ensure that the program addressed the airworthiness issues of such a fleet. However, although the program plan met FAR requirements and the PMI performed his required oversight activities, these activities did not result in the detection and correction of the systemic 84 Safety Recommendation A-98-51 specifically asked that the FAA do the following: “Review its national aviation safety inspection program and regional aviation safety inspection program inspection procedures to determine why inspections preceding these accidents failed to identify systemic safety problems at ValuJet and Fine Air[lines] and, based on the findings of this review, modify these inspection procedures to ensure that such systemic indicators are identified and corrected before they result in an accident.” On March 12, 2001, the Safety Board classified Safety Recommendation A-98-51 “Open— Unacceptable Response” because the FAA did not answer why the inspections failed to identify systemic safety problems at ValuJet and Fine Airlines and did not address how the program modifications ensure that such systemic indicators are identified and corrected before they result in an accident. 85 Safety Recommendation A-89-61 was issued as part of the Safety Board’s final report on the April 28, 1988 Aloha Airlines flight 243 accident. The airplane experienced an explosive decompression and structural failure at 24,000 feet while en route from Hilo to Honolulu, Hawaii. About 18 feet of cabin skin and structure aft of the cabin entrance door and above the passenger floorline separated from the airplane. For more information, see National Transportation Safety Board, Aloha Airlines, Flight 243, Boeing 737-200, N73711, Near Maui, Hawaii, April 28, 1988, Aircraft Accident Report NTSB/AAR-89/03 (Washington, DC: NTSB, 1989). 86 On September 22, 1992, the Safety Board classified Safety Recommendation A-89-61 “Closed— Acceptable Alternate Action” as a result of the implementation of several FAA initiatives to reinforce the requirements of the existing regulation (14 CFR 121.373) and to provide assurance that operator maintenance programs were satisfactory.

Analysis 47 Aircraft Accident Report deficiencies in the maintenance program that led to this accident. Thus, the Safety Board concludes that the Chalk’s Ocean Airways maintenance program plan was inadequate to maintain the structural integrity of its aircraft fleet. Further, the Safety Board concludes that the FAA’s procedures for maintenance program oversight, when applied to commercial operators of aircraft with limited manufacturer or engineering support, such as Chalk’s Ocean Airways, are insufficient to ensure the adequacy of such programs’ structural airworthiness plans and, thus, the safety of such aircraft operations and that the FAA’s failure to identify the inadequacy of the Chalk’s Ocean Airways maintenance program was causal to the accident. Therefore, the Board believes that the FAA should identify the systemic deficiencies in the maintenance program oversight procedures that led to this accident and modify those procedures to ensure that the maintenance program plans for commercial operators are adequate to ensure the continued airworthiness, both structural and otherwise, of the operator’s fleet. 2.4.2 Continuing Analysis and Surveillance System Program Guidance Inspector guidance for ensuring that an operator’s CASS meets the necessary requirement for certification or revision is currently found in FAA Order 8300.10, Airworthiness Inspector’s Handbook, volume 2, chapter 65, “Evaluate Continuing Analysis and Surveillance Program.” Inspector guidance for monitoring the CASS program is currently found in FAA Order 8300.10, volume 3, chapter 37, “Monitor Continuing Analysis and Surveillance Program.” These handbook sections were developed in the early 1990s. In March 2003, the FAA issued AC 120-16D, “Continuous Airworthiness Maintenance Programs,” which indicated that an air carrier’s CASS program should detect and correct air carrier maintenance program deficiencies through a closed-loop, continuous cycle of surveillance and investigations, data collection and analysis, corrective actions, and monitoring and feedback. AC 120-16D stated that an air carrier’s CASS program should include detailed policy and procedures for determining whether an air carrier needed to amend its maintenance program and for making such amendments. In addition, the guidance stated, “proactive surveillance and analysis forecasts faults in your [the air carrier’s] maintenance program … through the collection and analysis of a wide variety of data. It corrects those faults, including human factors issues, in advance of any specific event, accident, or incident.” In April 2003, the FAA published AC 120-79, “Developing and Implementing a Continuing Analysis and Surveillance System,” which was a comprehensive guide for the development of CASS programs. The AC provided information on many CASS-related topics and described model CASS programs for air carriers in three different size ranges.

Analysis 48 Aircraft Accident Report On March 5, 2004, the Safety Board issued Safety Recommendation A-04-14 as part of its investigation into the January 2003 Air Midwest flight 5481 accident in Charlotte, North Carolina.87 Safety Recommendation A-04-14 asked the FAA to “include the Continuing Analysis and Surveillance System guidance from Advisory Circular (AC) 120-16D, ‘Continuous Airworthiness Maintenance Programs,’ and AC 120-79, ‘Developing and Implementing a Continuing Analysis [and] Surveillance System,’ in Federal Aviation Administration Order 8300.10, Airworthiness Inspector’s Handbook.” On June 18, 2004, the FAA stated that it would include a reference to AC 120-16D and AC 120-79 in FAA Order 8300.10 and that it anticipated that the order would be revised by October 2004. On October 12, 2005, the Safety Board stated that a May 2005 check of FAA Order 8300.10 on the FAA’s Web site did not find this revision. The Board stated that, pending issuance of a revised FAA Order 8300.10 that incorporates the reference to the ACs, Safety Recommendation A-04-14 was classified “Open— Acceptable Response.” In December 2006, the FAA notified the Safety Board that the Airworthiness Inspector’s Handbook had been revised in October 2005 to include references to AC 120-16D and AC 120-79. However, the Board’s review of the handbook found that the references to both ACs only appeared in a chapter that discussed outsourcing maintenance (volume 2, chapter 69). In addition, the Board found that (1) a reference to only AC 120-79 was added to volume 2, chapter 95 of the handbook, which discusses an operator’s use of a Coordinating Agencies for Supplier Evaluation audit to satisfy the operator’s surveillance requirement under 14 CFR 121.373 and that (2) a reference to only AC 120-16D was added to volume 3, chapter 134 of the handbook, which discusses the evaluation of an outsource maintenance organization’s facility. For the handbook chapters that discuss evaluating and monitoring a CAMP (volume 2, chapter 64, and volume 3, chapter 36, respectively), a reference to only AC 120-16D appears. Also, for the handbook chapters that discuss evaluating and monitoring a CASS program (volume 2, chapter 65, and volume 3, chapter 37, respectively), a reference to only AC 120-16D appears. To effectively assess the adequacy of an operator’s CASS program, a PMI needs to consider the guidance in AC 120-79 in addition to the guidance in AC 120-16D. Also, for all of the CASS guidance references, only the AC number and the AC title appear. The handbook contains no specific information to inform the PMI of the purpose and contents of each AC. Such information would help PMIs to evaluate and monitor a company’s CASS. The Safety Board concludes that updating FAA Order 8300.10, Airworthiness Inspector’s Handbook, with the latest CASS guidance and an explanation of this guidance would help FAA aviation safety inspectors ensure that CASS programs are being effectively implemented at 14 CFR Part 121 air carriers. Therefore, the Board reiterates 87 National Transportation Safety Board, Loss of Pitch Control During Takeoff, Air Midwest Flight 5481, Raytheon (Beechcraft) 1900D, N233YV, Charlotte, North Carolina, January 8, 2003, Aircraft Accident Report NTSB/AAR-04/01 (Washington, DC: NTSB, 2004).

Analysis 49 Aircraft Accident Report Safety Recommendation A-04-14. Further, the Board classifies Safety Recommendation A-04-14 “Open—Unacceptable Response.” 2.4.3 Other Indicators of Potential Safety Deficiencies During the investigation of this accident, a number of cues from several sources served as indicators of potential safety deficiencies at Chalk’s Ocean Airways. In 2004 and 2005, Chalk’s Ocean Airways received and responded to repeated correspondence from the DOT regarding the DOT’s concerns with the economic fitness of the air carrier. The DOT sent copies of this correspondence to the POI. Although the DOT Air Carrier Fitness Division’s role does not include assessing air carrier safety, the correspondence served to notify the POI that Chalk’s Ocean Airways was exhibiting financial difficulties. The Safety Board notes that the financial distress of an operator can be an indicator that additional surveillance may be warranted.88 In addition, the DOT correspondence indicated that the POI expressed concerns that company managers were too busy with their flight duties to effectively attend to their compliance and management duties. The accident captain was a full-time line pilot but also served as the company’s director of safety, a position that required FAA approval for her to perform. During postaccident interviews, the husband of the accident captain reported that, in the year before the accident, she was becoming exhausted and stressed by work demands. Also, for an airline with a small fleet, there were a number of maintenance-related events that compromised flight safety. In November 2004, an in-flight emergency occurred on a company airplane when an elevator cable failed in flight. Chalk’s documented this event and informed the FAA by means of a service difficulty report. Also, a landing-gear fatigue failure incident in 2001 was attributed to unserviceable parts installed on the airplane by Chalk’s maintenance personnel. Further, through the CASS meetings and minutes, the PMI was made aware of repetitive maintenance issues, such as wing fuel leaks on the accident airplane. These leak issues continued to persist, even after the FAA was made aware that another company airplane received a major structural wing repair to fully address its fuel leak issues. The Safety Board is concerned that the FAA received cues from a number of sources that, when looked at in aggregate, served as indicators of potential safety 88 On December 28, 1988, the Safety Board issued Safety Recommendation A-88-155, which asked that the FAA provide POIs of operators under 14 CFR Parts 135 and 121 with similar indicators of financial distress and rapid growth; these indicators suggest when increased surveillance of those operations is warranted. On May 23, 1989, the Safety Board classified Safety Recommendation A-88-155 “Closed— Acceptable Action” after the FAA responded that it issued an action notice and guidance materials for POIs with regard to requested action. Subsequently, the FAA incorporated a “Financial Condition Assessment Decision Aid” into FAA Order 8300.10. The recommendation resulted from the Board’s investigation of the February 19, 1988, fatal accident involving a Fairchild Metro III operated as AvAir, Inc., flight 3378. For more information, see National Transportation Safety Board, AvAir Inc., Flight 3378, Fairchild Metro III, SA227 AC, N622AV, Cary, North Carolina, February 19, 1988, Aircraft Accident Report NTSB/AAR-88/10 (Washington, DC: NTSB, 1988).

Analysis 50 Aircraft Accident Report deficiencies at Chalk’s Ocean Airways. However, there is no evidence that the FAA conducted any meaningful increase in surveillance in response to the aggregate information. In fact, the FAA principal inspectors expressed no concerns with the company’s operations and maintenance. Therefore, the Safety Board concludes that the FAA received sufficient cues from a number of sources to alert it of potential safety deficiencies at Chalk’s Ocean Airways and that these cues should have prompted heightened vigilance and additional surveillance of the operator. 2.5 Certification Issues The accident airplane’s right wing was designed in accordance with the applicable certification requirements in Part 4aT of the Civil Air Regulations, dated November 1, 1943, and amended March 8, 1944. The Safety Board’s review of certification documents revealed no faulty methods or invalid assumptions for the wing structure certification basis. However, the Board notes that the certification requirements included a static strength analysis but not a fatigue analysis. No requirements for a fatigue analysis existed at the time of the G-73’s original certification because such an analysis had not yet been developed. In August 1968, when Frakes Aviation applied for the STC to increase the gross weight of the G-73 and replace its piston engines with turbopropeller engines, 14 CFR 21.19, “Changes Requiring a New Type Certificate,” was in effect. Paragraph (b)(2) of the regulation stated that a new application for a type certificate was required for transport-category airplanes if the proposed change involved engines using different principles of operation. However, the FAA granted Frakes Aviation the option to perform the analysis for the modifications according to the original type certificate, which was issued more than 20 years earlier. As mentioned in section 1.18.1, the practice of applying former regulations instead of new regulations is known as grandfathering. This practice is generally employed when a type certificate or STC applicant is developing derivative aircraft (those for which changes in the type design are considered minor)89 as long as the omission of current regulations does not have a negative impact on structural integrity, continued airworthiness, or safety of flight. A major change in type design may, in some cases, be accomplished without applying the most recent requirements at the time of type certificate or STC application (as demonstrated by the G-73’s increase in gross weight and conversion from piston to turbopropeller engines). Because the FAA allowed Frakes Aviation to use the original certification basis for the modifications, the analysis to support the modifications for the STC considered only static loading. A review of the Frakes Aviation STC, as approved by the FAA and applied to the accident airplane, revealed that, on the basis of the static strength analysis performed in support of the STC, the increase in gross weight and the conversion from 89 A minor change is one that has no appreciable effect on the weight, balance, structural strength, reliability, operational characteristics, or other characteristics affecting the airworthiness of the product.

Analysis 51 Aircraft Accident Report piston to turbopropeller engines for the accident airplane did not contribute to the circumstances of the accident. The accident airplane’s wing structure did not fail because of static loading but rather because of multiple-element fatigue damage that reduced the residual strength capability of the wing structure. However, had the FAA not allowed Frakes Aviation to use the original certification basis for the STC modification, Frakes Aviation would have had to apply for a new type certificate in 1968. As part of that process, Frakes Aviation would have most likely90 been required to perform a fatigue analysis, according to 14 CFR 25.571, “Fatigue Evaluation of Flight Structure,” which was enacted more than 3 years earlier. Such a fatigue analysis would have included an evaluation of the strength, design, and fabrication of those parts of the structure, including the wings, whose failure could result in catastrophic failure of the airplane. Also, this analysis likely would have included a determination of a safe operating life for the wing structure that would have been used as the basis for inspection and retirement requirements. Because no fatigue analysis was performed, no information is available for the dynamic loading experienced by the G-73 wing before or after the incorporation of the Frakes Aviation STC. Without the results of a complete fatigue analysis of the wing before and after the time of the STC, it is not possible to determine whether the fatigue damage and locations of fatigue cracks in the accident airplane’s wing structure were what could have been expected. Also, without a fatigue analysis, there was no existing information for the safe operating life of the G-73T wing structure that could have been used as the basis for inspection and retirement requirements. Therefore, the Safety Board concludes that the FAA missed an opportunity to recertify the Grumman Mallard G-73T airplane with a new type certificate that would likely have included a fatigue analysis of the airplane. Such a fatigue analysis likely would have included a determination of a safe operating life for the wing structure that would have been used as the basis for inspection and retirement requirements that could have prevented the accident. The Board notes that, according to the current FARs pertaining to type certificates and STCs, an operator can no longer accomplish such major modifications of primary structural elements without first conducting a detailed assessment of the certification basis and the analysis necessary to support such design changes, including, but not limited to, static, fatigue, and/or damage-tolerance analyses. 91 The Safety Board further notes that the accident airplane was not subject to the supplemental damage-tolerance-based inspections and procedures required by 90 Although fatigue requirements were in place at the time, applicants could negotiate the certification basis with the FAA. 91 The current version of 14 CFR 25.571 was revised when damage-tolerance regulations were enacted in December 1978; the section’s name changed to “Damage-Tolerance and Fatigue Evaluation of Structure.” The regulation requires, in part, that an applicant must perform a damage-tolerance evaluation to include a determination of the probable locations and modes of damage due to fatigue, corrosion, or accidental damage; repeated load and static analyses supported by test evidence and (if available) service experience; and special consideration for widespread fatigue damage. The regulation also states that an applicant must demonstrate with sufficient full-scale fatigue test evidence that widespread fatigue damage will not occur within the design service goal of the airplane.

Analysis 52 Aircraft Accident Report 14 CFR 121.370a, “Supplemental Inspections,” because of FAA exemptions.92 As a result, Chalk’s Ocean Airways was not required to account for the adverse effects that repairs, alterations, and modifications might have on fatigue cracking and the inspection of the airplane structure. Because of its concerns about the FAA exemptions to 14 CFR 121.370a, on July 24, 2006, the Safety Board issued Safety Recommendation A-06-52 to recommend that the FAA require records reviews, aging airplane inspections, and supplemental inspections for all airplanes operated under Part 121.93 The Board notes that the actions proposed by the safety recommendation would identify potential failures of structures in airplanes, like the G-73T, that are not currently subject to 14 CFR 121.370a. In its November 20, 2006, response to this recommendation, the FAA stated that it would not include, in the final rule requiring damage-tolerance-based supplemental inspections, airplanes that were type-certificated before 1958 and had a maximum passenger seating capacity of fewer than 30 seats because it would be cost prohibitive to do so. The Board strongly encourages the FAA to reconsider its position and take expeditious action on Safety Recommendation A-06-52. 92 According to the February 2005 final rule, 14 CFR 121.370a applies only to transport-category, turbine-powered airplanes that were type-certificated after January 1, 1958, and that had a maximum passenger seating capacity of 30 or more seats or a maximum payload of 7,500 pounds. 93 In addition to all airplanes operated under Part 121, the safety recommendation included all U.S.-registered airplanes operated under Part 129 and all airplanes used in scheduled operations under Part 135. This would include those airplanes operated under Part 135 that carry nine or fewer passengers and those that are operated in scheduled cargo service.

53 Aircraft Accident Report 3. Conclusions 3.1 Findings 1. The captain and the first officer were properly certificated and qualified under Federal regulations. No evidence indicated any medical or behavioral conditions that might have adversely affected their performance during the accident flight. There was no evidence of flight crew fatigue. 2. The accident airplane was certificated and equipped in accordance with Federal regulations. The recovered components showed no evidence of any system or powerplant failures but showed evidence of multiple failures of wing structural components. 3. The fire damage to the fuselage and empennage was a result of the failure of the right wing and the subsequent breach in the wing fuel tank. 4. The accident was not survivable. The emergency response was timely. 5. There was no evidence from the performance or appearance of the airplane that would have provided warning to the flight crew of the right wing’s imminent failure, and there was nothing that the crew could have done to regain control of the airplane after the in-flight separation of the right wing. 6. The right wing separated from the accident airplane at wing station 34 because of preexisting fatigue fractures and cracks in the rear Z-stringer, lower skin, and rear spar lower spar cap, and this multiple-element fatigue damage reduced the residual strength capability of the wing structure and caused the fatigue failure of the wing during normal flight operations. 7. The repetitive fuel leaks near the area where the accident airplane’s right wing separated from the fuselage were indicators of structural damage inside the right wing. 8. Chalk’s Ocean Airways most likely performed the doubler repair to the accident airplane’s lower skin at right wing station 34, and this repair should have been reflected in the company’s maintenance records. 9. The doubler repair to the accident airplane’s lower wing skin at right wing station 34 was ineffective because the doublers did not restore the load-carrying capability of the skin in the area of the fuel sump drain and the repair did not properly address the underlying cause of the skin cracking, which was the cracked or fractured rear Z-stringer.

Conclusions 54 Aircraft Accident Report

1. The establishment of repair thresholds in all maintenance programs would help

ensure that repeated occurrences of a specific discrepancy are sufficiently evaluated.

1. On the basis of the repetitive nature of the fuel leaks on the accident airplane and the

structural damage that was found during the fuel leak inspection of another company airplane that led to the August 2005 replacement of that airplane’s lower right wing skin and stringers, Chalk’s Ocean Airways should have performed a comprehensive inspection of and maintenance on the wing structures of the airplanes in its fleet.

1. The failure of Chalk’s Ocean Airways to identify and properly repair fatigue cracks in

the accident airplane’s wing structure and the numerous maintenance-related problems found on the accident airplane and another company airplane demonstrate that the company’s maintenance program and practices were deficient, and these deficiencies were causal to the accident.

1. The Chalk’s Ocean Airways maintenance program plan was inadequate to maintain

the structural integrity of its aircraft fleet.

1. The Federal Aviation Administration’s (FAA) procedures for maintenance program

oversight, when applied to commercial operators of aircraft with limited manufacturer or engineering support, such as Chalk’s Ocean Airways, are insufficient to ensure the adequacy of such programs’ structural airworthiness plans and, thus, the safety of such aircraft operations, and the FAA’s failure to identify the inadequacy of the Chalk’s Ocean Airways maintenance program was causal to the accident.

1. Updating Federal Aviation Administration (FAA) Order 8300.10, Airworthiness

Inspector’s Handbook, with the latest Continuing Analysis and Surveillance System (CASS) guidance and an explanation of this guidance would help FAA aviation safety inspectors ensure that CASS programs are being effectively implemented at 14 Code of Federal Regulations Part 121 air carriers.

1. The Federal Aviation Administration received sufficient cues from a number of

sources to alert it to potential safety deficiencies at Chalk’s Ocean Airways, and these cues should have prompted heightened vigilance and additional surveillance of the operator.

1. The Federal Aviation Administration missed an opportunity to recertify the Grumman

Mallard (G-73T) airplane with a new type certificate that would likely have included a fatigue analysis of the airplane. Such a fatigue analysis likely would have included a determination of a safe operating life for the wing structure that would have been used as the basis for inspection and retirement requirements that could have prevented the accident.

Conclusions 55 Aircraft Accident Report 3.2 Probable Cause The National Transportation Safety Board determines that the probable cause of this accident was the in-flight failure and separation of the right wing during normal flight, which resulted from (1) the failure of the Chalk’s Ocean Airways maintenance program to identify and properly repair fatigue cracks in the right wing and (2) the failure of the Federal Aviation Administration to detect and correct deficiencies in the company’s maintenance program.

56 Aircraft Accident Report 4. Recommendations 4.1 New Recommendations As a result of the investigation of this accident, the National Transportation Safety Board makes the following recommendations to the Federal Aviation Administration: Verify that the maintenance programs of commercial aircraft operators include stringent criteria to address recurring or systemic discrepancies to include, if necessary, further analysis of the discrepancies through a comprehensive engineering evaluation. (A-07-39) Identify the systemic deficiencies in the maintenance program oversight procedures that led to this accident and modify those procedures to ensure that the maintenance program plans for commercial operators are adequate to ensure the continued airworthiness, both structural and otherwise, of the operator’s fleet. (A-07-40) 4.2 Previously Issued Recommendation Reiterated and Classified in This Report The Safety Board reiterates the following recommendation to the Federal Aviation Administration: Include the Continuing Analysis and Surveillance System guidance from Advisory Circular (AC) 120-16D, “Continuing Airworthiness Maintenance Programs,” and AC 120-79, “Developing and Implementing a Continuing Analysis [and] Surveillance System,” in Federal Aviation Administration Order 8300.10, Airworthiness Inspector’s Handbook. (A-04-14) Further, Safety Recommendation A-04-14 (previously classified “Open— Acceptable Response”) is classified “Open—Unacceptable Response” in section 2.4.2 of this report.

Recommendations 57 Aircraft Accident Report 4.3 Previously Issued Recommendation Resulting From This Accident Investigation As a result of the investigation into this accident, the Safety Board issued the following recommendation to the FAA on July 24, 2006: Require records reviews, aging airplane inspections, and supplemental inspections for all airplanes operated under 14 Code of Federal Regulations (CFR) Part 121, all U.S.-registered airplanes operated under 14 CFR Part 129, and all airplanes used in scheduled operations under 14 CFR Part 135. This would include those airplanes operated under 14 CFR Part 135 that carry nine or fewer passengers and those that are operated in scheduled cargo service. (A-06-52) For more information about this recommendation, see sections 1.18.2.1 and 2.5 in this report. Member Hersman filed the following concurring statement on June 6, 2007, joined by Vice Chairman Sumwalt and Member Higgins. Member Higgins filed the following statement on June 6, 2007, and was joined by Member Hersman. BY THE NATIONAL TRANSPORTATION SAFETY BOARD MARK V. ROSENKER Chairman ROBERT L. SUMWALT Vice Chairman DEBORAH A. P. HERSMAN Member KATHRYN O. HIGGINS Member STEVEN R. CHEALANDER Member Adopted: May 30, 2007

58 Aircraft Accident Report Board Member Statements

Board Member Statements 59 Aircraft Accident Report

Board Member Statements 60 Aircraft Accident Report

Board Member Statements 61 Aircraft Accident Report

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63 Aircraft Accident Report 5. Appendixes Appendix A Investigation and Hearing Investigation The National Transportation Safety Board was initially notified of this accident during the afternoon of December 19, 2005. A go-team was assembled, which departed for Miami about 1900 and arrived on scene about 2200. Accompanying the team to Miami was Acting Chairman Mark Rosenker.1 The following investigative teams were formed: Aircraft Operations, Human Performance, Aircraft Structures, Aircraft Systems, Powerplants, and Maintenance Records. While the investigative team was in Miami, a specialist was assigned to transcribe the cockpit voice recorder at the Safety Board’s laboratory in Washington, D.C. Also, specialists in the areas of survival factors and witnesses, video/imaging, and materials assisted in the investigation. Parties to the investigation were the Federal Aviation Administration, Chalk’s Ocean Airways, Frakes Aviation, Grumman Mallard Owners Association, and Hartzell Propellers. In accordance with the provisions of Annex 13, paragraph 5.18, to the Convention on International Civil Aviation, the Transportation Safety Board of Canada participated in the investigation as the representative of the State of Design and Manufacture of the powerplants. Accordingly, Pratt & Whitney Canada participated in the investigation as a technical advisor to the Transportation Safety Board of Canada. In accordance with the provisions of Annex 13, paragraph 5.27, to the Convention on International Civil Aviation, the Bahamas Ministry of Transport participated in the investigation as the representative of the State with special interest in the accident by virtue of fatalities to its citizens. Public Hearing No public hearing was held for this accident. 1 Mark Rosenker served as acting chairman from March 2005 until August 11, 2006, when he was sworn in as the 11th chairman of the National Transportation Safety Board.

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FD07332 ｜ 2007_美国_AAR0705.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2007 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

aviation Attempted Takeoff From Wrong Runway Comair Flight 5191 Bombardier CL-600-2B19, N431CA Lexington, Kentucky August 27, 2006 ACCIDENT REPORT NTSB/AAR-07/05 PB2007-910406

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National Transportation Safety Board 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 Aircraft Accident Report Attempted Takeoff From Wrong Runway Comair Flight 5191 Bombardier CL-600-2B19, N431CA Lexington, Kentucky August 27, 2006 NTSB/AAR-07/05 PB2007-910406 Notation 7838E Adopted July 26, 2007

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Web at http://www.ntsb.gov. Other information about available publications also may be obtained from the Web site or by contacting: National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (800) 877-6799 or (202) 314-6551 Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2007-910406 from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605-6000 The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. National Transportation Safety Board. 2007. Attempted Takeoff From Wrong Runway, Comair Flight 5191, Bombardier CL-600-2B19, N431CA, Lexington, Kentucky, August 27, 2006. Aircraft Accident Report NTSB/AAR-07/05. Washington, DC. Abstract: This report explains the accident involving a Bombardier CL-600-2B19, N431CA, operated by Comair, Inc., which crashed during takeoff from Blue Grass Airport, Lexington, Kentucky. The safety issues discussed in this report focus on the need for (1) improved flight deck procedures, (2) the implementation of cockpit moving map displays or cockpit runway alerting systems, (3) improved airport surface marking standards, and (4) air traffic control policy changes in the areas of taxi and takeoff clearances and task prioritization. Safety recommendations concerning these issues are addressed to the Federal Aviation Administration.

National Transportation Safety Board A I R C R A F T Accident Report iii Contents Abbreviations and Acronyms.....................................................................................vii Executive Summary..........................................................................................................x

1. Factual Information.....................................................................................................1
2. 1  History of Flight.............................................................................................................................. 1
3. 2  Injuries to Persons........................................................................................................................... 7
4. 3  Damage to Airplane........................................................................................................................ 7
5. 4  Other Damage.................................................................................................................................. 7
6. 5  Personnel Information.................................................................................................................... 8
7. 5.1  The Captain.............................................................................................................................. 8
8. 5.2  The First Officer..................................................................................................................... 11
9. 6  Airplane Information.................................................................................................................... 14
10. 7  Meteorological Information......................................................................................................... 15
11. 8  Aids to Navigation........................................................................................................................ 15
12. 9  Communications........................................................................................................................... 15
13. 10  Airport Information.................................................................................................................... 15
14. 10.1  Airport Charts..................................................................................................................... 18
15. 10.2  Air Traffic Control............................................................................................................... 20
16. 10.2.1  Lexington Air Traffic Control Scheduling ................................................................ 23
17. 10.2.2  Amended Takeoff Clearance Procedure.................................................................... 24
18. 10.3  Taxi Demonstrations........................................................................................................... 24
19. 10.3.1  Operations/Human Performance Observations...................................................... 25
20. 10.3.2  Air Traffic Control Tower Observations.................................................................... 27
21. 10.4  Postaccident Events............................................................................................................ 28
22. 11  Flight Recorders........................................................................................................................... 29
23. 11.1  Cockpit Voice Recorder...................................................................................................... 29
24. 11.2  Flight Data Recorder........................................................................................................... 29
25. 12  Wreckage and Impact Information........................................................................................... 30
26. 12.1  Wreckage Site...................................................................................................................... 30
27. 12.2  Airplane Wreckage............................................................................................................. 31
28. 13  Medical and Pathological Information..................................................................................... 32
29. 14  Fire................................................................................................................................................. 33
30. 15  Survival Aspects.......................................................................................................................... 34
31. 15.1  Emergency Response.......................................................................................................... 34
32. 16  Tests and Research...................................................................................................................... 35
33. 16.1  Aircraft Performance Study............................................................................................... 35
34. 16.2  Takeoff Distance and Accelerate-Stop Calculations...................................................... 35
35. 17  Organizational and Management Information....................................................................... 36
36. 17.1  Flight Manuals..................................................................................................................... 36
37. 17.1.1  Taxi Procedures and Briefing...................................................................................... 36
38. 17.1.2  Checklist Usage............................................................................................................. 37
39. 17.1.3  Sterile Cockpit Procedures........................................................................................... 38
40. 17.1.4  Heading Bugs................................................................................................................. 38
41. 17.1.5  Normal Takeoff.............................................................................................................. 38
42. 17.1.6  Use of Alcohol................................................................................................................ 38

Contents National Transportation Safety Board A I R C R A F T Accident Report iv 1.17.1.7  Flight Crew Rest Periods.............................................................................................. 39 1.17.1.8  Crew Resource Management....................................................................................... 39 1.17.2  Crew Resource Management Training............................................................................ 40 1.17.3  Safety Program Personnel Initiatives............................................................................... 40 1.17.4  Federal Aviation Administration Oversight................................................................... 42 1.18  Additional Information.............................................................................................................. 43 1.18.1  Witness Information........................................................................................................... 43 1.18.2  Related Federal Aviation Administration Guidance..................................................... 43 1.18.2.1  Advisory Circular 120-74A.......................................................................................... 43 1.18.2.2  Safety Alert for Operators 06013................................................................................. 44 1.18.2.3  Certalert 07-01................................................................................................................ 44 1.18.2.4  Takeoff Clearance Notice............................................................................................. 44 1.18.3  Previous Related Safety Recommendations.................................................................... 45 1.18.3.1  Flight Crew Operations................................................................................................ 45 1.18.3.2  Air Traffic Control......................................................................................................... 47 1.18.4  Related Accident and Incidents........................................................................................ 50 1.18.5  Aviation Safety Reporting System Reports..................................................................... 53 1.18.6  Local Notices to Airmen Information.............................................................................. 53 1.18.7  Enhanced Taxiway Centerline Markings and Surface Painted Holding Position Signs.......................................................................................................................... 54 1.18.8  Department of Transportation Inspector General Report............................................. 55

1. Analysis.......................................................................................................................57
2. 1  General............................................................................................................................................ 57
3. 2  Taxi and Attempted Takeoff Sequence...................................................................................... 57
4. 2.1  Wrong Runway Departure.................................................................................................. 57
5. 2.1.1  Before Taxi Activities...................................................................................................... 57
6. 2.1.2  Taxi to Runway................................................................................................................ 59
7. 2.1.3  Takeoff Roll...................................................................................................................... 60
8. 2.1.4  Runway Incursions......................................................................................................... 61
9. 2.2  Pilot Human Factors............................................................................................................. 61
10. 2.2.1  Available Cues and Aids for Wayfinding.................................................................... 62
11. 2.2.2  Preflight Activities and Actions During the Taxi....................................................... 63
12. 2.2.3  Cues to Indicate a Takeoff From Runway 22.............................................................. 65
13. 2.2.4  Fatigue............................................................................................................................... 69
14. 2.2.5  Cockpit Discipline........................................................................................................... 72
15. 2.2.6  Summary of Pilot Human Factors................................................................................ 73
16. 2.3  Air Traffic Controller Human Factors............................................................................... 77
17. 2.3.1  Window of Opportunity During Which the Airplane Was Stopped Short of the

Wrong Runway..................................................................................................................................... 79 2.2.3.2  Critical Window During Which an Administrative Task Was Performed............. 81 2.2.3.3  Fatigue............................................................................................................................... 83 2.2.3.4  Summary of Air Traffic Controller Human Factors................................................... 85 2.3  Survival Factors............................................................................................................................. 86 2.3.1  Impact Sequence and Injury Information.......................................................................... 86 2.3.2  Emergency Response............................................................................................................ 88 2.3.3  Summary of Survival Factors.............................................................................................. 90 2.4  Efforts to Mitigate Airport Surface Operation Errors.............................................................. 90 2.4.1  Flight Deck Procedures........................................................................................................ 91 2.4.2  Technological Initiatives...................................................................................................... 93 2.4.3  Airport Surface Marking Standards................................................................................... 95

Contents National Transportation Safety Board A I R C R A F T Accident Report v 2.4.4  Taxi and Takeoff Clearances............................................................................................... 96 2.4.5  Controller Monitoring Responsibility................................................................................ 97 2.5  Air Traffic Control Staffing.......................................................................................................... 98 2.6  Other Related Issues..................................................................................................................... 99 2.6.1  Airport Charts....................................................................................................................... 99 2.6.2  Automatic Terminal Information Service Broadcasts................................................... 100 2.6.3  Local Notice to Airmen...................................................................................................... 101 2.6.4  Presence of Extended Taxiway Centerline ..................................................................... 101

1. Conclusions...............................................................................................................103
2. 1  Findings........................................................................................................................................ 103
3. 2  Probable Cause............................................................................................................................ 105
4. Recommendations...................................................................................................106
5. 1  New Recommendations............................................................................................................. 106
6. 2  Previously Issued Recommendations Reiterated in This Report......................................... 107
7. 3  Previously Issued Recommendations Resulting From This Accident Investigation........ 107
8. 4  Previously Issued Recommendations Classified in This Report.......................................... 108

Board Member Statements.........................................................................................110

1. Appendixes...............................................................................................................120

Investigation and Hearing A: .................................................................................................................. 120 Cockpit Voice Recorder B: ....................................................................................................................... 121 Blue Grass Airport Charts C: .................................................................................................................. 158

National Transportation Safety Board A I R C R A F T Accident Report vi Figures 1.  Groundpath Before Flight 5191 Aligned With Runway 26......................................................... 5 1a.  Groundpath as Flight 5191 Aligned With Runway 26............................................................... 6 2.  Blue Grass Airport........................................................................................................................... 16 3.  Taxiways Leading to Runways 4/22 and 8/26........................................................................... 18 4.  Injury Information According to Seat Assignment.................................................................... 33 5.  Enhanced Taxiway Centerline Markings and Surface Painted Holding Position Signs...... 55 6.  Multifunction Display ................................................................................................................... 67 6a.  Primary Flight Display................................................................................................................. 68 7.  Air Traffic Control Event Timeline............................................................................................... 78 8.  Approximate Tree Strike Areas and Injury Informatio............................................................. 87

National Transportation Safety Board A I R C R A F T Accident Report vii Abbreviations and Acronyms AC advisory circular ACOB air carrier operations bulletin AFSS automated flight service station agl above ground level APU auxiliary power unit ARFF airport rescue and firefighting ARTCC air route traffic control center ASAP aviation safety action program ASOS automated surface observing system ASR-7 airport surveillance radar-7 ASRS aviation safety reporting system ATC air traffic control ATCT air traffic control tower ATIS automatic terminal information service ATL Hartsfield-Jackson Atlanta International Airport ATOS air transportation oversight system BDL Bradley International Airport BNA Nashville International Airport C Celsius CAMI Civil Aeromedical Institute CFR Code of Federal Regulations cg center of gravity CRJ Canadair regional jet CRM crew resource management CVG Cincinnati/Northern Kentucky International Airport

Abbreviations and Acronyms National Transportation Safety Board A I R C R A F T Accident Report viii CVR cockpit voice recorder DBRITE digital bright radar indicator tower equipment DOT/IG Department of Transportation/Inspector General EFB electronic flight bag EFIS electronic flight information system EGPWS enhanced ground proximity warning system EICAS engine indicating and crew alerting system FAA Federal Aviation Administration FDR flight data recorder FLL Fort Lauderdale/Hollywood International Airport FMC flight management computer FMS flight management system FOQA flight operations quality assurance GRR Gerald R. Ford International Airport Hg mercury HOU Houston Hobby Airport HSI horizontal situation indicator ICAO International Civil Aviation Organization InFO information for operators JFK John F. Kennedy International Airport LEX Blue Grass Airport LOSA line operations safety audit MAC mean aerodynamic chord METAR meteorological aerodrome report MFD multifunction display MIA Miami International Airport msl mean sea level

Abbreviations and Acronyms National Transportation Safety Board A I R C R A F T Accident Report ix MSP Minneapolis-St. Paul International Airport NACO National Aeronautical Charting Office NAS National Airspace System NATCA National Air Traffic Controllers Association NFDC National Flight Data Center nm nautical mile NOTAM notice to airmen PFD primary flight display PIC pilot-in-command POI principal operations inspector RAAS runway alert and advisory system RDU Raleigh-Durham International Airport ROC Greater Rochester International Airport SAFO safety alert for operators SEA Seattle-Tacoma International Airport SMS safety management system S/N serial number TCAS traffic alert and collision avoidance system TRACON terminal radar approach control V1 takeoff decision speed VFR visual flight rules VMC visual meteorological conditions VR rotation speed

National Transportation Safety Board A I R C R A F T Accident Report x Executive Summary On August 27, 2006, about 0606:35 eastern daylight time, Comair flight 5191, a Bombardier CL-600-2B19, N431CA, crashed during takeoff from Blue Grass Airport, Lexington, Kentucky. The flight crew was instructed to take off from runway 22 but instead lined up the airplane on runway 26 and began the takeoff roll. The airplane ran off the end of the runway and impacted the airport perimeter fence, trees, and terrain. The captain, flight attendant, and 47 passengers were killed, and the first officer received serious injuries. The airplane was destroyed by impact forces and postcrash fire. The flight was operating under the provisions of 14 Code of Federal Regulations Part 121 and was en route to Hartsfield-Jackson Atlanta International Airport, Atlanta, Georgia. Night visual meteorological conditions prevailed at the time of the accident. The National Transportation Safety Board determines that the probable cause of this accident was 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. Contributing to the accident were the flight crew’s nonpertinent conversation during taxi, which resulted in a loss of positional awareness, and the Federal Aviation Administration’s (FAA) failure to require that all runway crossings be authorized only by specific air traffic control (ATC) clearances. The safety issues discussed in this report focus on the need for (1) improved flight deck procedures, (2) the implementation of cockpit moving map displays or cockpit runway alerting systems, (3) improved airport surface marking standards, and (4) ATC policy changes in the areas of taxi and takeoff clearances and task prioritization. Safety recommendations concerning these issues are addressed to the FAA.

National Transportation Safety Board A I R C R A F T Accident Report 1 Factual Information

History of Flight 1.1  On August 27, 2006, about 0606:35 eastern daylight time,1 Comair flight 5191, a Bombardier CL-600-2B19,2 N431CA, crashed during takeoff from Blue Grass Airport (LEX), Lexington, Kentucky. The flight crew was instructed to take off from runway 22 but instead lined up the airplane on runway 26 and began the takeoff roll. The airplane ran off the end of the runway and impacted the airport perimeter fence, trees, and terrain. The captain, flight attendant, and 47 passengers were killed,3 and the first officer received serious injuries. The airplane was destroyed by impact forces and postcrash fire. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 and was en route to Hartsfield-Jackson Atlanta International Airport (ATL), Atlanta, Georgia. Night visual meteorological conditions (VMC) prevailed at the time of the accident. According to a customer service agent working in the Comair operations area, the flight crew checked in for the flight at 0515.4 The agent indicated that the crewmembers were casually conversing and were not yawning or rubbing their eyes. The flight crew collected the flight release paperwork, which included weather information, safety-of-flight notices to airmen (NOTAM), the tail number of the airplane to be used for the flight, and the flight plan. The flight crew then proceeded to an area on the air carrier ramp where two Comair Canadair regional jet (CRJ) airplanes were parked. A Comair ramp agent, who was performing the security check of the accident airplane, noticed that the accident flight crew had boarded the wrong airplane and started its auxiliary power unit (APU). Another company ramp agent notified the flight crewmembers that they had boarded the wrong airplane. The flight crew then shut down the APU and proceeded to the correct airplane. The LEX air traffic control tower (ATCT) was staffed with one controller at the time of the accident airplane’s preflight activities, taxi, and attempted takeoff. The controller was responsible for all tower and radar positions. The cockpit voice recorder (CVR) recording began about 0536:08. At that time, the flight crew was conducting standard preflight preparations. About 0548:24, the CVR 1  All times in this report are eastern daylight time based on a 24-hour clock. 2  The accident airplane was a Canadair regional jet (CRJ)‑100 model, which is one of three models in the CL-600-2B19 series (the other two models are the CRJ-200 and CRJ-440). Bombardier acquired Canadair in December 1986. 3  A pilot for another air carrier was deadheading (that is, traveling on a flight as a nonrevenue passenger) to the destination airport. He was seated in the cabin instead of on the jumpseat in the cockpit. 4  The van driver who transported the flight crewmembers from the hotel where they stayed overnight to LEX stated that they did not appear tired and that he did not observe them yawning or stretching.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 2 recorded automatic terminal information service (ATIS) information “alpha,”5 which indicated that runway 22 was in use. About 1 minute afterward, the first officer told the controller that he had received the ATIS information.6 About 0549:49, the controller stated, “cleared to Atlanta Airport via Bowling Green, ERLIN TWO arrival.[7] Maintain six thousand [feet mean sea level (msl)] …. Departure’s [departure control radio frequency] one two zero point seven five. Squawk [transponder code] six six four one.” The first officer replied, “okay, got uh, Bowling Green uh, missed the other part. Six thousand, twenty point seven five. Six six four one.” The controller then repeated, “it’s ERLIN TWO. Echo Romeo Lima India November Two arrival,” and the first officer acknowledged the arrival information. About 0552:04, the captain began a discussion with the first officer about which of them should be the flying pilot to ATL. The captain offered the flight to the first officer, and the first officer accepted. About 0556:14, the captain stated, “Comair standard,” which is part of the taxi briefing,8 and “run the checklist at your leisure.”9 About 0556:34, the first officer began the takeoff briefing, which is part of the before starting engines checklist. During the briefing, he stated, “he said what runway … two four,” to which the captain replied, “it’s two two.” The first officer continued the takeoff briefing, which included three additional references to runway 22. After briefing that the runway end identifier lights were out, the first officer commented, “came in the other night it was like … lights are out all over the place.” The first officer also stated, “let’s take it out and … take … [taxiway] Alpha. Two two’s a short taxi.” The captain called the takeoff briefing complete about 0557:40.10 Starting about 0558:15, the first officer called for the first two items on the before starting engines checklist. When the captain pointed out that the before starting engines checklist had already been completed, the first officer questioned, “we did”?11 Afterward, 5  An ATIS is a continuous broadcast of recorded noncontrol information in selected terminal areas. 6  About 0556:28, the controller advised the flight crew that ATIS information “bravo” was now current; this ATIS also stated that runway 22 was in use. 7  ERLIN2 is a standard terminal arrival route. The flight paperwork included a different standard terminal arrival route. 8  For information about Comair’s taxi procedures and briefing, see section 1.17.1.1. 9  The CVR showed that the captain stated, “at your leisure,” several more times while giving instructions to the first officer. 10  The first item in the before starting engines checklist is the additional crewmember briefing, which the captain called complete 1 second earlier. The takeoff briefing is the second item in the checklist. 11  When the first officer called for the first item on the checklist, the additional crewmember briefing, the captain responded automatically and indicated that the item was complete. When the first officer called for the second item on the checklist, the takeoff briefing, the captain pointed out that the checklist had been completed.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 3 the first officer briefed the takeoff decision speed (V1) as 137 knots and the rotation speed (VR) as 142 knots.12 Flight data recorder (FDR) data for the accident flight started about 0558:50. The FDR showed that, at some point before the start of the accident flight recording, the pilots’ heading bugs13 had been set to 227º, which corresponded to the magnetic heading for runway 22. About 0559:14, the captain stated that the airplane was ready to push back from the gate. FDR data showed that, about 0600:08 and 0600:55, the left and right engines, respectively, were started. About 0602:01, the first officer notified the controller that the airplane was ready to taxi. The controller then instructed the flight crew to taxi the airplane to runway 22. This instruction authorized the airplane to cross runway 26 (the intersecting runway) without stopping. The first officer responded, “taxi two two.” FDR data showed that the captain began to taxi the airplane about 0602:17. About the same time, SkyWest flight 6819 departed from runway 22. About 0602:19, the captain called for the taxi checklist. Beginning about 0603:02, the first officer made two consecutive statements, “radar terrain displays” and “taxi check’s complete,” that were spoken in a yawning voice. About 0603:38, American Eagle flight 882 departed from runway 22. From about 0603:16 to about 0603:56, the flight crew engaged in conversation that was not pertinent to the operation of the flight.14 About 0604:01, the first officer began the before takeoff checklist and indicated again that the flight would be departing from runway 22. FDR data showed that, about 0604:33, the captain stopped the airplane at the holding position, commonly referred to as the hold short line,15 for runway 26. Afterward, the first officer made an announcement over the public address system to welcome the passengers and completed the before takeoff checklist. About 0605:15, while the airplane was still at the hold short line for runway 26, the first officer told the controller that “Comair one twenty one” was ready to depart at his leisure; about 3 seconds later, the controller responded, “Comair one ninety one … fly runway heading. Cleared for 12  V1 is the maximum speed during the takeoff at which a pilot must take the first action to stop the airplane within the accelerate-stop distance (that is, the runway length required to accelerate to a specified speed and bring the airplane to a complete stop). VR is the speed at which the rotation of an airplane is initiated to a takeoff attitude. FDR data showed that these airspeeds had been entered into the airplane’s electronic flight information system. 13  A heading bug is an indicator that is positioned around a compass rose on the primary flight and multifunction displays. It can be rotated to a specific heading for reference purposes or for commanding an autopilot to fly that heading. 14  This conversation concerned job opportunities and was a continuation of a previous discussion that took place while the airplane was parked at the gate and the crew was conducting preflight activities. 15  A hold short line is a painted marking on a taxiway at a runway intersection that indicates where an airplane is to stop if so instructed by air traffic control.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 4 takeoff.” Neither the first officer nor the controller stated the runway number during the request and clearance for takeoff. FDR data showed that, about 0605:24, the captain began to taxi the airplane across the runway 26 hold short line. The CVR recording showed that the captain called for the lineup checklist at the same time. About 0605:40, the controller transferred responsibility for American Eagle flight  882 to the Indianapolis Air Route Traffic Control Center (ARTCC). FDR data showed that, about 1 second later, Comair flight 5191 began turning onto runway 26. About 0605:46, the first officer called the lineup checklist complete. About 0605:58, the captain told the first officer, “all yours,” and the first officer acknowledged, “my brakes, my controls.” FDR data showed that the magnetic heading of the airplane at that time was about 266º, which corresponded to the magnetic heading for runway 26. About 0606:05, the CVR recorded a sound similar to an increase in engine rpm. Afterward, the first officer stated, “set thrust please,” to which the captain responded, “thrust set.” About 0606:16, the first officer stated, “[that] is weird with no lights,” and the captain responded, “yeah,” 2 seconds later. About 0606:24, the captain called “one hundred knots,” to which the first officer replied, “checks.”16 At 0606:31.2, the captain called, “V one, rotate,” and stated, “whoa,” at 0606:31.8. FDR data showed that the callout for V1 occurred 6 knots early and that the callout for VR occurred 11 knots early; both callouts took place when the airplane was at an airspeed of 131 knots. FDR data also showed that the control columns reached their full aft position17 about 0606:32 and that the airplane rotated at a rate of about 10º per second. The airplane impacted an earthen berm18 located about 265 feet from the end of runway 26, and the CVR recorded the sound of impact at 0606:33.0. FDR airspeed and altitude data showed that the airplane became temporarily airborne after impacting the berm but climbed less than 20 feet off the ground. The CVR recorded an unintelligible exclamation by a flight crewmember at 0606:33.3. FDR data showed that the airplane reached its maximum airspeed of 137 knots about 0606:35. The aircraft performance study for this accident showed that, at that time, the airplane impacted a tree located about 900 feet from the end of runway 26. The CVR recorded an unintelligible exclamation by the captain at 0606:35.7, and the recording ended at 0606:36.2. Figures 1 and 1a show key events in the airplane’s taxi to and attempted takeoff from runway 26. 16  The first officer’s statement indicated that the airspeed displayed on his indicator was the same as that displayed on the captain’s indicator. 17  FDR data showed that the right control column position reached 10.9º and that the left control column position reached 10.6º. According to the Bombardier CRJ maintenance manual, the control column aft travel limit is 11.1º ± 1.5º. FDR data for the accident airplane’s previous 12 takeoffs showed that the nominal control column input for rotation was between 4º and 5º. 18  The height of the berm, relative to the immediate terrain, was about 4 feet.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 5 Groundpath Before Flight 5191 Aligned With Runway 26 Figure 1.  Note: The runway configuration shown in this figure reflects the configuration that was in place at LEX before August 20, 2006. The runway and taxiway configurations at the time of the accident are shown in figures 2 and 3 of this report. 0605:24 Capt: “line-up check.” FDR: airplane resumes taxi 0605:18 ATC: “Comair one ninety one

cleared for takeoff.” 0605:15 F/O: “Comair one twenty one

ready to go.” 0605:06 CVR: takeoff checklist completed 0604:33 FDR: airplane stops 0603:04 CVR: taxi checklist completed 0602:19 CVR: taxi checklist begins 0603:56 CVR: nonpertinent conversation 0603:16 CVR: between Capt and F/O 0604:01 CVR: takeoff checklist begins 0605:46 F/O: “line-up check's complete.” 0605:41 FDR: airplane begins turning

onto runway 26 Start

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 6 Groundpath as Flight 5191 Aligned With Runway 26 Figure 1a.  Note: The runway configuration shown in this figure reflects the configuration that was in place at LEX before August 20, 2006. The runway and taxiway configurations at the time of the accident are shown in figures 2 and 3 of this report. 0606:18 Capt: “yeah.” 0606:12 Capt: “thrust set.” 0606:08 F/O: “set thrust please.” 0606:05 CVR: sound similar to increase

in engine rpm 0605:58 Capt: “all yours.” 0606:16 F/O: “[that] is weird with no lights.” 0606:24 Capt: “one hundred knots.” 0606:25 F/O: “checks.” 0606:36 CVR: end of recording 0606:33 CVR: sound of impact 0606:32 FDR: control column reaches

full aft position 0606:32 Capt: “whoa.” 0606:31 FDR: airspeed is 131 knots 0606:31 Capt: “V one, rotate.” 0606:00 FDR: airplane aligns with

runway 26 centerline 0605:59 F/O: “my brakes, my controls.” 0606:24 FDR: airspeed is 103 knots Continue

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 7 In a postaccident interview, the controller stated that he did not see the airplane take off.19 The controller also stated that, after hearing a sound, he saw a fire west of the airport and activated the crash phone (the direct communication to the airport’s operations center and fire station) in response. The air traffic control (ATC) transcript showed that the crash phone was activated about 0607:17 and that the airport operations center dispatcher responded to the crash phone about 0607:22. According to the ATC transcript, the controller announced an “alert three”20 and indicated that a Comair jet taking off from runway 22 was located at the west side of the airport just off the approach end of runway 8 (which is also the departure end of runway 26). Section 1.15.1 discusses the emergency response. Injuries to Persons 1.2  Injury chart. Table 1.  Injuries Flight Crew Cabin Crew Passengers Other Total Fatal 1 1 47 0 49 Serious 1 0 0 0 1 Minor 0 0 0 0 0 None 0 0 0 0 0 Total 2 1 47 0 50 Note: Title 49 CFR 830.2 defines a serious injury as any injury that (1) requires hospitalization for more than 48 hours, starting within 7 days from the date that the injury was received; (2) results in a fracture of any bone, except simple fractures of fingers, toes, or the nose; (3) causes severe hemorrhages or nerve, muscle, or tendon damage; (4) involves any internal organ; or (5) involves second- or third-degree burns or any burns affecting more than 5 percent of the body surface. Damage to Airplane 1.3  The airplane was destroyed by impact forces and a postcrash fire. Other Damage 1.4  A perimeter fence gate on the airport property and numerous trees beyond the airport property received damage from the airplane’s impact. 19  The controller’s actions at this time are further discussed in section 1.10.2. 20  As indicated in the airport’s emergency plan and the letter of agreement between the airport board and the ATCT, an alert 3 indicates that an aircraft has been involved in an accident on or near the airport.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 8 Personnel Information 1.5  The Captain 1.5.1  The captain, age 35, held an airline transport pilot certificate and a Federal Aviation Administration (FAA) first-class medical certificate dated August 21, 2006, with a limitation that required him to wear corrective lenses while exercising the privileges of this certificate.21 The captain received a type rating on the CL-65 on January 14, 2004. (The CL‑600-2B19 airplane is included in the CL-65 type rating.) The captain attended the professional pilot program at Comair Aviation Academy, Sanford, Florida, from July 1997 to August 1998. After graduation, the captain was employed as a flight instructor at the academy.22 The captain was hired by Comair in November 1999 and upgraded from first officer to captain in January 2004. At the time of the accident, he was based at Cincinnati/Northern Kentucky International Airport (CVG), Covington, Kentucky, as a reserve captain. The captain’s aviation résumé before his employment with Comair indicated that he had experience flying various general aviation airplanes. Comair employment and flight records indicated that the captain had accumulated 4,710 hours of total flying time, including 3,082 hours on the CL-65 and 1,567 hours as a CL-65 pilot-in-command (PIC). He had flown 571, 159, 56, and 8 hours in the 12 months, 90 days, 30 days, and 7 days,23 respectively, before the accident. The captain’s last PIC line check occurred on May 12, 2006; his last recurrent ground training occurred on November 16, 2005; and his last recurrent proficiency check occurred on July 31, 2006. FAA records indicated no accident or incident history or enforcement action, and a search of records at the National Driver Register found no history of driver’s license revocation or suspension. Comair records indicated that the captain had landed at or taken off from LEX six times (not including the accident flight) since September 2004. Three of the arrivals occurred during night conditions, and two of the departures (not including the accident flight) occurred during night conditions. His last flights to and from LEX before the accident trip sequence were on June 16, 2006 (during the day), and June 17, 2006 (at night), respectively. 21  The captain’s medical records showed that his distant and near vision measurements were corrected to 20/20 in each eye and combined (with no measurements listed for uncorrected vision). A medical application dated February 3, 2004, showed that the captain’s uncorrected distant vision measurement was 20/100 and that his uncorrected near vision measurement was 20/20. The captain’s medical records also indicated that he passed his color vision examination and that he had a normal field of vision. 22  The captain’s flight instructor certificate (airplane single- and multiengine–instruments) was issued in August 1998. 23  According to Comair’s Operations Manual, chapter 3, section 3.8.3, page 3-20, “Flight Time Limitations and Rest Requirements,” dated June 10, 2005, flight time limits must not exceed 1,000 hours in any calendar year, 100 hours in any calendar month, or 30 hours in any 7 consecutive days.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 9 The check airman who flew with the captain for his line check in May 2006 stated that he received standard scores (three out of a possible four). The first officer who flew with the captain on a six-leg trip on August 25 and 26, 2006, described him as someone who was “by the book” but easy to talk to and get along with. This first officer stated that the captain established a good atmosphere in the cockpit and demonstrated good crew resource management (CRM).24 This first officer further stated that the captain was in a good mood during the trip and that he did not recall the captain making any specific mistakes. A first officer who flew with the captain on August 20, 2006, stated that he would have had no problem speaking up to the captain if it had been necessary. A first officer who flew with the captain in early August 2006 stated that the captain followed standard operating procedures and called for checklists at the appropriate time. All of the interviewed Comair pilots who had flown with the captain reported that he had no difficulties navigating airports. In addition, instructors and check airmen stated that they had not heard anything negative about the captain. According to his wife, the captain was in good health and exercised regularly. She stated that he was a nonsmoker who did not drink alcohol often and did not take any medications.25 The captain’s wife also stated that his finances were stable and that he had not experienced any financial, health, or major life changes, besides the birth of their second child in May 2006, during the year that preceded the accident. She further stated that he did not take any sleep aids, had fairly normal sleep patterns, was “cheery” in the morning, and drank a cup of coffee each morning. She indicated that he wore contact lenses all of the time and that his night vision was fine. In addition, the captain’s wife stated that there was nothing remarkable or unusual about his activities or schedule in the days that preceded the accident. During the 4 days that preceded the accident, the captain’s activities were as follows: On Wednesday, August 23, 2006, the captain was off duty. He awoke that day • at 0800 and drove with his family during the afternoon from eastern Kentucky (where his relatives lived) to his home near the CVG area. After he arrived home, the captain ate dinner, performed routine activities around the house, and watched television. On Thursday, August 24, 2006, the captain awoke about 0630 and spent the • day running errands and performing routine activities around the house. On Friday, August 25, 2006, the captain awoke about 0615. He drove 40 minutes • to CVG and checked in for his “ready reserve”26 assignment about 0752. The captain was notified of a 2-day, six-leg trip assignment about 1225. The first 24  This first officer stated that a newly trained first officer was occupying the cockpit jumpseat during one of the flight legs on August 25, 2006, and that the captain briefed the newly trained first officer about the importance of adhering to the company’s sterile cockpit procedures (also known as sterile cockpit discipline). Section 1.17.1.3 discusses the FAA’s and the company’s sterile cockpit procedures. 25  The captain’s August 21, 2006, FAA medical application indicated that he did not use any prescription or nonprescription medications. 26  Ready reserve is standby duty at an airport while waiting for a flight assignment.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 10 leg departed CVG about 1432 and arrived at Gerald  R. Ford International Airport (GRR), Grand Rapids, Michigan, about 1548. The second leg departed GRR about 1603 and arrived at CVG about 1710. The third leg departed CVG about 1809 and arrived at Minneapolis-St. Paul International Airport (MSP), Minneapolis, Minnesota, about 2006.27 The captain and the first officer for this trip went to a hotel in the MSP area. Telephone records showed that the captain called his home telephone number about 2149 and that the call lasted for about 4 minutes. On Saturday, August 26, 2006, the captain met the first officer for the second day • of the trip about 0630 for a 0640 scheduled report time at MSP. The fourth leg of the trip departed MSP about 0740 and arrived at CVG about 0935, after which the captain was informed about a modification to his trip. In addition to the planned fifth and sixth legs of the trip, the captain would also be deadheading from CVG to LEX, flying three legs on August 27, and deadheading from ATL to CVG afterward.28 The fifth leg of the trip departed CVG about 1039 and arrived at Nashville International Airport (BNA), Nashville, Tennessee, about 1145. The sixth leg of the trip departed BNA about 1210 and arrived at CVG about 1306. The flight from CVG to LEX departed about 1429 and arrived about 1526, and the captain was released from duty about 1546.29 The captain arrived at a hotel in the LEX area.30 Because of the length of his layover, the captain’s family picked him up for dinner outside of the hotel about 1630. The captain returned to the hotel alone,31 where, according to his wife, he spent the evening watching television. Telephone records showed that the captain called his home telephone number about 2123 and that the call lasted for about 4 minutes. The captain’s wife stated that he was planning to go to sleep after the call had ended. On Sunday, August 27, 2006, the captain received a wakeup call about 0415. • He reported for duty at LEX at 0515.32 The captain’s wife did not speak with him that day. The accident flight was the first one that paired the captain and the first officer. 27  Comair records showed that the captain’s duty day was 12 hours 26 minutes. 28  The first officer for the six-leg trip stated that the captain was disappointed about the extension of the trip but took it in stride and was not distracted during the remaining flight legs. 29  Comair records showed that the captain’s duty day was 9 hours 6 minutes. 30  The hotel computer system indicated front desk activity associated with the captain’s assigned room about 1554. The hotel’s general manager stated that this activity might not correspond to the actual time that the captain checked in. Hotel key card records showed activity for the captain’s room at 1458 and 1511; however, after the accident, hotel personnel tested the lock on the captain’s room and determined that the actual time of key card activity was 1 hour later than indicated in the records (that is, 1558 and 1611). 31  Hotel key card records showed activity for the captain’s room at 1813 (1913 with the 1-hour correction indicated in the previous footnote). No further key card activity occurred after this time. 32  Comair required that pilots report for duty at field locations away from the pilots’ home base 45 minutes before a flight’s departure. The accident flight was scheduled for departure at 0600.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 11 The First Officer 1.5.2  The first officer, age 44, held an airline transport pilot certificate and an FAA first-class medical certificate dated July 18, 2006, with a limitation that required him to wear corrective lenses while exercising the privileges of this certificate.33 The first officer received a type rating on the CL-65 (second-in-command privileges only) on November 3, 2005.34 In 1995, the first officer began the American Flyers flight school pilot training program. In March 1997, he began working for Gulfstream International Airlines; during his employment there, he was a captain on the Beech 1900 and a simulator instructor. The first officer was hired by Comair in March 2002 and was based at John F. Kennedy International Airport (JFK), Jamaica, New York. Comair employment and flight records indicated that the first officer had accumulated 6,564 hours of total flying time, including 940 hours as PIC and 3,564 hours on the CL-65. He had flown 876, 245, 64, and 18 hours in the 12 months, 90 days, 30 days, and 7 days, respectively, before the accident. The first officer’s last recurrent proficiency check occurred on April 6, 2006, and his last recurrent ground training occurred on April 4,

1. FAA records indicated no accident or incident history or enforcement action, and

a search of records at the National Driver Register found no history of driver’s license revocation or suspension. Comair records indicated that the first officer had landed at or taken off from LEX 12 times (not including the accident flight) since September 2004. Six of the arrivals occurred during night conditions, and one of the departures (not including the accident flight) occurred during night conditions. His last flights to and from LEX before the accident flight were on August 26, 2006 (at night), and May 19, 2006 (during the day), respectively. The check airman who gave the first officer his April 2006 line-oriented evaluation in the simulator stated that the first officer met standards and that nothing stood out regarding his performance during the evaluation. The captain who flew with the first officer on August 25, 2006, stated that the first officer was involved with decision-making and had good situational awareness. This captain further stated that, during their flights together, the first officer consistently had his taxi charts out without prompting. The captain who flew with the first officer on a 3-day trip from August 20 to 22, 2006, stated that the first officer was articulate while performing the checklist and that he ensured that the captain was “with him” before going forward to the next item. The captain who flew with the first officer during a 5-day trip from August 9 to 13, 2006, described the first officer as a “thorough by-the-book pilot” who met standards and demonstrated good CRM. This captain, who was also a check airman, stated that the first officer used standard 33  The first officer’s medical records indicated that his distant vision measurement was 20/30 corrected to 20/20 in each eye and combined and that his near vision measurement was 20/20 (with no measurement listed for corrected vision in each eye and combined). The first officer’s medical records also indicated that he passed his color vision examination and that he had a normal field of vision. 34  The first officer also received a flight instructor certificate (airplane single engine) in November 1996 and a type rating on the Beech 1900 in November 2000.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 12 phraseology when performing checklists and demonstrated situational awareness and good sterile cockpit discipline. Finally, pilots, instructors, and check airmen stated that they had not heard anything negative about the first officer, and pilots who had flown with the first officer stated that he was looking forward to upgrading to captain.35 National Transportation Safety Board investigators were unable to interview the first officer as part of this accident investigation. His attending physician stated that the first officer was “medically unfit” to be interviewed. The first officer’s wife stated that he did not remember the accident. According to his wife, the first officer was in good health and exercised regularly. She stated that he drank alcohol occasionally and took a prescription medication to lower cholesterol.36 The first officer’s wife also stated that he had not experienced any major life changes during the year that preceded the accident but that he was affected by Comair’s pay cuts.37 She further stated that the first officer was generally a morning person who sometimes drank a cup of coffee in the morning. A captain and friend of the first officer described him as an evening person and recalled conversations they had regarding the difficulty of going to bed on nights that preceded an early report time.38 The first officer’s wife indicated that he did not have any sleep disorders. She also indicated that he wore contact lenses for a short time and had excellent night vision.39 In addition, the first officer’s wife indicated that there was nothing remarkable or unusual about his activities or schedule in the days that preceded the accident. The first officer was not on duty on August 23 and 24, 2006. The Safety Board attempted to determine the first officer’s activities during the 72 hours that preceded the accident but was only able to determine some of the first officer’s activities during the 2 preceding days,40 which were as follows: On Friday, August 25, 2006, the first officer commuted from his home near • Fort Lauderdale/Hollywood International Airport (FLL), Fort  Lauderdale, Florida, to JFK to report at 1150 for a 3-day trip. (His flight departed from 35  A progress report in the first officer’s file showed the highest rating (superior) for all performance elements, and the captain who submitted the progress report indicated on the form that the first officer was captain material. Other pilots who had recently flown with the first officer stated that they knew he was preparing to upgrade to captain and that he would make a good captain because of his adherence to standard operating procedures, experience, maturity, and good CRM. 36  The first officer’s July 18, 2006, FAA medical application indicated that he did not use any prescription or nonprescription medications. 37  A captain who had recently flown with the first officer stated that the company’s pay cuts affected first officers more than captains because first officers are at the lower end of the pay scale. This captain also stated that the pay cut was not necessarily a concern for this first officer. 38  According to this captain, he and the first officer discussed the difficulty of going to bed at 2100 on nights that preceded an early report time but that going to bed at 2300 resulted in less but better-quality sleep. 39  LEX security camera video showed that the first officer was not wearing glasses when he passed through the operations area on the day of the accident. The captain who flew with the first officer from August 20 to 22, 2006, stated that he did not wear glasses during the flights. 40  The first officer’s wife did not remember his activities from August 23 to 25, 2006.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 13 FLL about 0559 and arrived at JFK at 0832.) The first leg of the trip departed JFK about 1305 and arrived at Greater Rochester International Airport (ROC), Rochester, New York, about 1435. The next leg of the trip departed ROC about 1600 for JFK but diverted to Bradley International Airport (BDL), Windsor Locks, Connecticut, for fuel,41 arriving about 1815. The flight departed BDL about 1839 and arrived at JFK about 1955. Because of the airplane’s late arrival, Comair asked the pilots to reposition the airplane to LEX. According to the captain of this flight, the airplane pushed back from the gate about 2130 but did not take off until about 2300. On Saturday, August 26, 2006, the repositioning flight landed on runway 22 • at LEX42 about 0140.43 According to the captain of this flight, the first officer checked into his hotel room about 0210.44 Telephone records showed that the first officer made a call about 1443. Hotel key card records showed activity for the first officer’s room about 1530.45 A receipt from the hotel restaurant showed that the first officer purchased something to eat and two bottles of beer about 1826. Telephone records indicated that the first officer called the Comair System Operations Control Center about 1836 and 1844.46 The records also indicated that the first officer called his wife about 2049 and that the call lasted about 13 minutes. According to his wife, the first officer stated that he had been able to sleep in that morning and was going to bed early. She stated that he sounded “good as usual.” On Sunday, August 27, 2006, mobile phone records showed that the first officer • received a 24-second call about 0103 followed immediately by a 37‑second call that went to voicemail.47 The originating telephone number was identified 41  While en route to JFK, the flight crew received delaying vectors and holds from ATC and, as a result, decided to divert. 42  The captain of this flight reported that the left runway edge lights were illuminated but that only one‑eighth of the right runway edge lights were illuminated. (The right runway edge lights were out after the intersection of runway 22 with runway 26.) A NOTAM that was in effect at the time indicated that numerous right runway edge lights were out of service. 43  The first officer’s duty time for August 25 and 26, 2006, was 14 hours 10 minutes, including 9 hours 11 minutes of flight time. The captain of the flights stated that neither he nor the first officer took a nap when they were not flying. 44  The hotel computer system indicated front desk activity associated with the first officer’s assigned room about 0158. The hotel’s general manager stated that this activity might not correspond to the actual time that the first officer checked in. Hotel key card records showed activity for the first officer’s room at 2257 on August 25, 2006; however, after the accident, hotel personnel tested the lock on the first officer’s room and determined that the actual time of key card activity was 2 hours later than indicated in the records (that is, 0057 on August 26). Section 2.2.2.4 further discusses the time of the key card activity for the first officer’s room. 45  The time of the key card activity, with the 2-hour correction stated in the previous footnote, was 1730. 46  These conversations were regarding the first officer’s report time for the next day. His report time was originally scheduled for 0530 but was changed to 0515. 47  The Safety Board could not determine whether the first officer attempted to answer these calls.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 14 as that of the first officer’s brother.48 Telephone records showed that the first officer called the Comair System Operations Control Center about 0510 and that the call lasted 2 minutes 17 seconds.49 The first officer reported for duty at LEX at 0515. Airplane Information 1.6  The accident airplane, a Bombardier CL-600-2B19, serial number 7472, was manufactured in January 2001 and was delivered new to Comair. At the time of the accident, the airplane had accumulated 14,536 total flight hours and 12,048 total flight cycles.50 The airplane was equipped with two General Electric CF34-3A1 turbofan engines. The left (No. 1) engine was delivered new to Bombardier in December 1998 and was installed on the accident airplane on August 3, 2006. The left engine had accumulated 17,265 total flight hours and 14,850 total flight cycles since new. The right (No. 2) engine was delivered new to Bombardier in September 1994 and was installed on the accident airplane in November 2005. The right engine had accumulated 27,327 total flight hours and 25,373 total flight cycles since new. The airplane’s electronic flight information system (EFIS) was manufactured by Rockwell Collins and contained six electronic flight display positions. The captain’s and the first officer’s stations each contained multifunction display (MFD) and primary flight display (PFD) positions; the MFDs were located inboard of the PFDs. The panel between the captain’s and the first officer’s stations contained the engine indicating and crew alerting system (EICAS) positions. The MFDs included a present position map mode with which range settings of 5, 10, 20, 40, 80, 160, and 320 nautical miles (nm) could be selected and autopilot heading select information and weather and terrain information (on radar overlays) could be displayed.51 The PFDs displayed airspeed, altitude, attitude, and heading information. The airplane was configured with two cockpit flight crew seats; one cockpit observer’s seat; one retractable, aft-facing flight attendant jumpseat, which was mounted on the forward bulkhead; and 50 coach-class passenger seats. A review of the airplane’s maintenance logbooks from February 1 to August  7, 2006, showed that the maintenance records were up to date and complete with no 48  During a postaccident interview, the first officer’s brother did not remember placing the calls. 49  This conversation was concerning the first officer’s desire to deadhead to another base (at the end of his duty day) rather than the one originally assigned. The Safety Board listened to a tape of this telephone call. The first officer spoke clearly and was conversational throughout the call. 50  A cycle is one complete takeoff and landing sequence. 51  FDR data showed that the captain’s and the first officer’s MFDs were set to the present position map mode. The captain’s MFD range was set to 80 nm, and the first officer’s MFD range was initially set to 10 nm but was switched to 40 nm about 4 minutes before the takeoff roll. The captain’s and the first officer’s autopilot headings were set to 227º, and the MFD radar overlays were active.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 15 discrepancies noted. The airplane’s last maintenance check (a line check) occurred on the day of the accident. The load manifest showed that the airplane’s takeoff weight was 49,087 pounds with a forward center of gravity (cg) of 12 percent mean aerodynamic chord (MAC), which was within the airplane’s maximum allowable takeoff weight for the accident flight of 50,178 pounds and its forward cg range of 9 to 12 percent MAC. Meteorological Information 1.7  LEX has an automated surface observing system (ASOS), which is maintained by the National Weather Service. Augmentation and backup of the ASOS are provided by FAA personnel in the LEX ATCT. The ASOS records continuous information on wind speed and direction, cloud cover, temperature, precipitation, and visibility.52 The ASOS transmits an official meteorological aerodrome report (known as a METAR) each hour. The 0554 METAR indicated the following: winds from 200º at 7 knots, visibility 8 miles, few clouds at 9,000 feet, scattered clouds at 12,000 feet, temperature 24º Celsius (C), dew point 19º C, and altimeter setting 30.00 inches of mercury (Hg). The 0654 METAR indicated the following: winds from 220º at 8 knots, visibility 8 miles, few clouds at 4,700 feet, ceiling 6,000 feet broken and 9,000 feet overcast, temperature 23º C, dew point 20º C, altimeter setting 30.02 inches of Hg, rain began at 0612 and ended at 0651, 0.01 inch of precipitation measured.53 Sunrise at LEX on August 27, 2006, was at 0703, which was about 1 hour after the accident occurred. At the time of the accident, the moon was below the horizon. Aids to Navigation 1.8  No problems with any navigational aids were reported. Communications 1.9  No communications problems were reported. Airport Information 1.10  LEX is located about 4 miles west of the city of Lexington at an elevation of 970 feet msl. The airport has two runways, 4/22 and 8/26, as shown in figure 2. 52  Cloud cover is expressed in feet above ground level. Visibility is expressed in statute miles. 53  LEX security camera video from 0600 to 0607 showed no evidence of rain or restrictions to visibility at the time of the accident airplane’s taxi and attempted takeoff.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 16 Blue Grass Airport Figure 2.  Source: Lexington, Kentucky, Police Department Runway 4/22, the air carrier runway, was 7,003 feet long and 150 feet wide. It had high intensity runway lights.54 Runway 4/22 also had centerline lights and runway end identifier lights, but they were out of service at the time of the accident because of a construction project (as discussed in this section). Runway 4/22 conformed with the FAA airport certification requirements specified in 14 CFR 139.55 Runway 8/26, the general aviation runway, was used for about 2 percent of the airport’s total operations. It was not subject to the requirements of 14 CFR 139.56 Runway 8/26 was 3,501 feet long and 150 feet wide, but the paint markings limited the usable runway width to 75 feet.57 Runway 8/26 was used only for flights conducted when daytime visual flight rules (VFR) prevailed and for aircraft that weighed less than 12,500 pounds. Although the runway was equipped with runway edge lights when the 54  High intensity runway lights have five settings, step 1 through step 5, with step 5 being the brightest setting. At the time of the accident, the lights were on step 3. 55  Title 14 CFR 139 established minimum standards for airports that conduct U.S. air carrier operations. These standards include runway and runway safety area dimensions, airport lighting and markings, airport signage, and emergency response capabilities. Taxiways A and C (and their associated connectors) were also required to conform with 14 CFR Part 139. 56  Runway 8/26 was not used by scheduled passenger-carrying aircraft with more than 9 passenger seats or unscheduled passenger-carrying aircraft with at least 31 passenger seats. 57  According to the LEX director of operations, the 150-foot runway width was narrowed to 75 feet in 2001 because of pavement deterioration on the runway edges.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 17 width was 150 feet, these lights had been disconnected since 2001 when the runway was designated for daytime VFR use only.58 Runway 8/26 crossed runway 4/22 about 700 feet south of the runway 4/22 threshold. A 2,000-foot distance-remaining marker and a 1,000‑foot distance-remaining marker appeared on the north side of runway 8/26 after the intersection with runway 4/22.59 The hold short line for runway 26 was about 560 feet from the hold short line for runway 22. At the time of the accident, LEX was nearing the completion of a multiyear construction project. The project included shifting runway 4/22 325 feet to the southwest to accommodate a longer runway safety area at the approach end of runway 22, relabeling the existing taxiway connectors, demolishing taxiway A5 and taxiway A north of runway 8/26,60 and creating a new taxiway (labeled A7) at the end of runway 22. From August 18 to 20, 2006, LEX was closed to resurface and paint new markings on runway 4/22 and change taxiway connector signage. On August 20, the airport was reopened at 1800, a local NOTAM was issued to announce the closure of taxiway A north of runway 8/26,61 and low-profile barricades with flashing red lights were placed on that part of the taxiway. Former taxiway A5 was redesignated as taxiway A and was used by airplanes to access runway 22 before the construction of the new taxiway A7, which was planned to be completed about 30 to 45 days after the completion date of the repaving project (August 20). Figure 3 shows the locations of the existing (A), planned (A7), and former (A5 and A north of runway 8/26) taxiways. On August 27, 2006, as a result of the accident, a NOTAM was issued to announce the closure of runway 8/26, and lighted “X” markings were placed at the end of each runway 2 days later. Runway 8/26 remained closed until November 1, 2006, when new taxiway A7 was opened. 58  The disconnected runway edge lights could only be turned on by maintenance personnel. 59  These distance-remaining markers were unlighted. The marker lights were on the same circuit as the runway edge lights, which had been disconnected when the runway was designated for daytime VFR use only. 60  According to the program manager of the LEX construction project at the FAA’s Memphis, Tennessee, Airports District Office, it would not have been possible to continue to use taxiway A north of runway 8/26 to taxi airplanes to the new runway 22 threshold because that would have violated terminal instrument procedures criteria. 61  This information was not included in the ATIS information recordings on the day of the accident but was included in a sampling of ATIS broadcasts recorded each day between 0530 and 0630 from August 20 to 26, 2006.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 18 Taxiways Leading to Runways 4/22 and 8/26 Figure 3.  Airport Charts 1.10.1  The two main sources of airport charts that are available to the pilot community are produced by the FAA’s National Aeronautical Charting Office (NACO) and Jeppesen Sanderson, Inc. Both organizations receive the information for their publications from the National Flight Data Center (NFDC),62 which is within the FAA’s Aeronautical Information Services Division. 62  According to the FAA’s Web site, the NFDC is the principal element within the FAA responsible for collecting, collating, validating, storing, and disseminating aeronautical information and detailing the physical description and operational status of all components of the National Airspace System (NAS). The NFDC maintains the national aeronautical information database and provides aeronautical information to government, military, and private producers of aeronautical charts, publications, and flight management systems. The NFDC receives information regarding changes to the NAS from other FAA offices.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 19 The NACO chart for LEX that was current at the time of the accident was dated August 3, 2006. The chart showed the taxiway configuration at the completion of the construction project; that is, future taxiway A7 was shown on the chart, and taxiway A5 (which had been redesignated as taxiway A at the time of the accident) and taxiway A north of runway 8/26 were not shown. According to the LEX airport manager, LEX airport officials proposed that the August 3 airport chart revision show an interim airport configuration (including closed taxiway A north of runway 8/26 and former taxiway A5 redesignated as taxiway A) before the construction of taxiway A7. Because the construction schedule planned for the completion of taxiway A7 within 30 to 45 days after the repaving project was completed (August 20, 2006), airport officials expected that the NACO chart revision that followed63 (September 28, 2006) would show the airport’s final configuration. The program manager of the LEX construction project at the FAA’s Memphis Airports District Office stated that he recommended against publishing an interim chart because the chart would have been inaccurate during the time both before and after the construction project.64 The Jeppesen chart for LEX that was current at the time of the accident was dated January 27, 2006. This chart, which was issued to the accident flight crew, showed taxiway A5 and taxiway A north of runway 8/26.65 Jeppesen issued a revised chart for LEX on September 8, 2006.66 As with the NACO chart for LEX, the revised Jeppesen chart showed future taxiway A7 and did not show taxiway A5 and taxiway A north of runway 8/26.67 Appendix C shows the NACO and Jeppesen airport charts. After the accident, Comair published a notice, dated September 8, 2006, that was appended to each dispatch release for operations to and from LEX. The notice warned, “published airport diagrams may not accurately reflect actual airport signage and markings. Exercise extreme caution during all ground operations. Utilize high threat taxi procedures.[68] If unsure of position or taxi clearance clarify with ATC or request progressive taxi instructions.” The notice also specified the parts of the September 8, 2006, Jeppesen chart that were not accurate regarding the airport configuration at the time. The notice was removed from dispatch releases on November 3, 2006 (after new taxiway A7 was opened and the Jeppesen chart accurately reflected the airport configuration). 63  All NACO airport charts are published on a 56-day revision cycle. 64  An FAA official who was involved with the decision not to publish an interim airport chart stated that it was “a practice in circumstances” to recommend the publishing of an airport chart that depicts the ultimate airport configuration and that NOTAMs were to be used to advise pilots of any differences to the published charts. 65  According to the Jeppesen flight safety manager, the Jeppesen chart did not reflect information about the LEX construction project that was received on June 23, 2006, because of a software error. (Specifically, the information was received after normal work hours on a Friday, and the software recognized only those changes that were received during the regular business week. Jeppesen has since fixed this software problem.) On August 29, 2006, Jeppesen published a corrected chart on its Web site and sent this chart electronically to its customer airlines. 66  Even though the chart had been corrected on August 29, 2006, the official date of the revised LEX chart was September 8, 2006. 67  Although Jeppesen publishes airport charts on a 14-day cycle, the company revises only those charts for airports where there has been a modification from the information shown on a previous chart. 68  Section 1.17.1.1 describes these procedures.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 20 Air Traffic Control 1.10.2  The LEX ATCT and terminal radar approach control (TRACON) provide ATC services from the surface to 10,000 feet msl within 35 nm of Lexington. ATC radar data are obtained from an airport surveillance radar-7 (ASR-7) radar at the airport.69 The ASR‑7 radar received two transponder returns (about 0606:31 and 0606:35) from the accident airplane. About 0047 on the day of the accident, all LEX tower and radar positions70 were combined and were being worked by one controller at the local control position. In addition, the controller was responsible for obtaining releases from the Indianapolis ARTCC’s traffic management unit,71 recording the ATIS broadcasts,72 and performing all other required operational and administrative duties. The controller began his employment with the FAA in October 1988 and was assigned to LEX in January 1989. He had been working at the full-performance level since the mid-1990s. The controller was required to wear glasses to correct for nearsightedness while working air traffic, and he reported that he was wearing his glasses at the time of the accident. The controller also reported that he had not experienced any operational errors during the 2 years that preceded the accident.73 The controller reported that his activities during the 3 days that preceded the accident were as follows:74 On Thursday, August 24, 2006, at 0100, the controller finished a work shift that • had started the previous day at 1700. He went to sleep between 0130 and 0145 and awoke about 0915. Afterward, he performed routine activities around the house and ran errands. He worked from 1500 to 2100,75 returned home, and went to sleep about 2230. 69  LEX was not equipped with ground radar systems such as the airport movement area safety system and the airport surface detection equipment – model X. 70  The tower positions were clearance delivery, flight data, local control, and ground control, and the radar positions were radar departure/approach control and radar data. During his shift, the controller was also responsible for the duties of the controller-in-charge. 71  Controllers at the LEX ATCT were required to obtain a release from the Indianapolis ARTCC’s traffic management unit for all flights destined for Chicago-O’Hare International Airport, Detroit Metropolitan Wayne County Airport, and ATL. 72  ATC recordings indicated that the controller announced a new ATIS recording every hour, approximately on the hour, during his shift. 73  According to FAA Order 7210.56, “Air Traffic Quality Assurance,” all references to a specific operational error are removed from a controller’s records 2 1/2 years after the event. Also, all references to a specific operational error classified as low severity and all references to a specific operational deviation are removed from a controller’s record 1 year after the event. 74  The controller was working a “2-2-1” schedule, that is, two evening shifts, two day shifts, and one midnight shift. During a postaccident interview, the FAA’s vice president for terminal services stated that the 2-2-1 schedule was the most common shift rotation used by ATC facilities. 75  The controller was scheduled to work until 2200 but used 1 hour of annual leave at the end of his shift.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 21 On Friday, August 25, 2006, the controller awoke about 0715. He reported • feeling good that morning. He worked from 0815 to 1615 and arrived home from work about 1630. He performed routine activities around the house, had dinner, and went to sleep about 2230. On Saturday, August 26, 2006, the controller awoke about 0540. He stated that • he slept “very well” and that he did not feel tired. He worked from 0630 to 1430, returned home about 1445, went to sleep about 1530, and awoke between 1730 and 1800. The controller described the quality of his sleep during the afternoon as “not real good.” Between 1800 and 2230, the controller’s activities included eating dinner; running; visiting with friends at his home; and preparing for his next work shift, which was scheduled for 0000 to 0800 on Sunday, August 27 (the day of the accident). The controller arrived at the ATCT at 2325, signed in at 2330,76 and relieved another controller at 2337. The controller was the only one on duty in the ATCT from 0000 to 0640 on the day of the accident.77 The LEX traffic count log (LEX form 7230-10) for August 27, 2006, showed that, between 0000 and 0300, 14 air traffic operations were conducted in LEX airspace. There were no aircraft operations between 0300 and 0545. The controller stated that he stayed awake during the time with no air traffic by walking inside the tower cab and listening to an AM/FM radio.78 He recalled that, about 0545, a pilot of SkyWest flight 6819 had requested a clearance to its destination airport, which he issued. Afterward, pilots of American Eagle flight 882 and Comair flight 5191 had requested and received clearances to their destination airports. The controller stated that, after a Comair pilot had requested and received taxi instructions, the airplane proceeded to taxiway A, which is parallel to runway 22. (By that time, both the SkyWest and American Eagle flights had departed from runway 22.) The controller indicated that he saw the lights and the tail of the Comair airplane when it was across from the parking garage.79 Afterward, a Comair pilot told the controller that the flight was ready to depart, and the controller issued the takeoff clearance. The controller stated that he scanned runway 22 from the departure to approach ends to make sure that the runway was clear and that he scanned the digital bright radar indicator tower equipment (DBRITE) to see if there was any traffic. The controller stated that he communicated with a pilot of the American Eagle flight and then handed off the flight to the Indianapolis ARTCC. The controller also 76  The controller arrived 30 minutes early for his shift to earn credit time. 77  Another controller was scheduled to begin the day shift at 0630 but was 10 minutes late reportedly because of traffic. An additional controller working the day shift was scheduled to report for work at 0700. 78  A review of ATC tapes indicated that a radio was on during the controller’s shift. According to the FAA, at the time of the accident, the use of AM/FM radios, televisions, and electronic devices were authorized in specific locations in an ATC facility, such as a break room and lounges, but facility managers had some discretion with regard to this policy. The LEX facility manager permitted the use of AM/FM radios in the tower as long as the volume level did not create a distraction that would interfere with operations. According to the latest labor contract between the FAA and the National Air Traffic Controllers Association, AM/FM radios, televisions, and similar equipment are prohibited in all operating areas. 79  The controller stated that he noticed both the SkyWest and American Eagle airplanes at about the same point and that he also saw the American Eagle airplane at the hold short line for runway 22.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 22 stated that he then saw the Comair airplane make a turn toward what he “presumed to be [runway] 22,” which was the last time he observed the airplane. Further, the controller stated that, after he saw the airplane make this turn, he turned away from the tower cab windows (which overlooked the runway) and faced the tower cab’s center console so that he could begin the traffic count (that is, a count of the hourly air traffic operations, as recorded on flight progress strips, during his shift). The controller stated that it was his common practice to place all of the flight progress strips that he accumulated throughout the night into a pile and do the traffic count all at once instead of hourly, and he estimated that the traffic count would have taken between 2 and 5 minutes to complete.80 He recalled that, while performing this task, he heard a noise, saw fire west of the airport, and contacted the airport’s operations center and airport rescue and firefighting (ARFF). Afterward, he made additional accident notifications and completed the accident checklist paperwork. The controller stated that there was nothing unusual about the Comair flight or the clearance and that the pilots did not seem to be rushed. The controller also stated that he learned that the accident airplane had taken off from runway 26 between 1030 and 1100 after the radar data were reviewed and that he “couldn’t believe it.” The controller further stated that it might have been possible for him to detect that the accident airplane was on the wrong runway if he had been looking out the tower cab window. In addition, the controller stated that, in his 17 years working at LEX, an air carrier airplane had never departed from runway 26. The controller stated that he was not experiencing any health or personal issues that would have affected his performance on the day of the accident. He stated that he did not take prescription medications or use tobacco products and that he drank alcohol occasionally. He indicated that he had not consumed alcohol during the 24 hours that preceded the accident or taken any nonprescription medication during the 72 hours before the accident. The controller also stated that during his shift he was tired but felt “fine” and “alert.”81 The controller did not report monitoring the location and movement of the Comair airplane on the airport surface during the scans of runway 22 and the DBRITE. The controller stated that his normal work practice was to monitor airplanes during taxi and takeoff if another airplane was on final approach and he needed to ensure separation between the departing and arriving airplanes. The controller also stated that, when aircraft separation was not a factor, his decision to watch airplanes taxi and take off depended on whether he had other tasks to perform. 80  The traffic count was accomplished by examining each flight progress strip, counting the number of strips for each category, and marking the numbers on a standardized form. The controller was required to count a total of 17 flight progress strips for this shift; 14 of the strips were for the air traffic operations conducted between 0000 and 0300, and the remaining 3 strips (for the SkyWest, American Eagle, and Comair flights) were to be counted as part of the 0600 to 0700 traffic count. 81  The controller further stated that he “always managed to deal with” the lack of sleep during the midnight shift and that he felt “a little more tired on the mid[night] shift” compared with other shifts.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 23 Lexington Air Traffic Control Scheduling 1.10.2.1  The LEX air traffic manager82 stated that the LEX ATCT became a 24-hour facility in 1992 after an incident in which an airplane was cleared for a direct approach to LEX, but the pilots conducted the approach to and landed at a nearby airport.83 In 2005, the air traffic manager prepared two studies to support closing the LEX ATCT during the midnight shift.84 At LEX, work hours for the day shifts were 0630 to 1430, 0700 to 1500, or 0800 to 1600; work hours for the swing shifts were 1500 to 2300 or 1600 to 0000; and work hours for the midnight shift were 0000 to 0800. The LEX air traffic manager stated that there were typically four controllers on duty during the day shifts, one controller on duty from 1000 to 1800 (in addition to the day and swing shift controllers), and five controllers on duty during the swing shifts. The midnight shift had been staffed with one controller. On November 16, 2005, the LEX air traffic manager notified LEX ATC personnel by e-mail that, according to verbal guidance from the FAA’s vice president of terminal services, facilities with radar and tower responsibilities were to be staffed with two controllers on the midnight shift so that the functions could be split, although both controllers could be colocated in the tower. According to the LEX air traffic manager, this directive was precipitated by an August 17, 2005, incident at Raleigh-Durham International Airport (RDU), Raleigh, North Carolina, which involved a loss of aircraft separation while a controller was working both the radar and tower functions.85 The LEX position logs for January 1 through March 31, 2006, showed that the midnight shift was staffed with two controllers for 36 of the 90 days covered by the logs. 82  The air traffic manager had worked at the LEX ATCT since 1992 and had been the air traffic manager for 4 years at the time of the accident. Supervisors at the ATCT reported directly to him, and he reported to the hub manager located at CVG. 83  In July 1987, a Delta Air Lines Boeing 737 flight crew was cleared direct to LEX for an approach to the airport. At that time, the LEX tower and radar approach control were closed. After receiving the approach clearance, the flight crew located an airport with runway lights on, entered the traffic pattern, and landed. However, that airport was Capital City Airport, Frankfort, Kentucky, with a 5,000-foot runway instead of LEX, the destination airport, with a 7,000-foot runway. (Capital City Airport is located 17 nm from LEX.) The unavailability of ATC services at LEX was included as a contributing factor to the incident. For more information, see ATL87IA201 at the Safety Board’s Web site at http://www.ntsb.gov. 84  The first study was an airspace reclassification study, performed during winter 2005, to support closing the LEX ATCT from 0000 to 0630 and having the Indianapolis ARTCC be responsible for the airspace during that time. In April 2006, the FAA’s eastern terminal service unit indicated that additional information was needed before the airspace reclassification study could be forwarded to FAA headquarters. In July 2007, the FAA indicated that there was not a pending airspace reclassification study regarding LEX. The second study was a staff study, prepared in March 2005. This study, which was based on operational data from February 2004 to February 2005, showed that LEX did not have a sufficient traffic count (that is, 1.4 operations per hour) from 0000 to 0545 to justify ATC services during that time. As a result, the air traffic manager requested that the ATCT be closed during the midnight shift and that the Indianapolis ARTCC be responsible for the airspace during that time. The FAA’s eastern terminal service unit supported this request and forwarded the study to FAA headquarters in April 2005. In July 2007, the FAA stated that the staff study, “neither constitutes a request for reclassification of the airspace at LEX, nor meets the requirements of an airspace staff study that is needed for airspace change actions.” 85  This loss of separation was resolved when the departing airplane responded to a traffic alert and collision avoidance system resolution alert.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 24 In April 2006, the midnight shift was again staffed with one controller because traffic had increased during the day and swing shifts and the second midnight controller was needed on those shifts, according to the air traffic manager. After the accident, the midnight shift was consistently staffed with two controllers.86 Also, on November 17, 2006, the FAA issued Notice N JO 7210.639, “Consolidating Control Functions,” which modified FAA Order 7210.3, “Facility Operation and Administration,” to formalize the verbal guidance from the FAA’s vice president of terminal services regarding midnight shift staffing for facilities with radar and tower responsibilities.87 In addition, in January 2006, when the LEX ATCT was staffed with 19 controllers, the air traffic manager sent an e-mail to his hub manager, requesting that the tower be staffed with 21 controllers. At the time of the accident, the tower was still staffed with 19 controllers. In July 2007, the FAA stated that four additional controllers were hired at the LEX ATCT after the accident (two in November 2006 and two in May 2007). Amended Takeoff Clearance Procedure 1.10.2.2  On January 4, 2007, LEX ATCT Notice N7220.124, “Runway 22 Takeoff Clearance Procedure,” was issued to all LEX ATC personnel. The notice stated the following: “a takeoff clearance for Runway 22 shall not be issued until the aircraft has been physically observed having completed a crossing of Runway 26.” The notice indicated that the amended procedure was “an effort to add a layer of safety … and avoid pilot confusion.” Taxi Demonstrations 1.10.3  Members of the Operations/Human Performance and Survival Factors investigative teams conducted two taxi demonstrations—one during daytime conditions and one during nighttime conditions—on the day after the accident. The purpose of these demonstrations was to observe airport features, including runways 22 and 26, taxiway A, runway and taxiway markings, lighting, and signage. The ATC investigative team observed the nighttime demonstration from the tower. For the daytime observation, the Operations/Human Performance and Survival Factors investigative teams traveled around the airport by 15-passenger van. At the time, the weather conditions were overcast and rainy. For the nighttime observation, the Survival Factors investigative team traveled around the airport by 15-passenger van, 86  According to the FAA, at the time of the accident, the Duluth, Minnesota, and Fargo, North Dakota, ATCTs also did not consistently comply with the midnight shift staffing policy and were combining radar and tower functions. Further, four ATCTs—located at Tulsa, Oklahoma; Kansas City, Missouri; Springfield, Missouri; and Little Rock, Arkansas—were staffed with two controllers on the midnight shift but combined the radar and tower functions. All of the facilities are now in compliance with FAA guidance. 87  All FAA notices expire 1 year after issuance. Because the notices are temporary by nature, they are rarely renewed. According to Notice N JO 7210.639, the notice is to be in effect for 1 year or until changes are published in FAA Order 7210.3, change 3, whichever occurs first. The publication schedule in FAA Order 7210.3 indicated that submissions for change 3 were due on March 15, 2007, and that the effective date of the publication would be August 30, 2007.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 25 and the Operations/Human Performance investigative team traveled aboard a Comair CRJ‑100 airplane. At the time, weather conditions were broken to overcast clouds with no precipitation and good visibility, and the ramp, taxiway, and runway surfaces were dry. Also, the taxiway lights were on step 2,88 and the runway 22 high intensity runway lights were on step 3, as they were at the time of the accident. (As previously stated, runway 26 had no lighting.) The CRJ-100 demonstration airplane was positioned on the ramp near the gate from which the accident flight departed. The airplane taxied along the accident taxi route and down runway 26 to a point just past the intersection of runway 26 with runway 22; afterward, the airplane turned around and taxied down runway 26 to taxiway C and then to the ramp.89 Next, the airplane taxied from the ramp to runway 22 using the former taxiway A5 (which had been redesignated as taxiway A at the time of the accident). After reaching runway 22, the airplane taxied down the runway to taxiway C. During the taxi demonstration, the runway edge lights south of the intersection of runway 22 with runway 26 were dimmer on the right side than on the left side. These lights were repaired so that their intensity was returned to normal on both sides of runway 22. Section 1.10.3.1 describes the observations made by the Operations/Human Performance investigative team from the CRJ-100 demonstration airplane, and section 1.10.3.2 describes the observations made by the ATC investigative team from the tower. Operations/Human Performance Observations 1.10.3.1  The following observations90 were made by the Operations/Human Performance investigative team from a CRJ-100 airplane during the nighttime taxi demonstration:91 At the hold short line for runway 26: The black and yellow taxiway location sign for taxiway A and the red and • white runway holding position sign for runway 26 were visible to the left of the airplane. The signs were illuminated. The taxiway A yellow centerline split into three lines after the hold short • position for runway 26.92 The left centerline (referred to as a lead-on/off line) arced to the left onto the centerline of runway 26; this path was to the left of the white runway 26 numbers. The middle centerline arced slightly to the 88  The taxiway lights had three settings, steps 1 through 3, with step 3 being the brightest. 89  Taxiway C is shown on the airport charts in appendix C. 90  The Survival Factors investigative team made similar observations from the 15-passenger van as it traveled around the airport. 91  Figures 2 and 3 show the locations referenced in this section. 92  These lines were not outlined in black, as strongly recommended, but not required, by Advisory Circular 150/5340-1J, “Standards for Airport Markings,” dated April 29, 2005.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 26 left across runway 26 to the new taxiway A (designated as taxiway A5 on the Jeppesen chart that was current at the time of the accident). The right centerline led to former taxiway A (north of runway 8/26), which was blocked by low- profile barricades with flashing red lights. 93 The red and white runway holding position sign for runway 22 (which was • located on taxiway A on the north side of runway 26) was visible. The sign was illuminated. With the airplane’s taxi lighting configuration (which used lights located in • the wing root), the white runway 26 numbers were visible to the right of the airplane’s nose. The concrete in the area around the numbers was light in color and provided relatively low contrast to the numbers. With the airplane’s taxi lighting configuration, the taxiway A yellow centerline • markings were visible but appeared darker than the surrounding area. With the airplane’s takeoff lighting configuration (which included landing lights in the airplane’s nose and wing root lights), the markings were visible and appeared brighter than the surrounding area. In position on runway 26: White side stripes (edge markings) on runway 26 were illuminated with the • airplane’s takeoff lighting configuration. The markings appeared bright and reflective. With the airplane’s taxi lighting configuration, the markings were visible but not as bright. The white centerline striping on runway 26 was visible. • The white runway 26 numbers were positioned behind the airplane and were • not visible. A red and white runway holding position sign for runway 4/22 was visible to • the left of the airplane’s nose. The sign was illuminated. White edge lights for runway 22 were visible. • The 2,000-foot black and white distance-remaining marker on the right side of • runway 26 was not visible. The end of runway 26 was not visible with the dark horizon that existed at the • time.94 The runway 26 surface was brighter near the airplane than it was farther down • the runway. Blue taxiway lights were visible to the left and the right of the airplane. More • lights were present on the left than on the right sides. 93  Advisory Circular 150/5340-1J indicates that pavement markings that are no longer needed should be physically removed. 94  Operations/Human Performance investigative team members described the view as a “black hole” except for red obstruction lights on a shack to the right of runway 26 and on radio towers on the northwest side of the airport.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 27 In position on runway 22 at taxiway A (former taxiway A5): White precision runway markings were visible and illuminated with the • airplane’s takeoff lighting configuration. The white runway 22 numbers were visible in front of the airplane.  White centerline striping for runway 22 was visible and illuminated with the • airplane’s takeoff lighting configuration. White edge lights for runway 22 were visible, and the brightness was balanced • on the left and right sides of the runway. About 10 pairs of runway edge lights were visible. No red runway threshold lights were visible. White side stripes for runway 22 were visible, but their appearance was less • distinct compared with the appearance of the runway 26 side stripes. The end of runway 22 was not visible. • Ramp floodlights and terminal lighting were visible. • Air Traffic Control Tower Observations 1.10.3.2  During the nighttime demonstration, the airplane was clearly visible while on taxiway A between taxiway A6 and runway 22.95 The airplane was also clearly visible when it taxied from taxiway A to runway 26, although it was difficult to determine whether the airplane was actually on runway 26 or was on runway 22 because the approach ends of both runways appeared close together.96 As the airplane continued down runway 26 past its intersection with runway 22, the airplane’s position on runway 26 became more discernible because of the lighting on runway 22. As the airplane continued farther along runway 26, it became difficult to determine whether the airplane was on runway 26 or was located on an adjacent taxiway. When the airplane taxied from taxiway A to runway 22, it was easy to determine that the airplane was on that runway because the runway lights illuminated the airplane. Also, as the airplane proceeded down runway 22, the airplane’s location became even more discernible because of the additional illumination from its landing lights, which appeared brighter than they did when the airplane was on runway 26. The flashing red lights on the low-profile barricades located on taxiway A north of runway 8/26 were clearly visible from the tower. 95  Taxiway A6 is shown on the August 3, 2006, NACO chart and the September 8, 2006, Jeppesen chart in appendix C. 96  The parking garage lights provided ambient lighting, but it was not enough to distinguish the runway surface.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 28 Postaccident Events 1.10.4  Piper PA-2 Lance Event On November 9, 2006, a Piper PA-32 Lance was on a Part 91 flight from Shelby Municipal Airport, Shelby, North Carolina, to Logan/Cass County Airport, Logansport, Indiana, when the pilot decided to land for fuel at LEX.97 The pilot reported that night VMC prevailed at the time. After his airplane was refueled, the pilot began to taxi to runway 22 for takeoff. The pilot mentioned that runway 22 was lit up very well and that runway 26 was dark. He stated that, when approaching runway 22, he stopped the airplane before the runway 22 hold short line because he had to do the runup (preflight checks for airplanes with piston engines). The pilot stated that, after the runup was completed, he called the controller to report that he was ready to take off. The controller informed the pilot that the airplane was on runway 26 and instructed him to taxi the airplane onto runway 22. The pilot stated that his airplane was on the taxiway to runway 22 at all times and that the airplane had not aligned with runway 26. The pilot also stated that, when he stopped the airplane before the runway 22 hold short line, the airplane was apparently on runway 26, which likely gave the controller the mistaken impression that the airplane would be taking off from runway 26. Learjet 45 Event On January 1, 2007, a Learjet 45 (Flexjet flight 428) was on a Part 91 flight from LEX to Spirit of St. Louis Airport, St. Louis, Missouri. Night VMC prevailed at the time. The airplane was instructed to taxi to runway 22 and then was cleared for takeoff while the airplane was still on taxiway A but before it arrived at runway 26. According to the captain, he taxied the airplane across the runway 26 hold short line and made a slight left turn but did not see the taxiway to runway 22 where he expected to find it.98 The captain stated that he then saw the taxiway to his right and that, about the same time, the first officer saw the taxiway and pointed it out. Also about the same time, the controller informed the flight crew that it looked as if the airplane were lining up on runway 26 instead of runway 22. The captain stated that the first officer told the controller that they saw the taxiway for runway 22. The captain further stated that he turned the airplane toward the right and proceeded on taxiway A to runway 22. The captain stated that, although the airplane was on runway 26, the airplane was never lined up to take off from that runway.99 The first officer stated that he and 97  Before the time of this event and the next event described in this section, the construction project at LEX had been completed, so taxiway A north of runway 8/26 and former taxiway A5 (redesignated as taxiway A) no longer existed, and taxiway A7 was in use. 98  The taxiway to runway 22 required a wider left turn and then a straight-ahead path to the runway. 99  The captain added that it was not legal for him to take off from runway 26 because his company’s policy did not allow any takeoffs from runways that were less than 4,000 feet.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 29 the captain were not confused about the correct runway for takeoff. In addition, the first officer stated that he could not see the runway 22 approach lights, and the captain stated that he could not see the taxiway A lights, until the airplane had taxied up to the centerline of runway 26. Flight Recorders 1.11  Cockpit Voice Recorder 1.11.1  The airplane was equipped with a Fairchild model A100S solid-state CVR, serial number (S/N) 03035. The exterior case of the CVR sustained heat and structural damage, but the interior case did not appear to have any heat or structural damage. The audio information was extracted normally and without difficulty. The CVR was sent to the Safety Board’s laboratory for readout. The CVR recording contained four channels100 of good-quality audio data.101 A transcript was prepared of the entire 30-minute 29-second digital recording (see appendix B). Flight Data Recorder 1.11.2  The airplane was equipped with an L-3 Communications Fairchild Model F1000 FDR, S/N 102368. The FDR recorded flight information in a digital format using solid- state memory as the recording medium. The FDR was sent to the Safety Board’s laboratory for readout and evaluation. The FDR showed evidence of external damage as a result of the postcrash fire, but the internal components were in good condition, and the data were extracted normally. About 51 hours of data were recorded on the FDR, including about 7 minutes 46 seconds of data from the accident flight (from 0558:50 to 0606:36). Because of the damage to the airplane during the accident sequence, data recorded during the last second of data were invalid, and data for some parameters were invalid beginning 3 seconds before the end of the recording. The accident airplane’s FDR was not in compliance with the carriage requirements in 14 CFR 121.344, Appendix M. Specifically, the source of the vertical acceleration parameter was not updated at a rate that met the required recording intervals. Also, the pitch attitude parameter was recorded at a higher sample rate than the source was 100  The first through fourth channels were the captain’s station, the first officer’s station, the cockpit area microphone, and the frequency shift keying timing signal, respectively. 101  The Safety Board rates the audio quality of CVR recordings according to a five-category scale: excellent, good, fair, poor, and unusable. The Board considers a good-quality audio recording to be characterized by the following traits: most of the crew conversations could be accurately and easily understood. The transcript that was developed might indicate several words or phrases that were not intelligible. Any loss in the transcript could be attributed to minor technical deficiencies or momentary dropouts in the recording system or to a large number of simultaneous cockpit/radio transmissions that obscured each other.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 30 updated. On May 16, 2003, the Safety Board issued Safety Recommendation A‑03‑15 to the FAA because of problems with the quality of FDR data recorded by several regional jet airplanes, including the CRJ. Safety Recommendation A-03-15 asked the FAA to do the following: Require that all Embraer 145, Embraer 135, Canadair CL-600 RJ, Canadair Challenger CL-600, and Fairchild Dornier 328-300 airplanes be modified with a digital flight data recorder system that meets the sampling rate, range, and accuracy requirements specified in 14 Code of Federal Regulations Part 121.344, Appendix M. The FDR installed on the Pinnacle Airlines CRJ-200 airplane that was involved in the October 2004 accident in Jefferson City, Missouri, had the same parameter problem as the FDR installed on the Comair airplane. In its final report on the Pinnacle Airlines accident,102 the Safety Board stated that, since the time of that accident, the Board had downloaded FDR data from seven events involving CL-600-2B19 airplanes (including the Comair accident). All of these downloads showed that the FDRs recorded the vertical acceleration and pitch parameters from sources that did not meet the recording intervals required by 14 CFR 121.344, Appendix M. The Board concluded, in part, that the parameter quality problems with the FDR systems installed on CL-600-2B19 airplanes needed to be corrected so that future investigations involving these airplane models would not be hindered by inaccurate or incomplete data. As a result, on January 23, 2007, the Board reiterated Safety Recommendation A-03-15 and classified the recommendation “Open—Unacceptable Response.” Wreckage and Impact Information 1.12  Wreckage Site 1.12.1  No obvious tire marks or skid marks were found on the last 2,000 feet of the departure end of runway 26, but tire marks from the left and right main landing gear and the nose landing gear were found in the grass immediately off the end of the runway. About 130 feet off the end of the runway, the nose landing gear tire marks disappeared, but tire marks from the left and right main landing gear were still present. The left and right main landing gear tire marks continued for an additional 135 feet. Also, two ground rubs that were canted inward were found outboard of the main landing gear tire marks. These ground rubs appeared to be consistent with the main landing gear doors. A berm was located in this area. One of the main landing gear doors was found before the berm, and a few small pieces of debris were found beyond the berm. No significant pieces of wreckage were 102  National Transportation Safety Board, Crash of Pinnacle Airlines Flight 3701, Bombardier CL‑600- 2B19, N8396, Jefferson City, Missouri, October 14, 2004, Aircraft Accident Report NTSB/AAR-07/01 (Washington, DC: NTSB, 2007).

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 31 found until the airport perimeter fence, which was located about 380 feet off the departure end of runway 26. A perimeter fence gate that was in line with the extended centerline of runway 26 was torn from its hinges, and tire marks were found on the top of the gate. A ground rub and two tire marks, all of which were close to the extended runway centerline, were located about 585 and 620 feet, respectively, beyond the end of the runway. One of the tire marks appeared to be made by the nose landing gear, and the other appeared to be made by a main landing gear, with about 6 feet separating the tire marks. The first sizable piece of airplane wreckage, a segment of the wing flap, was located about 750 feet beyond the end of the runway and about 70 feet to the left of the extended runway centerline. About 900 feet beyond the departure end of the runway was the first tree strike with marks at 6 feet above ground level (agl). The tree had blue paint markings and small pieces of wreckage in the bark. A winglet tip was found forward and to the left of this tree, and the left winglet was found beyond the tree. The second and third tree strikes, with marks at 7 feet agl, were consistent with contact by the airplane at a 20º left-wing‑down attitude. A section of the outboard wing was found beyond the two trees. Along the airplane’s groundpath and about 35 feet beyond the three trees were 10 additional trees that were sheared off at about the same level but at an increasing height (12 feet agl) because the ground sloped downward after the first tree. Minor fire damage was observed on the third through ninth trees. Ground scars appeared about 400 feet beyond the first tree strike. Fire damage to the ground and four trees in this area was observed. The main wreckage was found about 900 feet beyond the first tree strike and about 1,800 feet west of the departure end of runway 26. Airplane Wreckage 1.12.2  The fuselage had separated into two main sections, and both wings had separated from the fuselage. The left and right engines remained attached to the aft fuselage. The empennage had separated from the aft fuselage. The left and right main landing gears had separated at their respective airframe attachment points, but part of the nose landing gear remained attached to the airframe. Impact forces and postcrash fire damaged the main avionics compartment and the components that were installed in the compartment. All of the primary and secondary flight control systems were identified in the wreckage, but the impact damage to the systems prevented an examination of flight control cable continuity. The main cabin door was closed and intact in the door frame. The exterior of the door was blackened by heat, and the interior of the door and the interior door handle were consumed by fire. The four latch pins were engaged in the door frame in the closed position. The forward service door was closed, and the unburned portion was intact in the door frame. The exterior door handle was in the closed position, and the interior door handle, which was partially consumed by fire, was also in the closed position. The

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 32 left overwing exit103 was found within the main cabin debris area on the right side of the main wreckage area. The exit release handle was in its closed position. The spring-loaded securing pins were extended. Portions of the right overwing exit frame and window exit were found in a pile of wreckage near their approximate position in the fuselage. The spring-loaded securing pins were found extended. A portion of the captain’s seat frame was found fragmented and burnt about 15  feet to the left of the cockpit area. The first officer’s seat was found in the cockpit separated into two pieces. The flight attendant jumpseat and the passenger seats and restraint systems were severely damaged or destroyed by impact forces and postcrash fire. Medical and Pathological Information 1.13  The Fayette County Coroner’s office examined the remains of the captain, flight attendant, and passengers. Their cause of death was “multiple injuries sustained in a commercial aviation crash with subsequent fire.” The major pathologic findings for these airplane occupants are shown in figure 4 along with injury information for the first officer. Toxicology tests were performed by the FAA’s Civil Aeromedical Institute (CAMI) on specimens from the captain and the first officer. Tissue specimens from the captain tested negative for ethanol and a wide range of drugs, including major drugs of abuse. In addition, the captain’s postmortem examination identified a contact lens over the left eye. Blood from the first officer104 tested negative for ethanol and a wide range of drugs, including major drugs of abuse, except that a low amount of pseudoephedrine was detected.105 The controller took a drug and alcohol test106 at 1330 on the day of the accident in accordance with 14 CFR 65.46, “Use of Prohibited Drugs.”107 The results were negative. 103  The overwing exits are located at row 8 (see figure 4 in section 1.13). 104  The specimen from the first officer was collected at 0656 on the day of the accident. 105  Pseudoephedrine is a decongestant that is available without a prescription in various preparations that are marketed for the treatment of cold or allergy symptoms. The captain who flew with the first officer on August 25 and 26, 2006, stated that the first officer showed no indication of a cold or an allergy during their flights. 106  A urine specimen was tested for the presence of alcohol and five drugs: marijuana, cocaine, phencyclidine, amphetamines, and opiates. 107  According to the FAA drug testing project manager, drug and alcohol testing is mandatory after any fatal accident, and the testing should be complete within 8 hours of the accident.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 33 Injury Information According to Seat Assignment Figure 4.  Note: Seat positions showing more than one color indicate more than one reported major pathologic finding in the autopsy reports. Note: The nonrevenue passenger (who was deadheading to ATL) is not depicted in the cabin because he was not assigned a seat. Fire 1.14  The airplane wreckage showed no evidence of a preimpact fire. The wreckage showed postcrash fire damage.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 34 Survival Aspects 1.15  The first officer, the only survivor of the accident, received serious, life-threatening blunt force injuries. He was rescued from the cockpit wreckage and was immediately transported to the University of Kentucky Hospital in Lexington. The first officer was discharged to a rehabilitation facility on October 13, 2006, where he remained until December 15, 2006. Emergency Response 1.15.1  A LEX public safety officer108 and a city of Lexington police officer109 were the first to arrive at the accident site. According to radio transmission audio recordings from the LEX operations center, the LEX public safety officer arrived on scene about 5 1/2 minutes after receiving alert 3 notification and located the fuselage about 3 1/2 minutes later. He and the police officer from the city of Lexington were able to free the first officer from the cockpit wreckage. Another LEX public safety officer arrived on scene while the first officer was being extricated. This LEX public safety officer used his sport‑utility vehicle to transport the first officer to the hospital rather than wait for an ambulance.110 This LEX public safety officer estimated that they arrived at the hospital (located about 7 miles from the accident site) before 0630. Two 3,000-gallon ARFF vehicles responded to the accident. To reach the accident site, the ARFF vehicles traveled about 2 1/2 miles from the ARFF station by way of public roads, a dirt road with a significant incline, and off-road terrain. The first ARFF vehicle to arrive on scene arrived about 11 minutes after the alert 3 notification and began fire suppression immediately using its high-flow turret to knock down most of the fire followed by the bumper turret and handlines for additional fire suppression. This ARFF vehicle had been directed to the location of the accident by a LEX public safety officer. The second ARFF vehicle to arrive on scene began additional fire suppression using its high-reach extendable turret.111 The LEX operations center incident report showed that the fire was controlled within about 3 minutes. 108  LEX public safety officers are cross-trained as police officers, firefighters, and emergency medical technicians. 109  City of Lexington police officers were notified of the accident by the police department’s dispatcher, who had received emergency calls from citizens. 110  The city of Lexington police officer traveled in the back of the sport-utility vehicle with the first officer. 111  The high-reach extendable turret was equipped with a forward-looking infrared camera. The operator of this ARFF vehicle did not activate the camera during the emergency response. After the accident, the camera system was modified so that it would activate at the time of engine start.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 35 Tests and Research 1.16  Aircraft Performance Study 1.16.1  The Safety Board performed an aircraft performance study for this accident. FDR and CVR data were time correlated. The latitude and longitude data recorded on the FDR, however, were not sufficient to determine the airplane’s exact position. As a result, the Board developed a time history of the accident airplane’s motion to identify the position of the airplane in the context of the transmissions recorded on the CVR. To develop the time history, the Board integrated acceleration and attitude data from the FDR and combined the results with wind and atmospheric data at the time of the accident, airport information, and wreckage documentation. FDR data showed that the airplane began to taxi about 0602:17, about 2 1/2 minutes after the flight crew initiated the pushback from the gate. FDR data also showed that the airplane was stopped at the hold short line for runway 26 from about 0604:33 to about 0605:23 and that the airplane had taxied across the runway 26 hold short line about 0605:24.112 In addition, FDR data showed that the airplane aligned with the runway 26 centerline about 0606:00 and began the takeoff roll about 0606:06. The aircraft performance data (V1, VR, and V2)113 referenced in the flight paperwork and recorded on the CVR assumed a takeoff on runway 22. The airplane impacted a berm (located about 265 feet from the end of runway 26) about 0606:32. FDR airspeed and altitude data showed that the airplane became temporarily airborne after impacting the berm but climbed less than 20 feet off the ground. Less than 1 second after impacting the berm, the airplane impacted the airport perimeter fence (located 380 feet from the end of runway 26) and experienced a vertical load factor of at least 2.5 Gs at that time.114 FDR airspeed and altitude data showed that the airplane accelerated about 4.3 knots per second from the time of the takeoff roll to the time that the airplane impacted the airport perimeter fence. About 0606:35, the airplane impacted the first tree (located about 920 feet from the end of the runway) and experienced a vertical load factor of at least 4.0 Gs. Takeoff Distance and Accelerate-Stop Calculations 1.16.2  Bombardier provided the Safety Board with accelerate-stop performance calculations for runway 26. These calculations showed the point beyond which a CRJ‑100 could not be stopped on the available runway, even with maximum braking applied. For the airplane to stop before the end of runway 26, maximum braking would have had to start when the airplane was at an airspeed of 103 knots. This speed would be reached 112  The airplane did not stop again along the remaining taxiway or the runway. 113  V2 is the takeoff safety speed. 114  G is a unit of measurement that is equivalent to the acceleration caused by the earth’s gravity (32.174 feet/second2).

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 36 when the airplane was 1,834 feet down runway 26, leaving 1,667 feet for stopping on the runway. In addition, Bombardier calculated that a CRJ-100 would need 3,593 feet to reach a V1 speed of 135 knots115 and 3,744 feet to start rotation. Organizational and Management Information 1.17  Comair, Inc., was founded in 1977 and provided service initially to and from Cincinnati, Cleveland, and Akron-Canton, Ohio. In 1984 Comair became a Delta Connection air carrier. In 1993 the company began to transition from turboprop116 to turbojet airplanes with the addition of 40- and 50-passenger seat CRJs to its fleet. In January 2002 Comair became a wholly owned subsidiary of Delta Air Lines. In 2002 Comair added the 70‑passenger-seat CRJ to its fleet and became an all-turbojet operation. Comair has its headquarters in Erlanger, Kentucky. At the time of the accident, the company served 97 cities in the United States, Canada, and the Bahamas, with an average of 772 flights per day, and employed more than 6,400 personnel, including 1,631 pilots (825 captains and 806 first officers). Flight Manuals 1.17.1  Taxi Procedures and Briefing 1.17.1.1  The Comair Operations Manual, chapter 4, section 4.4.1, page 4-23, “General Taxi Procedures,” dated September 1, 2005,117 stated that, before taxi, the captain should perform the taxi briefing and that, during taxi, the captain should verbalize the essential elements of taxi clearances received, emphasizing runway crossings. This section also stated that both flight crewmembers should monitor the progress of the taxi by utilizing the horizontal situation indicators (HSI), airport diagrams, and airport signage to confirm positions. Further, this section stated that, in the event that a taxi clearance would take the airplane into a part of the airport that was not briefed or if either flight crewmember lacked complete understanding of the taxi clearance, the crew should stop the taxi, refer to the airport diagram, and query ATC if required. Section 4.4.2, page 4-23, “Taxi Briefing,” stated that the captain’s taxi briefing was to include Comair standard taxi information. This information was to be briefed in its 115  As previously stated, the V1 speed according to Comair was 137 knots. A difference existed between Comair’s and Bombardier’s V1 speeds because Comair computed V speeds using interpolations for airplane weight and atmospheric conditions (altitude and temperature), whereas Bombardier computed V speeds using the exact airplane weight and atmospheric conditions. 116  The company had operated the Piper Navajo, Piper Chieftain, Embraer EMB-110, Shorts 330, Fairchild SA-227, Saab 340, and Embraer EMB-120 turboprop airplanes. 117  All of the taxi procedures in this section were dated September 1, 2005.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 37 entirety for the first flight as a crew and could be abbreviated to “Comair standard” for subsequent flights. The Comair standard taxi information included the following: Both flight deck crewmembers will have appropriate airport diagrams out and • available. Complicated or unexpected clearances shall be written down. • Traversing runways … requires extra vigilance. • If unsure of position or instructions … clear any runways, stop, and call ATC. • Section 4.4.4, page 4-25, “Airport/Field Taxi,” stated that, when clear of the ramp, the captain should verbalize the essential elements of the taxi clearance, placing special emphasis on runway crossings. Section 4.5.5, pages 4-27 and 4-28, “High Threat Taxi Procedures,” stated that flight crews were to use high threat taxi procedures when the operating environment presented “exceptional” hazards to safe taxi and that these procedures were to be used “when the captain deems the operation requires exceptional vigilance.” The section also stated that, during these operations, both pilots were to be heads-up during airplane movement and that they should monitor the taxi and hold short locations. In addition, the section stated, “both pilots must be familiar with the assigned taxi route before aircraft movement. If in doubt, remain clear of all runways and contact ATC.”118 Checklist Usage 1.17.1.2  The Comair CRJ Flight Standards Manual, volume I, chapter 3, sections 3.7.3 and 3.7.6 through 3.7.8, pages 3-60, 3-74, 3-76, and 3-78, dated November 30, 2005, stated that the first officer was to perform the before starting engines, taxi, before takeoff, and lineup checklists. These checklists contained challenge and response items, which were read by the first officer and responded to by the captain, and verbal response items, which were verbalized by the first officer. The manual also stated that the captain was to call for the taxi, before takeoff, and lineup checklists but did not specifically mention which crewmember was to call for the before starting engines checklist. According to Comair, although either pilot can call for the before starting engines checklist, the captain typically calls for it. 118  Comair used “pink sheets” to supplement airport information shown on Jeppesen charts. The pink sheets contained operational procedures and recommendations, including the use of high threat taxi procedures when appropriate, for a specific airport. A pink sheet had not been issued for LEX at the time of the accident.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 38 Sterile Cockpit Procedures 1.17.1.3  The Comair Operations Manual, chapter 5, section 5.13.2, pages 5-61 and 5-62, “Critical Phases of Flight/Sterile Cockpit,” dated December 1, 2005, stated the following:119 Critical phase of flight includes all ground operations involving taxi, takeoff and landing, and all other flight operations conducted below 10,000  ft, except cruise flight. Taxi is defined as ‘movement of an aircraft under its own power on the surface of an airport.’ No flight crewmember shall perform any duties during a critical phase of flight except those duties required for the safe operation of the aircraft. No flight crewmember may engage in, nor may any pilot-in-command permit, any activity during a critical phase of flight which could distract any flight crewmember from the performance of his duties or which could interfere in any way with the proper conduct of those duties … such as … engaging in nonessential conversations within the flight deck. Heading Bugs 1.17.1.4  The Comair CRJ Flight Standards Manual, volume I, chapter 3, section 3.7.3, page  3-63, “Before Starting Engines,” dated November 30, 2005, stated that flight crewmembers should set course selectors and heading bugs. Volume II of the manual, chapter 7, section 7.3.4, “Heading Bug,” dated November 30, 2005, stated that, on departure, if a turn is required at or below 400 feet agl, the heading bugs should be set to the heading required by ATC, the departure procedure, or the runway heading. This section also stated that, if a straight-out departure is planned or a turn is required by departure procedures above 400 feet agl, the heading bugs should be set to the runway heading. Normal Takeoff 1.17.1.5  The Comair CRJ Flight Standards Manual, volume II, chapter 7, section 7.4.4, pages  7-14 and 7-15, “Normal Takeoff,” dated November 30, 2005, stated that the nonflying pilot was to call “V1” and “rotate” as appropriate. The section also stated that the V1 callout should be made so that, upon reaching V1, the callout would be completed. In addition, the section stated that, at VR, the flying pilot should rotate the airplane smoothly toward the target pitch attitude in one continuous motion at a rate of about 3º per second. Use of Alcohol 1.17.1.6  The Comair Operations Manual, chapter 3, section 3.11, page 3-26, “Intoxicants and Illicit Drugs,” dated June 10, 2005, stated that a certificated airman would be subject to 119  These procedures were in accordance with 14 CFR 121.542, “Flight Crewmember Duties.”

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 39 termination if the airman consumed any alcohol within 12 hours of scheduled departure. (Title 14 CFR 121.458(d)(1) states that pilots may not perform flight crewmember duties within 8 hours of consuming alcohol.) Flight Crew Rest Periods 1.17.1.7  The Comair Operations Manual, chapter 3, section 3.8.3, page 3-18, “Flight Time Limitations and Rest Requirements,” dated June 10, 2005, stated that a pilot’s rest period begins 20 minutes either after actual block in or the last scheduled airplane movement or when actually released, whichever is later. This section also stated that the rest period at a field location ends when the crewmember reports to the gate or operations center (45  minutes before departure or 30 minutes before departure if necessary because of transportation). Further, the section stated that transportation to and from a local hotel is considered to be part of the rest period. Page 3-20 described the following rest requirements for pilots, which were based on the number of scheduled flight hours in the preceding 24 hours of the planned completion of each flight segment:120 For a scheduled flight time of less than 8 hours, the required rest in between • flights is 9 hours. For a scheduled flight time of between 8 and 9 hours, the required rest in • between flights is 10 hours. For a scheduled flight time of 9 or more hours, the required rest in between • flights is 11 hours. Crew Resource Management 1.17.1.8  The Comair Operations Manual, chapter 5, section 5.6.1.2, page 5-20, “Crew Resource Management,” dated May 15, 2005, stated that the captain was responsible for the CRM concept of “authority with participation.” This section also stated that the captain was responsible for providing leadership but would also elicit and welcome participation from other crewmembers during the conduct of a flight. This section further stated that the first officer was responsible for the CRM concept of “assertiveness with respect.” In addition, this section stated that the first officer would be an integral participant in the safe conduct of a flight and that the first officer would interact with the captain in a positive, consistent manner while still honoring the captain’s position. 120  These requirements were in accordance with 14 CFR 121.471(b).

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 40 Crew Resource Management Training 1.17.2  As part of their initial training at Comair, the flight crewmembers received two 8‑hour classes in basic CRM training, a 4-hour class in command leadership, and a 2‑hour class in CRM in automation. At the time of the accident, new captains received an additional 3-hour class in command leadership and an additional 2-hour class in CRM in automation during their upgrade training. Also, Comair provided a 2-hour “common day” class with pilots, dispatchers, and flight attendants in the same class. In addition, Comair provided CRM training during 2-hour modules in each recurrent training cycle. The topics presented during recurrent CRM training included teamwork, communication, decision-making, situational awareness, and workload management. The course referenced industry CRM guidance, accidents and incidents that occurred at Comair and other air carriers, and Safety Board reports and studies. The information was presented through lectures and interactive discussions based on event scenarios. Each CRM recurrent training module contained specific areas of emphasis. For example, the 2006 CRM module focused on managing errors and understanding how selective attention and selective noncompliance could increase the likelihood of an error. Also, the 2005 CRM module focused on understanding and managing the risks associated with daily operations and mitigating these risks by applying good decision-making and team-building skills. In addition to the CRM training modules, CRM skills were evaluated during simulator training, line-oriented evaluations, and checkrides. During a postaccident interview, a CRM facilitator instructor (who was also a check airman) stated that the CRM training at Comair was excellent. The instructor also stated that Comair’s culture encouraged first officers to speak up if a captain has made an error and that this aspect of CRM was reinforced during flight training. The instructor further stated that, when first officers have not spoken up during line checks after a captain has made an error, it was because of a lack of situational awareness rather than a hesitancy to speak up. Comair captains described CRM training as good. Comair first officers stated that they had no difficulties speaking up if they felt rushed or had concerns with the conduct of the flight. Also, the principal operations inspector (POI) for Comair stated that there had not been a crew interaction problem during the 5 years that preceded the accident. Safety Program Personnel Initiatives 1.17.3  At the time of the accident, Comair’s corporate compliance committee (which comprised the officers and the president of the company) met at least quarterly to review safety performance metrics and progress in achieving the company’s safety initiatives.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 41 The director of corporate safety reported to the corporate compliance committee. A flight safety specialist, an aviation safety action program (ASAP)121 coordinator, and two ASAP analysts reported to the director of corporate safety. Comair initiated action before the accident to create the position of manager of flight safety, but the change to the organizational structure did not occur until the week after the accident. The manager of flight safety reports to the director of corporate safety, and the flight safety specialist, ASAP coordinator, and two ASAP analysts now report to the manager of flight safety. The director of corporate safety stated that flight safety department staff provided briefings during initial and recurrent ground schools and worked closely with the training department to ensure that flight safety trends, such as navigation or altitude deviations, were addressed. Comair’s written safety policy is published in multiple locations, including the employee Web page and the corporate program safety manual. Pilots receive flight‑specific safety information through the dispatch release. Pilots receive other relevant flight safety information through communications on bulletin boards; the quarterly safety newsletter; and “Ops Notes,” which are one-page safety reports. One way Comair pilots can communicate flight safety concerns is through irregular operations reports, which are transmitted to flight operations managers; the corporate safety department; and the flight safety department, which tracks and evaluates them. Another way that pilots can communicate such concerns is through Comair communications logs, which are sent to and reviewed by the flight safety department. In addition, another way that pilots can communicate flight safety concerns is through the company’s ASAP. From May 2004 to July 2006, the company received more than 2,400 ASAP reports.122 The company’s ASAP event review committee meets weekly to review ASAP reports. According to Comair, no reports had been received describing circumstances related to those of the accident. In addition, the flight safety department reviews ASAP and irregular operations reports to monitor trends, and the information learned from these reviews is presented at quarterly flight safety committee meetings. Deviations that are identified through this process are evaluated so that recommendations can be proposed to reduce the deviations. The director of corporate safety stated that the company was working toward implementation of a flight operations quality assurance (FOQA) program123 by the end of

1. The director also stated that the company was examining FAA Advisory Circular

121  An ASAP is an FAA-approved, voluntary safety program that encourages pilots to report safety concerns in a nonpunitive environment, which allows the air carrier and the FAA to act on this information before an accident or an incident occurs. An ASAP depends on the willingness of pilots to voluntarily submit reports about other pilots or themselves. Comair’s ASAP for pilots began in May 2004. 122  Comair’s ASAP included dispatchers, and the company was working to add maintenance personnel to the program. An ASAP can also include flight attendants. 123  A FOQA program is an FAA-approved, voluntary program for the routine collection and analysis of FDR data gathered during aircraft operations.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 42 (AC) 120-92, “Introduction to Safety Management Systems [SMS] for Air Operators”124 (issued in June 2006), and was moving toward implementing an SMS program.125 In addition, the director stated that Comair was working on a Line Operations Safety Audit (LOSA) program;126 had contracted with the University of Texas at Austin, which developed the program in 1994 through FAA-sponsored research known as the Human Factors Research Project; and was awaiting the support of the company’s local pilot union. Comair’s corporate safety and compliance departments prepare monthly safety performance and compliance reports, which include monthly data showing the number of runway incursions reported during the previous 12 months and brief statements describing those incursions that occurred during the previous month. For the 12-month period ending July 2006, Comair reported 21 runway incursions. None of these incursions involved a takeoff from the wrong runway. Federal Aviation Administration Oversight 1.17.4  The FAA certificate management office for the Comair certificate is located in Atlanta, and the certificate management unit (which handles oversight) is located in Louisville, Kentucky. The POI and assistant POI for Comair had been in their positions for about 3  1/2 and 2 years, respectively, at the time of the accident. The certificate management unit also included two aircrew program managers and a cabin safety inspector. At the time of the accident, the FAA conducted its oversight of Comair through the air transportation oversight system (ATOS).127 The Safety Board’s review of ATOS records showed that the FAA had conducted more than 120 inspections at Comair 124  An SMS program incorporates proactive safety methods for air carriers to identify hazards, mitigate risks, and monitor the extent that air carriers are meeting their objectives. Program components include safety policy, safety risk management, safety assurance, and safety promotion. 125  On January 23, 2007, as a result of its investigation of the Pinnacle Airlines flight 3701 accident, the Safety Board issued Safety Recommendation A-07-10, which asked the FAA to “require that all 14 Code of Federal Regulations Part 121 operators establish Safety Management System programs.” On April 13, 2007, the FAA stated that it began a rulemaking project to meet the International Civil Aviation Organization’s deadline of January 1, 2009, for SMS requirements. The FAA also stated that pilot project trials had been scheduled to better address issues related to SMS implementation. 126  The LOSA program is an observational process that assesses CRM practices, the management of threats to safety, and human error during flight operations. Trained personnel associated with the project conduct line observations under conditions of confidentiality so that the operator is provided only with details of the observations and no information about the pilots who were involved. As a result, in contrast to a company line check, LOSA observations do not result in adverse actions against pilots who did not perform well during their observation. Also, LOSA observations have identified rule violations and deviations from procedures, which suggested that the pilots being observed did not view the LOSA observers as a threat and would be likely to perform in the same manner as they would without an observer present. 127  In 1998, the FAA established ATOS, which employs a systems safety approach to air carrier oversight. The benefits of the ATOS program’s system safety approach to air carrier oversight include a more integrated approach to oversight that better identifies risks to system safety and a more effective allocation of oversight resources to problem areas. Comair became an ATOS carrier in June 2006; before that time, the FAA conducted its oversight of the company under the National Program Guidelines. The guidelines, which have been in effect since 1985, are part of a traditional inspection program to ensure that airlines comply with safety regulations.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 43 between June 2006 and the time of the accident and that the results of these inspections were satisfactory. The POI stated that Comair anticipated the oversight system changeover and, as a result, had reviewed its processes to determine how they would align with ATOS inspection checklists. Additional Information 1.18  Witness Information 1.18.1  The two eyewitnesses to this accident were interviewed by the Safety Board. One eyewitness was an American Eagle station agent who was on a ramp by a gate when the accident airplane taxied past his location at a normal taxi speed. The station agent stated that he saw the airplane make a sharp, instead of a slight, turn to the left. He thought the flight crew might have made this turn so that the airplane could return to the gate. The station agent was not paying attention to the airplane when its engine power increased, but he then realized that the airplane was taking off from runway 26. He saw the airplane continue down the runway but did not notice if the nose of the airplane rose. The station agent then saw and heard an explosion followed by some “pops” and three or four smaller explosions. Also, he stated that the runway 22 lights and taxiway lights were illuminated. The other eyewitness to the accident was a resident of the living quarters portion of a horse trailer located on property near the airport. He was at home when he heard a “freight train” sound. He then looked outside and saw the accident airplane’s landing lights coming toward him. He saw the airplane strike the ground once or twice before becoming airborne and striking a group of trees on the property. He estimated that the airplane was about 10 feet in the air when it struck the first trees. He stated that he was not able to see the airplane after it struck the trees because horse barns on the property obstructed his view but that he was able to see fire and smoke at that point. Related Federal Aviation Administration Guidance 1.18.2  Advisory Circular 120-74A 1.18.2.1  AC 120-74A, “Parts 91, 121, 125, and 135 Flightcrew Procedures During Taxi Operations,” dated September 26, 2003, contained guidelines for establishing standard operating procedures to promote safe aircraft ground operations. In a section addressing crew verbal coordination on the flight deck, AC 120-74A states, “before entering a runway for takeoff, the flightcrew should verbally coordinate to ensure correct identification of the runway and receipt of the proper ATC clearance to use it.” Appendix 2 of AC 120-74A contained information about runway incursion prevention and recommended that flight crews “verify that the compass heading approximately matches the runway heading and taxiway orientation” to confirm proper runway or taxiway selection. Appendix 4 of AC  120-74A contains recommended normal procedures for surface

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 44 operations and departure and states that, after being cleared onto the active runway, the flight crew should “verbally confirm ATC clearance onto [the] active runway with other crewmembers and confirm proper runway selection using airport signs and markings and the airport diagram.” Appendix 4 also states that, when the airplane is at the takeoff end of the runway, the flight crew should “confirm proper runway selection using [the] HSI.” Safety Alert for Operators 06013 1.18.2.2  On September 1, 2006, the FAA issued Safety Alert for Operators (SAFO)128 06013, “Flight Crew Techniques and Procedures That Enhance Pre-takeoff and Takeoff Safety,” which discussed techniques, procedures, and items for consideration for training programs that emphasize safe operations in the pretakeoff and takeoff phases of flight. The SAFO provided reminders of existing FAA guidance on ground operations, such as AC  20‑74A, and stated that flight crews should “confirm, using the challenge and response technique, that the aircraft is actually positioned on the assigned runway by reference to the heading indicator.” Also, the SAFO recommended that pilots “use all available resources to ensure that the aircraft is positioned on the proper runway” and that flight crews of flight management system (FMS)-equipped airplanes “verbally announce that the proper runway and departure procedure are selected in the FMS and that the aircraft heading agrees with the assigned runway for takeoff.” Certalert 07-01 1.18.2.3  On January 9, 2007, the FAA issued Certalert 07-01,129 which suggested that airport operators supply detailed information about runway and taxiway closures and airport construction to air carriers and fixed-base operators on the airport. The certalert indicated that this information should be provided both textually and visually. To provide this information visually, the certalert suggested that airport operators create diagrams that pinpoint the exact location of any runway or taxiway closures and disseminate the diagrams by e‑mail, through a Web site, or by hand delivery. Takeoff Clearance Notice 1.18.2.4  On June 1, 2007, the FAA issued Notice N JO 7110.468, “Takeoff Clearance,” to amend the required phraseology for issuing aircraft departure instructions. The notice included the following procedures: “when issuing a clearance for takeoff, first state the ‘runway number followed by the takeoff clearance’” and “if the takeoff clearance is issued prior to the aircraft crossing all intervening runways, restate the runway to be crossed in conjunction with the takeoff clearance.” The notice indicated that this information would be incorporated into FAA Order 7110.65 on February 14, 2008. 128  FAA Order 8000.87, dated August 29, 2005, established SAFOs and stated, in part, that SAFOs conveyed “new important safety information” directly to operators as that information became available but that SAFOs were not mandatory. 129  Certalerts are advisory and cautionary in nature.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 45 Previous Related Safety Recommendations 1.18.3  Flight Crew Operations 1.18.3.1  Safety Recommendation A-89-15 On March 24, 1989, the Safety Board issued Safety Recommendation A-89-15 (urgent) as a result of two incidents of pilot deviation that involved departures of U.S. air carrier airplanes from the wrong runway at Houston Hobby Airport (HOU), Houston, Texas.130 Safety Recommendation A-89-15 asked the FAA to do the following: Take immediate corrective action, in conjunction with the airport authority, to prevent inadvertent takeoffs by air carrier airplanes on runway 17 at the Houston Hobby Airport. On May 1, 1989, the FAA stated that it and the HOU airport authority had posted additional guidance signs and issued NOTAMs regarding the closing of runway 17 and instructions for taxiing to runway 12R (which intersected runway 17 near the approach end of the runway). On the basis of these actions, the Safety Board classified Safety Recommendation A-89-15 “Closed—Acceptable Action” on July 12, 1989. Safety Recommendation A-89-74 Although the Safety Board believed that the actions taken by the FAA and the HOU airport authority were responsive toward eliminating additional inadvertent departures from runway 17 at HOU, the Board was concerned about preventing similar incidents at other airports. The Board thought that the incidents at HOU could have been prevented if the flight crews had compared their heading indicators with the runway heading as the crews aligned their airplanes with the runway centerline. Also, in its final report on the December 23, 1983, accident involving Korean Air Lines flight 84 and South Central Air flight 59, the Board found that the Korean Air Lines airplane was on the wrong runway and that the flight crewmembers could have made this determination if they had compared their heading indicator with the runway heading.131 As a result, on July 17, 1989, the Safety Board issued Safety Recommendation A-89-74, which asked the FAA to do the following: Assure that the ‘Normal Procedures’ section of the operations manuals of all air carriers operating under Title 14 Code of Federal Regulations Parts 121 and 135 requires flightcrews to cross-check the heading 130  The first incident occurred on January 10, 1989, when Eastern Airlines flight 536, a McDonnell Douglas DC-9, struck barricades on rotation during the takeoff roll from runway 17 (which had been closed because of construction) and overflew workers and equipment. The flight continued to its destination without further incident. The second incident occurred on March 23, 1989, when American Airlines flight 508, a McDonnell Douglas MD-82, struck a barricade on rotation during the takeoff roll from runway 17 (which was still closed). The flight continued to its destination without further incident. 131  For more information, see National Transportation Safety Board, Korean Air Lines, McDonnell Douglas DC-10-30, HL 7339, South Central Air Piper PA-31-350, N35206, Anchorage, Alaska, December 23, 1983, Aircraft Accident Report NTSB/AAR-84/10 (Washington, DC: NTSB, 1984).

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 46 indicator to the runway heading when the airplane is aligned with the runway for takeoff. On September 28, 1989, the FAA stated that almost every Part 121 and 135 air carrier had incorporated the recommended procedure into their before takeoff checklist. Nevertheless, the FAA stated that it planned to revise Air Carrier Operations Bulletin (ACOB) 8-85-1, “Crewmember Procedures and Responsibilities During Ground Operation in Restricted Visibility Conditions,”132 to address this procedure. On August  22, 1990, the FAA stated that it revised ACOB 8-85-1, to address the cross-check of the heading indicator to the runway heading when an airplane is aligned with the runway for takeoff. As a result of this action, the Safety Board classified Safety Recommendation A‑89-74 “Closed—Acceptable Action” on December 11, 1990. Safety Recommendations A-06-83 and -84 On December 12, 2006, the Safety Board issued Safety Recommendations A‑06‑83 and -84 after identifying that multiple Part 121 operators (including Comair) did not have procedures for positively verifying that an airplane is aligned on the correct departure runway133 and learning that some Part 121 operators (including Comair) did not provide guidance to their pilots about conducting takeoffs at night on unlighted runways.134 Safety Recommendations A-06-83 and -84 asked the FAA to do the following: Require that all 14 Code of Federal Regulations Part 121 operators establish procedures requiring all crewmembers on the flight deck to positively confirm and cross-check the airplane’s location at the assigned departure runway before crossing the hold short line for takeoff. (A-06-83) Require that all 14 Code of Federal Regulations Part 121 operators provide specific guidance to pilots on the runway lighting requirements for takeoff operations at night. (A-06-84) The FAA responded to these recommendations on March 13, 2007. With regard to Safety Recommendation A-06-83, the FAA stated that it intended to issue a SAFO 132  As part of its investigation into the accident, the Safety Board issued Safety Recommendation A‑84‑102, which asked the FAA to “require that air carriers incorporate in training of their crewmembers procedures and responsibilities during ground operations in restricted visibility conditions to enable them to operate safely in such conditions.” In response, the FAA issued ACOB 8-85-1 in May 1985. The Board classified Safety Recommendation A‑84‑102 “Closed—Acceptable Action” on September 12, 1985. 133  On March 23, 2007, Comair revised its operations manual to include a section titled, “Departure Runway Check.” This section states the following: “when taxiing onto the runway for departure, both flight crewmembers must check airplane heading to ensure that the heading corresponds to the assigned departure runway. The heading check must be used in conjunction with external cues to confirm the correct runway.” This procedure was added to the company’s lineup checklist. 134  The Safety Board’s postaccident survey of Part 121 operators revealed inconsistencies among those operators with rules governing or prohibiting takeoff operations from an unlighted runway at night. For example, one operator prohibited such takeoffs unless the flight crew was given permission from the company’s director of operations, who evaluated the risks involved. Another operator authorized takeoffs on unlighted runways as long as the visibility was adequate and enough ambient light was available for the flight crew to identify the runway surface and maintain directional control during the takeoff roll.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 47 recommending that “directors of safety, directors of operations, trainers, and pilots develop and implement explicit standard operating procedures to be contained in pilots’ operating manuals, supported in their training, and practiced in daily operations.” The FAA also stated that the SAFO would “emphasize the importance of making a final confirmation that the airplane is on the assigned runway once it has crossed the hold short line onto the runway.” (SAFO 07003, “Confirming the Takeoff Runway,” was issued on April 16, 2007.) The FAA further stated that it would also consider addressing this issue in Part 121 training requirements. With regard to Safety Recommendation A-06-84, the FAA stated that it planned to issue an Information for Operators (InFO) message135 that would reach directors of safety, directors of operations, trainers, and pilots in Parts 121, 125, 135, and 91. The InFO was expected to make two points: “no runway lights, no takeoff at night” and “no takeoff on a closed runway.” The FAA stated that the InFO would also recommend that directors of safety, directors of operations, trainers, and pilots of air carriers operating under Part 121 collaborate to include these key points in their pilots’ manuals and training programs and to have pilots apply the key points during flight operations. (InFO 07009, “Runway Lights Required for Night Takeoffs in Part 121, was issued on May 11, 2007.) The Safety Board’s analysis of the FAA’s actions in response to Safety Recommendations A-06-83 and -84 and the Board’s classifications for the recommendations are discussed in section 2.4.1. Air Traffic Control 1.18.3.2  Safety Recommendation A-00-67 On July 6, 2000, the Safety Board issued Safety Recommendations A-00-67 and ‑68 to address safety issues related to runway incursions and other airport surface events. Safety Recommendations A-00-67 and -68 asked the FAA to do the following: Amend 14 Code of Federal Regulations (CFR) Section 91.129(i) to require that all runway crossings be authorized only by specific air traffic control clearance, and ensure that U.S. pilots, U.S. personnel assigned to move aircraft, and pilots operating under 14 CFR Part 129 receive adequate notification of the change. (A-00-67) Amend Federal Aviation Administration Order 7110.65, “Air Traffic Control,” to require that, when aircraft need to cross multiple runways, air traffic controllers issue an explicit crossing instruction for each runway after the previous runway has been crossed. (A-00-68) 135  On October 20, 2006, the FAA issued Order N8000.91 to establish a method of sending information to operators in a timely manner. According to the order, an InFO message contains “valuable information for operators that should help them meet administrative requirements or certain regulatory requirements with relatively low urgency or impact in safety.” InFO messages are not mandatory.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 48 In an April 11, 2006, letter to the FAA, the Safety Board stated that it met with the FAA on June 30, 2005, to discuss safety recommendations related to runway incursions. During the meeting, the FAA cited its study of 1,300 runway incursion events involving pilot deviations and controller operational errors. The FAA found that only 28 of the 1,300 events included the use of 14 CFR 91.129(i) as a causal factor. The Board expressed concern with the FAA’s findings and noted that, during the first 6 months of 2005, the Board identified six cases that were relevant to Safety Recommendations A‑00‑67 and ‑68. Because the Board found six cases in a 6-month period using a more limited set of data than the FAA, the Board questioned whether the FAA considered the most appropriate data source for its study and whether the FAA might have applied criteria in the study that were too restrictive. During the June 2005 meeting, the FAA also stated its belief that no safety problem existed when proper procedures were followed and that pilots should never cross a runway unless authorized to do so. The Safety Board’s April 2006 letter expressed concern about situations in which pilots might be lost or pilots might believe that they had received permission to move to a position that was different than the one that the controller intended. Thus, because 14 CFR 91.129(i) allows pilots to cross a runway without requesting a specific clearance to do so, the regulation may not provide adequate protection against simple, individual mistakes that can have catastrophic consequences. Accordingly, the Board classified Safety Recommendations A-00-67 and -68 “Open— Unacceptable Response.” Safety Recommendations A-07-30 through -32 On April 10, 2007, the Safety Board issued Safety Recommendations A-07-30 and ‑31 to the FAA and A-07-32 to the National Air Traffic Controllers Association (NATCA) as a result of the Board’s concern about the effects of fatigue on air traffic controllers’ performance. Safety Recommendations A-07-30 and -31 asked the FAA to do the following: Work with the National Air Traffic Controllers Association to reduce the potential for controller fatigue by revising controller work-scheduling policies and practices to provide rest periods that are long enough for controllers to obtain sufficient restorative sleep and by modifying shift rotations to minimize disrupted sleep patterns, accumulation of sleep debt, and decreased cognitive performance. (A-07-30) Develop a fatigue awareness and countermeasures training program for controllers and for personnel who are involved in the scheduling of controllers for operational duty that will address the incidence of fatigue in the controller workforce, causes of fatigue, effects of fatigue on controller performance and safety, and the importance of using personal strategies to minimize fatigue. This training should be provided in a format that promotes retention, and recurrent training should be provided at regular intervals. (A-07-31)

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 49 Safety Recommendation A-07-32 asked NATCA to do the following: Work with the Federal Aviation Administration to reduce the potential for controller fatigue by revising controller work-scheduling policies and practices to provide rest periods that are long enough for controllers to obtain sufficient restorative sleep and by modifying shift rotations to minimize disrupted sleep patterns, accumulation of sleep debt, and decreased cognitive performance. (A‑07-32) On July 5, 2007, the FAA responded to Safety Recommendations A-07-30 and ‑31. Regarding Safety Recommendation A-07-30, the FAA stated that it had convened a working group to develop shift rotation and scheduling guidelines. According to the FAA, this working group would be chaired by an FAA quality assurance safety manager and a CAMI human factors fatigue expert, and the group would consist of members of the FAA’s Air Traffic Organization operational service units and operations planning service unit. The FAA stated that NATCA would be invited to participate by providing subject matter expertise. Regarding Safety Recommendation A-07-31, the FAA stated that it would develop and implement a fatigue awareness and countermeasures training program to be used by all Air Traffic Organization operational service units. The FAA also stated that its director of technical training would be the lead for the development and implementation of the curriculum and that CAMI fatigue experts would be providing technical support. In addition, the FAA stated that the modules being developed for initial training of TRACON, tower, and en route ATC specialists would incorporate fatigue awareness information and that initial curriculum content would be developed within 12 months. The Safety Board’s analysis of the FAA’s actions in response to Safety Recommendations A-07-30 and -31 and the Board’s classifications for the recommendations are discussed in section 2.2.3.3. Safety Recommendation A-07-32 is currently classified “Open—Await Response.” Safety Recommendation A-07-34 On April 10, 2007, the Safety Board issued Safety Recommendation A-07-34 to the FAA as a result of the Board’s concern about issues related to controller vigilance, judgment, and safety awareness. Safety Recommendation A-07-34 asked the FAA to do the following: Require all air traffic controllers to complete instructor-led initial and recurrent training in resource management skills that will improve controller judgment, vigilance, and safety awareness. On July 13, 2007, the FAA stated that it had delivered CRM workshops, posters, and follow-up support to the Phoenix, Chicago, Boston, and Los Angeles ATCTs and the Las Vegas, Philadelphia, and Miami ATCTs and TRACONs. The FAA also stated that the CRM implementation plan for fiscal years 2007 through 2009 included instructor‑led

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 50 training at “a percentage of” the highest-error-rate terminal and en route facilities and CRM training for initial hires in the FAA Academy and college training initiative programs. The FAA further stated that it would develop plans to train additional controllers on an initial and a recurrent basis. The Safety Board’s analysis of the FAA’s actions in response to Safety Recommendation A-07-34 and classification for the recommendation are discussed in section 2.2.3.2. Related Accident and Incidents 1.18.4  In addition to the 1989 Eastern Airlines flight 536 and American Airlines flight 508 incidents at HOU and the 1983 Korean Air Lines flight 84/South Central Air flight 59 accident in Anchorage (see section 1.18.3.1), the Safety Board has identified the following related accident and incidents: Singapore Airlines Flight 006 Accident On October 31, 2000, Singapore Airlines flight 006, a Boeing 747, crashed during an attempted takeoff from a partially closed runway at Chiang Kai-Shek International Airport, Taoyuan, Taiwan.136 Of the 179 occupants aboard the airplane, 83 were killed. The report by Taiwan’s Aviation Safety Council found that the pilots did not adequately review the taxi route to ensure that they understood that the route to runway 5L (the correct departure runway) required passing runway 5R (a parallel runway that was under construction and open only for taxi operations). The report also stated that the pilots did not verify the airplane’s position with the taxi route as they were turning onto the runway and that the company’s operations manual did not include a procedure to confirm an airplane’s position on the active runway before initiating takeoff. The report concluded that the flight crew lost situational awareness and took off from the wrong runway despite numerous available cues that provided information about the airplane’s position on the airport.137 The Aviation Safety Council recommended that Singapore Airlines “include in all company pre-takeoff checklists an item formally requiring positive visual identification and confirmation of the correct takeoff runway.” China Airlines Flight 011 Incident On January 25, 2002, China Airlines flight 011, an Airbus A340, departed from a taxiway at Ted Stevens Anchorage International Airport, Anchorage, Alaska, instead of the assigned runway. The available distance on the taxiway was 6,800 feet, but the airplane’s calculated takeoff distance was 7,746 feet. The airplane took off, but its main landing gear left impressions in a snow berm at the end of the taxiway. The airplane proceeded to 136  In accordance with the provisions of Annex 13 to the Convention on International Civil Aviation, the Safety Board participated in the investigation of this accident as a representative of the State of Manufacture. 137  Aviation Safety Council, Crashed on a Partially Closed Runway During Takeoff, Singapore Airlines Flight 006, Boeing 747-400, 9V-SPK, CKS Airport, Taoyuan, Taiwan, October 31, 2000, Aircraft Accident Report (Taiwan, Republic of China: Aviation Safety Council, 2002).

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 51 its destination and landed without further incident. The Safety Board determined that the probable cause of this incident was the captain’s selection of a taxiway instead of a runway for takeoff and the flight crew’s inadequate coordination of the departure, which resulted in a departure from a taxiway. The Board determined that a contributing factor to the incident was the lack of an operator requirement for the flight crew to verbalize and verify the runway in use before takeoff.138 As a result of this incident, China Airlines modified its Airbus A340 operating manual to include verbalization and verification of the runway in use. Alaska Airlines Flight 61 Incident On October 30, 2006, Alaska Airlines flight 61, a Boeing 737, took off from runway  34R instead of runway 34C (center), which was the assigned runway, at Seattle‑Tacoma International Airport (SEA), Seattle, Washington. The airplane continued uneventfully to its destination of Juneau International Airport, Juneau, Alaska.139 According to the captain of the flight, the ATIS that was current at the time indicated that departing aircraft were taking off either with the full length of runway 34R or at the point where the runway intersected taxiway Q. The first officer of the flight stated that the takeoff briefing included a departure from runway 34R. The captain stated that the controller instructed the flight crew to follow a Boeing 757 to runway 34R and that the 757 departed from runway 34R where the runway intersected taxiway Q. The captain also stated that the controller instructed the crew to taxi the airplane into position and hold on runway 34C. Further, even though he repeated this information to the controller, the captain was still thinking that the airplane would be taking off from runway 34R. During this time, the first officer was completing flight paperwork and conducting other preflight activities. After receiving takeoff clearance from runway 34C from the controller, the captain stated that he lined up the airplane on runway 34R and transferred control of the airplane to the first officer. The airplane departed uneventfully from runway 34R. According to the controller, he was scanning the runways and noticed that the airplane was rolling on runway 34R abeam the tower instead of runway 34C. Because there were no potential air traffic conflicts at the time, the controller thought that it would be safer to let the airplane depart from runway 34R than to have the pilots abort the takeoff. After the airplane had taken off, the controller informed the flight crew that the airplane had departed from the wrong runway. 138  More information about this accident, ANC02IA011, is available at the Safety Board’s Web site at http://www.ntsb.gov. 139  More information about this accident, DCA07IA008, is available at the Safety Board’s Web site at http://www.ntsb.gov.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 52 United Airlines Flight 1404 Incident On April 18, 2007, about 0625, United Airlines flight 1404, an Airbus A320, taxied onto a closed runway at Miami International Airport (MIA), Miami, Florida, and began its takeoff roll. Night VMC prevailed at the time. A NOTAM indicated that runway 9/27 was closed from 2300 on April 17 to 1000 on April 18; the NOTAM was included in the flight release paperwork. The runway closure was also included in the ATIS information broadcast. The flight crewmembers reported that they had the airport charts out and available. The controller told the flight crew to taxi the airplane to runway 30. The captain stated that he observed taxiway S almost directly opposite from the airplane’s position and chose to make a left turn from taxiway S onto taxiway Q. This parallel taxi route placed the airplane adjacent to runway 30, the assigned runway for takeoff. The captain stated that, as the airplane passed the intersection with taxiway T, he verified that the runway sign was for runway 30. The first officer stated that, during this time, he was busy with flight paperwork and was accomplishing flight control checks. Taxiway Q made a slight bend to the left after the intersection with taxiway T so that the taxiway was parallel with runway 27. The captain stated that he saw a runway, which he believed to be runway 30, when he looked to the right. The first officer called the tower and advised that the airplane was ready to depart on runway 30. The controller cleared the airplane for takeoff from runway 30 while the airplane was still on taxiway Q. The first officer acknowledged the clearance for takeoff but did not state the runway number for the departure. The captain stated that, as the airplane neared the end of taxiway Q, he observed the hold short line and that, because the airplane was cleared for takeoff, he chose to turn directly onto the runway without stopping and transfer control of the airplane to the first officer. The first officer stated that his heading display was rotating to the right and in the correct direction to line up with the runway, which was still located to the right. The first officer stated that he advanced the throttles, and, just before they reached the cruise thrust position, the airplane’s nose wheel light illuminated a truck flashing its lights on the right side of the runway. The captain and the first officer stated that they observed the truck at the same time. Simultaneously, the controller was querying the flight crew to determine whether the airplane was on runway 30. The first officer rejected the takeoff, and the captain assumed control of the airplane. Ramp personnel called the tower to advise that an airplane was on a closed runway, and the controller acknowledged this information. The controller subsequently advised the crew to use caution for workers and equipment on runway 27 and instructed the flight crew to taxi the airplane to runway 30. The airplane then took off to its destination airport—Dulles International Airport, Chantilly, Virginia—without further incident.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 53 The pilots reported that the runway 27 edge lights were on. However, an airport engineer who witnessed the incident stated that he immediately scanned runway 27 after the event and noted that the runway edge lights were off. Aviation Safety Reporting System Reports 1.18.5  The National Aeronautics and Space Administration’s aviation safety reporting system (ASRS) showed 114 reports of incidents from March 1988 to September 2005 in which flight crews of turbojet airplanes lined up on the wrong runway for takeoff. The ASRS reports indicated that wrong runway takeoff events involved both intersecting and parallel runways. The ASRS reports also indicated that the pilots involved in these events, pilots of other aircraft in the area at the time, or air traffic controllers detected the mistake either before or after takeoff. An ASRS report submitted in 1993 by an air carrier pilot operating out of LEX stated that the flight had been cleared for an immediate takeoff on runway 22 but that, because of the weather, the flight crewmembers told the controller that they “needed a moment to check departure routing with weather radar.” The report further stated that the flight crew realized that the airplane’s heading was not correct for the assigned runway and that “at that moment [the] tower called … to cancel takeoff clearance because [the airplane was] lined up on runway 26.” The pilot who submitted the report cited poor visibility and rain as factors in this event along with a “confusing” runway intersection in which multiple runway ends were in the same general location. Local Notices to Airmen Information 1.18.6  FAA Order 8400.10, “Aviation Safety Inspectors Handbook,” volume 3, chapter 6, states the following in paragraph 1151, “Flight Information”: NOTAM (L) or local information includes such information as airport and taxiway construction and certain airport lighting. This information is directly relevant to surface movement guidance and control. NOTAM (L) s can also contain information that is expected to be in effect for less than 1 hour concerning NAVAIDS [navigational aids], lighting, and runways. NOTAM (L)s are not normally transmitted beyond the area of coverage for the local FSS [flight service station] or automated flight service station.[140] LEX sends local NOTAMs via fax to its airport tenants. At Comair, the local NOTAMs are received by the System Operations Control Center at company headquarters. The local NOTAMs are then taken to the System Operations Control Center’s performance analyst, who reviews the local NOTAM. If the analyst determines 140  The other NOTAM categories are distant NOTAMs, which include information such as navigational aids, landing areas, and airport lighting facilities, and flight data center NOTAMs, which are regulatory in nature. All distant and flight data center NOTAMs are disseminated globally by the FAA and are included in flight dispatch paperwork.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 54 that the information might have an impact on a flight’s schedule, then the analyst forwards the local NOTAM to Comair’s planning performance group, which might make an adjustment to the schedule. If the analyst determines that the information in the local NOTAM might have an operational impact on the flight, then the analyst sends the information to the flight standards department for review. The department might decide to issue the local NOTAM as a company NOTAM. All company NOTAMs are included in the flight planning system and the flight dispatch paperwork. In a July 2007 meeting, the FAA told the Safety Board that it was planning to align the U.S. NOTAM system with that of the International Civil Aviation Organization (ICAO)141 in October 2007, at which time local NOTAMs would be converted to distant NOTAMs (because ICAO does not have local NOTAMs). According to the FAA, aligning with ICAO’s standard NOTAM procedures will help U.S. NOTAM information be processed in a more timely, accurate, complete, and traceable manner. The FAA indicated that training on new NOTAM policies and procedures would begin in August  2007. Also, the FAA has other planned actions to modernize the current NOTAM system; these actions include having digital NOTAM data displayed in the cockpit in textual and graphical formats.142 Enhanced Taxiway Centerline Markings and Surface Painted 1.18.7  Holding Position Signs In 2002, the FAA’s Office of Runway Safety and Operation Services sponsored a study to determine whether it was feasible to use paint markings to improve the situational awareness of pilots taxiing on the airfield. The study, which was undertaken by the Mitre Corporation, comprised an aviation industry team and a human factors team. A January 2005 Mitre Corporation report found that enhanced taxiway centerline markings (that is, parallel yellow dashed lines on a black background that appear on either side of a taxiway centerline for 150 feet before a runway holding position marking) provided “beneficial redundancy” to pilots and increased awareness that the pilots were entering the runway environment.143 The report also found that surface painted holding position signs (that is, white runway numbers on a red background that appear just before a runway holding position marking) were effective in increasing runway awareness among transport-category pilots. In spring 2005, authors of this report stated the following:144 141  The ICAO Council, among other things, adopts standards and recommended practices concerning air navigation. 142  This information was discussed at the FAA’s May 2007 “NOTAM Industry Day” briefing. 143  Cheryl R. Andrews, Steven L. Estes, Dr. Peter M. Moertl, and B. Oscar Olmos, Summary of Airport Surface Marking Project, Product No. 05W0000005, McLean, Virginia: Mitre Corporation, 2005. 144  Steven Estes, Oscar Olmos, Cheryl Andrews, Anthony D. Andre, Susan Chrysler, and Dan Hannon, “Better Taxiway Surface Markings: Safer Airports,” Ergonomics in Design, Spring 2005.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 55 Surface painted holding position signs meet several design goals. The orientation of the text supports directional information … they are also easy to understand because they mirror existing vertical signage and airport marking standards … they are easier to find because they are collocated with the hold line. Figure 5 shows an example of enhanced taxiway centerline markings and surface painted holding position signs. Enhanced taxiway centerline markings are not currently required, but, by June 30, 2008, all Part  139 airports with 1.5 million or more annual passenger enplanements will be required to have these markings before each runway holding position. Surface painted holding position signs are currently required only where the width of the holding position on the taxiway is greater than 200 feet. Enhanced Taxiway Centerline Markings and Surface Painted Holding Figure 5.  Position Signs Department of Transportation Inspector General Report 1.18.8  The Department of Transportation Inspector General’s (DOT/IG) office issued a report, dated March 16, 2007, that presented the results of the office’s review of staffing at combined radar approach control and tower with radar facilities.145 The report stated that the FAA’s vice president of terminal services issued verbal guidance in August 2005 indicating that two controllers should normally be on duty at those facilities that have 145  U.S. Department of Transportation, Review of Staffing at FAA’s Combined Radar Approach Control and Tower With Radar Facilities, Report Number AV-2007-038 (Washington, DC: DOT, 2007). 16 - 34 16 - 34 Hold short line Surface painted holding position sign Surface painted holding position sign Enhanced taxiway centerline markings

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 56 radar and tower functions. The report also stated that the vice president expected his area directors to disseminate this guidance to their hub managers who, in turn, would disseminate the guidance to facility managers. The DOT/IG found that, because the guidance was verbal, it was misinterpreted and inconsistently applied. The DOT/IG reviewed a statistical sample of 20 randomly selected weeks of staffing data (between August 28, 2005, and September 2, 2006) for the midnight shift at 15 of 62 facilities (a total of 2,100 shifts). The review identified 234 midnight shifts during which only one controller was scheduled. On the basis of this finding, the DOT/IG statistically projected (with a 95-percent confidence level) that about 2,563, or 11.1 percent of the 23,002 total midnight shifts at the 62 facilities were staffed with one controller between August 28, 2005, and September 2, 2006. The report noted that the number of noncompliant facilities was higher at the beginning of the sample period than toward the end. The DOT/IG also found evidence suggesting that, even when two controllers were on duty during the midnight shift, the radar and tower duties were combined for substantial periods instead of being staffed separately. The report stated that position logs at several facilities showed that the two controllers on duty alternated between working the combined position and taking breaks. In addition, the DOT/IG found that, before the Comair accident, the FAA had no controls in place to ensure that facilities had consistently implemented the verbal staffing policy guidance and were uniformly complying with it. The report noted that, after the accident, the FAA formalized the verbal guidance into Notice N JO 7210.639. The DOT/IG recommended that the FAA communicate in writing all future guidance changing or reiterating existing air traffic policies and procedures to ensure uniform implementation and compliance. The DOT/IG also recommended that the FAA develop and implement appropriate policies and procedures to ensure that facilities are complying with the provisions of FAA Notice N JO 7210.639.

National Transportation Safety Board A I R C R A F T Accident Report 57 Analysis

General 2.1  The captain and the first officer were properly certificated and qualified under Federal regulations. There was no evidence of any medical or behavioral conditions that might have adversely affected their performance during the accident flight. Before reporting for the accident flight, the flight crewmembers had rest periods that were longer than those required by Federal regulations and company policy. The accident airplane was properly certified, equipped, and maintained in accordance with Federal regulations. The recovered components showed no evidence of any structural, engine, or system failures. Weather was not a factor in this accident. No restrictions to visibility occurred during the airplane’s taxi to the runway and the attempted takeoff. The taxi and the attempted takeoff occurred about 1 hour before sunrise during night VMC and with no illumination from the moon. This analysis discusses the taxi and attempted takeoff sequence and the associated human factor issues, survival factors, efforts to mitigate surface navigation errors, ATC staffing, and other issues related to the accident flight. Taxi and Attempted Takeoff Sequence 2.2  The pilots attempted to take off from a different runway than the airplane had been cleared to use. Section 2.2.1 details the events leading to the attempted takeoff, section 2.2.2 considers the pilot human factors that might have played a role in this surface navigation error, and section 2.2.3 explains the ATC human factors that might have played a role. Wrong Runway Departure 2.2.1  Before Taxi Activities 2.2.1.1  The Comair Operations Manual indicated that the captain was to conduct the taxi briefing. The briefing was to incorporate Comair standard taxi information, including that both flight crewmembers should have the appropriate airport diagrams out and available and that traversing runways required extra diligence. Comair standard taxi information was to be briefed in its entirety for the first flight as a crew and could be abbreviated to “Comair standard” for subsequent flights. The accident flight was the pilots’ first flight

Analysis National Transportation Safety Board A I R C R A F T Accident Report 58 as a crew, but, about 0556:14, the captain stated “Comair standard” instead of all of the information in that portion of the taxi briefing, including that runway 26 was to be crossed while navigating to runway 22. The abbreviated briefing was contrary to company policy, and the Safety Board notes that it is prudent for pilots to fully conduct taxi briefings according to standard operating procedures. However, despite this abbreviated briefing (which occurred about 10 minutes before the accident), multiple and more salient cues existed to aid the flight crew while navigating to the runway, and the airport navigation task was relatively simple,146 as discussed in this analysis. The first officer was the flying pilot for the accident flight. About 0557:23, he briefed the taxi route as part of the takeoff briefing,147 stating, “let’s take it out and … take … [taxiway] Alpha. Two two’s a short taxi.” Although the CVR did not record either pilot explicitly referencing the airport chart, this statement is consistent with the first officer examining the chart because no specific taxi instructions had been provided to the flight crew. Also, the number of times that each crewmember had previously arrived at or departed from LEX was likely not sufficient to allow either one to have memorized taxiway identifiers and routes. During the takeoff briefing, the first officer stated that the runway end identifier lights were out and then commented, “came in the other night it was like … lights are out all over the place.” The first officer was referring to observations he made on a repositioning flight that landed on runway 22 about 0140 on the day before the accident. (The right runway edge lights after the intersection of runway 22 with runway 26 were out at that time.) The first officer did not brief that the taxi to runway 22 required crossing runway 26. The Safety Board was unable to determine why this information was not included in the first officer’s briefing. It is possible that the simplicity of the taxi and the use of only one taxiway might have led him to assume that it was unnecessary to include this additional information in his briefing. During postaccident interviews, other pilots indicated that they would brief this “short taxi”148 in a similar manner. No evidence indicated that the pilots were unaware of the need to cross runway 26 to arrive at runway 22. About 0602:01, the first officer notified the controller that the airplane was ready to taxi. The controller then instructed the flight crew to taxi the airplane to runway 22. Title 14 CFR 91.129(i), “Takeoff, Landing, Taxi Clearance,” permits pilots instructed to taxi to a point on the airport surface to cross all intersecting runways along the taxi route (without stopping) except for the assigned departure runway.149 Thus, the controller’s clearance for the airplane to taxi to runway 22 complied with 14 CFR 91.129(i), and the first officer’s response of “taxi two two” was an appropriate acknowledgment of the taxi 146  Comair’s high threat taxi procedures are used at those airports with an operating environment that presented “exceptional” hazards to safe taxi. However, these procedures were not in place for operations at LEX at the time of the accident. 147  As stated in section 1.1, the takeoff briefing is part of the before starting engines checklist. 148  Taxiway A is used for the taxi to both runways 4 and 22, but the taxi to runway 22 is significantly shorter than the taxi to runway 4, as shown on airport charts (see appendix C). 149  This regulation is discussed further in section 2.4.4.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 59 instruction. Because two airplanes, SkyWest flight 6819 and American Eagle flight 882, were given the same taxi clearance and had already correctly taxied to and held short of runway  22 without any special instructions, there was no apparent reason for the controller to have suspected that the pilots would have had difficulty navigating to the departure runway.150 Taxi to Runway 2.2.1.2  From about 0603:16 to 0603:56, while the captain was taxiing the airplane and performing navigational checking activities, both pilots resumed the nonpertinent discussion that was started while the airplane was parked at the gate. (Figure 1 shows the location of the airplane along the taxi route while this conversation was occurring.) The nonpertinent conversation was not in compliance with the sterile cockpit rule required by company procedures and 14 CFR 121.542 (see section 1.17.1.3). The primary reason for the sterile cockpit rule is to ensure that the pilots’ attention is directed to operational concerns during critical phases of flight (including taxi) and is not redirected or degraded because of nonessential activities or discussion. FDR data showed that, about 0604:33, the airplane stopped on taxiway A at the hold short line for runway 26, which was about 560 feet from the intended destination— the hold short line for runway 22. During this time, the first officer was completing the before takeoff checklist. About 0605:15, the first officer advised the controller that the airplane was ready to depart, and the controller told the flight crew that the airplane should fly the runway heading and was cleared for takeoff. Neither the first officer nor the controller stated the runway number during the request and clearance for takeoff, but ATC procedures did not require them to do so. Because the flight crew believed that the airplane was at the hold short line for runway 22 at the time of the takeoff clearance (see section 2.2.2.3), the absence of a reference to runway 22 in the request and clearance for takeoff was not a factor in this accident. The 50-second timeframe during which the airplane was stopped at the runway 26 hold short line should have provided the flight crew with ample time to look outside the cockpit and determine the airplane’s position on the airport. At this position, the flight crew would have been able to see the runway 26 holding position sign, the “26” painted runway number, the taxiway A lights across runway 26, and the runway 22 holding position sign in the distance.151 FDR data showed that, about 0605:24, the captain began to taxi the airplane across the runway 26 hold short line. FDR data also showed that, about 0605:41, the airplane began to turn onto runway 26, and the CVR showed that, about 0605:46, the first officer completed the lineup checklist. 150  In accordance with FAA Order 7110.65, “Air Traffic Control,” paragraph 3-7-2, the controller would have been required to provide turn-by-turn directions to the departure runway if the flight crew had so requested. 151  During the 50-second timeframe, the controller did not query the flight crew regarding why the airplane was stopped at the hold short line for runway 26. The controller’s actions during the taxi and attempted takeoff sequence are discussed in section 2.2.3.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 60 Takeoff Roll 2.2.1.3  About 0605:58, the captain transferred control of the airplane to the first officer, stating, “all yours,” to which the first officer acknowledged, “my brakes, my controls.” At this time, the captain would have switched his attention from outside to inside the cockpit, and the first officer would have switched his attention from inside to outside the cockpit. About 2 seconds later, the airplane was aligned with the centerline for runway 26. The CVR recording showed that the flight crew had referred to runway 22 as the departure runway multiple times before takeoff, and FDR data showed that the pilots’ heading bugs were set to 227º, which was consistent with the magnetic heading for runway 22. The Safety Board concludes that the captain and the first officer believed that the airplane was on runway 22 when they taxied onto runway 26 and initiated the takeoff roll. About 0606:16, the first officer stated, “[that] is weird with no lights,” to which the captain responded, “yeah.” At that time, the airplane was passing through the intersection of runway 26 with runway 22. About 0606:24, the captain called the 100‑knot airspeed check. About the same time, the airplane accelerated beyond the maximum airspeed that would have allowed the airplane to remain on the available runway if the flight crew had rejected the takeoff and used maximum braking.152 At 0606:31.2, the captain called, “V one, rotate,” followed immediately by his exclamation, “whoa.” The aircraft performance study for this accident showed that, at the time of the VR callout, the airplane was 236 feet from the end of the runway. The appearance of the runway end environment would have provided a salient cue to the flight crew that the airplane was in an extremely hazardous situation and could not remain on the ground. The airplane’s airspeed at the time of the captain’s VR callout was 131 knots, which was 11 knots below the planned VR airspeed of 142 knots (which the flight crew had briefed and entered into the airplane’s EFIS).153 Thus, the captain’s early VR callout and subsequent “whoa” exclamation indicated that he recognized that something was wrong with the takeoff. FDR data showed that, in response, the first officer pulled the control column full aft154 and that the airplane rotated at a rate of about 10º per second, which is three times the normal rotation rate. This abnormal column input showed that the first officer also recognized that something was wrong with the takeoff. Although numerous cues, including the lack of runway lighting, were available to indicate that the airplane was not on the assigned runway (see sections 2.2.2.1 and 2.2.2.3), 152  According to calculations by Bombardier, for the airplane to have stopped before the end of runway 26, maximum braking would have had to start when the airplane was at an airspeed of about 103 knots. 153  FDR data for the accident airplane’s 12 previous takeoffs indicated that rotation occurred at or after reaching the VR airspeed. 154  FDR data showed that the left and right control column inputs during the accident rotation reached 10.6º and 10.9º, respectively, and that the nominal control column input for rotation during the accident airplane’s 12 previous takeoffs was between 4º and 5º.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 61 the flight crew had not correctly interpreted these cues or noticed them until after it was too late to successfully abort the takeoff. The Safety Board concludes that the flight crew recognized that something was wrong with the takeoff beyond the point from which the airplane could be stopped on the remaining available runway. Runway Incursions 2.2.1.4  The FAA currently defines a runway incursion as “any occurrence in the airport runway environment involving an aircraft, vehicle, person, or object on the ground that creates a collision hazard or results in a loss of required separation with an aircraft taking off, intending to take off, landing, or intending to land.” ICAO defines a runway incursion as “any occurrence at an aerodrome involving the incorrect presence of an aircraft vehicle or person on the protected area of a surface designated for the landing and take-off of aircraft.” According to these definitions, ICAO would classify this accident as a runway incursion, but the FAA would not consider this accident to be a runway incursion because no other airplane impeded the accident airplane’s ability to take off. The Safety Board notes that the presence of another airplane on a runway should not be a consideration in determining whether a runway incursion has occurred; rather, criteria for making this determination should consider, among other things, whether an airplane’s movement is consistent with the clearances provided to the flight crew. As a result, the Safety Board concludes that, because the accident airplane had taxied onto and taken off from runway 26 without a clearance to do so, this accident was a runway incursion.155 At the Safety Board’s runway incursion forum in March 2007, the FAA announced that it planned to revise its definition of a runway incursion to align with ICAO’s definition by the end of fiscal year 2007 and that it would begin reporting runway incursions according to the revised definition in fiscal year 2008. The Board is encouraged by the FAA’s plan to adopt and apply the ICAO definition because wrong runway takeoffs should be reflected in runway incursion statistics so that runway safety trends can be accurately monitored and appropriate countermeasures can be taken. Pilot Human Factors 2.2.2  The flight crew’s performance on the day of the accident seemed to be uncharacteristic with past reports. The captain and the first officer were described favorably by company personnel, and pilots who had flown with them described both as competent pilots who had not previously demonstrated difficulty with airport surface operations. The captain was described as someone who managed the cockpit well, adhered to standard operating procedures, and demonstrated good CRM. The first officer was preparing for an opportunity to upgrade to captain and was described as someone who would have made a good captain because of his adherence to standard operating procedures. 155  Even though the FAA does not consider the SEA and MIA incidents (discussed in section 1.18.4) to be runway incursions, the Safety Board does consider these incidents to be runway incursions.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 62 The Safety Board examined possible reasons why the flight crew stopped at the incorrect hold short line and attempted to take off from the incorrect runway, as discussed in sections 2.2.2.1 through 2.2.2.4. Available Cues and Aids for Wayfinding 2.2.2.1  Pilots integrate many sources of wayfinding information, either alone or in combination, to establish their position and navigate to their intended destination on the airport. Wayfinding information sources include geographic knowledge of standard airport surface features that are common to all airports (such as terminal buildings, ramp areas, taxiways, and runways), knowledge of standard conventions for marking and identifying airport surface features, airport charts, and taxi instructions from ATC. Because both pilots were experienced, they should have been knowledgeable about basic airport geographic features and signage and surface marking standards (the Safety Board did not note any signage or surface markings at LEX that were not in compliance with FAA regulations), and they should have been skilled at interpreting airport charts. In addition to their knowledge about the specific route (taxiway A to runway 22), multiple external cues and features were available to the pilots to support their navigation to runway 22, and no evidence indicated that their view from the windscreen was obstructed. Observations from a CRJ-100 airplane after the accident demonstrated that, during nighttime conditions, taxiway location signs were visible along the full length of the taxi route, a runway 26 holding position sign adjacent to the runway 26 hold short line was visible, and the runway 26 numbers were visible. Also, evidence indicated that, at the time of the accident, the signs identifying the critical features along the taxi route (that is, the runway 26 holding position sign, the taxiway A extension across runway 26, and the runway 22 holding position sign) were illuminated and would have been visible to both pilots.156 The flight crewmembers had resources available to them within the cockpit to support their navigation to runway 22, including the Jeppesen airport chart. Even though discrepancies existed between the airport chart and the external cues available to the pilots because of an ongoing construction project at the airport,157 the chart depicted the paved taxiway and runway surfaces at the time of the accident. Another available resource within the cockpit was the instrumentation, including the heading bug, which had been set to 227º to correspond to the magnetic heading for runway 22. This heading information, which was clearly presented on both flight crewmembers’ MFDs and PFDs, would have provided the pilots with a real-time cue of their orientation relative to runway 22. 156  Although the first officer’s attention was focused inside the cockpit while the airplane was taxiing to the departure runway, he would have had multiple opportunities to look outside the cockpit and monitor the airplane’s progress along the taxi route. Such monitoring would have helped the first officer gauge and pace his activities with the available time left for taxi. 157  Taxiway A north of runway 26 had been closed (as indicated by a local NOTAM) and barricaded, and taxiway A5 had been redesignated as taxiway A. Neither of these changes was depicted on the airport chart. However, no evidence indicated that either pilot was confused by the discrepancies. In addition, the pilots of SkyWest flight 6819 and American Eagle flight 882 used the same chart to navigate to runway 22.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 63 In addition, the flight crewmembers could have communicated with the controller if they became unsure of their position at any time.158 However, the CVR did not record any statement by either flight crewmember about being unsure of the airplane’s position on the airport surface at any time during the taxi and takeoff roll. The CVR also did not record any indication that the crewmembers had attempted to confirm the airplane’s position on the runway before beginning the takeoff roll. The taxi routing and cues available to the accident pilots were identical to those that were available to the pilots of the two regional jets (SkyWest flight 6819 and American Eagle flight 882) that departed before Comair flight 5191. The SkyWest and American Eagle pilots had no difficulty identifying, and successfully navigating to, runway 22 using the available cues,159 even with the differences in taxiway signage and chart labeling.160 In addition, even though the airport configuration at the time of the accident had been in place for 1 week, the Safety Board did not identify any reports about surface navigation problems at LEX during that time.161 The Safety Board concludes that adequate cues existed on the airport surface and available resources were present in the cockpit to allow the flight crew to successfully navigate from the air carrier ramp to the runway 22 threshold. Preflight Activities and Actions During the Taxi 2.2.2.2  Because the availability of cues and aids for the pilots’ wayfinding task was not a factor in this accident, the Safety Board examined the crew’s actions during the preflight and taxi phases of the flight’s operation to identify possible reasons for the error. The flight crew proceeded from the Comair operations center to the air carrier ramp area, where two Comair CRJ airplanes were located. The crew initially boarded the wrong airplane,162 even though the tail number of the airplane to be used for the flight 158  Such communications would have been consistent with good CRM (while at towered airports) and company policy. In addition, this behavior would have been consistent with reports of the pilots’ past performance. 159  The SkyWest first officer stated that he became “momentarily confused” about the airplane’s orientation when he looked up while crossing runway 26 but that he was able to reorient himself after identifying the holding position sign for runway 22. 160  The SkyWest and American Eagle pilots did not recall seeing the low-profile barriers on taxiway A north of runway 26. The pilots’ lack of recall in this area indicates that the barriers were not significant elements in the pilots’ wayfinding and that the taxiway A closure did not encumber their navigation to runway 22. The pilots’ lack of recall does not indicate that the barriers were inconspicuous or difficult to see when approaching or crossing runway 26. In fact, observations in a CRJ-100 airplane after the accident indicated that the barriers would have been clearly visible to the pilots during the taxi. The pilots’ failure to recall these barriers is not unusual because people can have difficulty remembering things in their environment with which they did not interact. 161  After runway 26 was reopened (November 2006), two events occurred in which air traffic controllers informed pilots that their airplanes were on that runway instead of runway 22 (see section 1.10.4). However, an interview with the pilot involved in the first event indicated that he had stopped for preflight activities, was aware of the airplane’s position, and did not intend to depart on runway 26. An interview with the captain of the flight involved in the second event indicated that he became temporarily confused about the location of runway 22 but that the airplane was never lined up to take off from runway 26. An interview with the first officer of this flight indicated that he and the captain were never confused about the correct runway for takeoff. 162  The Safety Board does not know which pilot was the first one to board the wrong airplane.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 64 was included in the flight release paperwork, and started its APU. Although these actions likely consumed a portion of the crew’s available time at the gate, CVR evidence and interviews with ground personnel indicated that neither pilot appeared to be rushed or hurried as he completed required tasks. For example, as stated in section 2.2.1.2, the CVR recorded both crewmembers involved in a detailed nonpertinent discussion before and during pushback from the gate, which indicated that both crewmembers were relaxed. In addition, FDR data showed that the navigation to the runway was conducted at a normal pace, and the controller stated that the pilots did not seem to be rushed. Thus, the available evidence indicated that the flight crew was not under time pressure. The Safety Board reviewed the CVR recording to evaluate the flight crew’s workload and focus of attention during the taxi to the runway. While the captain was maneuvering the airplane along the taxi route, the first officer was performing preflight checklists, including some additional items that were necessary because the flight was the airplane’s first flight of the day. Although FDR data showed that the taxi lasted only about 2 1/2 minutes, the first officer had adequate time to complete the preflight activities. It is important to note that the first officer was experienced in his position and that these activities, including the first-flight-of-the-day items, would have been well learned and would not have presented him with a high workload condition. In addition to navigating the airplane along its taxi route, the captain would have been overseeing the first officer’s performance and providing cross-checking as necessary. The captain was also experienced in his position and would have been skilled at dividing his attention between controlling the airplane, navigating the airport, and monitoring the first officer’s performance. Moreover, with the captain’s level of experience, the control inputs associated with controlling an airplane on an airport surface would have required very little cognitive effort. The nonpertinent conversation occurred during 40 seconds of the 150-second taxi time (from about 0603:16 to about 0603:56). The timing of this discussion and its duration are the most salient evidence to demonstrate that neither pilot was experiencing high workload at the time or considered the taxi to runway 22 to be a challenging task. However, people have limited attention resources, and, when distracted by conversation, both real-time processing of information and prospective memory (that is, remembering to do something at a later time) can suffer.163 More than 20 years of research using the ASRS database has shown that pilots cite social conversation with other crewmembers as an activity that can distract the pilots from tasks that must be performed.164 Also, human factors research on aviation wayfinding indicated that any breakdown in a pilot’s assessment of position “can result 163  R.K. Dismukes, “Concurrent Task Management and Prospective Memory: Pilot Error as a Model for the Vulnerability of Experts.” Proceedings of the Human Factors and Ergonomics Society 50th Annual Meeting, 2006. 164  R.K. Dismukes, G.E. Young, and R.L. Sumwalt, Cockpit Interruptions and Distractions: Effective Management Requires a Careful Balancing Act. ASRS Directline, vol. 10, pages 4-9, 1998.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 65 in either a slight deviation from an intended path, or becoming totally lost.”165 In addition, active attention is thought to be necessary for maintaining situational awareness, and the allocation of attention to irrelevant stimuli can degrade awareness.166 Finally, research on distractions while driving found that drivers are less likely to detect changes that have occurred in the environment when they are involved in casual conversation because being engaged in a conversation may degrade the encoding of visual information.167 The first officer initiated the nonpertinent conversation as the captain was navigating along the taxi route. The captain had the responsibility to assert both his leadership role and command authority to stop the discussion. Rather, the captain allowed the conversation to continue and participated in it. Also, instead of initiating the nonpertinent conversation, the first officer should have been monitoring the captain’s actions and independently assessing the airplane’s location along the taxi route. The Safety Board concludes that the flight crewmembers’ nonpertinent conversation during the taxi, which was not in compliance with Federal regulations and company policy, likely contributed to their loss of positional awareness. It is important to note that the CVR did not record any statement by either flight crewmember about this loss of positional awareness. Cues to Indicate a Takeoff From Runway 22 2.2.2.3  The presence of runway markings—a white centerline and side stripes—ahead of the airplane would have facilitated the captain’s perception that the airplane had arrived at the hold short line for runway 22, even though the airplane was actually at the hold short line for runway 26. In addition, the angle from the runway 26 hold short line on taxiway A to runway 26 was the same as the angle from the runway 22 hold short line on former taxiway A (north of runway 8/26) to runway 22. Also, the taxiway A centerline split into three lines after the runway 26 hold short line. These extended taxiway centerlines led onto the closed portion of taxiway A, across runway 26 to runway 22, and onto the runway 26 centerline (a lead-on/off line). The presence of a lead-on/off line from a taxiway directly to a runway could have supported the captain’s perception that the airplane had arrived at the departure runway. In addition, as stated in section 2.2.1.1, the first officer told the captain during his takeoff briefing, “lights are out all over the place,” in reference to observations he made while landing on runway 22 about 0140 on the day before the accident. The first officer’s statement might have contributed to the captain’s perception that the airplane was taxiing onto runway 22 because he might have anticipated a dark runway environment. At the 165  R. Conejo and C.D. Wickens, The Effects of Highlighting Validity and Feature Type on Air‑to‑Ground Target Acquisition Performance, Technical Report ARL-97-11, Savoy, Illinois: University of Illinois Aviation Research Lab, 1997. 166  C.D. Wickens and J.S. McCarley, Attention-Situation Awareness (A-SA) Model of Pilot Error, Technical Report ARL-01-13/NASA-01/06, Savoy, Illinois: University of Illinois Aviation Research Lab, 2001. 167  Jason S. McCarley, Margaret J. Vais, Heather Pringle, Arthur F. Kramer, David E. Irwin, and David L. Strayer, “Conversation Disrupts Change Detection in Complex Traffic Scenes,” Human Factors, vol. 46, no. 3, pages 424-436, 2004.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 66 least, this statement reduced the significance of the first officer’s subsequent statement, “[that] is weird with no lights” (to which the captain responded “yeah”), as the airplane rolled down runway 26. There are well-known psychological concepts associated with perception and decision-making that can allow a person’s mistaken assessment to persist. For example, confirmation bias occurs when people seek out or observe elements in their environment that support their perception. Specifically, confirmation bias results from a tendency for people to primarily seek out confirming evidence of a belief while spending less effort to seek out negative evidence that can disconfirm the belief.168 Confirmation bias can cause a person to persist in holding an incorrect belief despite the availability of contradictory evidence. For the flight crew, confirmation bias was in place not only at the hold short line for runway 26 but also during the initial acceleration down the runway because the crew did not evaluate evidence that would contradict the airplane’s position on the airport surface at the time. There were cues available to the flight crew that were not consistent with a taxi onto runway 22. These cues included the runway holding position sign for runway 26, the 75-foot painted width of runway 26 (versus the 150-foot width of runway 22),169 and the absence of runway edge lights and precision runway markings (such as threshold markings and touchdown zone markings) on runway 26. However, once the flight crewmembers had navigated to what they believed was the correct runway, they were likely no longer giving strong weight to contradictory information as a result of confirmation bias. On July 17, 1989, the Safety Board issued Safety Recommendation A-89-74, which asked the FAA to ensure that the operations manuals of all Part 121 and 135 air carriers require flight crews to cross-check the heading indicator with the runway heading when the airplane is aligned with the runway for takeoff. The Board classified Safety Recommendation A-89-74 “Closed—Acceptable Action” on December 11, 1990, after the FAA revised ACOB 8-85-1 to address the need for pilots to cross-check the heading indicator with the runway heading before takeoff. These bulletins, however, are not mandatory, and, during this investigation, the Board determined that Comair and other Part 121 operators did not have procedures for positively verifying that an airplane was aligned on the correct departure runway.170 FDR data showed that, at some point before the start of the recording, the pilots’ heading bugs had been set to 227º to correspond to the magnetic heading for runway 22. 168  The Safety Board notes that confirmation bias has multiple definitions. This report refers to confirmation bias as a phenomenon that occurs automatically (that is, without conscious intervention or intent) at the perceptual level. 169  Postaccident observations from a CRJ-100 airplane indicated that the reduced available width of runway 26 was clearly visible at night because the side stripes were brightly illuminated by the airplane’s external lighting system. 170  As a result of this finding and the finding that that some Part 121 operators (including Comair) did not provide guidance to their pilots about conducting takeoffs at night on unlighted runways, the Safety Board issued Safety Recommendations A-06-83 and -84 on December 12, 2006 (see sections 1.18.3.1 and 2.4.1).

Analysis National Transportation Safety Board A I R C R A F T Accident Report 67 At the time that the first officer began to increase thrust for takeoff, FDR data showed that the magnetic heading of the airplane was about 266º, which corresponded to the magnetic heading for runway 26. Figures 6 and 6a show the approximate configuration of the captain’s MFD and PFD, including the heading bug setting and magnetic heading indication, when the airplane was lined up on the runway 26 centerline. As shown in the figures, the heading bug was offset by 40º, providing a salient cue that the airplane was not lined up on the correct departure runway. The CVR did not record any awareness by the flight crewmembers about this offset. Multifunction Display Figure 6.  Source: Rockwell Collins. The display was configured as requested by the Safety Board.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 68 Primary Flight Display Figure 6a.  Source: Rockwell Collins. The display was configured as requested by the Safety Board. The wayfinding task includes an ongoing cross-check between an airplane’s expected and actual position using available cues in the environment and aids in the cockpit. The CVR did not record any discussion by the flight crew about the need to cross-check the airplane’s position on the runway.171 The Safety Board concludes that the flight crewmembers failed to recognize that they were initiating a takeoff on the wrong runway because they did not cross-check and confirm the airplane’s position on the runway before takeoff and they were likely influenced by confirmation bias. 171  On March 23, 2007, Comair revised its operations manual to include a departure runway checklist item.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 69 Fatigue 2.2.2.4  The Safety Board examined whether pilot fatigue could have been a factor in this accident by assessing the preconditions that could allow for the development of a fatigued state and examining the nature of the pilots’ demonstrated performance deficiencies. Potential conditions that can lead to the development of a fatigued state include chronic sleep restriction, acute sleep loss, circadian disruption (work during times when one would normally be asleep), and time since awakening. The captain and the first officer received more than the minimum required rest periods during their respective trips in the days before the accident, and their flight and duty times in the week and month before the accident would not have precluded them from obtaining adequate sleep. Also, both pilots had only been awake for about 2 hours at the time of the accident.172 Two factors in the pilots’ schedules just before the accident could have been associated with the potential development of a fatigued state: acute sleep loss and circadian disruption. Evidence indicated that both flight crewmembers likely went to sleep between 2100 and 2200 on the night before the accident (as discussed later in this section) and awoke the next morning about 0415,173 which would have afforded each pilot about 6 to 7 hours of available sleep time (which is 1 to 2 hours less than the nominal 8-hour sleep period). Restricting sleep by 2 hours has been shown to result in slight decreases in the performance of simple cognitive tasks, but there are individual differences on whether such effects are realized.174 The captain and the first officer also awakened on the day of the accident at a time when they would normally be asleep. The pilots’ time of awakening occurred during the period known as the “circadian trough” (0300 to 0500), which is a time of decreased alertness and cognitive performance among people who are adapted to sleeping at night. However, at the time of the accident, the pilots had been awake for 2 hours, at which time circadian factors would have increased their alertness. More importantly, from a circadian disruption standpoint, the first officer likely went to sleep about 0230 on August 26, 2006.175 According to his wife, the first officer 172  A review of the flight and duty times for the pilots of SkyWest flight 6819 and American Eagle flight 882 showed that these times were similar to those of the accident pilots. 173  Hotel records indicated that the captain received a wake-up call at this time. The Safety Board estimated a similar wake-up time for the first officer. 174  H.P.A. Van Dongen, G. Maislin, et al., “The Cumulative Cost of Additional Wakefulness: Dose‑Response Effects on Neurobehavioral Functions and Sleep Physiology From Chronic Sleep Restriction and Total Sleep Deprivation,” Sleep, vol. 26, no. 2, pages 117-126, 2003. 175  Hotel key card records showed activity for the first officer’s room at 2257 on August 25, 2006. After the accident, hotel personnel tested the lock on the first officer’s room and determined that the actual time of key card activity was 2 hours later than shown in the records (that is, 0057 on August 26). However, the first officer’s repositioning flight arrived at LEX about 0140, and the captain of the flight estimated that the first officer checked into his hotel room about 0210. As a result, the Safety Board determined that the actual time of key card activity was 3 hours later than shown in the records, indicating that the first officer arrived in his room about 0157.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 70 was able to sleep in that morning. The Safety Board was unable to determine how many hours the first officer slept, but, if he had received 8 hours of sleep, the first officer would have awakened about 1030. With this awakening time, it could have been difficult for the first officer to fall asleep after the call to his wife (which ended at 2102) because he would have been awake for only about 11 hours. However, it is unknown whether this time since awakening would have affected the first officer’s ability to obtain restful sleep on the night before the accident because it is unknown whether he actually obtained 8 hours of sleep on the morning of August 26 and whether his estimated bedtime was close to his normal sleep time. Although there was evidence of some preconditions that were conducive to the development of fatigue in both flight crewmembers, the uncertainty associated with the pilots’ actual recent sleep times made it difficult to assess the degree of fatigue that they might have been experiencing on the morning of the accident. If the captain and first officer were able to maximize their available sleep time, they might have been experiencing only mild fatigue resulting from a slightly restricted sleep period (about 7 hours) the night before the accident. In addition, any use of caffeine by the crewmembers could have served as an effective countermeasure for mild fatigue impairment.176 The absence, or the presence, of preconditions that are conducive to the development of fatigue is not sufficient by itself to determine whether fatigue was a factor in an accident. For fatigue to be considered a factor, performance deficiencies need to be clearly discernible and consistent with the known effects of fatigue, and any evidence supporting alternative explanations for such deficiencies needs to be considered. In this accident, the surface navigation error and the attempted takeoff from the wrong runway were the most significant errors made by the flight crew. Other errors included the flight crew boarding the wrong airplane, the first officer asking during his takeoff briefing about the runway in use and offering up “two four,” the first officer repeating some items on the before starting engines checklist after having already completed it, and the first officer misidentifying the flight as “Comair one twenty one” when informing the controller that the flight was ready to depart. In addition, the CVR recorded the first officer using a yawning voice for two consecutive statements beginning about 0603:02. The CVR recording also indicated that the captain corrected some of the first officer’s errors.177 For example, the captain stated “its two two” when queried about the runway in use and pointed out that the before starting engines checklist had been completed. Such corrections are inconsistent with a fatigue impairment. 176  The wives of the captain and the first officer reported that their husbands drank coffee, and the CVR recorded the captain (about 0553:04) asking the flight attendant for a cola. 177  About 0549:49, the controller provided the flight crew with a modified clearance to ATL. The first officer told the controller that he “missed” the arrival route part of the clearance, but he acknowledged the rest of the clearance. The controller repeated the arrival information, which the first officer acknowledged. Because the arrival route information provided by the controller was different than that in the flight release paperwork, the first officer’s request for the controller to repeat the arrival information cannot be considered an error but rather a request for clarification, which is a normal event.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 71 This investigation was constrained by a lack of available information to establish the pilots’ sleep activities before the accident flight. For example, the Safety Board was unable to determine how much sleep the first officer obtained on the morning of August 26, 2006, whether either pilot received supplemental sleep (in the form of naps) during the afternoon of August 26, or whether the pilots’ sleep time was uninterrupted.178 Also, the Board was unable to obtain reliable information about the nominal sleep needs for the pilots or their normal sleep and wake patterns. It is important to note, however, that both crewmembers seemed to be aware of the need to obtain adequate rest for the next day.179 Specifically, each pilot called his wife on the evening of August 26, 2006. The telephone call from the captain to his wife ended about 2127. The captain told his wife that he was planning on going to sleep afterward. The telephone call from the first officer to his wife ended about 2102. The first officer told his wife that he was going to bed early. Also, the Safety Board listened to a taped telephone conversation made by the first officer to the Comair System Operations Control Center at 0510 on the day of the accident; he was clear and conversational at that time. Further, witnesses reported that the pilots did not demonstrate behaviors consistent with being tired, such as yawning, stretching, and rubbing their eyes. In addition, CVR evidence showed that (1) neither pilot acted withdrawn or irritable or made any statements about receiving an inadequate amount of sleep and (2) both pilots were sociable. The Safety Board concludes that, even though the flight crewmembers made some errors during their preflight activities and the taxi to the runway, there was insufficient evidence to determine whether fatigue affected their performance. Previous Fatigue-Related Accidents Even though there was insufficient evidence for the Safety Board to determine whether fatigue affected the Comair flight crew’s performance, the Board has previously cited fatigue impairment as a causal or a contributing factor for those accidents in which documented performance deficiencies were consistent with the effects of fatigue and clear evidence showed that the pilots’ recent activities were conducive to fatigue. For example, in its report on the June 1, 1999, American Airlines flight 1420 accident, the Board found that the flight crewmembers failed to discontinue the approach to the airport when severe thunderstorms had moved into the area and failed to ensure that the flight spoilers had extended after touchdown. The Board also found that the flight crewmembers were nearing the end of a long duty day and that, although the pilots had slept more than 9 hours the night before, they had been continuously awake for at least 16 hours by the 178  As stated in section 1.5.2, the Safety Board was unable to determine whether the first officer attempted to answer the two consecutive incoming calls to his cell phone about 0103 on the day of the accident. 179  The Safety Board has previously identified the need to improve fatigue awareness among pilots. Most recently, on February 7, 2006, the Safety Board issued Safety Recommendation A-06-11, which asked the FAA to “require 14 Code of Federal Regulations Part 121 and 135 operators to incorporate fatigue- related information similar to that being developed by the Department of Transportation Operator Fatigue Management Program into their initial and recurrent pilot training programs; such training should address the detrimental effects of fatigue and include strategies for avoiding fatigue and countering its effects.” Safety Recommendation A-06-11 was classified “Open—Acceptable Response” on November 9, 2006.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 72 time of the accident.180 According to the report, contributing to the accident was the flight crew’s “impaired performance resulting from fatigue.”181 Also, in its report on the October 19, 2004, Corporate Airlines flight 5966 accident, the Safety Board found that the flight crew did not follow established procedures and properly conduct a nonprecision approach at night in instrument meteorological conditions and did not adhere to the established division of duties between the flying and nonflying pilot. The Board also found that the pilots’ work schedule required them to go to bed and wake up much earlier than normal and that they had only a 9-hour rest period before having to report for duty. Before the accident flight, the captain told family members that he slept poorly, and other pilots saw him trying to take a brief nap in a meeting area. By the time of the accident, the flight crew had been awake for 15 hours and on duty for 14 1/2 hours and was performing the sixth flight leg of the day. According to the report, the pilots’ fatigue “likely contributed to their degraded performance.”182 In contrast to the Little Rock and Kirksville flight crews, the Comair captain and first officer had rest periods of more than 13 and 27 hours, respectively, before reporting for the accident flight. Also, the Comair pilots had only been awake for 2 hours and on duty for less than 1 hour at the time of the accident. Cockpit Discipline 2.2.2.5  The captain was responsible for establishing the tone in the cockpit so that disciplined adherence to standard operating procedures would be maintained and crew vigilance would not be reduced. However, as recorded on the CVR, the captain told the first officer several times, “at your leisure,” with regard to his performance of checklists, which was indicative of a casual cockpit atmosphere. The first officer apparently adopted this casual attitude when he told the controller that the flight was ready to depart at his leisure. According to Comair procedures, the captain was responsible for calling for the taxi, before takeoff, and lineup checklists, but the CVR did not record the captain formally call for the before takeoff checklist. Instead, after the first officer finished the taxi checklist, the captain stated about 1 minute later, “finish it up your leisure,” referring indirectly to the need to conduct the before takeoff checklist. Also, as previously stated, the captain performed an abbreviated taxi briefing, which was contrary to company guidance, and the flight crew engaged in a nonpertinent conversation while the airplane was in a critical phase of flight, which was not in compliance with the sterile cockpit regulation and 180  Research has indicated that lapses in cognitive performance occur when the waking day is extended beyond a normal length of 14 to 16 hours. For more information, see G.P. Kruger, “Sustained Work, Fatigue, Sleep Loss, and Performance: A Review of the Issues,” Work and Stress, vol. 3, pages 129‑141, 1989. 181  National Transportation Safety Board, Runway Overrun During Landing, American Airlines Flight 1420, McDonnell Douglas MD-82, N215AA, Little Rock, Arkansas, June 1, 1999, Aircraft Accident Report NTSB/ AAR-01/02 (Washington, DC: NTSB, 2001). 182  National Transportation Safety Board, Collision with Trees and Crash Short of the Runway, Corporate Airlines Flight 5966, BAE Systems BAE-J3201, N875JX, Kirksville, Missouri, October 19, 2004, Aircraft Accident Report NTSB/AAR-06/01 (Washington, DC: NTSB, 2006).

Analysis National Transportation Safety Board A I R C R A F T Accident Report 73 company procedures. The abbreviated briefing and the nonpertinent conversation were also examples of the flight crew’s casual cockpit atmosphere. The Safety Board has discussed the role of reduced cockpit discipline in other flight crew-involved air carrier accidents. For example, in its report on the August 16, 1987, Northwest Airlines flight 255 accident, the Board found that checklists (except for the before start checklist) were not being called for or accomplished according to company procedures and that, after pushback, the flight crew initiated conversations that were not related to duty requirements and diverted the crew’s attention from task-related activities. Regarding the role of cockpit discipline in these errors, the report stated, “it is the captain’s responsibility to structure the manner in which his crew will accomplish its duties … he must set the tone for how this information will be proffered.” The report further stated that a well-defined role structure in the cockpit reduces ambiguity about each crewmember’s responsibilities and when those responsibilities will be performed.183 In addition, data from the LOSA Collaborative184 showed that flight crewmembers who intentionally deviated from standard operating procedures were three times more likely to commit other types of errors, mismanage more errors, and find themselves in more undesired aircraft situations compared with those flight crewmembers who did not intentionally deviate from procedures. The Safety Board concludes that the flight crew’s noncompliance with standard operating procedures, including the captain’s abbreviated taxi briefing and both pilots’ nonpertinent conversation, most likely created an atmosphere in the cockpit that enabled the crew’s errors. Summary of Pilot Human Factors 2.2.2.6  Even with the discrepancies that existed between airport charts and signage, the navigational task that the pilots of Comair flight 5191 faced—taxi to runway 22 via taxiway A—was straightforward and inherently simple. The primary cues for this navigational task—the airport markings and signage at hold short positions—were accurate and available to the flight crew. Flight crews are responsible for maintaining positive control of an airplane during all phases of flight, including surface operations. An essential component to positive control is knowing the position of the airplane at all times. It was the accident pilots’ responsibility, once they were cleared to taxi, to safely maneuver the airplane to runway 22. Each pilot had experience and expertise to allow the successful completion of this task using only the standard airport marking conventions; that is, once the pilots detected and recognized signs off the air carrier ramp that identified taxiway A, they 183  National Transportation Safety Board, Northwest Airlines, Inc., McDonnell Douglas DC-9-82, N312RC, Detroit Metropolitan Wayne County Airport, Romulus, Michigan, August 16, 1987, Aircraft Accident Report NTSB/AAR-88/05 (Washington, DC: NTSB, 1988). 184  According to its Web site, the LOSA Collaborative is a network of researchers, safety professionals, pilots, and airline representatives collaborating to provide, among other things, oversight and implementation of LOSA and a forum for information exchange regarding LOSA. The referenced data were provided to the Safety Board in January 2007.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 74 had only to follow those signs and the taxiway centerline to the runway holding position sign for runway 22. Although this task is more difficult during night conditions, when surrounding features in the environment and horizon as well as other cues are not easily detectable, the critical features along the navigation route were internally lit or were illuminated by the airplane’s external lighting system. Both pilots were described to be in good health in the days before the accident.185 Postaccident toxicological testing for both pilots did not detect the presence of alcohol186 or any substances known to affect performance. Both pilots were required to wear corrective lenses during flight operations. Evidence indicated that the captain was wearing contact lenses during the accident flight, but the Safety Board could not determine whether the first officer was wearing corrective lenses during the flight. Even if the first officer had not been wearing corrective lenses, his ability to verify the airplane’s position during the taxi to runway 22 would most likely not have been affected.187 Evidence indicated that both pilots were able to read and interpret features inside the cockpit at intermediate distances and detect objects outside the cockpit at greater distances, and the pilots were described to have normal night vision. Observations in a CRJ-100 airplane after the accident demonstrated that no objects along the taxi route would have produced temporary flash blindness188 that could have impeded the pilots’ ability to detect signage and surface markings.189 As previously stated, numerous cues were available to the flight crew to indicate that the airplane was not at the position on the airport surface that it was supposed to be. For example, when the airplane stopped at the runway 26 hold short line instead of the runway 22 hold short line, the flight crew would have been able to see the runway 26 holding position sign and painted runway numbers, the continuation of taxiway A across runway 26, and the runway 22 holding position sign. Also, when the airplane was in 185  The first officer tested positive for a low level of pseudoephedrine. This drug, at low levels, is not considered to cause impairment. Performance-based side effects of pseudoephedrine are similar to those of caffeine. CAMI does not quantify this substance unless it is above therapeutic levels. The Safety Board was not able to determine why and when the medication was taken. 186  On August 26, 2006, at 1826, the first officer purchased food and two bottles of beer at the hotel restaurant. (Section 1.17.1.6 describes the FAA’s and Comair’s alcohol use policy.) According to the CAMI toxicology report, the first officer tested negative for ethanol. On the basis of known information about the first officer’s height, weight, and normal alcohol consumption, it is likely that the two beers would have been metabolized within a few hours of consumption. Research has shown that low blood alcohol concentrations do not appear to be associated with significant sleep disruption or reduced feelings of well being the next morning for normal, healthy people and that a low blood alcohol concentration is unlikely to have a significant impact on performance the next day. For more information, see B. Feige, H. Gann, R. Brueck, M. Hornyak, S. Litsch, F. Hohagen, and D. Riemann, “Effects of Alcohol on Polysomnographically Recorded Sleep in Healthy Subjects,” Alcoholism: Clinical and Experimental Research, vol. 30, pages 1527-1537, 2006. 187  At his July 18, 2006, FAA medical examination, the first officer’s uncorrected distance vision measurement was 20/30. 188  Temporary flash blindness results when an observer adapted to darkness is exposed to a very bright light and is then returned to conditions of darkness. Such high-intensity light exposures can dramatically reduce an observer’s visual acuity in low-light conditions for several minutes. 189  No aircraft were operating near the accident airplane during taxi. The CVR contained no mention of lightning, and ground personnel interviewed after the accident did not report the presence of lightning near the airport.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 75 position at runway 26 instead of runway 22, the crew would have been able to see the holding position sign for runway 22 and the 75-foot width of the runway (versus the 150‑foot width of runway 22). Given the numerous cues that were available to the flight crew and the simplicity of the navigation task, the Safety Board could not determine why the flight crew stopped the airplane at the incorrect hold short line and then attempted to take off from the incorrect runway. However, as previously stated, the Board believes that these events occurred because the flight crew did not use the available cues on the airport surface during taxi and did not cross-check and confirm the airplane’s position on the runway before departure. Also, the flight crewmembers engaged in a nonpertinent conversation during a critical phase of flight (taxi operations), which caused them to lose positional awareness. In addition, before the airplane arrived at the dark runway, the first officer briefed the outage of the runway end identifier lights, he recounted that lights were out during his arrival at LEX early on the morning that preceded the accident flight, and the flight crew most likely read the NOTAM in the flight release paperwork that indicated that the runway 4/22 centerline lights were out of service. This accident is not the first one involving a wrong runway takeoff in which pilots did not use existing cues to identify the airplane’s location on the airport surface or cross-check and verify the airplane’s position before takeoff. For example, the final report on the October 31, 2000, Singapore Airlines flight 006 accident (see section 1.18.4) stated that the pilots did not verify the airplane’s position on the taxi route as the airplane was turning onto the wrong runway and concluded that the flight crew lost situational awareness and took off from the wrong runway despite numerous available cues that provided information about the airplane’s position on the airport. However, the final report for that accident cited a possible reason for the flight crew’s actions: the pilots did not adequately review the taxi route to ensure that they understood that the route to the correct departure runway required passing a parallel runway that was under construction and was open only for taxi operations. Numerous other wrong runway events have occurred. The ASRS database showed 114 reports of incidents from March 1988 to September 2005 in which flight crews of turbojet airplanes lined up on the wrong runway for takeoff. The ASRS reports indicated that the pilots involved in these events, pilots of other aircraft in the area at the time, or air traffic controllers detected the mistake either before or after takeoff. Also, on October 30, 2006, an Alaska Airlines 737 departed from the wrong runway at SEA. According to postincident interviews, the controller instructed the flight crew to taxi the airplane into position and hold on runway 34C, but the captain assumed that the airplane would be taking off from runway 34R. After the airplane departed uneventfully from runway 34R, the controller informed the flight crew that the airplane had departed from the wrong runway. Most recently, on April 18, 2007, a United Airlines Airbus A320 taxied onto runway 27, which was closed, instead of runway 30, the assigned departure runway, at MIA and began the takeoff roll. A NOTAM, which was included in the flight release paperwork, and the ATIS information broadcast, which the flight crew received, indicated

Analysis National Transportation Safety Board A I R C R A F T Accident Report 76 that runway 27 was closed. Also, the flight crew reported that the airport charts were out and available. As the airplane proceeded down runway 27, the airplane’s nose wheel light illuminated a truck flashing its lights. The captain and the first officer stated that they observed the truck at the same time. Simultaneously, the controller queried the flight crew to determine whether the airplane was on runway 30. The flight crew rejected the takeoff, and the airplane continued uneventfully to its destination. The Comair flight 5191 accident and other wrong runway takeoff events demonstrate that all pilots are vulnerable to this and other types of surface navigation errors. Even when navigation tasks are straightforward and simple, there is a potential for a catastrophic outcome resulting from human error if available cues are not observed and considered during taxi and the airplane’s position is not cross-checked at the intended runway. Systemwide interventions, such as improved airport standard markings and technologies to improve pilots’ positional awareness while navigating airport surfaces, can help protect against human error during airport surface operations by providing a redundant display of critical information. Such interventions are further discussed in section 2.4. In addition, the Safety Board is concerned about the breakdown in sterile cockpit discipline in the sequence of events leading to this accident. The pilots’ actions with regard to sterile cockpit procedures, specifically, their nonpertinent conversation while the captain was taxiing the airplane, were uncharacteristic with past reports. A first officer who flew with the captain 2 days before the accident described the captain’s sterile cockpit discipline as very good and stated that, when a newly trained first officer was occupying the cockpit jumpseat during one of the flight legs, the captain briefed him about sterile cockpit discipline. The first officer was also described as having good sterile cockpit discipline. On February 7, 2006, the Safety Board issued Safety Recommendation A-06-7, which was the result of the Board’s investigation of the Corporate Airlines flight 5966 accident. Safety Recommendation A-06-7 asked the FAA to direct the POIs of all 14 CFR Part 121 and 135 operators to reemphasize the importance of strict compliance with the sterile cockpit rule.190 Also, the Board notes that sterile cockpit violations are among the types of intentional noncompliance that can be detected through LOSA observations (see section 1.17.3). On January 23, 2007, as a result of its investigation of the October 14, 2004, Pinnacle Airlines flight 3701 accident, the Board issued Safety Recommendation A-07-9, which asked the FAA to require that all 14 CFR Part 121 operators incorporate into their oversight programs periodic LOSA observations and methods to address and correct findings resulting from these observations.191 190  On April 28, 2006, the FAA issued SAFO 06004, “Approach and Landing Accident Reduction: Sterile Cockpit, Fatigue,” to emphasize the importance of sterile cockpit discipline. As a result, Safety Recommendation A-06-7 was classified “Closed—Acceptable Action” on November 9, 2006. 191  On April 13, 2007, the FAA stated that LOSA was not necessarily the only way in which an operator could accomplish oversight of the safety of its operations and that no-notice line checks, for example, offered many of the same advantages as LOSA with regard to the information gained. The FAA also stated its belief that the most effective approach to the underlying safety issues discussed in this recommendation was the effective implementation of SMS, for which a rulemaking project has begun.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 77 Air Traffic Controller Human Factors 2.2.3  Indications of the flight crew’s surface navigation error were visible from the tower during two distinct time periods. The first time period occurred when the airplane was stopped at the runway 26 hold short line for 50 seconds, from 0604:33 to 0605:23,192 during which time the first officer announced that the airplane was ready to depart and the controller issued a takeoff clearance. The airplane had been cleared to taxi to runway 22, and the flight crew was not required to stop the airplane short of runway 26. If the controller had noticed that the airplane had stopped in that location before issuing the takeoff clearance, the controller could have queried the flight crew, issued additional taxi instructions, or closely monitored the airplane’s subsequent progress. The controller’s postaccident statements indicated that he did not notice that the airplane had stopped short of runway 26. As a result, he missed an opportunity to prevent the flight crew’s surface navigation error and subsequent wrong runway takeoff attempt. The second time period lasted 28 seconds. It began about 0605:56, when the airplane began to align with runway 26, and ended about 0606:24, when the airplane accelerated beyond the maximum airspeed that would have allowed the airplane to remain on the available runway if the flight crew rejected the takeoff and used maximum braking. The airplane’s movements during this time were not consistent with the clearance provided by the controller and were a clear sign of a lack of positional awareness on the part of the flight crew. If the controller had been looking out the tower cab window and monitoring the flight, he could have addressed this situation by alerting the flight crewmembers that the airplane was on the wrong runway or, later, by instructing them to reject the takeoff. The controller did not take any such actions. The controller indicated that he did not see the airplane align with runway 26 or begin its takeoff roll because he had turned around to perform the traffic count, which is an administrative record-keeping task. The Safety Board examined possible reasons why the controller did not notice indications of the flight crew’s surface navigation error either during the 50-second window of opportunity, which began about 2 minutes before the accident, or during the 28-second critical window, which began about 39 seconds before the accident. Figure 7 shows a detailed timeline of communications and events that occurred in the 2 minutes before the accident. 192  Flight crews stop along a taxi route for various reasons, including a perception of potential traffic conflicts, passenger movements in the cabin, and uncertainty about the taxi clearance or the taxi routes. Some stops during taxi are accompanied by radio transmissions to ATC to explain the delay or seek clarification. Some controllers have a heightened sense of awareness when stops are made during taxi depending on the circumstances and the duration.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 78 Air Traffic Control Event Timeline Figure 7.  Note: COM, Comair; EGF, American Eagle; SKW, SkyWest; ZID, Indianapolis Air Route Traffic Control Center; TMU, traffic management unit.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 79 Window of Opportunity During Which the Airplane Was Stopped 2.2.3.1  Short of the Wrong Runway On the day of the accident, all LEX tower and radar positions were combined and were being worked by one controller.193 As a result, the controller had to switch his attention between tower and radar tasks. The controller’s tower responsibilities included controlling aircraft operations on the airport surface and during takeoffs and landings,194 and his primary source of visual information was the view of the airport surface.195 The controller’s radar responsibilities included controlling airplanes in the airspace around the airport,196 and his primary source of visual information was the DBRITE, which was mounted below the tower cab windows at the local control position. Despite the need to divide his attention between these tasks, the controller’s workload at this time was not excessive. When Comair flight 5191 stopped at the hold short line for runway 26, the controller had just finished obtaining that flight’s departure release from the Indianapolis ARTCC’s traffic management unit (a tower task) and coordinating a heading change for SkyWest flight 6819 with the ARTCC’s LEX sector controller (a radar task). After the Comair flight had stopped, the controller spent 8 seconds vectoring American Eagle flight 882 (a radar task). No ATC communications took place during the next 34 seconds. The first officer of the Comair flight then requested takeoff clearance. The controller immediately issued this takeoff clearance (a tower task), and the first officer repeated the clearance. About 2 seconds later, as the Comair airplane began to roll, the controller asked the flight crewmembers of the American Eagle flight whether they were satisfied with the airplane’s present heading or would like a new one to avoid weather (a radar task). Performance of concurrent tasks requires a division of attention. Some concurrent tasks can be performed simultaneously, but when concurrent tasks draw on different sources of visual information, they require a person to engage in selective attention, which involves the switching of attention back and forth between sources of information associated with each task to update information about the tasks in working memory.197 The timeline shown in figure 7 indicates the controller’s tower and radar tasks during the 50-second window of opportunity, and the controller’s communications during this time can be analyzed, along with task requirements, to draw conclusions regarding how the controller was focusing his attention during various time periods. The controller was facing certain considerations in performing radar-related tasks. For example, because the SkyWest and American Eagle flights were going to be 193  The decision to staff the LEX ATCT with one controller during the midnight shift is discussed in section 2.5. 194  The controller’s tower responsibilities also included monitoring in-flight aircraft operations within a radius of 4.3 nm and 2,500 feet agl. 195  Other sources of information that were used by the controller for his tower responsibilities included the DBRITE and flight progress strips. 196  This airspace was within 35 nm from the surface to 10,000 feet msl and included surrounding airports. 197  C.D. Wickens, Engineering Psychology and Human Performance, New York: HarperCollins, 1992.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 80 using the same route and airspace as they left the local area, the controller needed to ensure a separation of at least 10 miles in between these airplanes (in accordance with an agreement between the LEX ATCT and the Indianapolis ARTCC). Also, the SkyWest flight crew had requested a deviation around an area of precipitation that was located about 10 miles west of LEX, and the controller’s communications indicated his anticipation that the American Eagle flight crew might request a similar course deviation. The controller knew that, if this request were made, he would have to coordinate another heading change with the Indianapolis ARTCC’s LEX sector controller. These considerations increased the controller’s expectation that he would need information from the DBRITE to manage these aspects of his radar responsibilities, which increased the likelihood that he was frequently examining the DBRITE during the 50-second window of opportunity. However, the workload associated with the controller’s radar tasks would not have prevented him from periodically looking out the tower cab window. In contrast, the controller’s tower responsibilities at that time had become relatively simple. Because the controller had already obtained the Comair flight’s departure release and provided the flight crew with the clearance to taxi to runway 22 (which the first officer acknowledged), the only tower task he had to perform was to clear the airplane for takeoff. The controller did not have to frequently look at the runway environment to perform this task because he would have expected that the flight crew would inform him when the airplane was ready to depart, and he would be able to scan the runway at that time. Because no other traffic was on the airport surface to pose a conflict to the airplane during its taxi, the controller would not have expected much useful information to be obtained by frequently scanning the runway environment, which would have decreased the likelihood that he was frequently looking out the tower cab windows at the runway environment during the 50-second window of opportunity. The Safety Board concludes that the controller did not notice that the flight crew had stopped the airplane short of the wrong runway because he did not anticipate any problems with the airplane’s taxi to the correct runway and thus was paying more attention to his radar responsibilities than his tower responsibilities. Postaccident observations from the LEX ATCT revealed that, from the controller’s work station at night, it was somewhat difficult to see whether the CRJ-100 demonstration airplane was located at the hold short line for runway 26, on taxiway A, or at the hold short line for runway 22 because of (1) the proximity of these locations in the controller’s visual field as a result of the new taxiway configuration198 and (2) the reduced visibility of ground texture, linear perspective, and other monocular depth cues that are useful for judging distances beyond 15 to 20 feet. Although the controller had been working at the tower for 17 years and had presumably become an expert at recognizing aircraft positions on the airport surface, the use of former taxiway A5 (redesignated as taxiway A) to reach the runway 22 threshold was new to him because the runway had been shifted and the redesignated taxiway had been in place for only 1 week (four of the controller’s shifts) 198  From the tower cab, the hold short lines for runways 22 and 26 appeared close to each other because they were separated by less than 5º of visual angle.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 81 at the time of the accident.199 These factors would have made it more difficult for the controller to determine the airplane’s exact location. In addition, the controller was not required to determine that the airplane had reached the departure runway before he cleared the airplane for takeoff; he was only expected to determine that the airplane was at a location that was consistent with its taxi clearance. When the flight crew had stopped the airplane at the runway 26 hold short line, the airplane was in a location that was consistent with its taxi clearance. The controller reported that he did not see the airplane stop in this position. Even if the controller had seen the airplane at that time and noticed that it was not moving, a brief scan of the runway environment would not have informed him of whether the airplane had been stopped only briefly or for a longer period of time. Nevertheless, the controller could have detected that the airplane had stopped short of the wrong runway if he had been monitoring the airplane’s progress along the taxi route. Critical Window During Which an Administrative Task Was Performed 2.2.3.2  After the LEX controller cleared Comair flight 5191 for takeoff, he told American Eagle flight 882 to contact the Indianapolis ARTCC. According to the ATC transcript, the handoff of the American Eagle flight to the Indianapolis ARTCC occurred about 0605:40. About that time, Comair flight 5191, the only airplane for which the controller had responsibility, was turning onto runway 26 and had not yet deviated from the issued taxi clearance. The controller’s next active task would be to establish contact with the Comair flight and provide departure services (radar tasks), but he would likely not have expected to perform this task for about 1 minute.200 This 1-minute pause in active control tasks afforded the controller greater flexibility in terms of his allocation of attention. The controller stated that, after the handoff of the American Eagle flight to the Indianapolis ARTCC, he began the combined traffic count, which was an administrative record-keeping task.201 The standard operating procedure at LEX was to perform the traffic count on an hourly basis. However, the controller stated that he normally accumulated flight progress strips throughout the night and performed the traffic count once toward the end of his shift. The controller estimated that the traffic count would take 2 to 5  minutes to complete.202 The controller was expecting to be relieved by the incoming day shift controller at 0630, so he most likely wanted to complete the traffic count by that time. However, 199  When taxiway A north of runway 8/26 was used to reach the runway 22 threshold, the hold short lines for runways 22 and 26 were farther apart in the controller’s visual field. 200  The time between flight crew acknowledgment of the takeoff clearance and the controller’s acknowledgment of radar contact was 41 and 78 seconds for the SkyWest and American Eagle departures, respectively. 201  When the tower was staffed with more than one controller, the controller at the radar data position recorded the radar traffic count, and the controller at the clearance delivery position recorded the tower traffic count. When the midnight shift was staffed with one controller, that controller performed a combined radar and tower traffic count. 202  As a result, the controller must have expected that he would have to interrupt this administrative task to provide radar services to the Comair flight.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 82 because this task was not urgent or critical to flight safety and the day shift controller was not expected to arrive for more than 20 minutes, the accident controller could have delayed performing the traffic count until after he handed off the Comair flight to the Indianapolis ARTCC. If the controller had monitored the Comair flight during its takeoff, he most likely would have detected, during the 28-second critical window, the flight crew’s deviation from the taxi and takeoff clearances, and he could have then warned the flight crewmembers about their mistake and have possibly prevented the accident. Similar to air traffic controllers, pilots must also prioritize overlapping tasks, and inappropriate prioritization of tasks has often been documented as a factor in aircraft accidents and incidents.203 Task prioritization can break down under high workload conditions, but the controller’s workload was relatively light 1 minute before the accident. As a result, the Safety Board considered other factors that could influence task prioritization to understand the controller’s decision to perform an administrative task instead of monitoring the airplane. Research indicated that prioritization of concurrent tasks was strongly affected by procedural requirements and that tasks to be performed at a particular time tended to receive higher priority than nonrequired tasks.204 The controller was not required to monitor the Comair flight’s takeoff or perform the traffic count at that particular time. Because of the lack of a procedural requirement, the controller’s prioritization of attention would have been based on other factors. Research indicated that other factors that can affect task prioritization included a task’s perceived importance, the acceptability of its present status, and its ease of completion.205 The controller assumed that the likelihood of a surface navigation error was small. Before the accident, no air carrier airplane had attempted to take off on runway 26,206 and the controller had no reason to suspect that a flight crew would attempt to do so. No other traffic was on the airport surface to pose a conflict, so the potential for a ground collision was extremely low. As a result, the controller most likely considered the importance of monitoring the takeoff as low. In addition, the controller’s postaccident statements indicated that he had not adopted a practice of consistently monitoring takeoffs whenever possible. Because the controller performed the traffic count at the end of his shift instead of hourly, the status of this task had become an issue. The controller was nearing the 203  Research found that 23 percent of major aircraft accidents between 1960 and 1989 involved cockpit task management errors and that 32 percent of the accidents in this category involved pilot deficiencies in task prioritization. For more information, see C. Chou, D. Madhavan, and K. Funk, “Studies of Cockpit Task Management Errors,” International Journal of Aviation Psychology, vol. 6, pages 307-320, 1996. These researchers also studied aircraft incidents reported through ASRS and found that 35 percent of cockpit task management errors involved task prioritization. 204  Research on pilot prioritization of in-flight tasks indicated that significant individual differences existed in prioritizing tasks but that the primary factor might be procedural consistency or operating procedures that require a certain task to be performed at a certain time. For more information, see K. Colvin, K. Funk, and R. Braune, “Task Prioritization Factors: Two Part-Task Simulator Studies,” International Journal of Aviation Psychology, vol. 15, pages 321-338, 2005. 205  K. Colvin, K. Funk, and R. Braune, 2005. 206  A 1993 ASRS report indicated a near takeoff on runway 26 by an air carrier airplane (see section 1.18.5).

Analysis National Transportation Safety Board A I R C R A F T Accident Report 83 end of his shift and needed to complete the task, which he viewed as quick and easy, before he could be relieved of his duties. Although the controller decided that the traffic count needed to be performed at that time, the performance of that administrative task was not directly related to safety. Unexpected hazardous events can occur during airport operations, as demonstrated by this accident, and controller monitoring can provide an important redundant safety protection against such events. The Safety Board concludes that the controller did not detect the flight crew’s attempt to take off on the wrong runway because, instead of monitoring the airplane’s departure, he performed a lower-priority administrative task that could have waited until he transferred responsibility for the airplane to the next ATC facility. On April 10, 2007, the Safety Board issued Safety Recommendation A-07-34, which asked the FAA to require all air traffic controllers to complete instructor-led initial and recurrent training in resource management skills to improve controller judgment, vigilance, and safety awareness (see section 1.18.3.2). On July 13, 2007, the FAA stated that it had delivered CRM workshops, posters, and follow-up support to several ATCTs and TRACONs. The FAA also stated that the CRM implementation plan for fiscal years 2007 through 2009 included instructor-led training at “a percentage of” the highest-error-rate terminal and en route facilities and CRM training for initial hires in the FAA Academy and college training initiative programs. The FAA further stated that it would develop plans to train additional controllers on an initial and a recurrent basis. The Safety Board is encouraged that the FAA has provided CRM training to some ATC facilities but is concerned that such training may not be provided to all controllers, including those at smaller facilities (such as LEX). The Board is also concerned about the FAA’s plans for recurrent CRM training at only a percentage of the terminal and en route facilities with the highest error rates. The FAA needs to ensure that all controllers (and not just those at highest-error-rate facilities) receive this training on an initial and a recurrent basis. Pending this action, Safety Recommendation A-07-34 is classified “Open—Acceptable Response.” Fatigue 2.2.3.3  As stated in section 2.2.2.4, potential conditions that can lead to the development of a fatigued state include chronic sleep restriction, acute sleep loss, circadian disruption, and time since awakening. The controller’s reported duty times and sleep patterns from August 24 to 26, 2006, were not indicative of a chronic sleep restriction, but they were indicative of acute sleep loss, circadian disruption, and a long time since awakening. The controller reported that, on August 26, 2006, he awoke at 0540, worked from 0630 to 1430, and took a nap between about 1530 and 1730 (the quality of his sleep during the nap was described as “not real good”). As a result, the controller had slept about 2 hours in the 24 hours that preceded the accident (which is much less than the nominal sleep period of about 8 hours), and he had been continuously awake for more than 12 hours since his nap. In addition, the controller was adapted to sleeping at night, and the accident occurred at a time when he would have normally been asleep and when

Analysis National Transportation Safety Board A I R C R A F T Accident Report 84 circadian factors would tend to diminish alertness. Thus, the controller’s recent duty times and sleep patterns indicated that he would have been experiencing some fatigue at the time of the accident. However, a review of ATC tapes found that the controller’s communications throughout his shift (including those involving the SkyWest, American Eagle, and Comair flights) were prompt and professional. The review also found that the controller did not yawn during his transmissions or make any phraseology errors (except for not advising the flight crew that taxiway A north of runway 8/26 was closed, as discussed in section 2.6.2). Nevertheless, reducing daily sleep periods by as little as 2 hours can produce slight decreases in cognitive performance, and greater sleep restrictions can produce more pronounced effects.207 Fatigue tends to increase preoccupation with single tasks or elements, reduce scanning, increase vigilance errors, impair decision-making, and diminish awareness of one’s own degraded performance. These effects tend to have a negative effect on the performance of concurrent tasks. As discussed in section 2.4.4, the FAA’s existing procedures for issuing takeoff clearances allowed the controller to issue the takeoff clearance and scan the runway environment before the airplane crossed the intersecting runway. Also, as discussed in section 2.4.5, the FAA did not have a policy that explicitly required the controller to monitor airplanes during takeoff or a policy that explicitly stated that the controller was required to give higher priority to the monitoring of takeoffs rather than the performance of an administrative task. FAA Order 7110.65, “Air Traffic Control,” states that actions that are most critical to safety should be performed first, but this policy leaves a great deal of interpretation to the individual controller. The controller was not in the habit of monitoring takeoffs. The controller stated that his decision to monitor an airplane during takeoff depended on traffic spacing and the other tasks he had to perform. On the basis of this statement, the controller’s decision to perform the traffic count when Comair flight 5191 was taking off could have been consistent with his normal practice for monitoring departing airplanes. The Safety Board concludes that the controller was most likely fatigued at the time of the accident, but the extent that fatigue affected his decision not to monitor the airplane’s departure could not be determined in part because his routine practices did not consistently include the monitoring of takeoffs. The Safety Board further concludes that FAA operational policies and procedures at the time of the accident were deficient because they did not promote optimal controller monitoring of aircraft surface operations. On April 10, 2007, the Safety Board issued Safety Recommendations A-07-30 and -31 to the FAA to address its concerns about the potential impact of fatigue on air traffic controller performance.208 Safety Recommendation A-07-30 asked the FAA to work with NATCA to reduce the potential for controller fatigue by (1) revising controller 207  H.P.A. Van Dongen, G. Maislin, et al., 2003. 208  Also on April 10, 2007, the Safety Board issued Safety Recommendation A-07-32 to NATCA to address this issue (see section 1.18.3.2). The recommendation is currently classified “Open—Await Response.”

Analysis National Transportation Safety Board A I R C R A F T Accident Report 85 work scheduling policies and practices to provide rest periods that are long enough for controllers to obtain sufficient restorative sleep and by (2) modifying shift rotations to minimize disrupted sleep patterns, accumulation of sleep debt, and decreased cognitive performance. Safety Recommendation A-07-31 asked the FAA to develop a fatigue awareness and countermeasures training program for controllers and personnel who are involved in the scheduling of controllers for operational duty that addresses the incidence of fatigue in the controller workforce, causes of fatigue, effects of fatigue on controller performance and safety, and the importance of using personal strategies to minimize fatigue. On July 5, 2007, the FAA responded to Safety Recommendations A-07-30 and ‑31. The FAA stated that it had convened a working group to develop shift rotation and scheduling guidelines and that NATCA would be invited to participate in the group. The FAA also stated that it would develop, within 12 months, and implement a fatigue awareness and countermeasures training program to be used by all FAA Air Traffic Organization operational service units. Pending (1) the development of guidance for controller work scheduling policies and practices to provide rest periods that are long enough for controllers to obtain sufficient restorative sleep and (2) the modification of shift rotations to minimize disrupted sleep patterns, accumulation of sleep debt, and decreased cognitive performance, Safety Recommendation A-07-30 is classified “Open— Acceptable Response.” Pending the development and implementation of a fatigue awareness and countermeasures training program for controllers and personnel involved in the scheduling of controllers for operational duty, Safety Recommendation A-07-31 is classified “Open—Acceptable Response.” Summary of Air Traffic Controller Human Factors 2.2.3.4  The concurrent radar and tower tasks that required the controller to divide his attention occurred during the window of opportunity when the controller could have, but did not, notice that the airplane was stopped short of runway 26. After the controller transferred control of American Eagle flight 882 to the Indianapolis ARTCC, he did not have any further active radar duties. However, after the transfer, the controller performed an administrative task—the traffic count—instead of monitoring the departure of Comair flight 5191. The controller had turned around in the tower cab to perform this task before the start of the critical window. At that time, the airplane had not yet deviated from the issued clearances. However, at the end of the critical window, the airplane had accelerated beyond the maximum airspeed that would have allowed the airplane to remain on the available runway if the flight crew rejected the takeoff and used maximum braking. Thus, at that point, the controller missed his final opportunity to notice the flight crew’s error in enough time to take action to prevent the accident. The controller most likely considered the importance of monitoring the Comair flight’s takeoff as low because he assumed that there was little opportunity for a surface navigation error and no other traffic was on the airport surface to pose a conflict. On the other hand, the controller most likely considered that the traffic count was a higher priority at that time because he was nearing the end of his shift and needed to complete the task before he could be relieved of his duties. The controller did not appropriately prioritize

Analysis National Transportation Safety Board A I R C R A F T Accident Report 86 his tasks because the traffic count was not directly related to safety, but monitoring the takeoff would have provided an important safety protection. Because of the nature of their responsibilities, controllers are expected to be able to appropriately prioritize and perform concurrent tasks. Some controllers may not recognize the critical importance of their monitoring efforts in providing a redundant safety protection against unexpected flight crew errors and other threats to flight safety. This issue is further discussed in section 2.4.4. The controller’s recent duty times and sleep patterns indicated that he was most likely experiencing fatigue at the time of the accident. Also, the circumstances of this accident suggested that task prioritization could be improved by modifying existing FAA guidelines on duty priority so that they explicitly state that active control tasks with a direct flight safety benefit, such as monitoring departing and arriving aircraft, are a higher priority than administrative record-keeping tasks, such as a traffic count. This issue is further discussed in section 2.4.5. Survival Factors 2.3  Impact Sequence and Injury Information 2.3.1  The airplane’s impact with a berm located about 265 feet from the departure end of runway 26 caused the airplane to become momentarily airborne. No airplane debris (except for a main landing gear door) was found before the berm, indicating the airplane structure was intact before this point. Ground scars from the left main and nose landing gears were found about 620 feet from the end of the runway. The airplane then became airborne again, and the cockpit and the left wing impacted an initial group of trees located about 900 feet from the end of the runway. This impact caused the cockpit to break open and the left wing fuel tank to rupture, allowing a fuel-air mixture to ignite. The airplane then impacted the ground about 1,250 feet from the end of the runway, as evidenced by ground scars from the entire lower surface of the airplane. The airplane then slid 400 feet and struck two large diameter trees. The impacts breached the passenger cabin, separating it into two sections and allowing a large amount of fuel, fuel vapor, and fire to enter the cabin. The fuselage traveled another 150 feet before coming to a stop. The airplane structure continued to burn, and the fire eventually consumed the entire fuselage and cabin interior. The simultaneous impacts with two large diameter trees caused numerous blunt force fatal injuries to passengers. One of these tree strikes occurred on the left side of the fuselage several rows aft of the main cabin door.209 The other tree strike occurred in the area where the left inboard wing attached to the fuselage. This tree breached the left wing fuel tank and the cabin in the area of the left overwing exit, cut through the cabin as the airplane continued to slide, and exited the right side of the aft cabin. Figure 8 shows the approximate tree strike areas in the cabin. 209  This tree was uprooted and carried with the airplane to its final location.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 87 Approximate Tree Strike Areas and Injury Information Figure 8.  Note: On the basis of body location information and autopsy results, the Safety Board determined that, before the attempted takeoff, the passengers assigned to seats 2A and 2B most likely switched seats, the passenger assigned to seat 10D most likely moved to seat 7B, and the nonrevenue passenger most likely took seat 12B. Note: Seat positions showing more than one color indicate more than one reported major pathologic finding in the autopsy reports.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 88 The captain’s body was found in the forward area of the passenger cabin. The seriousness of the captain’s blunt force injuries would have precluded him from initiating any postaccident movement. Thus, the captain (and his seat) must have been separated from the cockpit during the impact sequence. The first officer was found in the remnants of his seat secured by the seat’s restraint system. He was extricated from the cockpit wreckage by first responders to the accident scene and transported to the hospital, as discussed in section 2.3.2. The flight attendant’s body was found close to his jumpseat. His autopsy report and those of several passengers in the forward area of the cabin showed a relative lack of blunt force injuries and evidence of smoke inhalation. These findings indicated that these occupants survived the impact but succumbed to the effects of the postcrash fire and smoke. It was not possible to determine the length of time that these occupants survived, but it is important to note that all of these occupants were found close to their seats. Several passengers who were seated in the forward left part of the cabin were found near each other in the aft right part of the cabin. It is likely that the forward tree strike caused these passengers and their seats to be displaced. Most of these passengers sustained fatal blunt force injuries. Most of the passengers seated in rows 7 through 9 (the overwing exit row and the rows immediately in front of and in back of it) were killed immediately by the flash fire that occurred after the left wing fuel tank was breached by the aft tree strike and fuel, fuel vapor, and fire entered the cabin. Two passengers were found outside of the cabin on the left side of the fuselage. These passengers sustained fatal thermal injuries, and neither sustained serious blunt force injuries. Evidence indicated that the passengers were likely thrown outside (through the break in the fuselage caused by the aft tree strike) when the airplane came to a stop. Several passengers who were seated in the aft cabin sustained some blunt force injuries, and most showed evidence of smoke inhalation. It was not possible to determine the length of time that these passengers survived, but it is important to note that all of the passengers were found close to their seats. Emergency Response 2.3.2  According to the aircraft performance study for this accident, the airplane struck trees and terrain west of the airport about 0606:35. The sounds of the accident took about 5 seconds to reach the tower. The controller stated that, after hearing these sounds, he saw a fire west of the airport. The ATC transcript showed that the controller activated the crash phone about 0607:17. Thus, about 37 seconds had elapsed between the time that the accident sounds could be heard in the tower and the time that the controller activated the crash phone. During this time, the controller had to turn around and look outside the tower cab window; assess the situation; and recognize that, even though the airplane

Analysis National Transportation Safety Board A I R C R A F T Accident Report 89 had been cleared to take off from runway 22, the airplane was actually located off the departure end of runway 26. The ATC transcript showed that the airport fire department responded to the crash phone about 0607:22. According to the ATC transcript, the controller announced an “alert three” and indicated that a Comair jet was located at the west side of the airport just off the approach end of runway 8. By providing clear and accurate information about the airplane’s status and location, the controller’s actions complied with the LEX ATCT’s standard operating procedures and letter of agreement with the airport board regarding emergency notifications. The first emergency responders to arrive on scene were a LEX public safety officer and a police officer from the city of Lexington. They arrived (independently of each other) in the general vicinity of the accident about 5 1/2 minutes after receiving notification of the accident and reached the fuselage within 3 1/2 minutes despite restricted visibility caused by tall vegetation near the accident site. The first ARFF vehicle arrived on scene about 11 minutes after alert 3 notification using route information provided by another LEX public safety officer (who was in the general vicinity of the accident site but was not yet on scene). This route was the most effective direct route available to the accident site. This ARFF vehicle immediately began fire suppression and knocked down most of the fire. The second ARFF vehicle arrived on scene shortly afterward and began additional fire suppression. The LEX operations center incident report showed that the fire was controlled about 3 minutes after the first ARFF vehicle arrived on scene. The assistant ARFF chief (who arrived on scene in the first ARFF vehicle) stated that, upon reaching the airplane, its top was gone, and its sides were mostly gone. Other first responders reported that the cabin interior was completely involved (that is, completely on fire) at the time of their arrival on scene. The LEX public safety officer and the police officer from the city of Lexington were able to free the first officer from the cockpit wreckage. Another LEX public safety officer and the city of Lexington police officer transported the first officer to the hospital in a sport-utility vehicle instead of waiting for an ambulance. This LEX public safety officer estimated that they arrived at the hospital (located about 7 miles from the accident site) before 0630. Because of the serious traumatic injuries that the first officer sustained from the accident, it was imperative that he be quickly transported to and receive immediate treatment from a trauma center. The Safety Board concludes that the first officer’s survival was directly attributable to the prompt arrival of the first responders; their ability to extricate him from the cockpit wreckage; and his rapid transport to the hospital, where he received immediate treatment. The Safety Board further concludes that the emergency response for this accident was timely and well coordinated.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 90 Summary of Survival Factors 2.3.3  The Safety Board’s definition of a survivable accident is as follows:210 An accident in which the forces transmitted to the occupant(s) through the seat and restraint system do not exceed the limits of human tolerance to abrupt accelerations and in which the structure in the occupants’ immediate environment remains substantially intact to the extent that a livable volume is provided for the occupants through the crash sequence. The captain and the passengers who received fatal blunt force injuries as a result of the simultaneous tree strikes were clearly in areas of the airplane in which the forces transmitted to the occupants exceeded the limits of human tolerance. Most of the passengers in the overwing area of the cabin did not experience similar forces; however, the large amount of fuel, fuel vapor, and fire forced into the cabin by the aft tree strike made the cabin environment immediately unsurvivable for those passengers. The flight attendant and most of the passengers in the forward and aft areas of the cabin also did not experience forces that exceeded the limits of human tolerance and maintained a livable volume of occupiable space for an undetermined amount of time. As stated in section 2.3.1, the flight attendant and these passengers were found close to their assigned seats. Because the impact forces did not exceed the limits of human tolerance and occupiable space was maintained for some of the airplane occupants, this accident was partially survivable. However, the environment inside the airplane deteriorated quickly as a result of the postcrash fire and smoke, which did not allow sufficient time or means for those occupants to evacuate.  Efforts to Mitigate Airport Surface Operation Errors 2.4  Surface operation errors, including those that lead to wrong runway takeoff events, can be mitigated in several ways, such as improved flight deck procedures, the implementation of cockpit moving map displays or cockpit runway alerting systems, improved airport surface marking standards, and ATC policy changes. These systemwide interventions, which are discussed in sections 2.4.1 through 2.4.5, can provide the necessary redundancy to reduce the opportunity for human error during surface operations and, if an error were to occur, to stop it before it becomes catastrophic. These interventions can also help prevent runway incursions, which is an issue on the Safety Board’s list of Most Wanted Transportation Safety Improvements. 210  This definition was cited in the Safety Board’s 1981 special study on cabin safety in large transport aircraft. According to the study, the definition (1) was developed using aviation crash injury research by Cornell University and aviation safety engineering and research by the Flight Safety Foundation and (2) was used in the Aircraft Crash Survival Design Guide, which was prepared by the U.S. Army Research and Technology Laboratories along with other Federal agencies. The definition has been used by the Board since that time to determine the survivability of accidents. In addition, the definition appeared in the Board’s 2001 safety report on the survivability of accidents involving Part 121 U.S. air carrier operations from 1983 to 2000.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 91 Flight Deck Procedures 2.4.1  Well-designed flight deck procedures can be an effective countermeasure against surface operation errors. After this accident, the Safety Board recognized the need to improve industry standards for confirming an airplane’s position at the departure runway before takeoff and, on December 12, 2006, issued Safety Recommendation A-06‑83. This recommendation asked that the FAA require all Part 121 operators to establish procedures requiring all crewmembers on the flight deck to positively confirm and cross-check the airplane’s location at the assigned departure runway before crossing the hold short line for takeoff. On April 16, 2007, the FAA issued SAFO 07003, “Confirming the Takeoff Runway,” in response to Safety Recommendation A-06-83. According to the SAFO, its purpose is to emphasize the importance of implementing standard operating procedures and training for flight crews to ensure that an airplane is at the intended runway. SAFO 07003 was aimed at directors of safety, directors of operations, fractional ownership program managers, trainers, and pilots. The SAFO stated that pilots should positively confirm and cross-check the takeoff runway and the airplane’s location at the assigned departure runway before crossing the hold short line and while in the takeoff position. The SAFO further stated that airplane-specific standard operating procedures should be established, implemented, and supported by pilot training that uses all available resources to confirm and cross-check an airplane’s position. The SAFO mentioned that these resources included the HSIs, which can confirm that an airplane’s position is where the flight crew intended, and air traffic controllers, who can help confirm an airplane’s position during taxi or at a hold short line. The Safety Board is encouraged that the FAA is providing renewed emphasis about the importance of cross-checking and confirming an airplane’s position on a runway. The Board also notes that SAFO 06013, “Flight Crew Techniques and Procedures That Enhance Pre-takeoff and Takeoff Safety” (see section 1.18.2.2), addressed the issue of training and procedures for improving safety during taxi operations. This SAFO referenced AC 120‑74A, “Parts 91, 121, 125, and 135 Flightcrew Procedures During Taxi Operations,” which outlined best practices for surface operations. The AC indicated that these best practices include sterile cockpit procedures to protect against human error and procedures to maximize “heads-out” time for both pilots to provide necessary redundancy. The FAA’s issuance of SAFO 07003 addressed the intent of Safety Recommendation A-06-83. However, SAFOs are, by definition, advisory only, and the recommendation asked the FAA to require all Part 121 operators to establish procedures requiring flight crewmembers to positively confirm and cross-check an airplane’s location at the assigned departure runway before crossing the hold short line for takeoff. Also, the Board’s survey of Part 121 operators found that many did not include the procedures recommended in SAFO 06013, which had been issued in September 2006. SAFO guidance may be an acceptable alternate response to a Board recommendation if an FAA survey finds that all Part 121 operators have implemented the recommended procedures.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 92 Because the decision to implement a SAFO rests with an operator and because of the importance to flight safety that the information in SAFO 07003 (as well as SAFO 06013) be required and extended to Part 91K211 and 135 operators, Safety Recommendation A‑06‑83 is classified “Closed—Acceptable Alternate Action/Superseded.” In addition, the Safety Board concludes that a standard procedure requiring Part 91K, 121, and 135 pilots to confirm and cross-check that their airplane is positioned at the correct runway before crossing the hold short line and initiating a takeoff would help to improve the pilots’ positional awareness during surface operations. Therefore, the Safety Board believes that the FAA should require that all 14 CFR Part 91K, 121, and 135 operators establish procedures requiring all crewmembers on the flight deck to positively confirm and cross- check the airplane’s location at the assigned departure runway before crossing the hold short line for takeoff. This required guidance should be consistent with the guidance in AC 120-74A and SAFOs 06013 and 07003. In addition, after the accident, the Safety Board also recognized the need to improve industry standards regarding takeoffs at night on unlighted runways. As a result, on December 12, 2006, the Board issued Safety Recommendation A-06-84, which asked the FAA to require all Part 121 operators to provide specific guidance to pilots on the runway lighting requirements for takeoff operations at night. On May 11, 2007, the FAA issued InFO 07009, “Runway Lights Required for Night Takeoffs in Part 121.” This InFO recognized that, even though runway lighting varied among airports and runways, every pilot operating under Part 121 needed to understand the following: (1) pilots should not take off at night on a runway without lights; (2) pilots must check NOTAMs for runway light outages and taxiway and runway closures, and takeoffs are not permitted on closed runways; and (3) a pilot must think beyond pertinent NOTAMs because inoperative runway lights do not necessarily cause a runway to be closed by the airport authority, or a runway may be unusable even if its runway lights are fully operational. The InFO recommended that Part 121 directors of safety, directors of operations, trainers, and pilots collaborate to make these three points clearly understood by their flight crews and include these points in their pilot operating manuals, training programs, and plans for any night takeoff. Even though the information in InFO 07009 is responsive to Safety Recommendation  A-06-84, InFOs are advisory only, and the recommendation asked the FAA to require Part 121 operators to provide pilot guidance on runway lighting requirements for night takeoff operations. However, if the FAA can determine, by surveying all Part 121 operators, that the guidance in the InFO has been adopted, then the Safety Board could consider the InFO to be an acceptable alternative action to the recommendation. Pending the results of an FAA survey of all Part 121 operators to determine whether they have adopted the guidance in InFO 07009, Safety Recommendation A-06-84 is classified “Open—Acceptable Alternate Response.” Finally, in its report on the February 16, 2005, crash of a Cessna Citation 560 in Pueblo, Colorado, the Safety Board discussed the need for pilots to receive training in 211  Title 14 CFR 91 Subpart K applies to fractional ownership operations.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 93 monitoring skills and have opportunities to practice these skills.212 On February 27, 2007, the Board issued Safety Recommendation A-07-13, which asked the FAA to “require that all pilot training programs be modified to contain modules that teach and emphasize monitoring skills and workload management and include opportunities to practice and demonstrate proficiency in these areas.”213 If this recommendation were implemented, pilots would receive training that would not only benefit in-flight operations but also airport surface operations. Technological Initiatives 2.4.2  Advances in technology can provide pilots with improved positional awareness while navigating airport surfaces. Such technologies were discussed and illustrated at the Safety Board’s Runway Incursion Forum in March 2007. Cockpit moving map displays in which the aircraft’s position is superimposed on a map of the airport surface, including all runways, taxiways, and terminal areas, would help pilots orient themselves during navigation if they were to become lost, thus mitigating surface navigation errors. A cockpit moving map display could be an effective countermeasure against the type of perceptual error and confirmation bias that occurred with this accident. Efforts to establish digital maps of airports were included as part of the FAA’s Safe Flight 21 program, and cockpit-based tools for surface navigation were addressed in the FAA’s 2002 Blueprint for Runway Safety. In addition, research showed that, if airborne electronic map displays were extended to airport surface navigation, they could significantly decrease navigational errors, such as wrong turns in low visibility conditions.214 On March 23, 2007, the FAA announced that it was accelerating the certification process to facilitate the installation in air carrier cockpits of class 2 electronic flight bags (EFB), which are portable devices that can display various textual and graphical data, including moving maps.215 The FAA’s decision to accelerate the certification process and allow class 2 EFBs to be used for ground operations was the result of the agency’s recognition that the requirements for the ground use of these devices could be relaxed compared with the more stringent class C standards for the airborne use of the devices. The FAA’s decision to relax the standards for the ground use of class 2 EFBs was partly the result of the agency’s review of human factors research on the safety benefits of these systems. According to the FAA, the research showed that pilots had better awareness of their position on the airport’s surface using an “own ship” position display, and recent 212  National Transportation Safety Board, Crash During Approach to Landing, Circuit City Stores, Inc., Cessna Citation 560, N500AT, Pueblo, Colorado, February 16, 2005, Aircraft Accident Report NTSB/AAR‑07/02 (Washington, DC: NTSB, 2007). The report includes a discussion of the Safety Board’s previous work in the area of pilot monitoring. 213  On May 17, 2007, the FAA stated that 14 CFR Part 61 and the Aircraft Type Rating Practical Test Standard specifically addressed the CRM requirement for airman certification and checking. The FAA also stated that it would consider identifying in its work program a list of required inspections that would reemphasize to regional and flight standards district office managers the need to validate the training that is already required and verify its effectiveness. 214  V. Battiste, M. Downs, and R.S. McCann, “Advanced Taxi Map Display Design for Low-Visibility Operations,” Proceedings of the Human Factors and Ergonomics Society, pages 997-1001, 1996. 215  Class 2 EFBs operate using the airplane’s power system.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 94 tests demonstrated that pilots typically glanced at such displays and then quickly looked out their windows to verify that information visually, thus eliminating the concern that pilots would be “heads down” too long for safe operations. The FAA expected to have guidance on its streamlined certification process for the ground use of class 2 EFB moving map displays by the end of April 2007. (As of July 3, 2007, this guidance had not been issued.) The class C certification standards, which were established in 2003, will remain the same for these devices, but the new certification process is expected to lower the cost for their deployment and implementation. In addition to cockpit moving map displays, the Safety Board reviewed other available technologies that might have alerted the accident flight crewmembers about their surface navigation error. For example, after the Singapore Airlines flight 006 accident, Boeing developed a wrong runway alert that compares the runway selected in the flight management computer (FMC) with the airplane’s position or heading at the time of takeoff. This optional upgrade to EICAS software annunciates a cautionary EICAS alert when a takeoff is attempted on a runway that is not the FMC-selected runway.216 Also, Honeywell developed the runway alert and advisory system (RAAS), which is a software addition to the company’s enhanced ground proximity warning system (EGPWS). RAAS does not require the installation of additional hardware but does require an airplane to be equipped with a global positioning system. RAAS uses the same runway database as EGPWS to provide an aural advisory to pilots when their airplane is approaching or is on a runway during taxi operations. The RAAS system also provides pilots with an aural advisory when their airplane is on a runway of an operator- defined insufficient length or if the airplane is positioned for an intersection departure of insufficient length. In addition, RAAS provides an aural advisory to pilots if a takeoff is attempted on a taxiway. Research conducted by Honeywell indicated that RAAS could mitigate flight crew surface navigation errors that could lead to wrong runway takeoffs. Currently, eight CRJ airplanes have RAAS installed. The Safety Board is encouraged by the FAA’s actions with regard to cockpit moving map displays for surface navigation and cockpit runway alerting systems. However, these technologies have not been mandated despite their demonstrated safety benefits. These technologies need to be considered in the same category as existing technological interventions such as the traffic alert and collision avoidance system (commonly referred to as TCAS) and EGPWS. The Safety Board concludes that the implementation of cockpit moving map displays or cockpit runway alerting systems on air carrier aircraft would enhance flight safety by providing pilots with improved positional awareness during surface navigation. Therefore, the Safety Board believes that the FAA should require that all 14 CFR Part 91K, 121, and 135 operators install on their aircraft cockpit moving map displays or an automatic system that alerts pilots when a takeoff is attempted on a taxiway or a runway other than the one intended. 216  According to Boeing, 14 air carriers currently have airplanes equipped with this alert.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 95 Airport Surface Marking Standards 2.4.3  In 2002, the FAA sponsored a study to determine whether paint markings would improve the situational awareness of pilots taxiing on an airfield. The study, which was undertaken by the Mitre Corporation, found that enhanced taxiway centerline markings and surface painted holding position signs (see figure 5) were effective in increasing runway awareness among transport-category pilots. The FAA is expected to modify its airport marking standards according to the enhanced taxiway centerline marking recommendations from the Mitre Corporation’s January 2005 report. Specifically, the FAA is requiring that, by June 30, 2008, all Part 139 airports with 1.5 million or more annual passenger enplanements have enhanced taxiway centerline markings before each runway holding position.217 According to AC 150/5340-1J, “Standards for Airport Markings,” the enhanced taxiway centerline markings were designed to make hold short lines more conspicuous to pilots and help prevent a loss of situational awareness. The markings were also intended to alert pilots that they were approaching a runway holding position and that they “should go into a ‘heads-up’ mode of operation until they determine the exact location of the holding position.”218 Even though the FAA-sponsored study found that surface painted holding position signs were effective in increasing positional awareness for pilots, the FAA did not modify its requirement for these holding position signs. Currently, the signs are only required where the width of the holding position on the taxiway is greater than 200 feet. From a human factors standpoint, surface painted holding position signs provide pilots with an unambiguous cue of their position on the airport surface. The central location of these position signs (adjacent to the taxiway centerline) increases their conspicuity, providing a critical redundancy to existing signage. The Safety Board is encouraged by the FAA’s plan to incorporate enhanced taxiway centerline markings at airports with 1.5 million or more annual passenger enplanements. However, the Board is concerned that other Part 139 airports will not be required to implement these markings and that surface painted holding position signs will still only be required where the width of the holding position on the taxiway is greater than 200 feet. The Safety Board concludes that enhanced taxiway centerline markings and surface painted holding position signs provide pilots with additional awareness about the runway and taxiway environment. Therefore, the Safety Board believes that the FAA should require that all airports certificated under 14 CFR Part 139 implement enhanced taxiway centerline markings and surface painted holding position signs at all runway entrances. 217  According to the FAA’s passenger enplanement data for 2005 (the most recent data available), these markings will be required at 75 airports. LEX is not one of those airports; during 2005, it had about 0.5 million passenger enplanements. 218  AC 150/5340-1J also stated, “installation at other airports is at the option of the airport operator. If an airport operator decides to exercise this option, the enhanced markings must be installed at all holding positions on the airport.”

Analysis National Transportation Safety Board A I R C R A F T Accident Report 96 Taxi and Takeoff Clearances 2.4.4  As stated in section 2.2.1.1, 14 CFR 91.129(i) permits pilots, after receiving taxi clearance, to cross all intersecting runways along the taxi route (without stopping) except for the assigned departure runway. On July 6, 2000, the Safety Board issued Safety Recommendations A-00-67 and -68, which asked, in part, that the FAA (1) amend 14 CFR 91.129(i) to require that all runway crossings be authorized only by specific ATC clearance and (2) amend FAA Order 7110.65 to require that, for aircraft that need to cross multiple runways, air traffic controllers issue an explicit crossing instruction for each runway after the previous runway has been crossed. The Board classified these safety recommendations “Open—Unacceptable Response” on April 11, 2006. If these safety recommendations had been implemented before this accident, the controller would have been required to issue a specific taxi clearance for the airplane to cross runway 26 and then issue a specific taxi clearance for the airplane to continue taxiing to runway 22. These procedures would have provided the flight crew with better awareness of the airplane’s position along the taxi route and would have required the controller to visually observe the airplane’s position and monitor the taxi as the airplane progressed toward the departure runway. Thus, the flight crew’s surface navigation error might have been prevented. In addition, Mitre reports cited pilot and controller concerns about the adequacy of runway crossing requirements, and most of these pilots and controllers thought that it would be beneficial to safety to modify 14 CFR 91.129(i) so that it required a specific clearance for each runway crossing.219 The Safety Board concludes that this accident demonstrates that 14 CFR 91.129(i) might result in mistakes that have catastrophic consequences because the regulation allows an airplane to cross a runway during taxi without a pilot request for a specific clearance to do so. Therefore, the Safety Board reiterates Safety Recommendations A-00-67 and -68. In addition, no FAA guidance specifically prohibits issuing a takeoff clearance until all intersecting runways to the departure runway have been crossed. On January 4, 2007, the LEX air traffic manager issued a notice that stated that controllers at the tower were not to issue takeoff clearances for runway 22 until the departing airplanes were observed to have completely crossed runway 26.220 Such guidance would benefit other airports with intersecting runways. On June 1, 2007, the FAA issued Notice N JO 7110.468 to amend the required phraseology for issuing departure instructions. According to this notice, a controller has to specifically clear an airplane across all intervening runways before issuing a takeoff clearance. However, this guidance does not instruct controllers to wait until an airplane has crossed the runways before issuing the takeoff clearance. 219  (a) Reports by Airline Pilots on Airport Surface Operations: Part 2. Identified Problems and Proposed Solutions for Surface Operational Procedures and Factors Affecting Pilot Performance, Technical Report No. MTR94W0000060.v2, McLean, Virginia: Mitre Corporation, 1994; and (b) Reports by Air Traffic Control Tower Controllers on Airport Surface Operations: The Causes and Prevention of Runway Incursions, Technical Report No. MTR98W0000033, McLean, Virginia: Mitre Corporation, 1998. 220  In addition, in its July 17, 1989, letter transmitting Safety Recommendation A-89-74 (see section 1.18.3.1), the Safety Board noted that the controllers at HOU were required to observe airplanes cross the approach end of runway 17 before issuing a clearance for takeoff for runway 12. This requirement was the result of two pilot deviation events in early 1989 that involved departures of U.S. air carrier airplanes from the wrong runway at the airport.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 97 The Safety Board concludes that, if controllers were required to delay a takeoff clearance until confirming that an airplane has crossed all intersecting runways to a departure runway, the increased monitoring of the flight crew’s surface navigation would reduce the likelihood of wrong runway takeoff events. Therefore, the Safety Board believes that the FAA should prohibit the issuance of a takeoff clearance during an airplane’s taxi to its departure runway until after the airplane has crossed all intersecting runways. Controller Monitoring Responsibility 2.4.5  FAA Order 7110.65, paragraph 2-1-2, “Duty Priority,” states that controllers should “give first priority to separating aircraft and issuing safety alerts” and that “good judgment shall be used in prioritizing all other provisions of this order based on the requirements of the situation at hand.” Visual monitoring of takeoffs and landings is not specifically required by the order, so a controller’s decision whether to monitor a takeoff or landing is thus left to his or her judgment. Unless other active, flight safety-related control tasks demand attention, controllers should visually monitor departing and arriving airplanes because such monitoring can allow the detection of unexpected threats to flight safety, including surface navigation errors. Thus, the monitoring of takeoffs and landings should have a higher priority than performing administrative tasks because such tasks, although required, do not directly affect flight safety, whereas visual monitoring of takeoffs and landings provides a safety protection. The Safety Board recognizes that controllers may not be able to continuously monitor all takeoffs and landings in their area of operations. Research on performance criteria for ATC specialists indicated that local (tower) controllers spent about 38 percent of their time looking out of tower cab windows.221 These controllers were looking at the DBRITE and flight progress strips during most of their other time, which was necessary because these sources of information were routinely changing and thus required visual attention. Even though controllers cannot continuously monitor departing and arriving airplanes, controllers can prioritize their duties so that they give priority to monitoring tasks over the performance of administrative tasks. The LEX controller stated that he monitored the takeoff of departing airplanes when arriving airplanes were on final approach so that he could ensure that the departing airplanes took off in time to maintain adequate separation. The controller stated that he might decide to watch other airplanes take off but that this decision depended on whether he needed to attend to other duties. The controller’s decision to perform the traffic count instead of monitoring the Comair flight’s departure, in addition to his description of his normal monitoring practices for departing airplanes, suggested that he did not regard the visual monitoring of takeoffs and landings as a necessary flight safety activity. However, 221  K. Cardosi and A. Yost, Controller and Pilot Error in Airport Operations: A Review of Previous Research and Analysis of Safety Data, Technical Report No. DOT/FAA/AR-00/51 (Washington, DC: Department of Transportation, 2001).

Analysis National Transportation Safety Board A I R C R A F T Accident Report 98 after the accident, the controller acknowledged that it might have been possible for him to detect that the accident airplane was on the wrong runway if he had been looking out the tower cab windows. Administrative tasks should not have priority over radar and tower monitoring tasks. The Safety Board concludes that, if controllers were to focus on monitoring tasks instead of administrative tasks when aircraft are in the controller’s area of operations, the additional monitoring would increase the probability of detecting flight crew errors. Therefore, the Safety Board believes that the FAA should revise FAA Order 7110.65, “Air Traffic Control,” to indicate that controllers should refrain from performing administrative tasks, such as the traffic count, when moving aircraft are in the controller’s area of responsibility. Air Traffic Control Staffing 2.5  In August 2005, an operational error occurred during the midnight shift at RDU, which resulted in a loss of separation between a departing and an arriving airplane. At the time, one controller was performing radar and tower functions in the tower cab. The FAA attributed this incident to “controller situational awareness and actions,” specifically, the controller’s “failure to maintain constant surveillance and awareness of [radar] displays and traffic situation, failure to comprehend and project the future status of displayed data, and failure to provide attention to detail necessary for the safe operation of aircraft under control.” The FAA’s final report on the operational error described the traffic situation as “moderately difficult” because the controller was handling nine airplanes (one departure, six arrival, and two taxiing airplanes) and thunderstorms were in the airspace, which led the controller to vector one of the airplanes off of a standard arrival route. As a result of this incident, the FAA issued verbal guidance in late August 2005 indicating that all facilities with radar and tower responsibilities were to be staffed with two controllers during the midnight shift so that the functions could be split.222 In November 2005, the LEX air traffic manager notified his staff by e-mail about this guidance. Staffing during the midnight shift at LEX (0000 to 0800) was frequently not in compliance with this guidance. The midnight shift at LEX was staffed with one controller until January 2006. Between January and March 2006, the midnight shift was staffed with two controllers 40 percent of the time. In April 2006, the shift was again staffed with one controller because traffic had increased during the day and swing shifts and the second 222  As stated in section 1.10.2.1, in November 2006 the FAA issued Notice N JO 7210.639 to formalize this verbal guidance.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 99 midnight controller was needed on those shifts.223 As a result of this staffing change, only one controller was performing both radar and tower functions at the time of the accident. As discussed in section 2.2.3.1, the controller’s combined radar and tower responsibilities imposed concurrent tasks, which required him to engage in selective attention during the minutes before the accident. However, the controller’s performance of concurrent tasks should not have precluded adequate monitoring of Comair flight  5191 during its attempted takeoff. As discussed in section 2.2.3.2, after he transferred responsibility of American Eagle flight 882 to the Indianapolis ARTCC, the controller’s sole operational responsibility was the Comair flight. Thus, no radar duties were interfering with the controller’s tower responsibilities during the 28-second critical window just before the accident. The controller’s workload was not excessive, and ample time was available during the Comair flight’s taxi and takeoff roll for him to perform all necessary radar tasks while also monitoring the flight’s progress on the airport surface. As a result, the Safety Board concludes that, even though the air traffic manager’s decision to staff midnight shifts at LEX with one controller was contrary to FAA verbal guidance indicating that two controllers were needed, it cannot be determined if this decision contributed to the circumstances of this accident. Other Related Issues 2.6  Airport Charts 2.6.1  At the time of the accident, the flight crew had the most recent Jeppesen chart for LEX, which was dated January 2006. This chart showed taxiway A5 and taxiway A north of runway 8/26. However, at the time of the accident, taxiway A5 had been redesignated as taxiway A, and taxiway A north of runway 8/26 had been closed. The Jeppesen flight safety manager stated that the Jeppesen chart did not reflect information about the LEX runway and taxiway configuration (received from NFDC on June 23, 2006) because of a software error. After the accident, Jeppesen posted a revised chart on its Web site on August 29, 2006, and issued the revised chart on September 8,

1. This chart showed future taxiway A7 but not taxiway A5 and taxiway A north

of runway  8/26 (the taxiway configuration at the completion of the construction project). Jeppesen and FAA officials indicated that it was not unusual during long-term construction projects for airport charts to differ slightly from what was actually present on the airport and for the changes to be included in local NOTAMs. 223  In a postaccident interview, the LEX air traffic manager stated that he understood the midnight shift staffing guidance but that he thought he had some flexibility to manage the ATCT and its staff as he deemed necessary.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 100 In addition, the August 3, 2006, NACO chart for LEX had been updated by the FAA to show the taxiway configuration at the completion of the construction project (future taxiway A7 was shown but not taxiway A5 and taxiway A north of runway 8/26). The program manager of the LEX construction project at the FAA’s Memphis Airports District Office stated that he did not recommend publishing an interim chart because the chart would have been inaccurate during the time both before and after the construction project. Neither the Jeppesen nor the NACO chart reflected the taxiway identifiers that were present on the airport at the time of the accident. However, the CVR did not record any discussion between the flight crewmembers indicating confusion about the airport taxiways, and the discrepancies between the Jeppesen chart available to the flight crew and the taxiway identifiers on the airport at the time would not have misled the pilots to runway 26 instead of runway 22. Nevertheless, the Safety Board recognizes that, under different circumstances, up-to-date charts might be necessary for a flight crew’s successful navigation on an airport and that, for those circumstances, the charts would need to be complete, accurate, and timely. The Safety Board concludes that, because of an ongoing construction project at LEX, the taxiway identifiers represented in the airport chart available to the flight crew were inaccurate, and the information contained in a local NOTAM about the closure of taxiway A was not made available to the crew via ATIS broadcast or the flight release paperwork. Automatic Terminal Information Service Broadcasts 2.6.2  The flight crew indicated that it had received ATIS information “alpha,” and the controller advised the flight crew when ATIS information “bravo” was current. Neither ATIS broadcast indicated that taxiway A north of runway 8/26 had been closed as part of the airport construction project. FAA Order 7110.65, paragraph 2-9-3g, “Content,” states that taxiway closures that affect the entrance or exit of active runways should be included in ATIS broadcasts. After the accident, the Safety Board determined that the taxiway closure information had been included in a sampling of ATIS broadcasts recorded between 0530 and 0630 each day between August 20 and 26, 2006. FAA Order 7110.65, paragraph 2-9-2d, “Operating Procedures,” allows controllers to supplement ATIS information during their direct communications with pilots. The CVR showed that the controller did not advise the flight crew about the status of taxiway A north of runway 8/26. Because the construction project affected the entrance and exit paths of runway 4/22, either the ATIS broadcasts or the controller’s direct communications with the pilots should have included information about the altered taxiway A configuration. The Safety Board was not able to determine what effect, if any, information about the closure of taxiway A north of runway 8/26 (either through the ATIS broadcasts or the controller’s direct communications with the flight crew) would have had on the circumstances of this accident. However, this possible cue would not have had the same salience as the primary cues—the airport markings and signage—that were accurate

Analysis National Transportation Safety Board A I R C R A F T Accident Report 101 and available to the flight crew. It is also important to note that the airplane turned onto runway 26 before it would have encountered the area on taxiway A that had been closed. Thus, the Safety Board concludes that the controller’s failure to ensure that the flight crew was aware of the altered taxiway A configuration was likely not a factor in the crew’s inability to navigate to the correct runway. Nevertheless, the Board recognizes that, under different circumstances, information on an altered taxiway configuration might be necessary for a flight crew’s successful navigation on an airport and that, for those circumstances, the crew would need to receive complete, accurate, and timely ATIS information. Local Notice to Airmen 2.6.3  The local NOTAM that indicated that taxiway A north of runway 8/26 was closed was not included in the Comair flight planning system or the flight release paperwork for the accident flight because the company determined that the information in the local NOTAM did not affect safety of flight. The Safety Board was not able to determine what effect, if any, this information would have had on the circumstances of this accident. However, this possible cue would not have had the same salience as the primary cues— the airport markings and signage—that were accurate and available to the flight crew. In addition, the Board’s analysis of the accident determined that the taxi to runway 22 was relatively simple and could have been successfully conducted by using the cues and aids available to the flight crew. Thus, the Safety Board concludes that, because the information in the local NOTAM about the altered taxiway A configuration was not needed for the pilots’ wayfinding task, the absence of the local NOTAM from the flight release paperwork was not a factor in this accident. As stated in section 1.18.6, the FAA has planned initiatives to modernize the current NOTAM system. These initiatives include aligning the U.S. NOTAM system with that of ICAO by October 2007 so that U.S. NOTAM information can be processed and provided to flight crews in a more timely, accurate, complete, and traceable manner and having digital NOTAM data displayed in the cockpit in textual and graphical formats. For this accident, even though the information in the local NOTAM was not necessary for the flight crew’s successful navigation to the correct runway, such information might be necessary under different circumstances. Thus, the Safety Board is pleased that the FAA is taking a proactive role to improve the current NOTAM system. Presence of Extended Taxiway Centerline 2.6.4  One of the three centerlines that diverged from the taxiway A hold short position for runway 8/26 led to taxiway A north of runway 8/26, which had been closed and was blocked by low-profile barricades with flashing red lights. This extended taxiway centerline had not been removed at the time of the accident.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 102 The LEX construction plan called for the removal of taxiway A north of runway 8/26 and the associated extended taxiway centerline within 30 to 45 days of that taxiway’s closure. Because proper barricades had been put into place until such time, and because the CVR did not record any confusion between the flight crewmembers about the taxiway A configuration, the Safety Board concludes that the presence of the extended taxiway centerline to taxiway A north of runway 8/26 was not a factor in this accident.

National Transportation Safety Board A I R C R A F T Accident Report 103 Conclusions

Findings 3.1  The captain and the first officer were properly certificated and qualified under Federal

regulations. There was no evidence of any medical or behavioral conditions that might have adversely affected their performance during the accident flight. Before reporting for the accident flight, the flight crewmembers had rest periods that were longer than those required by Federal regulations and company policy. The accident airplane was properly certified, equipped, and maintained in accordance

with Federal regulations. The recovered components showed no evidence of any structural, engine, or system failures. Weather was not a factor in this accident. No restrictions to visibility occurred during

the airplane’s taxi to the runway and the attempted takeoff. The taxi and the attempted takeoff occurred about 1 hour before sunrise during night visual meteorological conditions and with no illumination from the moon. The captain and the first officer believed that the airplane was on runway 22 when

they taxied onto runway 26 and initiated the takeoff roll. The flight crew recognized that something was wrong with the takeoff beyond the

point from which the airplane could be stopped on the remaining available runway. Because the accident airplane had taxied onto and taken off from runway 26 without

a clearance to do so, this accident was a runway incursion. Adequate cues existed on the airport surface and available resources were present in

the cockpit to allow the flight crew to successfully navigate from the air carrier ramp to the runway 22 threshold. The flight crewmembers’ nonpertinent conversation during the taxi, which was not in

compliance with Federal regulations and company policy, likely contributed to their loss of positional awareness. The flight crewmembers failed to recognize that they were initiating a takeoff on the

wrong runway because they did not cross-check and confirm the airplane’s position on the runway before takeoff and they were likely influenced by confirmation bias. Even though the flight crewmembers made some errors during their preflight activities

and the taxi to the runway, there was insufficient evidence to determine whether fatigue affected their performance.

Conclusions National Transportation Safety Board A I R C R A F T Accident Report 104 The flight crew’s noncompliance with standard operating procedures, including the

captain’s abbreviated taxi briefing and both pilots’ nonpertinent conversation, most likely created an atmosphere in the cockpit that enabled the crew’s errors. The controller did not notice that the flight crew had stopped the airplane short of the

wrong runway because he did not anticipate any problems with the airplane’s taxi to the correct runway and thus was paying more attention to his radar responsibilities than his tower responsibilities. The controller did not detect the flight crew’s attempt to take off on the wrong runway

because, instead of monitoring the airplane’s departure, he performed a lower-priority administrative task that could have waited until he transferred responsibility for the airplane to the next air traffic control facility. The controller was most likely fatigued at the time of the accident, but the extent

that fatigue affected his decision not to monitor the airplane’s departure could not be determined in part because his routine practices did not consistently include the monitoring of takeoffs. The Federal Aviation Administration’s operational policies and procedures at the

time of the accident were deficient because they did not promote optimal controller monitoring of aircraft surface operations. The first officer’s survival was directly attributable to the prompt arrival of the first

responders; their ability to extricate him from the cockpit wreckage; and his rapid transport to the hospital, where he received immediate treatment. The emergency response for this accident was timely and well coordinated.

A standard procedure requiring 14

Code of Federal Regulations Part 91K, 121, and 135 pilots to confirm and cross-check that their airplane is positioned at the correct runway before crossing the hold short line and initiating a takeoff would help to improve the pilots’ positional awareness during surface operations. The implementation of cockpit moving map displays or cockpit runway alerting

systems on air carrier aircraft would enhance flight safety by providing pilots with improved positional awareness during surface navigation. Enhanced taxiway centerline markings and surface painted holding position

signs provide pilots with additional awareness about the runway and taxiway environment. This accident demonstrates that 14

Code of Federal Regulations 91.129(i) might result in mistakes that have catastrophic consequences because the regulation allows an airplane to cross a runway during taxi without a pilot request for a specific clearance to do so.

Conclusions National Transportation Safety Board A I R C R A F T Accident Report 105 If controllers were required to delay a takeoff clearance until confirming that an

airplane has crossed all intersecting runways to a departure runway, the increased monitoring of the flight crew’s surface navigation would reduce the likelihood of wrong runway takeoff events. If controllers were to focus on monitoring tasks instead of administrative tasks when

aircraft are in the controller’s area of operations, the additional monitoring would increase the probability of detecting flight crew errors. Even though the air traffic manager’s decision to staff midnight shifts at Blue Grass

Airport with one controller was contrary to Federal Aviation Administration verbal guidance indicating that two controllers were needed, it cannot be determined if this decision contributed to the circumstances of this accident. Because of an ongoing construction project at Blue Grass Airport, the taxiway identifiers

represented in the airport chart available to the flight crew were inaccurate, and the information contained in a local notice to airmen about the closure of taxiway A was not made available to the crew via automatic terminal information service broadcast or the flight release paperwork. The controller’s failure to ensure that the flight crew was aware of the altered taxiway A

configuration was likely not a factor in the crew’s inability to navigate to the correct runway. Because the information in the local notice to airmen (NOTAM) about the altered

taxiway A configuration was not needed for the pilots’ wayfinding task, the absence of the local NOTAM from the flight release paperwork was not a factor in this accident. The presence of the extended taxiway centerline to taxiway A north of runway 8/26

was not a factor in this accident. Probable Cause 3.2  The National Transportation Safety Board determines that the probable cause of this accident was 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. Contributing to the accident were the flight crew’s nonpertinent conversation during taxi, which resulted in a loss of positional awareness, and the Federal Aviation Administration’s failure to require that all runway crossings be authorized only by specific air traffic control clearances.

National Transportation Safety Board A I R C R A F T Accident Report 106 Recommendations

New Recommendations 4.1  As a result of the investigation of this accident, the National Transportation Safety Board makes the following recommendations: —To the Federal Aviation Administration: Require that all 14 Code of Federal Regulations Part 91K, 121, and 135 operators establish procedures requiring all crewmembers on the flight deck to positively confirm and cross-check the airplane’s location at the assigned departure runway before crossing the hold short line for takeoff. This required guidance should be consistent with the guidance in Advisory Circular 120‑74A and Safety Alert for Operators 06013 and

1. (A-07-44)

Require that all 14 Code of Federal Regulations Part 91K, 121, and 135 operators install on their aircraft cockpit moving map displays or an automatic system that alerts pilots when a takeoff is attempted on a taxiway or a runway other than the one intended. (A-07-45) Require that all airports certificated under 14 Code of Federal Regulations Part 139 implement enhanced taxiway centerline markings and surface painted holding position signs at all runway entrances. (A-07-46) Prohibit the issuance of a takeoff clearance during an airplane’s taxi to its departure runway until after the airplane has crossed all intersecting runways. (A-07-47) Revise Federal Aviation Administration Order 7110.65, “Air Traffic Control,” to indicate that controllers should refrain from performing administrative tasks, such as the traffic count, when moving aircraft are in the controller’s area of responsibility. (A-07-48)

Recommendations National Transportation Safety Board A I R C R A F T Accident Report 107 Previously Issued Recommendations Reiterated in 4.2  This Report The Safety Board reiterates the following recommendations to the Federal Aviation Administration: Amend 14 Code of Federal Regulations (CFR) Section 91.129(i) to require that all runway crossings be authorized only by specific air traffic control clearance, and ensure that U.S. pilots, U.S. personnel assigned to move aircraft, and pilots operating under 14 CFR Part 129 receive adequate notification of the change. (A-00-67) Amend Federal Aviation Administration Order 7110.65, “Air Traffic Control,” to require that, when aircraft need to cross multiple runways, air traffic controllers issue an explicit crossing instruction for each runway after the previous runway has been crossed. (A-00-68) Previously Issued Recommendations Resulting From 4.3  This Accident Investigation As a result of the investigation into this accident, the Safety Board issued the following recommendations to the Federal Aviation Administration (FAA) on December 12, 2006: Require that all 14 Code of Federal Regulations Part 121 operators establish procedures requiring all crewmembers on the flight deck to positively confirm and cross-check the airplane’s location at the assigned departure runway before crossing the hold short line for takeoff. (A-06-83) Require that all 14 Code of Federal Regulations Part 121 operators provide specific guidance to pilots on the runway lighting requirements for takeoff operations at night. (A-06-84) For additional information about these recommendations, see sections 1.18.3.1 and 2.4.1 of this report. Also, the Board issued the following recommendations to the FAA on April 10, 2007: Work with the National Air Traffic Controllers Association to reduce the potential for controller fatigue by revising controller work-scheduling policies and practices to provide rest periods that are long enough for

Recommendations National Transportation Safety Board A I R C R A F T Accident Report 108 controllers to obtain sufficient restorative sleep and by modifying shift rotations to minimize disrupted sleep patterns, accumulation of sleep debt, and decreased cognitive performance. (A-07-30) Develop a fatigue awareness and countermeasures training program for controllers and for personnel who are involved in the scheduling of controllers for operational duty that will address the incidence of fatigue in the controller workforce, causes of fatigue, effects of fatigue on controller performance and safety, and the importance of using personal strategies to minimize fatigue. This training should be provided in a format that promotes retention, and recurrent training should be provided at regular intervals. (A-07-31) Require all air traffic controllers to complete instructor-led initial and recurrent training in resource management skills that will improve controller judgment, vigilance, and safety awareness. (A-07-34) For additional information about these recommendations, see section 1.18.3.2 of this report. In addition, the Board issued the following recommendation to the National Air Traffic Controllers Association on April 10, 2007: Work with the Federal Aviation Administration to reduce the potential for controller fatigue by revising controller work-scheduling policies and practices to provide rest periods that are long enough for controllers to obtain sufficient restorative sleep and by modifying shift rotations to minimize disrupted sleep patterns, accumulation of sleep debt, and decreased cognitive performance. (A‑07-32) For additional information about this recommendation, see section 1.18.3.2 of this report. Previously Issued Recommendations Classified in 4.4  This Report Safety Recommendation A-06-83 is classified “Closed—Acceptable Alternate Action/Superseded,” and Safety Recommendation A-06-84 is classified “Open— Acceptable Alternate Response,” in section 2.4.1 of this report. Safety Recommendations A-07-30 and -31 are classified “Open—Acceptable Response” in section 2.2.3.3 of this report.

Recommendations National Transportation Safety Board A I R C R A F T Accident Report 109 Safety Recommendation A-07-34 is classified “Open—Acceptable Response” in section 2.2.3.2 of this report. BY THE NATIONAL TRANSPORTATION SAFETY BOARD MARK V. ROSENKER Chairman ROBERT L. SUMWALT Vice Chairman Deborah A. P. Hersman Member KATHRyn O. HIGGINS Member Steven R. chealander Member Adopted: July 26, 2007 Members Hersman and Higgins filed the following concurring statements on August 2, 2007.

National Transportation Safety Board A I R C R A F T Accident Report 110 Board Member Statements

Board Member Statements National Transportation Safety Board A I R C R A F T Accident Report 111

Board Member Statements National Transportation Safety Board A I R C R A F T Accident Report 112

Board Member Statements National Transportation Safety Board A I R C R A F T Accident Report 113

Board Member Statements National Transportation Safety Board A I R C R A F T Accident Report 114

Board Member Statements National Transportation Safety Board A I R C R A F T Accident Report 115

Board Member Statements National Transportation Safety Board A I R C R A F T Accident Report 116

Board Member Statements National Transportation Safety Board A I R C R A F T Accident Report 117

Board Member Statements National Transportation Safety Board A I R C R A F T Accident Report 118

Board Member Statements National Transportation Safety Board A I R C R A F T Accident Report 119

National Transportation Safety Board A I R C R A F T Accident Report 121 Appendixes

Appendix A Investigation and Hearing Investigation The National Transportation Safety Board was initially notified of this accident on August 27, 2006, about 0645. A go-team departed Washington, D.C., about 1030 and arrived on scene about 1145. Accompanying the team to Lexington was Member Deborah A.P. Hersman. The following investigative teams were formed: Operations, Human Performance, Structures, Systems, Powerplants, Air Traffic Control, Meteorology, Aircraft Performance, Maintenance Records, Survival Factors, and Witnesses. While the investigative teams were in Lexington, specialists were assigned to conduct the readout of the flight data recorder and transcribe the cockpit voice recorder at the Safety Board’s laboratory in Washington, D.C. Parties to the investigation were the Federal Aviation Administration, Comair, Blue Grass Airport, Air Line Pilots Association, General Electric Aircraft Engines, International Association of Machinists and Aerospace Workers, National Air Traffic Controllers Association, and Teamsters Local 513 (Flight Attendants). In accordance with the provisions of Annex 13 to the Convention on International Civil Aviation, the Transportation Safety Board of Canada (the Safety Board’s counterpart agency in Canada) participated in the investigation as the representative of the State of Design and Manufacture. Transport Canada and Bombardier Aerospace participated in the investigation as technical advisors to the Transportation Safety Board of Canada, as provided in Annex 13. Public Hearing No public hearing was held for this accident.

National Transportation Safety Board A I R C R A F T Accident Report 122 Appendix B Cockpit Voice Recorder The following is the transcript of the Fairchild model A100S cockpit voice recorder, serial number 03035, installed on a Comair CRJ-100, N431CA, which crashed while attempting to take off from the wrong runway on August 27, 2006. LEGEND CAM Cockpit area microphone voice or sound source hOT Flight crew audio panel voice or sound source RDO Radio transmissions from accident aircraft PA Voice transmitted over aircraft public address system CLR Radio transmission from the Blue Grass Airport clearance controller GND Radio transmission from the Blue Grass Airport ground controller TWR Radio transmission from the Blue Grass tower controller E882 Radio transmission from Eagle flight eight eighty-two S6819 Radio transmission from Skywest flight sixty-eight nineteen -1 Voice identified as the Captain -2 Voice identified as the First Officer -3 Voice identified as the male Flight Attendant -4 Voice identified as the aircraft mechanical voice -5 Voice identified as ACM (additional crew member pilot) -? Voice unidentified * Unintelligible word # Expletive @ Non-pertinent word ( ) Questionable insertion [ ] Editorial insertion Note 1: Times are expressed in eastern daylight time (EDT). Note 2: Generally, only radio transmissions to and from the accident aircraft were transcribed. Note 3: Words shown with excess vowels, letters, or drawn out syllables are a phonetic representation of the words as spoken. Note 4: Radio transmissions from CLR, GND and TWR all appear to be the same controller.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 123

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME (EDT)

TIME (EDT) & SOURCE CONTENT

& SOURCE CONTENT

05:36:07.7 START of RECORDING START of TRANSCRIPT

05:36:18.4 CAM [sound of rustling similar to someone entering the cockpit]

05:36:50.2 CAM-3 * well, I reported at five-thirty ***.

05:37:26.9 CAM-1 ***.

05:37:50.9 CAM-1 everything else is good.

05:37:52.7 CAM [sound similar to crewmember testing oxygen mask]

05:38:03.4 HOT-? [sound similar to crewmember conducting hot microphone test]

05:38:04.3 CAM-1 circuit breakers, checked, nose wheel steering is off, hydraulic pumps, all off, landing gear lever, down, spoiler lever, lever, re- tracted, flaps lever, set to flaps twenty, radar, off, AHRS, mag, landing gear manual release, ADG manual release, battery mas- ter, on, fire protection, checked, nav lights, on, external ** A/C, no APU, hydraulic pump 3A is on, nosewheel door, closed, air- craft/crew docs, on board, flight compartment safety inspection is complete.

05:38:28.4 CAM [sound similar to crewmember checking an oxygen mask]

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 124

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME (EDT)

TIME (EDT) & SOURCE CONTENT

& SOURCE CONTENT

05:38:40.9 HOT [three tones similar to CVR test tone]

05:38:53.0 CAM-? [sound of person whistling]

05:38:55.7 CAM [sound of hi-lo chime]

05:39:07.6 CAM-4 [sound of chimes similar to fire protection fire test signal] smoke.

05:39:13.3 CAM-1 smoke.

05:39:20.8 CAM-4 [sound of triple chime] bleed air duct.

05:39:24.9 CAM-1 I was talking to another guy I flew with yesterday. he was uh, had put his, bid in for uh, JFK captain. he wasn't real happy about it but......

05:39:35.4 CAM-2 First Officer?

05:39:36.3 CAM-1 yeah.

05:39:37.9 CAM-3 would you turn the smoking-seatbelt sign on for me?

05:39:40.2 CAM [sound of chime]

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 125

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME (EDT)

TIME (EDT) & SOURCE CONTENT

& SOURCE CONTENT

05:39:41.0 CAM-1 you got it. here come the lights.

05:39:43.5 CAM-2 why wasn't he too happy about it? he can always change it.

05:39:46.8 CAM-1 yeah, you know he just uh, he's just not really looking forward to reserves, that's all. but he feels like you know and I think he's right if he wants to get out of here. that's his decision he wants to do but. he's gotta get that PIC....

05:40:01.1 CAM-2 exactly.

05:40:01.9 CAM-1 ...you gotta bite the bullet sometimes but, I mean, nobody wants to do reserve there.

05:40:08.5 CAM-2 nope, not here. not the way they do it. they just they have.....

05:40:11.0 CAM [sound of chime]

05:40:12.9 CAM-2 ...no clue. they don't utilize....

05:40:14.3 CAM-? it's time.

05:40:14.4 CAM-? all right.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 126

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME (EDT)

TIME (EDT) & SOURCE CONTENT

& SOURCE CONTENT

05:40:16.5 CAM-2 ... the people effectively.

05:40:17.3 CAM [sound of chime]

05:40:21.9 CAM-2 you know, you're on for six days and you might fly eight hours 'cause they *.

05:40:27.1 CAM-1 it's amazing though right now, they are using everybody pretty efficiently. um, just shows you what they can do. like I mean I don't have more than ten hours in a hotel, any of these days that I've been on....

05:40:38.2 CAM-2 really.

05:40:38.7 CAM-1 ...and it's been that way for all month. now September rolls around and I'll guarantee you it'll be a different story.

05:40:47.4 CAM [sound of chime]

05:40:50.3 CAM-2 because I know Cincinnati base, they have a lot of reserves. but I understand.

05:40:55.8 CAM-1 *.

05:40:56.0 CAM-1 then, they send them all to New York.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 127

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME (EDT)

TIME (EDT) & SOURCE CONTENT

& SOURCE CONTENT

05:40:57.1 CAM-2 right, exactly.

05:40:58.4 CAM-1 yeah.

05:40:59.9 CAM [sound similar to stick shaker test]

05:41:04.6 CAM-4 glideslope whoop whoop, pull up, wind shear, wind shear, wind shear, terrain, terrain, whoop whoop, pull up. [sound of chime]

05:41:09.4 CAM-? [sound of person whistling]

05:41:22.6 CAM-4 [sound of triple chime] gear bay overheat.

05:41:45.7 CAM-4 TCAS system tests okay.

05:41:50.1 INT-1 test, test.

05:41:52.4 CAM [sound of three hi-lo chimes]

05:42:10.8 CAM-1 funny you were talking about @ I mean, I, I, I flew with a guy who was, he said he filled out the application process, he filled out the application and went through the background checks. actually I did my uh, my MV/LOE with him uh, about three or four weeks ago and uh, he was telling me all about it.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 128

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME (EDT)

TIME (EDT) & SOURCE CONTENT

& SOURCE CONTENT

05:42:33.3 CAM-2 well that might do all that stuff prior to actually, giving you, the interview date.

05:42:38.5 CAM-1 uh huh.

05:42:39.3 CAM-2 but you are by no means guaranteed anything….

05:42:42.2 CAM-1 yeah.

05:42:44.4 CAM-2 but.

05:42:45.1 CAM-1 I just talked to my wife about it, we looked at, we looked at it on line. you know and I was looking at the pay scales and uh, yeah I know they provide a place ta, for you to live and things like that and was at four thousand, I don't know, forty-four hundred dollars.

05:43:01.8 CAM-2 fifty-two, fifty-two twelve, a month for the first * month tax free.

05:43:07.9 CAM-? how is it?

05:43:08.4 CAM-2 yeah.

05:43:09.4 CAM-1 yeah the last time I looked at it or it was like forty-five or some- thing and but. I talked to a guy who was in the military, he said he was, he said it's really pretty for a desert, you know it's....

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 129

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME (EDT)

TIME (EDT) & SOURCE CONTENT

& SOURCE CONTENT

05:43:22.8 CAM-2 yeah well there's a guy, a military guy, up uh, a first officer, in Kennedy, he's like I think you're doing the right thing. he says if not to visit, maybe to be an ex-patriot and live there is not a good thing.

05:43:40.9 CAM-1 yeah, what I heard, you know you can't buy land uum, they'll let you buy a condo, like on a high rise or something, thank you, but you can't buy property.... here they come Kelly.

05:44:04.9 CAM-2 yeah howdy, like yeah, yeah * and then I kept thinking about it.... I guess, when I'm, I'm deciding on making a major decision, if it doesn't feel right in my gut. or if I don't have a little voice, if it's starts talking to me and I'm like I need to re-evaluate.

05:44:29.5 CAM-1 yeah

05:44:43.2 CAM-2 you know it'd be nice to go over there and fly heavy metal, fly in- ternational, but they work you hard over there I've been told.

05:44:50.3 CAM-1 oh do they?

05:44:51.1 CAM-2 yeah, they fly you if they can up to a hundred hours ** they have triple sevens *. like for you with the kids, you'd get a housing al- lowance at a villa. and for me and my wife with no kids, we'd get an apartment. the apartments don't allow any animals and I have four dogs and I'm not, I'm not about to give up, I've had 'em for a while. if I fly overseas, I wanna start and finish here in the States.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 130

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME (EDT)

TIME (EDT) & SOURCE CONTENT

& SOURCE CONTENT

05:45:32.4 CAM-1 yeah.

05:45:32.9 CAM-2 ***.

05:45:36.1 CAM-1 you were overseas already. is that what you said?

05:45:36.9 CAM-2 no, if I, if I did fly overseas.

05:45:38.8 CAM-1 ah, okay.

05:45:44.8 CAM-1 emergency equipment, checked, crew oxygen masks, checked left and right, ** psi, CVR, checked, standby instruments, checked, fire protection, checked, gravity cross-flow, checked, duct monitor, checked, hydraulics, auto and on, ice detector, has been checked, cabin signs are on, emergency lights are armed , stall protection system, checked, anti-skid, checked and armed, MLG bay overheat, checked, stab/mach trim, engaged, engine controls, checked, aileron rudder trims checked yaw damper en- gaged, cabin/exterior checks complete gear and safety pins, have been removed acceptance checklist is complete.

05:46:19.5 CAM-2 * it just became I started looking at it a little more, there was just too many * to get through.

05:46:30.3 CAM-1 you know I....

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 131

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME (EDT)

TIME (EDT) & SOURCE CONTENT

& SOURCE CONTENT

05:46:31.4 CAM-2 is this First Officer single?

05:46:34.8 CAM-1 I don't think so but his, his name is, he's got an Arab uh.

05:46:40.5 CAM-2 oh.

05:46:42.3 CAM-1 he got a, he has some kind of Arab name. @ or something er.

05:46:50.9 CAM-1 he might blend in a little bit but I heard it's like sixty or seventy percent European I mean.

05:46:55.2 CAM-2 well it's not even owned by United Arab Emirates. it's owned by a British company.

05:47:01.1 CAM-1 oh really.

05:47:08.9 CAM-2 yeah but you gotta deal with a lot of Brits and Australians. you know it some of these Brits are a little up tight.

05:47:34.5 CAM-2 if circumstances were different I, I'd consider it, they are as such.

05:47:46.7 CAM-2 plus if I have the opportunity to make Captain.

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TIME (EDT)

TIME (EDT) & SOURCE CONTENT

& SOURCE CONTENT

05:47:51.0 CAM-1 yeah.

05:47:55.9 CAM-2 I'm gonna talk to my dad to see if maybe he can help me out but I think I'm gonna invest in a seven three type rating. if I make Cap- tain here. I need like three hundred PIC to be eligible to meet their requirements and then I'll....

05:48:14.1 CAM-1 who's that, Southwest? isn't that three thousand PIC?

05:48:16.7 CAM-2 fifteen hundred.

05:48:18.6 CAM-1 fifteen hundred?

05:48:18.7 CAM-2 actually no, thirteen hundred PIC.

05:48:20.8 CAM-1 oh, okay.

05:48:21.1 CAM-2 like thirteen hundred, that's a weird number.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 133

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TIME (EDT)

TIME (EDT) & SOURCE CONTENT

& SOURCE CONTENT

05:48:24.4 ATIS Lexington Bluegrass information Alpha, 0854 automated weather. wind one niner zero at eight, visibility eight, few clouds six thousand, sky broken niner thousand. temperature two four, dew point one niner, altimeter three zero zero zero. ILS and vis- ual approaches in use. landing and departing runway two two. runway two two glideslope out of service. pilots use caution for construction on air carrier ramp. hazardous weather information available on HIWAS, Flight Watch or Flight Service frequencies. all departures contact ground control on one two one point niner. advise you have information Alpha.

05:49:42.2 RDO-2 clearance good morning. Comair one ninety one's going to At- lanta with ALPHA.

05:49:49.3 CLR Comair one ninety one, Lexington clearance. cleared to Atlanta Airport via Bowling Green, ERLIN TWO arrival. maintain six thousand, expect flight level two seven zero one zero minutes af- ter departure. departure's one two zero point seven five. squawk six six four one.

05:50:06.5 RDO-2 okay, got uh, Bowling Green uh, missed the other part. six thou- sand, twenty point seven five. six six four one.

05:50:14.1 CLR Comair one ninety one, it's ERLIN TWO, Echo Romeo Lima, In- dia, November Two arrival. 05:50:20.4 RDO-2 'kay ERLIN Two, 'preciate it, Comair one ninety one.

05:50:38.0 CAM-2 nothing like **.

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05:50:41.2 CAM [sound of click]

05:50:44.6 CAM-? [sound of person whistling]

05:50:53.7 CAM-1 direct Bowling Green, Bowling Green the ERLIN TWO. is that good?

05:50:58.4 CAM-2 any easier than that.

05:50:59.9 CAM-1 [sound of laughter]

05:51:29.3 CAM-1 Chattanooga looks good for the alternate.

05:51:29.8 CAM-5 well, how's it going guys?

05:51:30.5 CAM-2 dude, what's up?

05:51:32.6 CAM-5 how you doin'?

05:51:33.3 CAM-1 hey good, how you doin'?

05:51:34.8 CAM-5 I'm @ with Air Tran trying to get a lift to work this morning.

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TIME (EDT)

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& SOURCE CONTENT

05:51:37.1 CAM-1 hey, no problem any seat, * you already got one.

05:51:38.8 CAM-5 there you go.

05:51:40.0 CAM-1 beauty.

05:51:43.2 CAM-5 all right sir.

05:51:44.4 CAM-1 'preciate it.

05:51:45.1 CAM-5 you bet.

05:51:46.1 CAM-1 any time.

05:51:47.2 CAM-5 thanks a lot.

05:51:47.7 CAM-1 can I get the white sheet from you?

05:51:48.9 CAM-5 all right.

05:51:51.2 CAM-1 there you go sir.

05:51:52.5 CAM-5 thanks a lot.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 136

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TIME (EDT)

TIME (EDT) & SOURCE CONTENT

& SOURCE CONTENT

05:51:53.8 CAM-1 any time.

05:52:04.3 CAM-1 well @ did you bring it in the other day or what's the sequence? keep on with whatever you're doing.

05:52:09.1 CAM-2 it don't matter to me.

05:52:11.3 CAM-1 oh. I'm easy buddy. but, I tell you, I always feel good like I could eat a little more when I get a seatbelt like this man. [sound of laughter]

05:52:19.6 CAM-2 Jesus.

05:52:22.9 CAM-2 *, I'll take us to Atlanta.

05:52:24.0 CAM-1 sure.

05:52:24.5 CAM-2 I looked at, for some weird reason, I don't have that. I have the airport diagram and the arrival and departure plates. I don't have the San Antonio charts.

05:52:36.3 CAM-1 uh, okay.

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TIME (EDT)

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& SOURCE CONTENT

05:52:42.2 CAM-2 either I'm just waiting for the stuff to come up from Cincinnati or for now or the secretary there.

05:52:50.6 CAM-1 [sound of chuckle]

05:52:51.8 CAM-2 very capable.

05:52:52.8 CAM [sound of click]

05:52:55.2 CAM-2 plus we have, we don't have a chief pilot any more.

05:52:57.9 CAM-1 oh, that's right. I heard @ got promoted or something.

05:53:00.2 CAM-3 ** passenger!s request for an electric cart in the gatehouse for a passenger.

05:53:03.7 CAM-1 @, can I grab another Coke from you?

05:53:05.2 CAM-3 would you like ice?

05:53:06.1 CAM-1 no thanks.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 138

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TIME (EDT)

TIME (EDT) & SOURCE CONTENT

& SOURCE CONTENT

05:53:27.2 CAM-1 thank you.

05:53:27.7 CAM-3 can I have the PA please so I can do my verification?

05:53:29.4 CAM-1 sure.

05:53:58.3 CAM-2 ** three *.

05:54:12.5 CAM-2 sixteen-forty *.

05:54:20.2 CAM-? [sound of person whistling]

05:55:04.4 CAM-2 I think I have *** this thing I got. my wife called a little excited about it but *** yeah you'd be gone like three or four days at a time, which you know with your wife and kids it might be a little difficult.

05:55:20.2 CAM-3 it's all yours.

05:55:21.0 CAM-1 all right.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 139

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TIME (EDT)

TIME (EDT) & SOURCE CONTENT

& SOURCE CONTENT

05:55:24.9 PA-1 ladies and gentlemen from the flight deck, like to take this time to welcome you also on board Comair flight fifty one ninety one di- rect flight to Atlanta. we'll be cruising at uh, twenty-seven thou- sand feet this morning. and once we do get in the air, it looks like one hour and seven minutes enroute. distance of travel today, we got we got four hundred and twenty two miles. weather condi- tions Atlanta, * some light winds out of the east, looks like some broken clouds and current temperature of seventy-two degrees Fahrenheit. we'll try to keep it as quiet as possible. hopefully you can catch a nap going into Atlanta. it's our pleasure having you all on board.

05:56:14.0 CAM-1 for our own briefing, Comair standard. run the checklist your lei- sure. keep me out of trouble. I'll do the same for you. I don't jump on the brakes on your landing. I'll follow along with you. just let me know when you want me to take it. that's it.

05:56:23.8 CAM [sound of two clicks similar to pilot seat adjustment]

05:56:25.2 CAM-2 I'll do the same whenever you're ready.

05:56:26.9 CAM-1 all right.

05:56:27.6 GND information Bravo is now current. the altimeter's three zero zero zero.

05:56:28.0 CAM-2

• control ***.

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05:56:30.4 CAM-1 sounds good.

05:56:34.1 CAM-2 right seat flex takeoff procedures off of um.... he said what run- way? one of 'em. * two four.

05:56:43.4 CAM-1 it's two two.

05:56:45.9 CAM-2 one ninety at eight

05:56:49.9 CAM-2 two two up to six, white data FMS, flaps twenty. smokes or breaks come back here. come into four or two two. on two two the ILS is out. or the glideslope is, the REILS are out. the uh, came in the other night it was like [sound similar to audible ex- hale] lights are out all over the place.

05:57:07.8 CAM-1 all right.

05:57:08.4 CAM-2 right. remember this runway predicated, before we just go back to Cincinnati.

05:57:12.9 CAM-1 okay.

05:57:13.7 CAM-2 uum, no continuous, anti-ice, weather radar, hand fly 'til about ten. taxi instructions with ATC.

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TIME (EDT)

TIME (EDT) & SOURCE CONTENT

& SOURCE CONTENT

05:57:21.7 CAM-1 all right.

05:57:23.3 CAM-2 let's take it out and um, take uuuh, Alpha. two two's a short taxi.

05:57:31.1 CAM-1 yeah.

05:57:35.4 CAM-2 any questions?

05:57:36.5 CAM-1 no questions. before starting at your leisure.

05:57:38.4 CAM-2 ACM crew briefing.

05:57:39.3 CAM-1 complete.

05:57:40.0 CAM-2 takeoff brief.

05:57:40.4 CAM-1 complete.

05:57:40.7 CAM-2 radios, NAV aids.

05:57:42.0 CAM-1 uh, six thousand, your side, both in white data, confirmed the flight plan. we got uh, tower, ground twenty one *, is everything on one? do you know?

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 142

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TIME (EDT)

TIME (EDT) & SOURCE CONTENT

& SOURCE CONTENT

05:57:49.7 CAM-2 no it's not.

05:57:50.7 CAM-3 do you want to do a brief?

05:57:53.5 CAM-1 nothing differed back there that I saw. weather's good Atlanta, scattered to broken clouds. seventy degrees uum, standard chimes, standard calls. if we do have an emergency, I like to open the door and talk face to face.

05:58:04.5 CAM-3 okay.

05:58:06.0 CAM-1 that's about it. anything for me?

05:58:07.0 CAM-3 sounds great.

05:58:07.9 CAM-1 all right.

05:58:08.4 CAM-3 see you in Atlanta.

05:58:12.2 CAM-1 uuh, start engines your leisure.

05:58:14.8 CAM-2 uuuh, ACM crew brief.

05:58:16.7 CAM-1 complete.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 143

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TIME (EDT)

TIME (EDT) & SOURCE CONTENT

& SOURCE CONTENT

05:58:17.1 CAM-2 takeoff brief

05:58:18.3 CAM-1 hey man, we already did that one.

05:58:20.5 CAM-2 we did?

05:58:21.0 CAM-1 yeah.

05:58:21.2 CAM-2 I'm sorry.

05:58:22.2 CAM-? [sound of laughter]

05:58:23.3 CAM-2 I'll get it to ya.

05:58:24.1 CAM-1 [sound of laughter]

05:58:24.6 CAM-2 papers, manifest.

05:58:26.0 CAM-1 it's complete out the door.

05:58:27.2 CAM-2 fuel quantity.

05:58:27.4 CAM-1 required to have (seventy), seventy-three.

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TIME (EDT)

TIME (EDT) & SOURCE CONTENT

& SOURCE CONTENT

05:58:30.0 CAM-? **.

05:58:33.3 CAM [sound of several clicks similar to cockpit door operation]

05:58:35.1 CAM-2 V speeds, takeoff data fifty temp. V one, V r is thirty-seven forty- two * forty-five ********. [spoken at a very fast speed] you got normal thrust ** point two.

05:58:43.5 CAM-1 set for flaps twenty.

05:58:44.5 CAM-2 doors.

05:58:44.9 CAM-1 closed.

05:58:45.3 CAM-2 beacon.

05:58:45.6 CAM-1 on.

05:58:46.0 CAM-2 fuel pumps.

05:58:46.8 CAM-1 number one's on.

05:58:48.7 CAM-2 see this is telling me that I really need to do something.

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05:58:51.7 CAM-1 [sound of laughter]

05:59:05.7 RDO-1 and ground, Comair one ninety one, just a heads-up on the push.

05:59:11.1 GND Comair one ninety one advise ready to taxi.

05:59:13.3 RDO-1 roger.

05:59:14.1 INT-1 hey, how you doin'? you ca.... can you hear me? okay, brakes released, we're cleared to push sir.

05:59:24.6 HOT-2 must be one of us, skinny flight attendant.

05:59:26.5 HOT-1 [sound of laughter]

05:59:33.0 E882 ground, Eagle flight eight eighty two ready to taxi with Alpha.

05:59:42.0 HOT-1 he said it's okay to turn one at your leisure.

05:59:43.6 GND Eagle flight eight eighty two taxi to runway two two. altimeter three zero zero zero and the wind's two zero zero seven.

05:59:45.4 HOT-2 that's pretty cool the family got to come down.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 146

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TIME (EDT)

TIME (EDT) & SOURCE CONTENT

& SOURCE CONTENT

05:59:47.2 HOT-2 how long of a ride is that?

05:59:50.9 HOT-1 uuuuh. maybe, maybe an hour.

05:59:52.9 E882 taxi to **, Eagle flight eight eighty two.

05:59:57.5 HOT-2 that's cool.

06:00:09.4 HOT-1 both kids were sick though, they, well they all got colds. it was an interesting br, dinner last night.

06:00:16.1 HOT-2 really.

06:00:16.6 HOT-1 huh, oh gosh.

06:00:19.1 HOT-2 how old are they?

06:00:20.0 HOT-1 three months and two years old. who was sneezing, either nose wiped, diaper change I mean that's all we did all night long.

06:00:31.0 HOT-2 oh yeah I'm sure.

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TIME (EDT)

TIME (EDT) & SOURCE CONTENT

& SOURCE CONTENT

06:00:32.2 GND ** sixteen ninety two thanks, turn right heading two seven zero runway two two, cleared for takeoff.

06:00:32.4 HOT-2 [sound of laughter]

06:00:34.9 HOT-2 that's a nice range, age range.

06:00:37.7 HOT-1 yeah, I like two years apart basically and that's the kinda what we were going for.

06:00:45.3 HOT-1 my wife wants four, I, I, I'm, I was good at one.

06:00:48.5 HOT-2 she wants four.

06:00:49.9 CAM [sound of chime]

06:00:50.1 HOT-1 yeah.

06:00:50.2 HOT-1 [sound of chuckle]

06:00:52.7 HOT-2 it'd be like honey….

06:01:02.7 CAM [sound of chime]

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TIME (EDT)

TIME (EDT) & SOURCE CONTENT

& SOURCE CONTENT

06:01:07.1 HOT-2 yeah, it's especially being on reserve it, it's gotta be tough being away.

06:01:12.2 HOT-1 ah, tough on her, oh my God. that's why she came down yester- day. she's like, I just need to get out of this house.

06:01:18.0 HOT-2 yeah, I bet.

06:01:18.9 HOT-1 I'm like I understand. I, I told her, why don't you just spend the night. she said well, if you're gonna get up at oh dark thirty and she said you'll end up waking up the babies. I'm like yeah, you're probably right.

06:01:32.1 HOT-2 yeah it would just be like being at home.

06:01:35.5 HOT-1 yeah, she's like you know, I don't know, she's like I'll....

06:01:38.5 HOT-2 instead of having her rush back and drive....

06:01:40.6 HOT-1 and we got a dog.

06:01:40.8 GND *** Lexington tower roger, hold short.

06:01:42.9 HOT-2 aah, trust me the dog . be on the @ slim-fast diet for a night.

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TIME (EDT)

TIME (EDT) & SOURCE CONTENT

& SOURCE CONTENT

06:01:47.4 HOT-1 [sound of laughter]

06:01:48.7 HOT-2 uh, parking brake.

06:01:49.6 HOT-1 that's on.

06:01:50.0 HOT-2 number two, actually, engine.

06:01:51.7 HOT-1 one and two are started.

06:01:52.5 HOT-2 starting engines complete.

06:01:54.3 HOT-1 and before taxi.

06:01:55.6 HOT-2 anti-iiiiice.

06:01:56.6 HOT-1 windshields and probes are low and on.

06:01:58.3 HOT-2 nosewheel steering.

06:01:59.5 HOT-1 that's armed.

06:02:00.0 HOT-2 taxi check complete.

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TIME (EDT)

TIME (EDT) & SOURCE CONTENT

& SOURCE CONTENT

06:02:01.3 RDO-2 Comair one ninety one is ready to taxi we have ALPHA.

06:02:03.8 GND Comair one ninety one, taxi to runway two two. altimeter three zero zero zero and the winds are two zero zero at eight.

06:02:08.9 RDO-2 three triple zero and taxi two two, Comair one ninety one.

06:02:12.6 GND Eagle flight runway two two, cleared for takeoff.

06:02:15.1 HOT-1 clear left.

06:02:17.3 HOT-2 on the right.

06:02:17.9 GND Skywest six eight nineteen radar contact, say altitude leaving.

06:02:18.9 HOT-1 flaps twenty, taxi check.

06:02:21.0 HOT-2 full right.

06:02:23.8 GND Skywest sixty eight nineteen, climb and maintain one zero thou- sand, ten thousand, join Victor one seventy one and resume *, own navigation.

06:02:24.0 HOT-2 full left.

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TIME (EDT)

TIME (EDT) & SOURCE CONTENT

& SOURCE CONTENT

06:02:25.5 HOT-1 test your brakes any time.

06:02:31.1 HOT-2 I want to *** down.

06:02:32.3 HOT-1 sure.

06:02:41.5 HOT-2 let's see, comin' back.

06:02:51.6 HOT-2 brakes.

06:02:52.3 HOT-1 they're checked.

06:02:53.2 HOT-2 right, flaps.

06:02:54.4 HOT-1 set twenty, indicating twenty.

06:02:55.6 HOT-2 flight controls.

06:02:56.3 HOT-1 check left.

06:02:58.3 HOT-2 on the right, trims.

06:02:59.5 HOT-1 engage zero seven point two.

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& SOURCE CONTENT

06:03:02.2 HOT-2 radar terrain displays. [spoken in a yawning voice]

06:03:04.0 HOT-2 all the taxi check's complete. [spoken in a yawning voice]

06:03:12.0 HOT-1 finish it up your leisure.

06:03:16.4 HOT-2 yeah, I know three guys at Kennedy. actually two guys uh.... @@ he went but he didn't get past the sim.

06:03:26.7 HOT-1 oh, really.

06:03:29.1 HOT-2 and then um, a First Officer from Cinci....

06:03:34.5 GND Eagle flight radar contact, radar contact. say altitude leaving.

06:03:35.1 HOT-2 got through the second part....

06:03:37.2 HOT-2 what do you do the uh, these tests.... and he didn't, and that's as far as he got.

06:03:40.8 GND Eagle flight eight eighty two, climb and maintain one zero thou- sand, ten thousand.

06:03:49.3 HOT-2 and then @@ he actually got offered the position.

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& SOURCE CONTENT

06:03:54.5 HOT-1 did he take it or....

06:03:55.5 HOT-2 yeah.

06:03:56.1 HOT-1 ah, okay.

06:04:01.2 HOT-2 second engine started, anti-ice probes windshield low.

06:04:03.1 GND

• sixteen ninety one, previous question.

06:04:05.6 HOT-2 hydraulics checked, APU's on, FMS we got runway two two out of Lexington up to six.

06:04:13.3 HOT-2 thrust reversers are armed, auto crossflow is manual, ignition is off, altimeters three triple zero across the board, crosschecked. I'll be in the back.

06:04:24.8 HOT-1 got one.

06:04:25.7 TWR Skywest sixty eight nineteen contact Indy center one two six point three seven.

06:04:29.6 S6819 two six three seven, Skywest sixty eight nineteen.

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& SOURCE CONTENT

06:04:32.6 TWR Eagle flight eight eighty two, turn right heading two seven zero, join Victor one seventy-one. resume navigation.

06:04:37.5 E882 two seven zero, join victor one seventy one, ****.

06:04:38.2 PA-2 and folks one * time from the flight deck, we'd like to welcome you aboard. we're going to be underway momentarily.... sit back relax enjoy the flight. Kelly, when you have a chance, please prepare the cabin.

06:04:48.2 CAM [sound hi-lo chime similar to cabin/cockpit interphone signal]

06:04:49.3 HOT-2 pre-takeoff * complete cabin report received CAS.

06:04:53.4 HOT-1 checked and clear.

06:04:54.4 HOT-? , six seven, . [whispered]

06:04:56.6 HOT-1 oh.

06:04:58.1 HOT-2 oh yeah.

06:04:59.4 HOT-2 I'm looking at it 'cause like, okay I see seven but it's....

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TIME (EDT) & SOURCE CONTENT

& SOURCE CONTENT

06:05:01.9 HOT-1 yeah there's a green extra one there but....

06:05:06.3 HOT-2 uuuh, cabin report's received, CAS clear, ** before takeoff check's complete, ready.

06:05:12.6 HOT-1 all set.

06:05:15.1 RDO-2 "churliser" [at your leisure spoken very fast] Comair one twenty one ready to go.

06:05:17.7 TWR Comair one ninety one, Lexington uh, tower, fly runway heading, cleared for takeoff.

06:05:19.2 HOT-? *.

06:05:21.0 RDO-1 runway heading, cleared for takeoff, one ninety one.

06:05:23.7 HOT-1 and line-up check.

06:05:25.1 TWR Eagle flight eight eighty two, that heading work for you, do you wanna go uh, northwest around the uh, weather that's ahead of you?

06:05:30.7 E882 no that looks fantastic. thank you very much.

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06:05:32.7 TWR

• say again please.

06:05:33.8 E882 *** eight eighty two.

06:05:34.4 HOT-1 throw that bad boy on.

06:05:36.3 TWR Eagle flight eight eighty two, contact Indy center one two six point three seven. good day.

06:05:39.5 E882 twenty six, thirty seven, * eight eighty two.

06:05:41.3 HOT-2 transponder's on, packs on, bleeds closed, cleared for takeoff, runway heading. six grand.

06:05:45.4 HOT-1 all right.

06:05:46.4 HOT-2 anti-ice off, lights set, takeoff config's okay, line-up check's com- plete.

06:05:51.2 CAM [sound of clicks similar to pilot adjusting his seat]

06:05:57.6 HOT-1 all yours Jim.

06:05:58.9 HOT-2 my brakes, my controls.

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& SOURCE CONTENT

06:06:05.0 CAM [sound similar to increase in engine RPM]

06:06:07.8 HOT-2 set thrust please.

06:06:11.7 HOT-1 thrust set.

06:06:16.3 HOT-2 dat is weird with no lights.

06:06:18.0 HOT-1 yeah.

06:06:24.2 HOT-1 one hundred knots.

06:06:25.1 HOT-2 checks.

06:06:31.2 HOT-1 V one, rotate.

06:06:31.8 HOT-1 whoa.

06:06:32.2 CAM [unknown ambient noise]

06:06:32.6 HOT-1 #.

06:06:33.0 CAM [sound of impact]

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 158 36 o 36

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME (EDT)

TIME (EDT) & SOURCE CONTENT

& SOURCE CONTENT

06:06:33.3 HOT-? [unintelligible exclamation]

06:06:33.8 CAM [sound similar to stick shaker]

06:06:34.7 CAM [sound of chime]

06:06:34.7 CAM [sound similar to stall warning starts and continues to end of re- cording]

06:06:35.1 HOT-? #.

06:06:35.7 HOT-1 [unintelligible exclamation]

06:06:36.2 END of RECORDING END of TRANSCRIPT

National Transportation Safety Board A I R C R A F T Accident Report 159 Appendix C Blue Grass Airport Charts National Aeronautical Charting Office chart dated August 3, 2006 SE-1, 03 AUG 2006 to 31 AUG 2006 SE-1, 03 AUG 2006 to 31 AUG 2006 Not For Navigation

Appendix C National Transportation Safety Board A I R C R A F T Accident Report 160 Jeppeson chart dated January 27, 2006 Reprinted with permission by Jeppeson

Appendix C National Transportation Safety Board A I R C R A F T Accident Report 161 Jeppeson chart dated September 8, 2006 Reprinted with permission by Jeppeson

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FD07333 ｜ 2007_美国_AAR0706.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2007 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

aviation Runway Overrun and Collision Southwest Airlines Flight 1248 Boeing 737-7H4, N471WN Chicago Midway International Airport Chicago, Illinois December 8, 2005 ACCIDENT REPORT NTSB/AAR-07/06 PB2007-910407

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National Transportation Safety Board 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 Aircraft Accident Report Runway Overrun and Collision Southwest Airlines Flight 1248 Boeing 737-7H4, N471WN Chicago Midway International Airport Chicago, Illinois December 8, 2005 NTSB/AAR-07/06 PB2007-910407 Notation 7753F Adopted October 2, 2007

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Web at http://www.ntsb.gov. Other information about available publications also may be obtained from the Web site or by contacting: National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (800) 877-6799 or (202) 314-6551 Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2007-910407 from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605-6000 The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. National Transportation Safety Board. Year. Runway Overrun and Collision, Southwest Airlines Flight  1248, Boeing 737-7H4, N471WN, Chicago Midway International Airport, Chicago, Illinois, December 8, 2005. Aircraft Accident Report NTSB/AAR-07/06. Washington, DC. Abstract: This report explains the accident involving a Boeing 737-7H4, N471WN, operated by Southwest Airlines (SWA), which departed the end of runway 31C after landing at Chicago Midway International Airport. The safety issues discussed in this report include the flight crew’s decisions and actions, the clarity of assumptions used in on board performance computers, SWA policies, guidance, and training, arrival landing distance assessments and safety margins, runway surface condition assessments and braking action reports, airplane-based friction measurements, and runway safety areas. Safety recommendations concerning these issues are addressed to the Federal Aviation Administration.

National Transportation Safety Board A I R C R A F T Accident Report iii Contents Abbreviations and Acronyms......................................................................................vi Executive Summary........................................................................................................ ix

1. Factual Information.....................................................................................................1
2. 1  History of Flight.............................................................................................................................. 1
3. 2  Injuries to Persons........................................................................................................................... 6
4. 3  Damage to Aircraft.......................................................................................................................... 6
5. 4  Other Damage.................................................................................................................................. 6
6. 5  Personnel Information.................................................................................................................... 6
7. 5.1  The Captain.............................................................................................................................. 6
8. 5.2  The First Officer....................................................................................................................... 7
9. 6  Aircraft Information........................................................................................................................ 8
10. 6.1  General...................................................................................................................................... 8
11. 6.2  Southwest Airlines On Board Performance Computer .................................................... 9
12. 7  Meteorological Information .......................................................................................................... 9
13. 7.1  Chicago Midway International Airport Weather Information........................................ 9
14. 7.2  Flight Crew Dispatch and In-Flight Weather Information............................................. 10
15. 8  Aids to Navigation........................................................................................................................ 11
16. 9  Communications........................................................................................................................... 11
17. 10  Airport Information.................................................................................................................... 11
18. 10.1  Chicago Midway International Airport Winter Operations—General....................... 13
19. 10.2  Chicago Midway International Airport Winter Operations

on the Day of the Accident................................................................................................ 14 1.10.3  Chicago Midway International Airport Runway Safety Areas ................................... 14 1.11  Flight Recorders........................................................................................................................... 16 1.11.1  Cockpit Voice Recorder...................................................................................................... 16 1.11.2  Flight Data Recorder........................................................................................................... 16 1.11.3  Flight Data Recorder Information From Other Landing Airplanes............................ 17 1.12  Wreckage and Impact Information........................................................................................... 18 1.13  Medical and Pathological Information..................................................................................... 18 1.14  Fire................................................................................................................................................. 19 1.15  Survival Aspects.......................................................................................................................... 19 1.16  Tests and Research...................................................................................................................... 19 1.16.1  Airplane Simulation and Performance Studies ............................................................. 19 1.17  Organizational and Management Information....................................................................... 21 1.17.1  Southwest Airlines Information........................................................................................ 21 1.17.2  Southwest Operations Guidance Information................................................................ 21 1.17.2.1  Thrust Reverser Procedures and Information........................................................... 21 1.17.2.2  Autobrake Procedures and Information.................................................................... 23 1.17.2.3  On Board Performance Computer-Related Guidance and Information .............. 23 1.17.2.4  Mixed Braking Action Report and Tailwind Limitation Guidance....................... 28 1.17.3  Southwest Airlines Postaccident Actions........................................................................ 29 1.18  Additional Information.............................................................................................................. 29 1.18.1  Airplane Landing Performance Information.................................................................. 29

Contents National Transportation Safety Board A I R C R A F T Accident Report iv 1.18.1.1  Previously Issued Urgent Safety Recommendation Related to Landing Distance Assessments............................................................................... 30 1.18.1.2  Landing Distance Assessment Technical Bulletin ................................................... 33 1.18.2  Contaminated Runway and Landing Information ....................................................... 35 1.18.2.1  Runway Surface Condition Reports........................................................................... 35 1.18.2.2  Correlation Between Runway Surface Condition and Airplane Braking Ability ............................................................................................. 35 1.18.2.3  Previous Contaminated Runway-Related Safety Recommendations................... 38 1.18.3  Previous Runway Safety Area Safety Recommendations............................................. 41

1. Analysis.......................................................................................................................43
2. 1  General............................................................................................................................................ 43
3. 2  Pilots’ Decision to Land, Knowledge, and Actions.................................................................. 44
4. 2.1  Interpretation and Use of Mixed Braking Action Reports ............................................. 44
5. 2.2  On Board Performance Computer Displays and Underlying Assumptions............... 46
6. 2.3  Thrust Reverser Usage and Autobrakes ........................................................................... 49
7. 3  Landing Distance Assessments .................................................................................................. 52
8. 3.1  Preflight and Arrival Landing Distance Calculations/Assessments............................ 53
9. 3.2  Safety Alert for Operators Discussion and Industry Practice

Regarding Landing Distance Assessments........................................................................ 55 2.3.3  Landing Distance Assessments Summary ....................................................................... 56 2.4  Runway Surface Condition Assessments.................................................................................. 58 2.4.1  Braking Action Reports........................................................................................................ 58 2.4.2  Contaminant Type and Depth ........................................................................................... 59 2.4.3  Airport Runway Surface Friction Measuring Devices ................................................... 60 2.4.4  Runway Surface Condition Assessments Summary........................................................ 60 2.4.5  Correlating Runway Surface Condition to Airplane Landing Performance................ 61 2.5  Airplane-Based Friction Measurements..................................................................................... 62 2.6  Runway Safety Areas.................................................................................................................... 63

1. Conclusions.................................................................................................................65
2. 1  Findings.......................................................................................................................................... 65
3. 2  Probable Cause.............................................................................................................................. 67
4. Recommendations.....................................................................................................68
5. 1  New Recommendations............................................................................................................... 68
6. 2  Previously Issued Recommendation Resulting From This Accident Investigation and

Classified in this Report....................................................................................................................... 69

1. Appendixes.................................................................................................................70

Investigation and Public Hearing A: ........................................................................................................70 Cockpit Voice Recorder B: .........................................................................................................................71 FAA Safety Alert For Operators 06012 C: .............................................................................................225

National Transportation Safety Board A I R C R A F T Accident Report v Figures 1.  Photograph of the accident airplane in the roadway intersection. ........................................... 4 2.  Diagram showing the accident airplane where it came to rest (on a heading of 340°) in the intersection off the end of runway 31C....................................... 5 3.  The MDW airport layout plan with surrounding streets and properties............................... 12 4.  OPC display showing the results of OPC calculations based on the accident conditions with fair braking action............................................................................... 26 5.  OPC display showing the results of OPC calculations based on the accident conditions with poor braking action. ........................................................................... 27 6.  Draft winter operations guide that was developed by an industry group. ........................... 34 7.  CRFI values for various runway surface conditions. ................................................................ 37

National Transportation Safety Board A I R C R A F T Accident Report vi Abbreviations and Acronyms AC advisory circular ACM airport certification manual agl above ground level ARFF aircraft rescue and firefighting ASOS automated surface observing system ASRS aviation safety reporting system ATC air traffic control ATCT air traffic control tower ATIS automatic terminal information service ATP airline transport pilot BWI Baltimore/Washington Thurgood Marshall International Airport C Celsius CFME continuous friction measurement equipment CFR Code of Federal Regulations CRFI Canadian Runway Friction Index CVR cockpit voice recorder DEC decelerometer DOA Department of Aviation DOT Department of Transportation EASA European Aviation Safety Agency

Abbreviations and Acronyms National Transportation Safety Board A I R C R A F T Accident Report vii EFB electronic flight bag EMAS engineering materials arresting system F Fahrenheit FAA Federal Aviation Administration FAR Federal Aviation Regulations FDR flight data recorder FOM flight operations manual FRM flight reference manual Hg inch of Mercury ICAO International Civil Aviation Organization ILS instrument landing system IRFI International Runway Friction Index JAA Joint Aviation Authorities JWRFMP Joint Winter Runway Friction Measurement Program MDW Chicago Midway Airport mm millimeter msl mean sea level MU coefficient of friction N1 engine fan speed NASA National Aeronautics and Space Administration NWS National Weather Service OPC on board performance computer

Abbreviations and Acronyms National Transportation Safety Board A I R C R A F T Accident Report viii OpSpec operations specification POI principal operations inspector psi pounds per square inch RBF read-before-flight RSA runway safety area RVR runway visual range S/N serial number SAFO safety alert for operators sm statute mile SWA Southwest Airlines SWAPA Southwest Airlines Pilots Association

National Transportation Safety Board A I R C R A F T Accident Report ix Executive Summary On December 8, 2005, about 1914 central standard time, Southwest Airlines (SWA) flight 1248, a Boeing 737-7H4, N471WN, ran off the departure end of runway 31C after landing at Chicago Midway International Airport, Chicago, Illinois. The airplane rolled through a blast fence, an airport perimeter fence, and onto an adjacent roadway, where it struck an automobile before coming to a stop. A child in the automobile was killed, one automobile occupant received serious injuries, and three other automobile occupants received minor injuries. Eighteen of the 103 airplane occupants (98 passengers, 3 flight attendants, and 2 pilots) received minor injuries, and the airplane was substantially damaged. The airplane was being operated under the provisions of 14 Code of Federal Regulations Part 121 and had departed from Baltimore/Washington International Thurgood Marshall Airport, Baltimore, Maryland, about 1758 eastern standard time. Instrument meteorological conditions prevailed at the time of the accident flight, which operated on an instrument flight rules flight plan. The National Transportation Safety Board determined that the probable cause of this accident was the pilots’ failure to use available reverse thrust in a timely manner to safely slow or stop the airplane after landing, which resulted in a runway overrun. This failure occurred because the pilots’ first experience and lack of familiarity with the airplane’s autobrake system distracted them from thrust reverser usage during the challenging landing. Contributing to the accident were Southwest Airlines’ 1) failure to provide its pilots with clear and consistent guidance and training regarding company policies and procedures related to arrival landing distance calculations; 2) programming and design of its on board performance computer, which did not present inherent assumptions in the program critical to pilot decision-making; 3) plan to implement new autobrake procedures without a familiarization period; and 4) failure to include a margin of safety in the arrival assessment to account for operational uncertainties. Also contributing to the accident was the pilots’ failure to divert to another airport given reports that included poor braking action and a tailwind component greater than 5 knots. Contributing to the severity of the accident was the absence of an engineering materials arresting system, which was needed because of the limited runway safety area beyond the departure end of runway 31C.   The safety issues discussed in this report include the flight crew’s decisions and actions, the clarity of assumptions used in on board performance computers, SWA policies, guidance, and training, arrival landing distance assessments and safety margins, runway surface condition assessments and braking action reports, airplane-based friction measurements, and runway safety areas.

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National Transportation Safety Board A I R C R A F T Accident Report 1 Factual Information

History of Flight 1.1  On December 8, 2005, about 1914 central standard time,1 Southwest Airlines (SWA) flight 1248, a Boeing 737-7H4, N471WN, ran off the departure end of runway 31 center (31C) after landing at Chicago Midway International Airport (MDW), Chicago, Illinois. The airplane rolled through a blast fence, an airport perimeter fence, and onto an adjacent roadway, where it struck an automobile before coming to a stop. A child in the automobile was killed, one automobile occupant received serious injuries, and three other automobile occupants received minor injuries. Eighteen of the 103 airplane occupants (98 passengers, 3 flight attendants, and 2 pilots) received minor injuries, and the airplane was substantially damaged. The airplane was being operated under the provisions of 14 Code of Federal Regulations (CFR) Part 121 and had departed from Baltimore/Washington International Thurgood Marshall Airport (BWI), Baltimore, Maryland, about 1758 eastern standard time. Instrument meteorological conditions prevailed at the time of the accident flight, which operated on an instrument flight rules flight plan. The accident occurred on the first flight of the first day of a scheduled 3-day trip. The flight departed BWI about 2 hours late because of deteriorated weather conditions in the Chicago area. The captain was the flying pilot for the accident flight, and the first officer performed the duties of the monitoring pilot. The pilots reported that they had thoroughly reviewed the two weather information and dispatch documents they received from dispatch before they left BWI. A third document authorizing the release of the accident flight was prepared but was not delivered to the pilots before departure. This document revised the expected landing winds (from “calm” to “090° at 11 knots”), runway braking action (from “wet-good” to “wet-fair”), and landing runway (from 04R to 31C) based on the changing weather. The pilots stated that they subsequently received updated MDW weather information and runway condition/braking action reports2 for runway 31C, which was the runway in use at MDW at the time. Postaccident interviews with the pilots and evidence from cockpit voice recorder (CVR)3 data and air traffic control (ATC) communications indicated that the runway 31C braking action reports were mixed, reporting good or fair braking action for the first half of the runway and poor braking action for the second half. 1  Unless otherwise indicated, all times are central standard time, based on a 24-hour clock. 2  Braking action reports are generated by pilots who have used the runway and provided to other arriving pilots by air traffic control. According to Federal Aviation Administration Order 7110.65, “Air Traffic Control,” braking action reports provided by controllers are to include a description of the braking action, using the terms “good,” “fair,” “poor,” or “nil,” and the type of airplane or vehicle from which the report was received. 3  For a complete transcript of the CVR recording, see appendix B.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 2 The pilots also stated (and CVR evidence confirmed) that they reviewed and discussed the company’s new autobrake system procedures while en route from BWI to MDW; the accident landing was the first time either pilot landed using autobrakes.4 About 1833:17, as the airplane was nearing MDW at an assigned altitude of 10,000 feet,5 ATC issued the pilots instructions to enter a holding pattern. (ATC indicated that the hold was because of runway-clearing snowplow operations at MDW.) About 1844:04, the pilots advised ATC that they were entering the holding pattern at 10,000 feet. The first officer stated that, while in the holding pattern, he entered the updated weather and runway conditions and wind information (090° at 11 knots) in the on board performance computer (OPC)6 to determine the landing distance required for runway 31C. The reported wind conditions resulted in a computed tailwind component of 8 knots.7 All SWA 737s are limited to landing with a 10-knot or less tailwind component under all runway surface conditions. Additionally, SWA policies and flight operations manuals indicate that the company does not authorize landings on runways with more than a 5‑knot tailwind component with poor braking action. Postaccident statements and CVR evidence indicated that the accident pilots were aware of these limitations and believed that they would be unable to land at MDW if the braking action was reported poor for the full length of the runway. The first officer entered multiple scenarios into the OPC, entering fair and poor pilot braking action reports separately because the OPC was not designed to accept mixed braking action report inputs. Based on the first officer’s inputs, the OPC estimated that the airplane would stop about 560 feet before the departure end of the runway with fair braking action and about 40 feet before the departure end of the runway with poor braking action.8 The pilots stated that they decided that, consistent with SWA policies, they 4  According to an SWA bulletin issued the day of the accident, pilots were to begin using the company’s autobrake system procedures beginning December 12, 2005. During postaccident interviews, the pilots told investigators that they believed the autobrake policy was implemented the day of the accident. A review of recent SWA bulletins revealed that the autobrake implementation date had changed several times. For additional information regarding the 737 autobrake system and SWA’s autobrake procedures and implementation details, see section 1.17.2.2. 5  Unless otherwise indicated, all altitudes in this report are reported as height above mean sea level. 6  The OPC is a laptop computer with which every SWA airplane cockpit is equipped and that SWA pilots use in performing takeoff and landing performance calculations. For additional information, see sections 1.6.2 and 1.17.2.3. 7  According to flight data recorder information, the actual crosswind component at touchdown was between 8 and 9 knots. 8  During postaccident interviews (and consistent with CVR evidence), the pilots recalled a 30-foot stopping margin for calculations with poor braking action. They noted that they were allowed to land with any positive margin; however, CVR evidence and postaccident interviews indicated that the pilots were concerned about the small stopping margin shown for poor runway braking action. The captain stated that he was glad the 5-knot tailwind component limit for poor runway conditions would prevent them from making the landing under those conditions.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 3 would divert to one of their alternate destinations (Kansas City or St. Louis, Missouri)9 if the tailwind component increased to above 10 knots or if pilot braking action reports indicated poor braking action for the full length of the runway. The automatic terminal information service (ATIS) reported a runway visual range (RVR)10 for runway 31C of about 5,000 feet. About 1854:10, ATC began providing the pilots with radar vectors and descent instructions as they departed the holding pattern for the final approach course for the instrument landing system (ILS) approach to runway 31C. At that time, the RVR was reported as 4,500 feet variable to 5,000 feet,11 and the ATIS was reporting winds from 100° at 11 knots. About 1903:44, ATC cleared the pilots to intercept the runway 31C localizer. Less than a minute later, ATC cleared them for the approach and advised that the braking action reported for runway 31C was “fair except at the end [it’s]…poor.” According to the CVR transcript, when the pilots contacted the MDW Air Traffic Control Tower (ATCT) at 1909:53.7, controllers advised them to “continue for [runway] 31C the winds zero nine zero at nine, brakin’ action reported good for the first half, poor for the second half.” About 1912:28, the first officer received a landing clearance from the ATCT. Flight data recorder (FDR) data indicated that the airplane was aligned on the runway centerline as it touched down at an airspeed of about 124 knots. The speed brakes deployed and brake pressure increased within about 1 second. Both pilots described the touchdown as “firm.” The captain stated that he tried to deploy the thrust reversers immediately after touchdown but had difficulty moving the thrust reverser levers to the reverse thrust position. He further stated that he felt the antiskid system cycle after the airplane touched down but then felt it stop cycling and that the airplane seemed to accelerate. He said that he subsequently applied the wheel brakes manually but made no further effort to activate the thrust reversers. He told investigators that he believed that the use of the autobrake system distracted his attention from the thrust reversers after his initial attempt to deploy them. The first officer said that, when he sensed a decrease in the airplane’s deceleration during the landing sequence, he exclaimed, “brakes, brakes, brakes,” and manually applied the brakes. He stated that he then looked at the throttle console and saw that the thrust reverser levers were still in the stowed position. The first officer moved the captain’s hand away from the thrust reverser levers and, about 15 seconds after touchdown, initiated deployment of the thrust reversers to the maximum reverse setting. FDR evidence 9  Both pilots indicated that SWA fosters an environment in which pilots can make decisions about whether they should divert to an alternate airport without pressure or concern for repercussions. This is consistent with statements made by all other SWA pilots interviewed. Also, another SWA flight, arriving at MDW minutes before the accident flight, diverted to St. Louis because of landing weight considerations. The captain of that flight stated that he had “diverted several times as a captain for SWA and has never gotten any grief” from the company. 10  RVR is an instrumentally derived value that represents the horizontal distance a pilot will see down the runway from the approach end by observing runway lights or markings. 11  During postaccident interviews, both pilots stated that the airplane was clear of the clouds from about 1,400 feet to touchdown and that they estimated that the landing RVR was about 5,000 feet.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 4 confirmed the systems functions described by the pilots and indicated that full thrust reverser deployment occurred about 18 seconds after touchdown. However, the airplane ran off the departure end of runway 31C and continued through the runway safety area (RSA),12 a blast fence, a navigational aid antenna, across an airport road, through an airport perimeter fence, and onto an adjacent public roadway. The airplane struck a northbound automobile on that roadway before it came to rest near an intersection located on the northwest corner of the airport. (Figures 1 and 2 show the airplane’s position off the end of runway 31C.) The first officer stated that, after the airplane came to a rest, he performed the emergency evacuation checklist while the captain checked on the passengers in the cabin. The passengers evacuated through the forward left and the right rear cabin doors. Photograph of the accident airplane in the roadway intersection. (Looking southeast, Figure 1.  towards the departure end of runway 31C.) 12  An RSA is a designated area abutting the edge of runways that is intended to reduce the risk of damage to an airplane that runs off those surfaces. For additional information regarding MDW RSAs, see section 1.10.3.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 5 Diagram showing the accident airplane where it came to rest (on a heading of 340°) in Figure 2.  the intersection off the end of runway 31C.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 6 Injuries to Persons 1.2  Injury chart. Table 1.  Injuries Flight Crew Cabin Crew Passengers Other Total Fatal 0 0 0 1 1 Serious 0 0 0 1 1 Minor 0 1 17 3 21 None 2 2 81 5 90 Total 2 3 98 10 113 Note: Title 14 CFR 830.2 defines a serious injury as any injury that (1) requires hospitalization for more than 48 hours, starting within 7 days from the date that the injury was received; (2) results in a fracture of any bone, except simple fractures of fingers, toes, or the nose; (3) causes severe hemorrhages or nerve, muscle, or tendon damage; (4) involves any internal organ; or (5) involves second- or third-degree burns or any burns affecting more than 5 percent of the body surface. A minor injury is any injury that does not qualify as a fatal or serious injury. Damage to Aircraft 1.3  The airplane had substantial, repairable damage. Other Damage 1.4  The airplane rolled through an airport blast fence, an ILS array, a frangible airport perimeter fence, and onto a roadway, where it struck an automobile and a fire hydrant. Damage to the wing leading edges and engine nacelles of the airplane aligned with vertical posts from the airport perimeter fence; there was no damage observed in the airplane cockpit or cabin. Personnel Information 1.5  The Captain 1.5.1  The captain, age 59, was a pilot in the U.S. Air Force for 26 years before he was hired by SWA on August 3, 1995. He was hired as a first officer and was upgraded to captain in July 2000. The captain held a multiengine airline transport pilot (ATP) certificate with a type rating in the Boeing 737. The captain held a first-class Federal Aviation Administration (FAA) airman medical certificate, dated September 21, 2005, with the limitation that he “must wear corrective lenses.”13 According to the captain’s SWA employment and flight records, he had flown about 15,000 hours total flight time, including 9,500 hours as pilot-in-command, about 13  During postaccident interviews, the captain stated that he was wearing glasses at the time of the accident.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 7 4,500 hours of which were in 737 airplanes. He had flown about 198, 137, 58, 14, and 2 hours in the 90, 60, 30, and 7 days and 24 hours, respectively, before the accident. Company records showed that the captain obtained his initial 737 type rating in May 1995 and that his most recent line check, proficiency check, and recurrent training occurred in June and July 2005. A search of FAA records revealed no accident or incident history, enforcement action, or pilot certificates and ratings failure or retest history. A search of the National Driver Register found no record of driver’s license suspension or revocation. The captain had not flown for the 4 days before the accident flight. He told investigators that he slept well the night before the accident and commuted to BWI from his home in Buffalo, New York, arriving at BWI about 1235. The accident airplane was pushed back from the gate about 1650 for its departure to MDW. During postaccident interviews, the captain stated that the weather on the accident night was the worst he had experienced but that he expected to be able to land safely and uneventfully. He estimated that he had landed when the runway conditions were poor because of winter weather about 12 to 15 times during his tenure with SWA. However, he indicated that there was never a time previously when he thought he would not be able to stop before the end of the runway. The captain further told investigators that he had not previously used the autobrake system during a simulator or airplane landing. The First Officer 1.5.2  The first officer, age 34, was a Saab 340 pilot for Mesaba Airlines for 6 years (2 years as first officer, 4 years as captain) before he was hired by SWA as a 737 first officer on February 17, 2003. He held a multiengine ATP certificate with a type rating in the 737. The first officer held a first-class FAA airman medical certificate, dated October 18, 2005, with the limitation that he “must wear corrective lenses.”14 According to the first officer’s SWA employment and flight records, he had flown about 8,500 hours total flight time, including 4,000 hours as pilot-in-command and about 2,000 hours as second-in-command in 737 airplanes. He had flown about 243, 151, 83, 8, and 2 hours in the 90, 60, 30, and 7 days and 24 hours, respectively, before the accident. Company records showed that the first officer obtained his initial 737 type rating in November 2001 and his most recent 737 proficiency check and recurrent training occurred in February 2005. A search of FAA records revealed no accident or incident history, enforcement action, or pilot certificate or rating failure or retest history. A search of the National Driver Register found no record of driver’s license suspension or revocation. The first officer was assigned to a reserve line of flying at the time of the accident, and checked in for reserve duty at BWI about 1040 on December 8. He told investigators that he had about 8 hours of sleep the night before and took a nap the day of the accident flight. 14  During postaccident interviews, the first officer stated that he was wearing glasses at the time of the accident.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 8 During postaccident interviews, the first officer stated that he had extensive experience with weather conditions similar to those they encountered on the night of the accident, although most of that experience was before he was hired by SWA. He stated that he had only landed in snow a few times since he was hired by SWA, and, in those instances, “nothing unusual occurred.” The first officer further told investigators that he had not previously used the autobrake system during a simulator or airplane landing. Aircraft Information 1.6  General 1.6.1  The accident airplane, serial number 32471, was manufactured by Boeing and received its FAA airworthiness certificate on July 13, 2004. At the time of the accident, the airplane had accumulated about 5,273 total flight hours and 2,901 cycles.15 The airplane was equipped with two CFM International16 CFM56-7B24 turbofan engines, both of which were new when the airplane was delivered to SWA. According to flight dispatch information, the airplane’s actual takeoff weight for the accident flight was 129,000 pounds; the FDR recorded an actual MDW landing weight of 118,280 pounds. (The pilots used an estimated landing weight of 119,700 pounds in their OPC stopping margin calculations.) Airplane documentation indicates that the maximum structural takeoff and landing weights are 154,500 and 128,000 pounds, respectively. Each of the airplane engines is equipped with a hydraulically actuated thrust reverser system, which is used to slow the airplane after landing. When the thrust reversers are deployed, blocker doors change the direction of the engine fan air exhaust, moving it outward and forward to create reverse thrust. The thrust reversers are operated by levers located on the forward side of the thrust levers on the throttle quadrant. Postaccident examination of the thrust reverser components from the accident airplane revealed no evidence of preimpact anomaly. The 737-700 autobrake system is designed to automatically apply brakes upon main landing gear strut compression and wheel spinup after touchdown. The system senses deceleration during the landing roll and automatically modulates brake pressure accordingly. Postaccident examination of the autobrake system components from the accident airplane revealed no evidence of preimpact anomaly. 15  An airplane cycle is one complete takeoff and landing sequence. 16  CFM International is jointly owned by General Electric Aircraft Engines of the United States and Societe Nationale d’Etude et de Construction de Moteurs d’Aviation of France.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 9 Southwest Airlines On Board Performance Computer 1.6.2  SWA equips each airplane cockpit in its fleet with an OPC,17 which is stowed behind the captain’s seat and is accessible by either pilot. The OPC is used by flight crews for numerous performance calculations, including weight and balance, takeoff performance, en route performance, and expected landing performance and stopping margins. With regard to landing performance and stopping margins, SWA pilots enter current data regarding the landing runway, wind speed and direction, airplane gross weight at touchdown, temperature, altimeter setting, and reported runway braking action into the OPC, and the OPC calculates the airplane’s landing performance. The OPC alerts pilots if it calculates that the airplane will not stop on the available runway length under the conditions entered by displaying negative stopping margin numbers in white digits inside of a bracketed red block instead of the standard black digits against a white background.18 SWA policies do not authorize landings on runways with good or fair braking action with more than a 10-knot tailwind component or with more than a 5-knot tailwind component on runways with poor braking action. If the computed tailwind component exceeds these tailwind component limits, the OPC displays the stopping margin associated with the maximum tailwind limit rather than the actual tailwind component because of the OPC calculation assumptions that were established by SWA. The reported wind conditions for the accident landing resulted in a tailwind component of 8 knots, which was presented on the OPC display for calculations with both fair and poor runway braking action conditions. However, when the pilots input poor braking action, the stopping margins that were displayed by the OPC were based on the unit’s maximum 5‑knot tailwind limit. (For additional OPC-related information, see section 1.17.2.3.) Meteorological Information 1.7  Chicago Midway International Airport Weather Information 1.7.1  About 0620 on the day of the accident, the National Weather Service (NWS) Chicago Regional Forecast Office began issuing snow advisories for northern Illinois. The advisories indicated that snow would begin in northeastern Illinois and the Chicago metropolitan area by mid-morning and continue into the evening hours, with snowfall rates increasing by mid-afternoon. About 1819 (less than 1 hour before the accident), the NWS forecast office issued a winter weather advisory that indicated that a heavy snow warning was in affect for the Chicago area until midnight and estimated a total snow accumulation of between 6 and 9 inches. Snow was reported at MDW beginning about 17  Although OPCs are generally assigned to a specific airplane, each OPC database contains information for all airplanes in the SWA fleet; thus, OPCs can be exchanged between airplanes. If an OPC is unavailable, pilots may obtain required performance parameters from dispatch personnel. 18  In addition, when the wind limits are exceeded, the OPC displays a description of the limits on the bottom of the screen in white letters with black background. For an example, see the OPC display in figure 5 in section 1.17.2.3 (“Wind limits: 5T/10X”).

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 10 1347 on December 8 and ending about 0126 on December 9, 2005, with about 10 inches of total snow accumulation. An official weather observation recorded at MDW about 1853 indicated winds from 100° at 11 knots; visibility 1/2 statute mile (sm) in moderate snow and freezing fog; ceiling broken at 400 feet above ground level (agl) and overcast at 1,400 feet agl; temperature minus 3° Celsius (C) (28° Fahrenheit [F]); dew point temperature minus 4° C (23° F); altimeter setting 30.06 inches of Mercury (Hg). Remarks: automated observation system, runway 31C 10-minute-averaged RVR 4,500 feet, snow increment 1 inch new snow last hour, 10 inches total, hourly liquid precipitation less than 0.01 inch (trace). As previously noted, according to postaccident interviews with ATC personnel, the ILS to runway 31C was the only approach available to commercial flights landing at MDW on the night of the accident because of approach visibility requirements. A special weather observation recorded at MDW after the accident (at 1937) indicated winds from 160° at 5 knots; visibility 1/4 sm in heavy snow and freezing fog; sky condition obscured vertical visibility 200 feet; temperature minus 3° C (28° F); dew point temperature minus 4° C (23° F); altimeter setting 30.05 inches Hg. Remarks: automated observ[ing] system, runway 31C 10-minute-averaged RVR 3,000 feet. Weather observations at MDW are made by an automated surface observing system (ASOS). The 5-minute observations surrounding the time of the accident indicated the following conditions:19 Weather observation at 1910: winds from 110º at 8 knots, visibility 1/2 mile • in moderate snow and freezing fog, ceiling broken at 400 feet agl, overcast at 1,400  feet agl, temperature minus 4° C, dew point temperature minus 5° C, altimeter 30.06 inches Hg. Remarks: runway 31C visual range 4,500 feet variable 5,000 feet, hourly precipitation less than 0.01 inches. Weather observation at 1915: winds from 110º at 7 knots, visibility 1/2 mile • in moderate snow and freezing fog, sky obscured vertical visibility 300 feet, temperature minus 4° C, dewpoint temperature minus 5° C, altimeter 30.06  inches Hg. Remarks: runway 31C visual range 4,500  feet variable 5,000 feet, hourly precipitation less than 0.01 inches. Flight Crew Dispatch and In-Flight Weather Information 1.7.2  SWA records indicated that the airplane’s original dispatch release was revised three times before the accident flight. Examination of these documents indicated that the revisions resulted from changes in alternate airport destinations, the contingency fuel load, and the planned landing runway at MDW. The accident flight’s release calculations were based on the use of runway 31C. The release included two alternate airport destinations and enough fuel for the most distant alternate plus 90 minutes of contingency fuel. 19  The ASOS equipment is located at the center of the airport with additional sensors at the approach end of runway 31C. The ASOS system is augmented as needed by FAA-contracted, NWS-certified weather observers located in the ATCT.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 11 The MDW forecast information in the dispatch paperwork was issued by the NWS about 1515 on December 8 and was considered valid from 1500 that day to 1200 on December 9. This forecast indicated the following conditions after 1500: winds from 080° at 11 knots, visibility 1/2 sm in moderate snow and freezing fog, overcast ceiling at 400 feet agl; temporarily between 1500 and 1600, visibility 1/4 sm in moderate snow and freezing fog, sky obscured vertical visibility 200 feet. After 1600, winds from 070° at 8 knots, visibility 1 sm in light snow and mist, ceiling overcast at 500 feet agl; temporarily between 1600 and 1900 visibility 1/2 sm in moderate snow and freezing fog, sky obscured vertical visibility 400 feet. After 1900, winds from 050° at 7 knots, visibility 2 sm in light snow, ceiling overcast at 700 feet agl. After 2100, winds from 340° at 12 knots, visibility better than 6 sm in light snow, ceiling overcast at 2,500 feet agl, temporarily between 2100 and 0000, visibility 3 sm in light snow showers. Related NWS forecast information indicated that the arrival of the snow system could be slightly delayed but predicted a significant snow event for the area the afternoon and evening of the accident. A subsequent terminal forecast issued about 1738 predicted the snow ending and higher ceilings and improved visibilities in the early morning of December 9, as the system moved out of the area. Aids to Navigation 1.8  No problems with any navigational aids were reported. Communications 1.9  No communications problems between the pilots and any of the air traffic controllers who handled the accident flight were reported. Airport Information 1.10  MDW is located about 10 miles southwest of downtown Chicago at an elevation of about 620 feet in an area that includes residential, commercial, and industrial land uses. (Figure 3 shows the MDW airport layout plan with surrounding streets and properties. Runway 31C is highlighted in yellow.)

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 12 The MDW airport layout plan with surrounding streets and properties. Runway 31C is Figure 3.  highlighted in yellow.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 13 The airport is owned by the City of Chicago and operated by the Chicago Department of Aviation (DOA). MDW has five runways, including one set of two parallel runways (4R/22L and 4L/22R) and one set of three parallel runways (13L/31R, 13C/31C, and 13R/31L). Runway 31C is 6,522 feet long by 150 feet wide and is made of grooved concrete. The usable landing distance for runway 31C is 5,826 feet.20 Runway 31C is equipped with an ILS approach, a visual approach slope indicator system, and runway end identifier lights. According to postaccident interviews with ATC personnel, the ILS approach to runway 31C was the only approach available to commercial flights landing at MDW on the night of the accident because of approach visibility requirements. When the accident pilots departed the holding pattern for the final approach to runway 31C, the RVR was reported as 4,500 variable to 5,000 feet. The approach visibility requirement for runway 13C was 1 sm, whereas the requirement for the ILS approach to runway 31C was 5/8 sm visibility or 3,000 feet RVR. The FAA certificated MDW as a 14 CFR Part 139 airport with Index D aircraft rescue and firefighting (ARFF) capabilities. Examination of FAA Airport Certification/ Safety Inspection records for MDW from the years 2003, 2004, and 2005 revealed no deficiencies. Chicago Midway International Airport Winter Operations— 1.10.1  General The MDW 2005-2006 Snow Removal Manual provides an overview of the procedures used by the Chicago DOA for snow removal operations at MDW. According to this manual and MDW personnel, snow removal and anti-icing operations are conducted from runway end to runway end. During snow removal operations, an MDW airport operations supervisor is positioned in the ATCT to act as a liaison between air traffic controllers in the tower and snow removal teams on the field. This coordination effort is intended to optimize use of the runways and minimize delays. The operations supervisor receives pilot reports regarding field conditions and/or runway braking action from ATC and relays them to snow removal teams as necessary. The operations supervisor also maintains a handwritten “snow log” that documents the snow removal and runway friction test activities. The FAA-approved Airport Certification Manual (ACM) for MDW states that the airport is responsible, in part, for monitoring runway conditions and pilot reports, snow and ice removal as necessary, and coordination with ATC, air carriers, and other airport users during snow and ice events. The ACM also specifies that the airport will conduct 20  Displaced thresholds located at each end of runway 31C reduced the usable landing distance from 6,522 to 5,826 feet. A displaced threshold is a runway threshold located at a point other than the physical beginning or end of the runway. The portion of the runway so displaced may be used for takeoff but not for landing. Landing airplanes may use the displaced area on the opposite end for rollout. Most often the offset threshold is in place to give arriving aircraft clearance over an obstruction while still allowing departing aircraft the maximum amount of runway available.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 14 friction tests on the active runway, or any other runway available for aircraft use, on a “frequent” basis during events involving freezing precipitation or snow. Chicago Midway International Airport Winter Operations 1.10.2  on the Day of the Accident According to MDW officials, early on the day of the accident, the Chicago DOA had received adverse weather reports and initiated the notification and mobilization phases of the snow operations plan. Snow began falling at the airport about 1347, at which time snow removal operations commenced. Snow removal operations involved the use of runway brooms, snow plows, a snow blower, deice machines, and runway friction testing equipment. According to postaccident interviews and documentation, runway 13C/31C had been cleared five times during the 5 1/2 hours of snowfall before the accident, most recently about 1845. Friction test logs indicated that runway 31C was friction-tested before this clearing about 1839, with resultant coefficient of friction (MU) readings21 of .59/.45/.37 (average .47).22 A friction test conducted about 1847 produced results of .72/.59/.68 (average .67). The most recent field conditions reported on the MDW Web site (which were updated about 1850) indicated that runway 31C had a trace to 1/16 inch of wet snow over 90 percent of its surface, with 10 percent of its surface clear and wet. A friction test conducted after the accident (about 1922) produced results of .41/.40/.38 (average .40). Chicago Midway International Airport Runway Safety Areas 1.10.3  According to Advisory Circular (AC) 150/5300-13, change 7, “Airport Design,” the RSA for runway 13C/31C at MDW should have extended 1,000 feet beyond the runway ends and been 500 feet wide.23 FAA documentation indicates that, at the time of the accident, the runway 31C RSA extended 82 feet beyond the end of the runway and was 500 feet wide. The FAA’s RSA determination for this runway, dated September 20, 2000, stated, “it does not appear practicable to achieve the RSA standards” because the runway could not be realigned on site, and the acquisition of land for an RSA would require relocation of Central Avenue, 55th Street, and many businesses and homes in the area. However, the FAA instructed the Chicago DOA to “explore all options to bring the RSAs into full conformance with FAA standards.” 21  For additional information regarding evaluation of contaminated runways and friction measurements, see section 1.18.2. 22  MU friction values range from 0.0 to 1.0, where 0.0 is the lowest friction value, and 1.0 is the theoretical best friction value available. Friction testing devices provide MU values for the first, second, and third sections of the runway length. These values are then averaged for an overall friction value representing the entire runway surface. 23  According to the National Transportation Safety Board’s postaccident simulation study, using routine procedures under the accident conditions, the accident airplane would have required an additional 750 feet of runway to come to a complete, unobstructed stop.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 15 In 2003, the FAA asked the Chicago DOA to assess enhancement measures for improving the RSAs at MDW. In May 2004, the city stated in a response letter that there were no alternatives for achieving a standard RSA at MDW. The letter also stated the following: The runway could not be shortened and still meet the aircraft operational • requirements. Extending the RSA would require acquisition and major impact to surrounding • commercial properties and residential neighborhoods, public roadways, and public utility infrastructure. [The use of an] EMAS [engineering materials arresting system] was assessed, • but insufficient spacing existed for installation of EMAS without shortening the runway, thus reducing the operational capacity of the airport. The letter concluded that RSA enhancement at MDW could be obtained incrementally by improvements such as relocation of light poles and service road signs within the RSA. According to MDW officials, the FAA made no further requests to the city for improvements to MDW RSAs, including the installation of shorter, nonstandard EMAS beds,24 before the accident. After the accident, in April 2006, the Chicago DOA sent a letter and an EMAS study to the FAA. The letter summarized options for improving the MDW RSAs and concluded that a nonstandard EMAS bed with a 35-foot setback could be installed at the end of runway 31C. Engineering calculations showed that the nonstandard arrestor bed would be capable of stopping a Boeing 737-700 weighing 102,400 pounds and rolling at a ground speed of up to 57 knots on a wet runway without the use of thrust reversers. After the accident, the National Transportation Safety Board asked the EMAS system manufacturer to model the accident scenario25 and estimate the effect a nonstandard EMAS installation off the end of runway 31C would have had on the accident sequence. The EMAS manufacturer estimated that an arrestor bed 229 feet long would fit in the overrun area off the end of runway 31C. The manufacturer’s simulations predicted that, based on the accident airplane’s estimated runway exit speed of 53 knots, a 737 landing under conditions similar to the accident airplane would continue 206 feet into the EMAS bed before stopping. The simulations indicated that the airplane could have been traveling as fast as 58 knots when it ran off the end of the runway and still stop within a 229-foot‑long EMAS bed. The simulations indicated that a nonstandard EMAS installation would have stopped the accident airplane before it departed airport property. 24  Although the FAA was aware of the feasibility of nonstandard EMAS installations and had approved such installations at several airports (for example: John F. Kennedy International Airport, New York, New York; Bob Hope Airport, Burbank, California; Baton Rouge Metropolitan Airport, Ryan Field, Baton Rouge, Louisiana; and Barnstable Municipal Airport-Boardman/Polando Field, Hyannis, Massachusetts), it did not publish guidance related to this option until 2005. In September 2005, the FAA issued AC 150/5220-22A, “Engineered Materials Arresting Systems (EMAS) for Aircraft Overruns.” 25  Safety Board investigators provided the manufacturer with data regarding the accident scenario, including airplane weight, airport and weather conditions, and likely runway exit speed for the modeling simulations.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 16 After the accident, the FAA approved the installation of nonstandard EMAS beds at MDW, and MDW and City of Chicago officials began to work toward installation of nonstandard EMAS beds at the ends of runways 31C, 13C, 4R, and 22L. By early December 2006, the first portion (170 feet long and 170 feet wide) of an EMAS bed had been installed off the departure end of runway 31C, with an additional 40-foot-long portion planned. Airport and city officials indicated that the installation of EMAS beds at the ends of affected MDW runways would be completed before winter 2007, pending relocation of localizer antennas at the ends of runways 13C, 4R, and 22L. Flight Recorders 1.11  Cockpit Voice Recorder 1.11.1  The accident airplane was equipped with a Honeywell model 6022 CVR, serial number (S/N) CVR120-05823. The CVR showed no signs of damage and was sent to the Safety Board’s laboratory in Washington, DC, for readout and evaluation. The CVR was played back normally and without difficulty and contained six separate channels of good quality26 audio information. The recording started at 1712:58.2 and continued uninterrupted until 1914:01.3. A transcript was prepared of the entire 2-hour, 44.7-second recording (see appendix B). Flight Data Recorder 1.11.2  The accident airplane was equipped with a Honeywell model solid state FDR, S/N 10452, that recorded airplane flight information (including altitude, airspeed, heading, wind direction and speed, control wheel and column position, elevator/aileron/rudder position, engine fan speed, thrust reverser status and position, thrust reverser interlock, brake pressure, and autobrake status) in a digital format using solid-state memory devices. The FDR showed no evidence of damage or excessive wear and was sent to the Safety Board’s laboratory for readout and evaluation. The following information was obtained from the accident airplane’s FDR data and physical evidence: The main landing gear touched down about 1,250 feet beyond the runway’s • approach threshold.27 At the time, the airplane’s ground speed was about 131 knots, its airspeed was 124 knots, its heading was 316°, and its vertical acceleration reached about 1.4 Gs. 26  The Safety Board uses the following categories to classify the levels of CVR recording quality: excellent, good, fair, poor, and unusable. A good quality recording is one in which most of the flight crew conversations could be accurately and easily understood. 27  The airplane touched down within the Boeing-recommended touchdown zone of 1,000 to 2,000 feet beyond the runway threshold. The OPC calculated the landing/stopping distance based on a touchdown point of 1,500 feet beyond the runway threshold.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 17 The ground spoilers were fully deployed, autobrakes were applied, and vertical • acceleration increased to a peak value of about 1.7 Gs within about 1.2 seconds of touchdown. About 10 seconds after touchdown, engine fan speed (N • 1) decreased from about 32 percent at touchdown to about 20 percent, where it remained for about 8 seconds. Autobrakes were deactivated about 12 seconds after touchdown, and • pilot‑commanded brake pressure increased to 3,000 pounds per square inch (psi). The first indication of thrust reverser activity was recorded about 15 seconds • after touchdown, with full deployment about 18 seconds after touchdown. N1 reached 80 percent about 9 seconds later (about 27 seconds after touchdown) at a ground speed of about 62 knots. The thrust reversers were fully deployed and the brake pressure was 3,000 psi • when the nose landing gear departed the runway overrun at a speed of about 53 knots. The airplane came to a stop about 500 feet beyond the end of the runway on a • heading of about 340° with a collapsed nose landing gear about 8 seconds after it departed the runway overrun. Flight Data Recorder Information From Other Landing 1.11.3  Airplanes FDRs from five air carrier airplanes that landed in the 25 minutes before the accident were evaluated. Table 2 provides a comparison of selected parametric data for those five air carrier airplanes and the accident flight. Comparison of selected parametric data for five air carrier airplanes and the accident Table 2.  flight. Airline and flight number Airplane type Time Touchdown ground speed in knots Vertical load (G) Gross weight (lbs) Seconds to brake use Seconds to full thrust reverser deployment Seconds to 40 knots United Airlines 1446 A320 1849 128 1.33 113,830 3.5* 6 18 SWA 2920 737 1852 140 N/A** 114,560 0.5 4 21 SWA 321 737 1901 121 1.5 103,320 6.0 4 25 SWA 2947 737 1902 132 1.95 110,320 8.0 4 26 SWA 1830 737 1904 126 1.35 105,520 2.0 4 24 Accident flight 737 1913 131 1.41 118,280 3.3* 18 33 *Note: The autobrake system initially applied the brakes for United Airlines flight 1446 and the accident flight. **N/A in this table indicates not available.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 18 Wreckage and Impact Information 1.12  The airplane came to rest on a magnetic heading of about 340° at the south side of an intersection located on the northwest corner of MDW. The airplane was resting on the engines, both main landing gear, and the nose of the fuselage, with the nose landing gear collapsed and folded aft. The damage to the airplane was largely limited to the forward lower fuselage, engine cowlings and components, forward portions of the wings, and other wing components,28 with limited damage farther aft. The rear part of an automobile was found damaged beneath the forward portion of the airplane’s left fuselage. Postaccident interviews and physical evidence indicate that the automobile was northbound on the roadway and was struck from behind by the airplane. Postaccident examination and testing of components in the airplane’s throttle, antiskid,29 ground spoiler, and wheel brake systems revealed no evidence of preimpact anomalies. In addition, investigators examined the engine controls and the throttle quadrant (including the thrust levers) in the flight deck area and associated linkages below the cockpit floor level; no evidence of preimpact anomalies was found. Medical and Pathological Information 1.13  In accordance with Federal regulations, postaccident drug testing was conducted on urine specimens obtained from the captain and first officer;30 test results were negative. In addition, both pilots volunteered blood samples for analysis within 24 hours of the accident. These test results were negative for alcohol and a wide range of drugs, including drugs of abuse.31 The Cook County Medical Examiner’s Office reported the cause of death of the automobile passenger as “compressional asphyxia.” Other postaccident medical information indicated that another automobile occupant received serious injuries, including multiple fractures, head injuries, and right shoulder pain, and 21 people (1  flight attendant, 17 airplane passengers, and 3 automobile occupants/pedestrians) received minor injuries, including multiple aches and pains, sprains/strains, contusions and abrasions, and a whiplash-type injury, as a result of the accident. 28  Damage along the wings aligned with observed damage to the airport blast fence and perimeter fence. 29  The accident airplane’s antiskid system is designed to modulate wheel brake pressure to ensure a fixed slip ratio between the tire and ground during braking. 30  These tests were to include alcohol, amphetamines, cocaine, marijuana, opiates, and phencyclidine. 31  The drugs tested in the postaccident analysis include (but are not limited to) marijuana, cocaine, opiates, phencyclidine, amphetamines, benzodiazapines, barbiturates, antidepressants, antihistamines, meprobamate, and methaqualone.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 19 Fire 1.14  No evidence of an in-flight or a postcrash fire was found. Survival Aspects 1.15  According to postaccident interviews and airport documentation, the first ARFF units arrived at the airplane about 2 minutes after the accident and assisted with the evacuation. The captain instructed a flight attendant to open the left front door and told the first officer to help passengers at the bottom of that door’s evacuation slide.32 He used a megaphone to advise passengers that they should evacuate through the front of the airplane. According to City of Chicago records, about 14 minutes after the accident, ARFF personnel positioned mobile stairs at the right rear door and assisted passengers in exiting through that door as well. The first officer and about half of the airplane passengers evacuated through the left front cabin door. The captain, three flight attendants, and about half of the passengers evacuated through the right rear door using the mobile stairs provided by ARFF personnel. During postaccident interviews, flight attendants described the evacuation as “orderly” and stated that passengers deplaned calmly. The right front, left rear, and right and left overwing exits were not opened during the evacuation. Tests and Research 1.16  Airplane Simulation and Performance Studies 1.16.1  A postaccident engineering study was conducted to examine the deceleration times and distances required for the accident flight and the four other SWA 737-700 airplanes that landed before it. The Safety Board’s airplane performance study identified an airplane braking ability (braking coefficient)33 that would replicate the accident airplane’s ground speed and runway deceleration performance and quantified the effects that different winds, ground spoiler deployment schedules, and reverse thrust throttle settings and stowage schedules would have had on the airplane’s stopping performance. 32  The captain chose to initiate the evacuation through the front of the airplane because the nose of the airplane was closer to the ground after the nosewheel collapsed. The first officer described the evacuation slide at the left front exit as “almost flat to the ground.” 33  Airplane braking coefficient is defined as the ratio of the retarding force due to braking relative to the normal force (that is, weight minus lift) acting on the airplane. The estimated airplane braking coefficient incorporates effects due to the runway surface, contaminants, and airplane braking system (antiskid efficiency, tire pressure, brake wear, etc.).

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 20 Simulations that replicated the accident airplane configuration, use of deceleration devices, and weather34 and runway conditions (see case #31 in table 3) showed that, under these conditions, the airplane would have required about another 753 feet beyond the end of the runway to come to a stop. A simulation case performed under the same conditions but with an equivalent headwind instead of tailwind component (see case #33 in table 3) showed that the airplane could have stopped about 584 feet before the departure end of the runway. A simulation case performed under identical airplane configuration, weather, and runway conditions, but using SWA routine/planned deceleration procedures to decelerate,35 showed that the airplane would likely have stopped about 1,351 feet beyond the end of the runway (see case #53 in table 3). Under the same conditions and if the pilots had used Boeing’s reverse thrust procedures36 (see case #54 in table 3), simulations showed that the airplane would likely have stopped about 531 feet beyond the end of the runway. However, simulations in which maximum reverse thrust was selected 2 seconds after touchdown and maintained until the airplane came to a complete stop (see case #60 in table 3) showed that the airplane could have stopped about 271 feet before the departure end of the runway. Stopping distances and runway exit speeds for various deceleration scenarios Table 3.  calculated during postaccident airplane performance simulations. Simulation Case # Simulation ground speed at runway exit Calculated runway 31C distance remaining #31 (accident event conditions) 50 knots -753 feet #33 (accident event conditions, but with a headwind) not applicable 584 feet #53 (SWA reverse thrust) 46 knots -1,351 feet #54 (Boeing reverse thrust) 30 knots -531 feet #60 (Maximum reverse thrust stop) not applicable 271 feet The previous four SWA 737-700 airplanes landed on runway 31C about 1853, 1901, 1902, and 1904; one of these airplanes exited the runway at taxiway B (the last taxiway before the runway end), the other three airplanes exited at the runway-end taxiway. FDR data indicated that the flight crews on these four airplanes deployed reverse thrust (three out of the four flight crews commanded maximum reverse thrust) early in the landing roll. The Safety Board’s study showed that timely and sustained application of reverse 34  FDR data indicated that the actual tailwind component at touchdown was between 8 and 9 knots. The Safety Board’s simulations were based on a 9-knot tailwind component. 35  SWA planned deceleration procedures specified that reverse thrust be selected within 2 seconds of touchdown and maintained until the airplane decelerated through 80 knots, followed by smooth throttle movement to forward idle thrust as the airplane decelerated from 80 to 60 knots. 36  Boeing’s published reverse thrust procedures were similar to SWA’s except that thrust reversers were to be maintained until the airplane decelerated through 60 knots, followed by smooth throttle movement to reverse idle thrust as the airplane decelerated from 60 to 30 knots.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 21 thrust (including maximum reverse thrust as needed)37 could have been used to stop the accident airplane on the runway. The study showed that the accident airplane landed in generally deteriorating runway surface conditions; the flight’s braking ability was about five times worse than would be expected on a bare and dry runway. The study also stated that the calculated ground roll distances were most sensitive to the airplane braking coefficient magnitude, winds, and time delay to commanded reverse thrust under the landing conditions. However, the study noted that the landing distances would have been less sensitive to similar wind and time delay variations if the landings were conducted on a dry or wet runway. Organizational and Management Information 1.17  Southwest Airlines Information 1.17.1  SWA began service on June 18, 1971, and is based in Dallas, Texas. At the time of the accident, SWA operated about 3,000 scheduled daily domestic departures to 62 destinations and had more than 31,000 employees. The company’s all-737 fleet consisted of 194 737-300s, 25 737-500s, and 222 737-700s. Five other runway-related accidents or incidents involving SWA have occurred since 1983,38 including three lateral runway excursions and two runway overruns, one of which involved a contaminated runway surface (heavy rain). Southwest Operations Guidance Information 1.17.2  Thrust Reverser Procedures and Information 1.17.2.1  SWA policies and procedures specified the use of thrust reversers for all landings, regardless of runway length or condition. At the time of the accident, SWA’s FAA- approved flight operations manual (FOM) stated, in part, that after the airplane touches down on the runway, the pilots should do the following: Initiate reverse thrust: Raise the reverse thrust levers to the reverse idle interlocks. After the interlocks release, modulate reverse thrust, as required. Avoid exceeding engine limits. Minimum reverse thrust is 65 percent N1 [engine fan speed]. When required, reverse thrust to engine limits may be used. Initiating reverse thrust at touchdown is an important factor in 37  SWA procedures indicate that maximum reverse thrust is available for routine use at the pilots’ discretion, and, as noted, was also used by three of the four SWA 737s that landed at MDW before the accident airplane. See section 1.17.2.1 for related SWA flight operations manual text. 38  More information on these five events, FTW03MA160, LAX01IA109, DCA00MA030, FTW96IA210, and FTW85FA202, is available on the Safety Board’s Web site at http://www.ntsb.gov/ntsb/query.asp.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 22 minimizing brake temperatures, minimizing brake and tire wear, and reducing stopping distances. The SWA FOM also stated the following: Under braking advisories less than ‘GOOD’ use Normal Landing Procedures except for the following: [Manual] Brakes and thrust reversers should be applied together.[39] Use thrust reversers as soon as possible during landing roll. In addition, the SWA FOM stated the following: Both pilots will monitor systems for warning flags, lights, or out of tolerance conditions. The [first officer] will advise the captain of deviations from established policies, procedures, and/or regulations. SWA pilots are trained to move the thrust reverser levers aft smoothly and promptly after touchdown and to keep their forearms on the throttle knobs to keep the throttles at idle during thrust reverser deployment. If the throttle levers are forward of the idle detent by about 1/4 inch,40 the reverse thrust levers cannot be operated. A postaccident survey of SWA personnel and pilots, a review of SWA maintenance records, and a review of aviation safety reporting system (ASRS) data revealed no evidence of systemic thrust reverser difficulties. Several SWA pilots did report difficulties deploying the thrust reversers when they tried to move the reverse thrust levers past the interlock position too rapidly; those pilots reported that the levers moved readily when they tried to deploy the thrust reversers again after the interlocks released. Postaccident interviews with the previous 10 flight crews for the accident airplane revealed that they reported no difficulty deploying the thrust reversers. According to SWA personnel, there was no policy allowing pilots to apply a credit for the use of reverse thrust during their landing distance assessments (which would increase the calculated stopping margin for a landing) until 1998, when a reverse thrust credit was incorporated into landing distance calculations for the 737-700 model only. SWA pilots received instruction regarding the reverse thrust credit during differences training when qualifying for the 737-700 model. However, until 1 week before the accident, the information in two out of three FOM locations incorrectly indicated that reverse thrust was not included in 737-700 OPC landing distance calculations. At the time of the accident, the information was correct in two of the three FOM locations. Most SWA 39  For additional information regarding activities that have been grouped together in an automatic task sequence, such as manual brakes and thrust reversers, see section 2.2.3. 40  The thrust lever interlock latch prevents movement of the reverse thrust levers (and thus prevents thrust reverser actuation) when the forward thrust lever is forward of the idle stop.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 23 pilots interviewed after the accident were aware of the OPC reverse thrust credit for the 737-700; however, some were not. Autobrake Procedures and Information 1.17.2.2  At the time of the accident, SWA planned to implement a policy requiring the use of autobrakes under certain landing conditions on December 12, 2005 (4 days after the accident). Previously, SWA’s policy did not permit the use of autobrakes because the company’s fleet was not then fully equipped with autobrakes. As the fleet became fully equipped, the company took steps to implement autobrake use. In preparation, SWA provided its pilots with a self-study training module on the autobrake system and related SWA procedures (which both accident pilots had completed). SWA pilots were also provided with a series of bulletins regarding the repeatedly delayed start-date for autobrake usage. The most recent of these bulletins was issued December 8, 2005, and noted that the company’s autobrake procedures and policies were to be used by SWA pilots beginning December 12, 2005, and therefore were not in effect (or authorized) on the day of the accident.41 During postaccident interviews, the pilots told Safety Board investigators that they had read the daily read-before-flight (RBF) letters before the accident flight but that they failed to notice the new delay in autobrake procedure implementation.42 CVR evidence and postaccident statements indicated that they both believed that the autobrake policy was in effect for the accident flight. A previous autobrake-related RBF letter indicated that the autobrake policy would be in effect as soon as materials were available in the cockpit. On the day of the accident, “flow” cards and checklists with information regarding autobrake procedures had been placed in SWA airplanes. When using autobrakes, pilots can select from several autobrake system settings, including the following: Maximum (MAX): Should be used when minimum stopping distance is • required.43 Medium (MED): Should be used for wet or slippery runways or when landing • rollout distance is limited. Minimum (MIN): These settings provide a moderate deceleration effect suitable • for all routine operations. On Board Performance Computer-Related Guidance and Information 1.17.2.3  Pilots may use a variety of aids when performing airplane performance and landing distance calculations. Options include tabular performance charts and on board electronic 41  For additional information regarding the increased effort and cognitive resource-use required by new procedures, see section 2.2.3. 42  The Safety Board’s review of SWA RBF letters revealed that there had been several delays in the autobrake implementation dates associated with the autobrake procedure implementation. 43  The accident flight crew selected MAX autobrakes for the landing and transitioned to maximum manual braking about 12 seconds after touchdown.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 24 computing devices (also known as OPCs at SWA). The FAA evaluates and approves operators’ procedures for the use of electronic computing devices with an interactive interface, and advisory guidance regarding the certification and operational approval process for these devices is provided in AC 120-76A.44 AC 120-76A addresses human factors design issues and contains references to other sources for detailed human factors guidance, including a series of reports developed by the Department of Transportation (DOT) in conjunction with the FAA regarding human factors in the design and evaluation of OPC-type devices.45 The advisory material states that the results of calculations should be displayed in a manner that is understood easily and accurately and that users should be aware of any assumptions upon which the flight performance calculations are based. Tabular charts preceded on board electronic computing devices and are still used by many airlines today. These charts present critical information and assumptions through notations directly on the applicable chart or on an introductory performance page. To calculate landing distance using a chart, pilots survey rows and columns of values, select the most appropriate value for conditions, and adjust for inputs accordingly. Use of charts sometimes requires mathematical adjustments or interpolations to account for values that are not exactly listed. OPC-like devices help reduce the pilots’ workload by eliminating the need for pilot adjustments and interpolations; however, research shows that it is important for pilots to be aware of the critical underlying performance calculation assumptions.46 As previously stated, SWA provides its pilots with an OPC, and the company’s FOM provides guidance regarding the use of that OPC. The SWA FOM identifies, in part, the following runway conditions with regard to OPC use: WET-FAIR—to be used when braking action is reported as fair; and WET-POOR—to be used when braking action is reported as poor. The SWA FOM further states the following: The [OPC-calculated] landing distance information is provided to give an indication of the braking effort necessary to stop the airplane within the available landing length….Individual pilot braking technique and 44  Although there is no requirement for the manufacturers of Class 1, Type B electronic computing devices (like SWA’s OPCs) and/or operators using such to adhere to the guidance contained in AC 120‑76A, FAA evaluators and principal operations inspectors are encouraged to reference the advisory materials during the approval process. 45  (a) http://www.volpe.dot.gov/opsad/efb/vreppub.html; (b) AS 25-11, FAA Policy Statement ANM‑99-2, FAA Policy Statement ANM-01-03, DOT-VNTSC-FAA-00-22; RTCA/DO-257; (c) U.S. Department of Transportation, Human Factors Considerations in the Design and Evaluation of Electronic Flight Bags (EFBs), Version 2, Report Number DOT-VNTSC-FAA-03-07 (Washington, DC: DOT, 2003); and (d) U.S. Department of Transportation, A Tool Kit for Evaluating Electronic Flight Bags, Report Number DOT-VNTSC- FAA-06-21 (Washington, DC: DOT, 2006). 46  (a) K. Mosier and L. Skitka, “Human Decision Makers and Automated Decision Aids: Made for Each Other?,” Automation and Human Performance: Theory and Applications, R. Parasuraman and M. Mouloua (Eds.), Mahwah, New Jersey: Lawrence Erlbaum Associates, 1996; and (b) U.S. Department of Transportation, Human Factors Considerations in the Design and Evaluation of Electronic Flight Bags (EFBs), Version 1: Basic Functions, Report Number DOT-VNTSC-FAA-00-22 (Washington, DC: DOT, 2000).

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 25 experience will provide equivalent braking efforts that can then be related to the OPC output. The MAX distance is based on maximum manual braking (without the use of thrust reversers) at touchdown. The approximate stop margins calculated by the OPC are based on three different levels of deceleration as defined by the autobrake system and are based on touching down 1,500 feet from the [runway approach] threshold. The MIN, MED, and MAX values are calculated using the deceleration rates for [associated autobrake settings]. The stop margins include the effects of reverse thrust (-300/-500: stop margins do not include the effects of reverse thrust).[47] Additionally, according to SWA’s FOM, company procedures authorize pilots to land using a MAX autobrake setting, “provided a positive stopping margin is computed” by the OPC. Specific OPC-related training was provided to SWA pilots during 1 day of dispatch training and two additional classroom training periods. During training, one scenario addressed use of the OPC from takeoff to landing during a normal flight, whereas another addressed use of the OPC from takeoff to landing during an abnormal flight.48 Additionally, upon completion of the specific OPC training, pilots spent 3 classroom days with a check airman instructor who covered additional FOM topics, including use of the OPC. Most SWA pilots, instructors, and check airmen who were interviewed told investigators that the company’s pilots had adapted well to the use of the OPC and had a good understanding of and trusted the system. There were no procedures in place for pilots to verify or check the numbers calculated by the OPC with another independent source. Postaccident examination of the data stored on the accident OPC confirmed that the pilots had entered the expected airplane touchdown weight and updated weather data. As previously noted, evidence indicated that the pilots selected WET-FAIR and WET-POOR as possible runway conditions and that the OPC estimated 560 and 40 feet, respectively, of runway remaining under those conditions. (As previously noted, SWA procedures permit company pilots to land with any positive calculated stopping margin.) Based on its assumptions, the OPC display would reflect the landing distance associated with a maximum tailwind component of 5 knots for poor braking action even if the 47  SWA pilots were type-rated in all three 737 models owned by SWA (-300/-500/-700) and switched between these models on a day-by-day or flight-by-flight basis. Pilots were taught that stopping margins assumed reverse thrust credit (85 percent to MAX) for the -700 model only and not for the other two models (-300/-500). This method of calculation resulted in a more favorable stopping margin for the -700. As noted, until 1 week before the accident, OPC-related information in the SWA FOM stated that reverse thrust was not included in the landing distance calculations in two of three locations; the incorrect information remained in one location when the accident occurred but has since been corrected. 48  Beginning in July 2005, SWA recurrent training included a scenario involving a potential conflict between runway condition reports from two different sources; however, the accident pilots had completed their 2005 recurrent training before that date, and the training still did not include interpretation of mixed-condition runway braking action reports.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 26 computed tailwind component exceeded 5 knots. Figures 4 and 5 show OPC-displayed results of OPC calculations based on the accident conditions with fair and poor braking action, respectively. Note that in both figures the OPC display shows the tailwind value of 8 knots even though the displayed landing distance is based on the OPC tailwind limit of 5 knots. In figure 5, the white “8T” with a red background and the “Wind limits: 5T/10X” remark in white with a black background near the bottom of the display indicate that the tailwind limits for poor braking action were exceeded. OPC display showing the results of OPC calculations based on the accident conditions Figure 4.  with fair braking action. The Safety Board’s investigation revealed that if SWA OPCs had used the actual tailwind component of 8 knots instead of the company limit of 5 knots, the stopping margin for poor braking action would have been -260 feet. Because of its negative value, this number would have been presented as bracketed white digits inside of a red block (instead of the standard black digits against white background) to alert the pilots that they could not safely land on the runway. The Board notes that calculations performed using Boeing’s more conservative data, an 8‑knot tailwind component, and poor braking action indicated that the airplane would have stopped 2,070 feet beyond the end of the runway. Similar calculations performed using fair braking action indicated that the airplane would have stopped 260 feet beyond the end of the runway. A review of SWA guidance and MEL/CDL Return Module Menu 31C 5826 - DT 8T / 7X [ -810 ] 350 560 Runway Condition: WET _ FAIR Air Conditioning: BLEEDS ON Anti-Ice: ENGINE ON

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 27 training regarding OPC assumptions revealed one reference in the OPC section of the flight reference manual (FRM) but none in the FOM. Further, no references were made to this topic during initial, recurrent, or OPC-related ground training. Note: the white “8T” with a red background and the “Wind limits: 5T/10X” remark in white with a black background near the bottom of the display indicate that the tailwind limits for poor braking action were exceeded. OPC display showing the results of OPC calculations based on the accident conditions Figure 5.  with poor braking action. As a result of its investigation of the July 31, 1997, accident involving a Federal Express McDonnell Douglas MD-11 that crashed while landing on runway 22R at Newark International Airport, Newark, New Jersey,49 the Safety Board determined that some flight crewmembers may lack proficiency in the operation of airplane performance computing devices and that confusion about calculated landing distances may result in potentially hazardous miscalculations of available runway distances after touchdown. In August 2000, the Safety Board issued Safety Recommendation A-00-95, which asked the FAA to require principal operations inspectors (POI) assigned to Part 121 operators that 49  National Transportation Safety Board, Crash During Landing, Federal Express, Inc., McDonnell Douglas MD-11, N611FE, Newark International Airport, Newark, New Jersey, July 31, 1997, Aircraft Accident Report NTSB/AAR-00/02 (Washington, DC: NTSB, 2000). MEL/CDL Return Module Menu Wind limits: 5T/10X. 31C 5826 - DT 8T / 7X [ -730 ] [ -30 ] 40 Runway Condition: WET _ POOR Air Conditioning: BLEEDS ON Anti-Ice: ENGINE ON

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 28 use auxiliary performance computers50 to review and ensure the adequacy of training and procedures regarding the use of this equipment and interpretation of the data generated, including landing distance data. As a result of this recommendation, in August 2002, the FAA issued Flight Standards Information Bulletin for Air Transportation 02-03, which was intended to 1) call attention to the importance of operating procedures and pilot training related to OPCs and 2) cause operators and POIs to review those procedures and related training to ensure their adequacy, if OPCs are to be used by the operator. In December 2002, Safety Recommendation A-00-95 was classified “Closed—Acceptable Action.” Mixed Braking Action Report and Tailwind Limitation Guidance 1.17.2.4  SWA guidance indicates that mixed braking action reports are not unexpected during routine operations and company policy requires pilots to defer to the more critical braking action assessment when mixed braking action conditions are reported. Specifically, SWA’s FAA-approved FOM, chapter 3, “Normal Operations,” pages 3.23.1 through 3.23.5, states the following: Braking action reports less than good are classified according to the most critical term emphasis added. Operations are prohibited on all surfaces classified as nil. The Safety Board’s review of SWA training materials revealed that, at the time of the accident, the topic of mixed conditions was not routinely or explicitly introduced to pilots during training. Further, the topic was not addressed in the FOM sections regarding braking action and runway friction reports, entering runway conditions into the OPC, and/or programming the OPC for landing. After the accident, SWA published a revision to chapter 3 of the FOM, which added, “If a combination is given (e.g., fair to poor), use the more restrictive of the two.” In addition, SWA implemented pilot training specific to interpretation of braking action reports, including mixed conditions.51 According to SWA’s FOM, chapter 2 (“Operational Considerations”), page 2.2.6 “landing is not authorized … when wind limitations are exceeded.” The FOM, chapter 2, page 2.2.9, indicates that SWA’s maximum tailwind component for landing under poor braking action conditions is 5 knots; under all other conditions, the maximum tailwind component for landing is 10 knots. As previously noted, when the wind limits for a given braking action are exceeded, the OPC displays a description of the limits on the bottom of the screen in white letters with black background, but uses SWA’s programmed maximum tailwind component (not the actual computed component) to calculate landing distance. For an example, see the OPC display in figure 5 (“Wind limits: 5T/10X”). 50  “Auxiliary performance computer” is another term for an electronic computing device or OPC. 51  For additional information regarding postaccident SWA actions, see section 1.17.3.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 29 Southwest Airlines Postaccident Actions 1.17.3  As a result of this accident, SWA revised its operational policies and procedures and guidance as follows: Amended sections of its FOM to reinforce the company’s policy requiring • pilots to enter the most restrictive braking action report in the OPC for landing distance assessments and provided additional training specific to braking action reports, including mixed conditions.52 Revised its OPC to standardize the use of thrust reverser credit in landing • distance assessments for all airplane types and to modify the landing output screens to show the amount of reverse thrust needed to obtain the calculated distances. Reinforced thrust reverser policies regarding the immediate deployment of • thrust reversers after landing. Revised the procedures for use of thrust reverse to be consistent with the Boeing • guidance, such that pilots are to begin reducing the reverse thrust at 60 knots instead of 80 knots. Clarified FOM guidance regarding the responsibility of the monitoring pilot • to monitor thrust reverser deployment and to call out any specific related deviation. Implemented an autobrake familiarization period before autobrake use (in • addition to the existing flight crew autobrake training and related information package) and revised FOM to include a technical description of the autobrake system. SWA required that pilots complete at least four familiarization landings (two as the flying pilot and two as the monitoring pilot) on dry runways with ample stopping margins before using the autobrake system on a routine basis. Added a 15 percent safety margin to its arrival landing distance calculations • and revised its OPC to reflect the additional margin.53 Additional Information 1.18  Airplane Landing Performance Information 1.18.1  Two categories of airplane landing distance performance information are pertinent to normal commercial airplane operations. The first, preflight (or dispatch) landing distance 52  Preaccident SWA guidance regarding braking action reports was consistent with the postaccident guidance, stating, “braking action reports less than good are classified according to the most critical term (fair, poor, nil, or combinations).” 53  The added safety margin was consistent with that recommended in the FAA’s August 31, 2006, Safety Alert for Operators 06012. For more information, see section 1.18.2.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 30 performance data, is used during flight planning to determine the maximum takeoff weight at which the airplane can depart an airport and, after its planned fuel burn, land on the available landing distance at the destination/alternate airport. This determination is based on specific 14 CFR requirements for dry or wet/slippery runway conditions. Dispatch landing distance calculations are intended to ensure that dispatched airplanes will be able to land safely at the intended destination airport or a planned alternate and are based on estimated landing weights and forecast conditions. According to Federal regulations, the dry and wet/slippery landing performance data used for dispatch calculations are obtained by multiplying the numbers demonstrated54 during certification landings on a level, smooth, dry, hard-surfaced runway by factors of 1.67 and 1.92, respectively.55 The second category, arrival (or operational) landing distance information, is used by pilots while en route and uses updated information, including runway conditions, weather, and planned configurations, to determine the landing distance required. Airplane landing performance data for conditions other than bare and dry are typically calculated rather than demonstrated via a flight test. Operational landing distance assessments are intended to ensure that the arrival weather and runway surface conditions and the planned airplane configuration, pilot technique, and deceleration devices will result in a safe landing distance at the arrival weight. Dispatch planning distance calculations are required and standardized by U.S. and international aviation authorities. However, U.S. Federal regulations do not require or standardize arrival landing distance assessments, nor do they specify safety margins for such assessments. Previously Issued Urgent Safety Recommendation Related to Landing 1.18.1.1  Distance Assessments As a result of this accident, on January 27, 2006, the Safety Board issued urgent Safety Recommendation A-06-16, which asked the FAA to do the following: Immediately prohibit all 14 CFR Part 121 operators from using the reverse thrust credit in landing performance calculations. The stated intent of this recommendation was to ensure adequate landing safety margins for landings on contaminated runways. The FAA responded in part by conducting an internal review of existing regulations, orders, notices, ACs, International Civil Aviation Organization (ICAO) and foreign country requirements, airplane manufacturer- developed material, independent source material, and the current practices of air carrier operators. 54  For these demonstrations, the airplane is decelerated using maximum manual braking and full spoiler deployment but no reverse thrust during the landing roll. 55  U.S.-based airplane manufacturers have not historically demonstrated landing performance on all possible runway surface conditions, including a wet/slippery runway, largely because of the difficulties involved in attaining representative and repeatable conditions during a finite flight test program.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 31 The FAA does not require landing performance calculations at the time of arrival, nor does it impose standards for these manufacturer-supplied or operator-packaged landing performance data or the use of such data. Therefore, the FAA observed numerous inconsistencies and wide variation in operators’ practices regarding airplane landing performance calculations at the time of arrival. These inconsistencies were observed in numerous related areas, including the circumstances under which the landing distance for the time of arrival was calculated; the data used for such calculations, which were either provided by the manufacturer or developed by the operator or a third-party vendor; the currency of landing distance assessment data; application of safety margins; the existence of landing distance performance information; and the application of credit for the use of thrust reversers. Landing distance performance information is available in a wide variety of informational documents and is available for a range of runway or braking action conditions using various airplane deceleration devices and settings under a variety of meteorological conditions, depending on the operator and the source. During the Safety Board’s investigation of the SWA flight 1248 accident, investigators determined that two different operators were using manufacturer-supplied landing performance data that were not the most suitable or currently available. Further, in some cases, the landing performance data presented by the operator and/ or third‑party vendor were less conservative (provided a larger stopping margin) than the manufacturer’s data for the same conditions (as was the case with SWA’s data in this accident). The operational landing performance data used to define landing limitations may be based on a wide range of assumptions, depending on the manufacturer and whether the data have been modified before presentation to pilots. Although operators practices may differ, manufacturer-provided dispatch landing performance data are typically included in an airplane flight manual, while arrival landing performance data are included in the airplane’s quick reference handbook for accessibility in the cockpit. (Both dispatch and arrival landing performance data are typically available to operators using electronic flight bags [EFB].) On June 7, 2006, the FAA published an “Announcement of Policy for Landing Performance After Departure for All Turbojet Operators,” which stated, in part, that the FAA considered a 15 percent margin as the minimum acceptable safety margin between the expected actual airplane landing distance and the available runway landing distance at the time of arrival. In a June 13, 2006, letter to the Safety Board, the FAA stated its belief that the actions described in its June 7 notice would yield a greater safety benefit than a blanket prohibition against taking credit for use of thrust reversers. The Board supported the FAA’s planned action and its timely implementation. As a result, the FAA planned to issue mandatory Operations Specification (OpSpec) N 8400.C082 to all 14 CFR Part 91 subpart K, 121, 125, and 135 turbojet operators, requiring the following: Use of an operationally representative air distance; • Use of data at least as conservative as the manufacturer’s data; •

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 32 Use of the worst reported braking action for the runway during landing • distance assessments; and Operators’ addition of an extra margin of at least 15 percent to the landing • distance calculation.56 Further, OpSpec N 8400.C082 would require POIs to ensure that operators’ flight crew and dispatcher training programs provide information about all aspects and assumptions of actual landing distance performance determinations. The FAA intended that operators comply with OpSpec N 8400.C082 by October  2006. However, the FAA encountered considerable industry opposition to its June 7 proposal, and, on August 31, 2006, decided not to issue the mandatory OpSpec but, rather, to pursue formal rulemaking regarding these issues. In the interim, the FAA published Safety Alert for Operators (SAFO) 06012, compliance with which was voluntary. SAFO 06012 suggested that operators (1) establish procedures that require assessing the landing distance as close as practicable to the time of arrival if conditions have adversely changed since the preflight landing distance assessments, (2) apply a safety margin of at least 15 percent to the calculated airplane landing distance when such assessments are required at the time of arrival, and (3) provide information regarding all aspects of actual landing distance performance assessments in their flight crew and dispatcher training programs, among others. FAA personnel told Safety Board staff that the FAA intended to pursue formal rulemaking in the area of landing distance assessments and believed that operators would voluntarily comply with SAFO 06012 in the interim. The Safety Board is currently investigating two additional accidents involving contaminated runway overruns by air carrier airplanes. On February 18, 2007, a Shuttle America Embraer EMB-170 ran off the end of snow-contaminated runway 28 at Cleveland Hopkins International Airport in Cleveland, Ohio. This ongoing investigation has revealed that Shuttle America did not require its pilots to perform landing distance assessments based on conditions at the time of arrival.57 Additionally, on April 12, 2007, a Pinnacle Airlines Bombardier Regional Jet CL600-2B19 ran off the end of snow-covered runway 28 at Cherry Capital Airport in Traverse City, Michigan. This ongoing investigation has revealed that Pinnacle had incorporated an arrival landing distance assessment 56  The FAA-advocated minimum safety margin of 15 percent was established based on historic links to the FAA-mandated additional 15 percent factor for wet/slippery dispatch requirements and the 15 percent factor embedded in the European Aviation Safety Agency and the European Joint Aviation Authorities’ operational requirements for landing on a contaminated runway. 57  More information on this accident, CHI07MA072, is available on the Safety Board’s Web site at .

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 33 requirement consistent with SAFO 06012;58 however, the accident flight crew in this case did not perform an arrival landing distance assessment.59 In a May 8, 2007, response regarding Safety Recommendation A-06-16, the Safety Board stated, “A year after this urgent recommendation was issued, the FAA has not yet taken any effective action in response to it.” The Board cited FAA-issued guidance advising the use of a 15 percent safety factor in landing distance assessments but noted that the FAA was unable to say how many Part 121 operators had adopted that guidance. In its letter, the Board classified Safety Recommendation A-06-16, “Open—Unacceptable Response.” Landing Distance Assessment Technical Bulletin 1.18.1.2  In January 2007, Safety Board staff attended a meeting with FAA, Boeing, SWA, and SWA Pilots Association (SWAPA) personnel at which the history and practices related to landing distance assessments at the time of arrival were discussed. Figure 6 shows a related draft winter operations guide that was developed by an industry group. SWA is currently incorporating the information contained in this guide, which it plans to incorporate in October 2007, and Boeing attached similar guidance to a bulletin, dated August 23, 2007, that was issued to all operators of Boeing turbojet airplanes.60 The Boeing guidance recommends that operators develop arrival landing distance assessment procedures for their flight crews to use to ensure that a full‑stop landing can be made on the arrival runway in the conditions (weather and runway) existing at the time of arrival and with the deceleration means and airplane configuration to be used. The Boeing guidance also recommends that the landing distance assessment use the most adverse braking condition in the landing distance assessment and that an additional safety margin be applied to the resultant landing distance. 58  If requested by an operator, the FAA may approve another OpSpec, which would require that operator to conduct arrival landing distance assessments and include a minimum 15 percent safety margin for every landing. As a result of Pinnacle’s request, the FAA issued an OpSpec. Pinnacle’s resultant documentation states, “When landing on a contaminated runway, the landing runway must have a minimum safety margin of 15 percent available length beyond the calculated landing distance. The landing distance must take into account the actual runway conditions existing at the time of arrival, the expected deceleration means, and aircraft configuration to be used. If the safety margin is not available, the pilot should not land the aircraft, absent an emergency. This will be considered the minimum acceptable safety margin. These requirements are separate from the regulatory landing distance calculations required by FAR [Federal Aviation Regulation] 121.195 for dispatch, and are only necessary when a contaminated landing runway is expected.” 59  More information on this accident, DCA07FA037, is available on the Safety Board’s Web site at . 60  Boeing plans to issue similar guidance to all operators of Douglas airplanes in October 2007.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 34 Draft winter operations guide that was developed by an industry group. Figure 6.  he ai

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 35 Contaminated Runway and Landing Information 1.18.2  Runway Surface Condition Reports 1.18.2.1  Three methods typically used to describe a runway’s surface condition are: 1) runway contaminant type and depth observations, 2) ground surface vehicle friction measurements,61 and 3) pilot braking action reports. Safety Board public hearing testimony indicated that, regardless of the method used, the reported runway surface conditions may differ from the actual runway surface conditions encountered by a landing flight. In SAFO 06012, the FAA stated that joint industry and international government tests have not established a reliable correlation between any of these runway surface condition description methods and an airplane’s braking ability. In part, the FAA attributed this to the fact that runway surface conditions can change significantly in very short periods of time, depending on precipitation, accumulation, usage, temperature, direct sunlight, and runway maintenance/treatment. Runway contaminant type and depth reports may also be adversely affected by the observer’s vantage point and/or a lack of uniformity of contaminants across the runway’s surface. The FAA also stated that operators should not base their landing distance calculations solely on ground surface vehicle runway friction measurements because extensive testing did not indicate that “a repeatable correlation exists through the full spectrum of runway contaminant conditions.”62 Further, pilot braking action reports are subjective, reflecting individual pilot expectations, perceptions, and experiences, and are sensitive to airplane type and the actual deceleration methods used to slow or stop the airplane. Mixed pilot braking action reports (for example, fair for the first half of the runway and poor for the second half), and conflicting braking action reports from different sources (for example, an air carrier pilot, a general aviation pilot, or a ground vehicle) can also make the interpretation and use of such reports more difficult. The FAA acknowledges that braking action reports are subjective and advises pilots to consider all available information and make landing decisions based on the most restrictive reports, the pilots’ experience, and sound judgment. Correlation Between Runway Surface Condition and Airplane 1.18.2.2  Braking Ability During its investigation of this accident, the Safety Board noted that different methods and terminologies were used throughout the aviation industry to define the relationship between runway surface condition and an airplane’s braking ability (also 61  Runway contaminant type and depth observations and ground surface vehicle friction measurements are provided by airport operations personnel and may be broadcast in an ATIS message. According to AC 150/5200-30A, “Airport Winter Safety and Operations,” the FAA considers two types of friction testers— the decelerometer (DEC) and the continuous friction measurement equipment (CFME)—to be “generally… reliable” when the runway surface is contaminated by ice (or wet ice) or compacted snow. (MDW uses both DEC and CFME friction testers.) AC 150/5200-30A also states that friction tests “…will be reliable as long as the depth of dry snow does not exceed 1 inch and the depth of wet snow or slush does not exceed 1/8 inch.” 62  Variability in equipment design and calibration is also an issue with ground surface vehicle friction measurements.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 36 termed “airplane braking coefficient” in this report). For example, the European Aviation Safety Agency (EASA) and Joint Aviation Authorities (JAA) state that a correlation between contaminant type and depth and the effective braking ability of an antiskid-controlled braked wheel “may be used to [calculate airplane landing performance conservatively] in the absence of any direct test evidence.” Both Boeing and SWA calculate operational airplane landing performance based on correlations between airplane braking ability and braking action reports.63 Transport Canada provides guidance that can be used to correlate ground surface vehicle friction survey measurements to airplane performance on certain winter-contaminant surfaces in the form of Canadian Runway Friction Index (CRFI) tables in its Aeronautical Information Manual.64 Existing FAA guidance on runway surface condition reporting, contained in AC  91‑6A, “Water, Slush, and Snow on the Runway,” dated May 24, 1978, does not correlate runway braking action and an airplane’s braking ability. In August 1989, the FAA issued a draft AC (91-6B), “Performance Information for Operation with Water, Slush, Snow, or Ice on the Runway,” that proposed that such a correlation be used “if the braking performance is based on analysis rather than tests.” However, the draft AC was never published, and the guidance contained in AC 91-6A remains in effect. The FAA allows airplane manufacturers and operators (like Boeing and SWA) to define custom braking action/airplane braking ability correlations. SAFO 06012 advocates the use of a specific correlation between reported braking action and runway contaminant type and depth to predict turbojet landing performance when manufacturer- supplied wet or contaminated runway landing distance data are unavailable. In addition, SAFO 06012 stated, “The FAA considers the data developed for showing compliance with the European contaminated runway certification…to be acceptable for making landing distance assessments for contaminated runways at the time of arrival.” ICAO published yet another method used to define the relationship between runway surface condition and an airplane’s estimated braking action. This correlation of the measured runway braking action (MU reading) to estimated braking action is shown in table 4. Correlation of the measured runway braking action to estimated braking action. Table 4.  Measured Runway Braking Action (MU Reading) Estimated Braking Action 0.40 and above Good 0.39 to 0.36 Medium to good 0.35 to 0.30 Medium 0.29 to 0.26 Medium to poor 0.25 and below Poor 63  Although both are based on correlations between airplane braking ability and braking action reports, Boeing and SWA correlations differ in the numeric values and the braking action report terminology used. 64  For additional information, see section 1.18.2.2.1.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 37 Canadian Runway Friction Index 1.18.2.2.1  A detailed method of measuring and reporting friction on contaminated runways to determine landing distances has been in use in Canada for about 30 years. Runway friction values obtained from decelerometers (DEC) are reported as CRFI values and are included in surface condition reports and notices to airmen. The information contained in the CRFI tables is based on field test performance data of airplanes braking on winter‑contaminated surfaces and provides recommended landing distances based on the CRFI values. Figure 7 shows the CRFI values for various runway surface conditions, highlighting the CRFI values for loose snow 3 millimeters (mm) deep or less on pavement, which ranged from 0.16 to 0.76. CRFI values for various runway surface conditions. Note that the CRFI values for loose Figure 7.  snow 3 mm deep or less on pavement ranged from 0.16 to 0.76 (see the bold horizontal line). International Runway Friction Index 1.18.2.2.2  In January 1996, the Joint Winter Runway Friction Measurement Program (JWRFMP), consisting of a group of representatives from international organizations,65 convened to do the following: Study methods of friction measurement and define an International Runway • Friction Index (IRFI) for worldwide use; 65  Thirty international organizations from 12 countries, including the United States, Canada, Japan, Norway, France, Austria, Germany, Scotland, Sweden, and Switzerland, participated in this program.

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 38 Establish an international methodology whereby a common indication of • runway conditions could be established worldwide; and Study the operational performance of aircraft on contaminated surfaces and • establish a relationship with the harmonized IRFI. In contrast to the CRFI, which used only DECs in measuring friction values, the IRFI was designed to use readings from a variety of friction testing devices (DEC and continuous friction measurement equipment [CFME] from multiple manufacturers). The results of this study were incorporated into American Society for Testing and Materials report 2100-02, “Standard Practice for Calculating the International Runway Friction Index,” which prescribed methods for calculating the IRFI for winter surfaces and produced a harmonized scale for expressing pavement friction characteristics, regardless of the friction measurement equipment used. The IRFI obtained by using this practice has not been extended to address the braking performance of an aircraft; therefore, no tables of recommended landing distances based on the IRFI exist at this time. Several FAA publications66 indicate that the FAA does not believe that it is possible to predict aircraft braking performance from MU values obtained from runway friction surveys. Further, according to the FAA’s Aeronautical Information Manual, “no correlation has been established between MU values and the descriptive terms ‘good,’ ‘fair,’ ‘poor,’ and ‘nil’ used in braking action reports.” Previous Contaminated Runway-Related Safety Recommendations 1.18.2.3  In 1982, the Safety Board conducted a special investigation to examine commercial airplane operations on contaminated runways.67 As a result of this investigation, the Board issued several contaminated runway-related safety recommendations to the FAA. Safety Recommendation A-82-152 asked that the FAA do the following: Amend 14 CFR 139.31 and … 139.33 to require that airports certified under 14 CFR Part 139 and located in areas subject to snow or freezing precipitation have an adequate snow removal plan, which includes criteria for closing, inspecting, and clearing contaminated runways following receipt of “poor” or “nil” braking action reports and to define the maximum snow or slush depth permissible for continued flight operations. On November 18, 1987, the FAA issued Amendment 139-14 to Part 139, requiring snow and ice control plans in ACMs at airports where snow and icing conditions regularly occur. As a result of this action, the Safety Board classified Safety Recommendation A-82‑152 “Closed—Acceptable Action.” 66  These FAA publications include AC 150/5200-31A, CertAlert 95-06, CertAlert 05-01, and the FAA’s Aeronautical Information Manual. 67  National Transportation Safety Board, Large Airplane Operations on Contaminated Runways, Special Investigation Report NTSB/SIR-83/02 (Washington, DC: NTSB, 1983).

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 39 Safety Recommendation A-82-155 asked that the FAA do the following: Convene an industry-government group to develop standardized criteria for pilot braking assessments and guidance for pilot braking action reports for incorporation into pilot training programs and operations manuals. The FAA formed the Joint Aviation/Industry Landing and Takeoff Performance task group to review this recommendation, among others. The task group included representatives from Aerospace Industries Association, Air Line Pilots Association, Air Transport Association of America, Flight Safety Foundation, Inc., National Air Carrier Association, Inc., and the Regional Airline Association. However, because the FAA provided no evidence of progress in this area after 4 years, the Safety Board classified Safety Recommendation A-82-155 “Closed—Unacceptable Action.” Safety Recommendation A-82-168 asked that the FAA do the following: In coordination with the National Aeronautics and Space Administration [NASA], expand the current research program to evaluate runway friction measuring devices which correlate friction measurements with airplane stopping performance to examine the use of airplane systems such as antiskid brake and inertial navigation systems to calculate and display in the cockpit measurements of actual effective braking coefficients attained. In a response letter dated April 1, 1983, the FAA indicated that it was working with NASA to form a runway braking action test program. In a January 1984 letter, the FAA indicated that it was involved with NASA in efforts to develop a method for obtaining runway braking condition information with a more quantitative basis than subjective pilot reports. However, in a May 5, 1987, letter, the FAA expressed concern that such a system would encourage operations from a runway with a very low friction coefficient and, further, that it would be of little value because of the differences in braking performance between dissimilar aircraft models. In response, the Safety Board stated that it did not believe that the FAA and NASA had conducted sufficient research to conclude that objective measurements taken from dissimilar airplanes would not be meaningful and that “such reports would be very useful to airport operators as a means of detecting the degradation of runway conditions in winter weather and would provide a basis upon which the pilots of large airplanes could make better decisions.” Therefore, in April 1988, the Board classified Safety Recommendation A-82-168 “Closed—Unacceptable Action.” As a result of the December 20, 1995, accident involving a Tower Air 747 at John F. Kennedy International Airport,68 the Safety Board issued Safety Recommendation A‑96‑164, which asked that the FAA do the following: 68  National Transportation Safety Board, Runway Departure During Attempted Takeoff, Tower Air Flight 41, Boeing 747-136, N605FF, JFK International Airport, December 20, 1995. Aircraft Accident Report NTSB/AAR-96-04 (Washington, DC: NTSB, 1996).

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 40 Require the appropriate Aviation Rulemaking and Advisory Committee to establish runway friction measurements that are operationally meaningful to pilots and air carriers for their slippery runway operations (including a table correlating friction values measured by various types of industry equipment), and minimum coefficient of friction levels for specific airplane types below which airplane operations will be suspended. In its response, the FAA stated that it did not consider it technologically feasible to establish runway friction measurements that were operationally meaningful to pilots and air carriers for slippery runway operations. The FAA noted its participation in the JWRFMP, which had a goal of developing the IRFI and correlating it with airplane stopping capability. However, the FAA maintained that there were serious shortcomings in several operationally significant aspects of the IRFI standard, in addition to the historical record of failures attempting to correlate ground friction measurements with airplane performance. The FAA did not expect any new developments related to this recommendation. In June 2002, the Safety Board responded that, although the FAA’s effort to develop an operationally meaningful runway friction measurement tool was unsuccessful, it did result in the development of an international standard for determining a runway friction index. The Board also stated that proposed testing might yield more meaningful tools and encouraged the FAA to continue its efforts in this area. However, the Board acknowledged that the technology to convert the runway friction index into an operational tool did not exist at the time and, therefore, classified Safety Recommendation A-96-164 “Closed— Reconsidered.” As a result of the June 1, 1999, accident involving an American Airlines MD-82 at Little Rock National Airport in Little Rock, Arkansas,69 the Safety Board issued Safety Recommendation A-01-54, which asked that the FAA do the following: For all 14 CFR Part 121 and 135 operators, require the use of automatic brakes, if available and operative, for landings during wet, slippery, or high crosswind conditions, and verify that these operators include this procedure in their flight manuals, checklists, and training programs. On June 21, 2004, the FAA issued a notice (N8400.68) to its POIs, recommending the use of autobrakes for landings in adverse conditions caused by weather and directing POIs to convey the information in N8400.68 to their respective certificate holders. Because issuance of this notice met the intent of the recommendation, the Safety Board classified Safety Recommendation A-01-54 “Closed—Acceptable Alternate Action.” According to SWA representatives, the company’s efforts to equip its airplanes with autobrakes and develop and implement related procedures stemmed, in part, from these actions. 69  National Transportation Safety Board, Runway Overrun During Landing, American Airlines Flight 1420, McDonnell Douglas MD-82, N215AA, Little Rock, Arkansas, June 1, 1999. Aircraft Accident Report NTSB/ AAR-01-02 (Washington, DC: NTSB, 2001).

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 41 Previous Runway Safety Area Safety Recommendations 1.18.3  As a result of its investigation of the May 6, 2003, accident involving a Southwest Airlines airplane that overran the end of the runway after landing at Burbank, California,70 the Safety Board issued Safety Recommendations A-03-11 and -12, which addressed RSAs and asked that the FAA do the following: Require all 14 Code of Federal Regulations Part 139 certificated airports to upgrade all runway safety areas that could, with feasible improvements, be made to meet the minimum standards established by Advisory Circular  150/5300-13. These upgrades should be made proactively, not only as part of other runway improvement projects. (A-03-11) Require all 14 Code of Federal Regulations Part 139 certificated airports to install engineered materials arresting systems in each runway safety area available for air carrier use that could not, with feasible improvements, be made to meet the minimum standards established by Advisory Circular 150/5300‑13, “Airport Design.” The systems should be installed proactively, not only as part of other runway improvement projects. (A-03‑12) In an August 7, 2003, letter, the FAA indicated that it agreed with the intent of these recommendations and stated that FAA Order 5200.8, “Runway Safety Area Program,” established a program to bring all RSAs up to current standards, whenever possible. The letter stated that the FAA’s goal was to upgrade 456 RSAs by 2007 and that such improvements “may be initiated at any time.” The FAA stated that its goal was to upgrade at least 65 RSAs per year through 2007 and that 71, 68, and 74 RSAs were upgraded in fiscal years 2000, 2001, and 2002, respectively. The FAA also noted that eight EMAS beds had already been installed and that several more installations were planned. The Board asked the FAA to provide annual updates on RSAs that could not meet the standards and the specific alternatives that would be used to improve the safety of these RSAs. The issue of RSA improvements was discussed at the Safety Board’s June 2006 public hearing that was held for the accident involving SWA flight 1248. In response to questioning during this hearing, FAA personnel indicated that, under current FAA policy, it is possible that some RSAs will not meet the dimensional standards or have arrester beds installed even after the FAA considers its improvement projects successfully completed. In a July 7, 2006, letter, the FAA indicated that 208 RSA upgrades and 15 EMAS installations had been completed though fiscal year 2005. The letter further stated that more than 90 percent of the RSA upgrades would be completed by 2010, and all RSA 70  For additional information, see National Transportation Safety Board, Aircraft Accident Brief NTSB/ AAB-02/04 (Washington, DC: NTSB, 2002).

Factual Information National Transportation Safety Board A I R C R A F T Accident Report 42 upgrades would be completed by 2015. A recent update from FAA personnel indicated that 303 RSA improvement projects were completed. The update further indicated that 37 RSA upgrades and 5 EMAS installations were completed in fiscal year 2006 and that 20 RSA upgrades and 1 EMAS installation had been accomplished to date in fiscal year 2007. Safety Recommendations A-03-11 and -12 are currently classified “Open—Acceptable Response.”

National Transportation Safety Board A I R C R A F T Accident Report 43 Analysis

General 2.1  The pilots were properly certificated and qualified under Federal regulations. No evidence indicated any medical or behavioral conditions that might have adversely affected their performance during the accident flight. There was no evidence of flight crew fatigue. The accident airplane was properly certificated and was equipped, maintained, and dispatched in accordance with industry practices. No evidence indicated any failure of the airplane’s powerplants, structures, or systems that would have affected the airplane’s performance during the accident landing.71 The pilots received thorough weather information for MDW and two alternate airport destinations in their dispatch documents and were well aware of the winter weather conditions in the area. They obtained numerous weather updates while en route from BWI to MDW and discussed conditions under which they would divert to one of the alternate destinations. Therefore, the Safety Board concludes that the pilots had adequate initial and updated weather information throughout the flight. About 10 inches of snow accumulated at MDW on the day of the accident, and snow was falling at a moderate rate at the time of the accident. However, the accident runway had been recently cleared and treated with deice fluid, and four other SWA 737- 700 airplanes landed and successfully stopped on runway 31C in the 21 minutes before the accident.72 On the basis of this information, the Safety Board concludes that MDW personnel monitored runway conditions and provided appropriate snow removal services on the night of the accident. This analysis will discuss the flight crew’s decisions and actions, the clarity of assumptions used in OPCs, company policies and guidance, arrival landing distance assessments and safety margins, runway surface condition assessments and braking action reports, airplane-based friction measurements, and RSAs. 71  Section 2.2.3 discusses the thrust reverser operation. 72  The pilots of another SWA flight, which would have arrived at MDW minutes before the accident flight, elected to divert to an alternate airport because of airplane landing weight considerations.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 44 Pilots’ Decision to Land, Knowledge, and Actions 2.2  During its investigation, the Safety Board evaluated the pilots’ decision to land at MDW and their actions during the approach and landing. Section 2.2.1 details the pilots’ use of braking action reports, which included mixed braking actions, during their arrival landing distance assessments. Section 2.2.2 discusses the information displayed by the OPC during the arrival landing distance assessment and the pilots’ awareness of the underlying OPC assumptions. Section 2.2.3 explains the pilots’ use of autobrakes and reverse thrust during the accident landing. Integral to these issues is the pilots’ awareness of SWA guidance and policies relevant to their decision and actions during the accident landing. These issues are addressed in this and subsequent sections. Interpretation and Use of Mixed Braking Action Reports 2.2.1  As previously noted, the accident pilots were aware of the inclement weather in the Chicago area before they left BWI and obtained updated weather information throughout the flight. The Safety Board’s review of recorded CVR information indicated that weather, landing performance assessments, landing criteria (including autobrake usage), and suitable alternates dominated the crew’s conversation during the 2-hour flight. Although not required by FAA regulations, SWA policies required the company’s pilots to perform a landing distance calculation before the approach, using updated weather, airplane configuration,73 and runway conditions. On the basis of the most current ATIS report for MDW, the accident pilots evaluated and discussed performance calculations for both fair and poor reported braking conditions. Although the pilots’ calculations resulted in positive stopping margins for both fair and poor braking conditions (560 and 40 feet, respectively), and company policy indicated that landing was authorized with any positive stopping margin, the crew was concerned about the small positive stopping margin with poor braking action. Information from the CVR and postaccident interviews indicates that the pilots were also aware of a company policy for a maximum 5-knot tailwind component with a reported braking action of poor. Updated wind information resulted in a landing tailwind component of 8 knots. The pilots verbalized the decision not to land if the braking action was reported as poor for the full length of the runway. As the airplane neared MDW, air traffic controllers provided the accident pilots with mixed runway 31C braking action reports. These reports indicated that the braking action was good or fair for the first half of runway 31C and poor for the second half. (The Safety Board notes that the accident flight was cleared for the approach to runway 31C because approach visibility requirements precluded approaches to all other MDW runways on the night of the accident.) However, the MDW controller did not routinely follow FAA procedures requiring controllers to include the type of airplane from which the braking action reports were made; in this case, the reports were provided by the pilots of several arriving 737s. Further, the controller did not provide the accident pilots with a report obtained from the pilot of a smaller airplane that described the braking action as 73  For example, although the dispatch calculations were based on 30° of flaps, the actual configuration at the time of landing was 40° of flaps.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 45 poor, as required. Therefore, the Safety Board concludes that the MDW ATCT controller did not follow FAA guidance when he did not provide all of the required braking action report information.74 All of the braking action reports provided by ATC to the accident pilots were mixed and reported poor braking action on some portion of the runway. For example, 8 to 9 minutes before touchdown, the pilots received a braking action report of “fair…except at the end it’s poor,” and 3 minutes before touchdown they received a braking action report of “good for the first half, poor for the second half.” SWA policy requires pilots to defer to the more critical braking action assessment when they receive mixed braking action reports. Therefore, because “poor” braking conditions were reported for a portion of the runway and SWA guidance indicates a maximum 5-knot tailwind to land if such conditions are reported, the pilots should not have landed at MDW. The Safety Board concludes that because the pilots did not use the more critical braking action term (poor) during their landing distance assessment (which, combined with the associated tailwind limitation, would have required them to divert), they were not in compliance with SWA’s policies. The pilots did not discuss interpretation of mixed runway condition reports, although their behavior and other discussion suggests that they interpreted the runway condition as closer to fair than poor. They stated during postaccident interviews (and CVR evidence indicates) that they were not aware of SWA’s guidance regarding mixed braking action reports. On the day of the accident, three preceding company aircraft (same make, model, policies, and procedures) landed with braking action reports containing the term poor and with similar wind conditions. Based on this and information obtained from postaccident interviews, it appears that other SWA pilots also were not aware of the mixed braking action report guidance in the FOM or did not adhere to it. The fact that other SWA pilots decided to land at MDW in these conditions likely influenced the accident pilots’ decision to land; the accident pilots were less likely to consider their decision to land as contrary to company guidance if other SWA crews landed in similar conditions. SWA guidance regarding how to provide a braking action report includes an example of a mixed condition report, indicating that mixed conditions were not unexpected during routine operations. However, the Safety Board’s review of SWA training materials revealed that the topic of mixed conditions was not routinely introduced to pilots during training and was absent in the FOM for the topics of braking action and runway friction reports, entering runway condition into the OPC, and programming the OPC for landing, all of which defined the runway condition categories. The Safety Board notes that, after this accident, SWA amended the wording in its FOM to clarify its policy regarding mixed braking action reports and provided its pilots with additional training specific to braking action reports, including mixed conditions. 74  The influence this information would have had on the pilots’ decision to land is unknown, although it is unlikely that it would have led them to divert. SWA guidance specifies that its pilots should use braking action information provided by “other commercial airplanes (emphasis added).” Also, the accident pilots were aware that several of the airplanes preceding them to MDW, and from which braking action reports were obtained, were commercial airplanes (including several SWA 737s).

Analysis National Transportation Safety Board A I R C R A F T Accident Report 46 On Board Performance Computer Displays and Underlying 2.2.2  Assumptions The Safety Board evaluated the clarity of the information displayed to the pilots on the SWA OPC and the underlying assumptions (including reverse thrust credit) upon which the resultant landing distance assessments were based. Pilots use a variety of aids to accomplish airplane performance calculations, including tabular performance charts. The information on tabular charts is designed to be clear and readily available;75 however, pilots must survey rows and columns and select the most appropriate value, apply required adjustments, and sometimes interpolate between listed values. SWA provides its pilots with an OPC for such calculations. Using an OPC or similar electronic computing device instead of tabular charts can decrease the pilots’ workload because the computing device can automatically apply adjustments and interpolate based on the operator’s programming. However, if pilots misunderstand the output because they are unaware of critical performance calculation assumptions, use of an electronic computing device can lead to errors in decision-making. For example, as the accident pilots neared MDW, they used the OPC to calculate the airplane’s landing distance multiple times, assessing updated weather conditions and stopping margins on runway 31C under both fair and poor braking action conditions. All of the resultant OPC calculations indicated that they could land and stop the airplane in the available runway length. The OPC indicated a stopping margin of about 560 feet before the end of the runway for fair braking action and about 40 feet before the end of the runway for poor braking action. However, evidence indicates that the landing distances displayed on the OPC could have been misleading to the crew because the pilots were not aware of at least two underlying OPC assumptions, neither of which was displayed on the OPC. Both of these assumptions resulted in OPC indications showing larger (more favorable) stopping margins. One OPC assumption that the accident pilots were not aware of was that stopping margins displayed by the OPC for poor runway conditions were in some cases based on a lower tailwind component than that which was presented. Typically, the stopping margin output corresponded to the presented tailwind component. However, the tailwind component exceeded the 5-knot limit for poor runway conditions, but the displayed stopping margin was instead based on the tailwind limit of 5 knots, not the actual 8-knot tailwind component, as entered by the flight crew. Although in these cases the actual tailwind component is highlighted with white text on a red background, and the tailwind component limits are presented at the bottom of the display in white text on a black background, there is no indication that the stopping margin is not based on the presented tailwind component. 75  Tabular charts present critical information and assumptions through notations either directly on the applicable chart or on an introductory overview page.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 47 For the accident landing, the OPC-calculated stopping margin of 40 feet for poor runway braking action was based on the company-programmed 5-knot tailwind component limit, despite the fact that the display showed the actual 8-knot tailwind component based on the winds input by the pilots. Calculations based on the 5-knot tailwind limit resulted in more favorable displayed stopping margins. If the OPC calculations had been based on the actual 8-knot tailwind component, the stopping margin would have been -260 feet (or 260 feet beyond the departure end of the runway), indicating that there was not enough runway available to land with poor braking action. This information would have provided the pilots with a more conservative and realistic indication of the expected landing performance. To highlight negative stopping margin values and to alert pilots that it is not safe to land on a particular runway, SWA’s OPC uses alternate graphics and the color red on the display.76 CVR and postaccident interview evidence indicated that both pilots were uncomfortable with the low positive stopping margins exhibited by the OPC. Had a negative stopping margin been shown and highlighted on the OPC display, the pilots would have been further alerted to the potential hazards involved in a landing on runway 31C at MDW under the accident conditions. The accident pilots were also not aware that the 737 stopping margins computed by the SWA OPC were designed to incorporate the use of reverse thrust for the 737-700 model only,77 which resulted in more favorable stopping margins. Postaccident interviews with SWA pilots indicated that some (including the accident crew) assumed that none of the 737 OPC landing distance calculations took into account the use of reverse thrust. Because of this, the accident pilots believed that their intended use of reverse thrust during the landing roll would provide them with several hundred feet more stopping margin than the OPC estimated. A review of SWA guidance and training regarding the OPC revealed one reference regarding wind calculation assumptions in the FRM. However, no related information was provided in the FOM, and no slides were devoted to this topic during initial, recurrent, or OPC-related ground training. This review also revealed that although pilots were taught that thrust reverser use was assumed for the -700 and not for the -300 or ‑500 models during “differences” training when qualifying for the -700 model, SWA’s FOM guidance on OPC assumptions regarding the use of reverse thrust was inconsistent and may have been misleading to pilots. Until 1 week before the accident, information was incorrect in two of three locations in the FOM, stating that reverse thrust was not included in the landing distance calculations.78 Interviews with SWA pilots indicated that they were not uniformly aware of this and other landing distance assumptions, such as air distance.79 76  Negative values are presented in brackets as white digits inside of a red block instead of the standard black digits against a white background. 77  SWA pilots were type-rated in one of three 737 models owned by SWA (-300/-500/-700), but were expected to fly all three 737 models. Therefore, they had to be aware of differences between the models, as they switched between these models on a day-by-day or flight-by-flight basis. 78  At the time of the accident, the information was correct in two of the three FOM locations. 79  Air distance is the distance allowance from the threshold crossing point at 50 feet agl to the estimated touchdown point, upon which the landing performance calculations are based.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 48 Therefore, the Safety Board concludes that if the pilots had been presented with stopping margins associated with the input winds or had known that the stopping margins calculated by the OPC for the 737-700 already assumed credit for the use of thrust reversers, the pilots may have elected to divert. Another OPC-programming factor observed by the Safety Board is that the airplane performance data programmed into the OPC by SWA was less conservative than the airplane performance data recommended by Boeing for braking action reports worse than good; this resulted in more favorable displayed stopping margins. Calculations performed using the Boeing-recommended data for a landing on runway 31C and the actual tailwind component of 8 knots showed that the airplane would require a longer landing distance than available under both fair and poor braking action conditions (an additional 260 and 2,070 feet beyond the departure end of the runway, respectively).80 The Safety Board concludes that if Boeing’s recommended airplane performance data were used in SWA’s OPC calculations, the resulting negative stopping margins for even fair braking action conditions would have required the pilots to divert. After this accident, SWA redesigned its arrival landing distance performance calculations to consistently reflect the assumption of two-engine reverse thrust and revised its OPC display to show the reverse thrust level assumed based on the conditions. Additionally, SWA modified its OPC display to consistently present output associated with the actual tailwind component. When the tailwind component exceeds authorized limits for landing (5 knots for poor braking action, 10 knots for good or fair braking action) a numeric stopping margin value is not presented. Finally, SWA amended its FOM guidance and policies regarding OPC reverse thrust assumptions to ensure consistency and to clarify the assumption of reverse thrust use across all 737 models. In response to this accident, the FAA issued SAFO 06012 to all turbojet operators, encouraging them to require pilots to perform arrival landing assessments if the weather conditions, runway, or airplane landing configuration has changed since the dispatch calculation and to train pilots regarding all aspects and assumptions used in these assessments. However, the Safety Board notes that operators are not required to comply with FAA guidance material such as this SAFO.81 FAA advisory material regarding electronic flight performance calculations82 suggests that the output be displayed in a manner that is understood easily and accurately and that users of such devices should be aware of any assumptions upon which the flight performance calculations are based. There is no specific guidance suggesting that these assumptions be as clear to pilots as similar information would be on a tabular chart, however. Such clarity is critical because airplane performance data and related OPC assumptions are not consistent across manufacturers, airplane models, or operators 80  As previously mentioned, SWA’s OPC display would have alerted the pilots to these negative stopping margin values by presenting the numbers as bracketed white digits inside a red block instead of the standard black digits against a white background. 81  Although not required by the FAA, SWA did require its pilots to conduct arrival landing distance assessments at the time of the accident. 82  There are currently no requirements for the design and certification of airplane OPCs; all current guidance is advisory in nature.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 49 and may be based on information other than what the pilots entered. In the case of the accident flight, the SWA OPC screen did not display OPC assumptions (for example, the thrust reverser credit assumptions) when they were applicable; this information would have been readily available on a tabular chart. Therefore, the Safety Board concludes that presentation of the OPC assumptions upon which landing distance calculations are based is critical to a pilot’s decision to land. Therefore, the Safety Board believes that the FAA should require all 14 CFR Part 121 and 135 operators to ensure that all on board electronic computing devices they use automatically and clearly display critical performance calculation assumptions. As a result of its evaluation of the accident pilots’ decision to land and their actions during the approach and landing, the Safety Board determined that if the pilots had been aware of existing company guidance and policies in several areas, including runway braking action reports and the underlying assumptions factored into OPC stopping margin calculations, they would have made a better-informed landing decision. Accident evidence indicated that other SWA pilots were similarly unaware of SWA’s guidance and policies in these areas. Therefore, the Safety Board concludes that SWA did not provide its pilots with clear and consistent guidance and training regarding company policies and procedures in several areas, including interpretation of braking action reports and the assumptions affecting landing distance assessments. Therefore, the Safety Board believes that the FAA should require all 14 CFR Part 121 and 135 operators to provide clear guidance and training to pilots and dispatchers regarding company policy on surface condition and braking action reports and the assumptions affecting landing distance/stopping margin calculations, to include use of airplane ground deceleration devices, wind conditions and limits, air distance, and safety margins. Thrust Reverser Usage and Autobrakes 2.2.3  According to SWA procedures, the flying pilot was required to deploy the thrust reversers as soon as possible after nosewheel touchdown for all landings. SWA guidance especially emphasized immediate deployment of reverse thrust when braking actions were reported to be less than good. The accident pilots reported that they were aware of the company’s reverse thrust policies and routinely carried them out; however, for the accident landing, the captain (the flying pilot) did not deploy reverse thrust immediately after the airplane touched down. During postaccident interviews, the captain stated that he tried to deploy the thrust reversers promptly after touchdown but was not successful. SWA procedures also required the monitoring pilot to be attentive for procedural deviations during all landings. The first officer stated that, when he realized that the captain had not deployed the thrust reversers, he moved the thrust levers to command reverse thrust (thrust reverser activation was initiated about 15 seconds after touchdown according to FDR data). FDR data indicated that the thrust reversers were eventually fully deployed about 18 seconds after touchdown, and the pilots held maximum reverse thrust until the airplane came to a stop off the end of the runway. The Safety Board’s review of FDR data from four SWA 737s that landed and came to a stop on runway 31C at MDW during the 21 minutes before the accident indicated

Analysis National Transportation Safety Board A I R C R A F T Accident Report 50 that reverse thrust on these airplanes was deployed promptly after landing. Postaccident calculations showed that, if the pilots had promptly initiated and maintained maximum reverse thrust throughout the landing roll, the airplane would not have run off the end of the runway. Therefore, the Safety Board concludes that the pilots would have been able to stop the airplane on the runway if they had commanded maximum reverse thrust promptly after touchdown and maintained maximum reverse thrust to a full stop. Despite the captain’s reported difficulties in his initial attempt to deploy the thrust reversers, they extended normally in a coordinated manner for the first officer. The captain’s seat position was the same as he routinely used, and the CVR recorded no comments or utterances indicating that the pilots were having difficulty with the thrust reverser levers. Further, postaccident examination of the throttle quadrant and reverse thrust systems provided no evidence of mechanical irregularity or failure; the levers were in a position to be deployed at any time during the landing rollout. In addition, postaccident interviews with other SWA pilots indicated that most had not experienced any difficulty deploying the thrust reversers, nor had they heard of others doing so, aside from occasionally not waiting long enough at the interlock position. Any difficulties that were described by SWA pilots were reportedly resolved immediately upon second attempt.83 Finally, the pilots who had flown the accident airplane for the 10 flights before the accident reported experiencing no difficulties in deploying the thrust reversers in that airplane. Therefore, the Safety Board concludes that the pilots’ delay in deploying the thrust reversers cannot be attributed to mechanical or physical difficulties. SWA planned to implement a new policy the week after the accident that would have required the use of autobrakes during landings under some conditions, including the accident landing conditions.84 In preparation, SWA provided its pilots with a self‑study training module on the system and related procedures. Despite having completed the training module, neither of the accident pilots had previous operational experience with autobrakes. Information from the CVR indicates that although both pilots expressed concern, the captain, in particular, was hesitant to use the autobrakes for the first time in the weather and runway conditions that existed for the accident landing. The pilots discussed possible contingencies (for example, autobrake failure, loss of directional control, and reversion to manual braking). They ultimately agreed that use of the autobrakes would allow them to stop in the shortest distance and used the autobrakes on maximum setting during the accident landing. Use of autobrakes when landing on short or slippery runways required a change in the sequence of landing tasks for both the flying pilot and the monitoring pilot. Before 83  A review of ASRS data revealed no history of difficulty in deploying the thrust reversers for the Boeing 737 series airplanes. 84  In part, SWA developed this new policy because of FAA guidance resulting from a Safety Board recommendation (A-01-54). The company issued a series of autobrake-related bulletins, some of which estimated policy implementation dates. The most recent bulletin, issued by SWA the morning before the accident, indicated that required autobrake usage would begin 4 days later (on December 12); however, the accident pilots mistakenly believed that the company’s autobrakes policy was already effective the day of the accident. At the time of the accident, the cockpit checklists and the pilots’ FOM guidance had already been updated to reflect the new autobrake procedures. Had this new policy been in effect at the time of the accident, the pilots would have been required to use the maximum autobrake setting for that landing.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 51 SWA’s new autobrakes procedures took effect, procedures required the flying pilot to manually apply wheel brakes and deploy the thrust reversers simultaneously as soon as possible after touchdown. However, with the use of autobrakes, only one of these two tasks was required at touchdown; the prompt manual application of wheel brakes was no longer necessary. Research indicates that carrying out new procedures requires more effort and cognitive resources than does carrying out routine procedures and limits the number of tasks that can be carried out simultaneously.85 Because of the pilots’ concerns regarding the autobrakes and their unfamiliarity with the system’s operation, it would have been natural for them to focus on the autobrake system’s performance after the airplane touched down. During postaccident interviews, both pilots reported that they were preoccupied by the autobrake system during the accident landing. The captain reported that his focus on the autobrake system performance distracted him from trying to deploy the thrust reversers again after his first attempt was unsuccessful. The first officer had the additional task of monitoring the autobrakes light on the front instrument panel during the landing rollout, although he reported that he maintained his focus outside of the cockpit and on their stopping performance. Research also indicates that activities that have been grouped together in an automatic task sequence require substantial effort to separate.86 In this case, applying the wheel brakes would normally be accomplished with deployment of the thrust reversers, and omitting one of these linked activities (wheel brakes) could help explain omission of the other (thrust reversers). The pilots stated that, as the landing roll continued, they were not satisfied with the airplane’s deceleration, and FDR data indicated that, about 12 seconds after touchdown, they transitioned from autobrakes to maximum manual wheel braking. FDR data indicated that the thrust reversers deployment was initiated 15 seconds after touchdown, with full thrust reverser deployment occurring 18 seconds after touchdown. According to postaccident interviews with SWA personnel, similar distractions were observed in SWA pilots during the development of the company’s autobrake program. SWA check airmen and their first officers reported concern prior to use and difficulty with the transition from using autobrakes to manual braking after touchdown; some were so distracted that they delayed reverse thrust application. Pilots also indicated that these challenges persisted for the first few landings only, until they had the chance to acclimate to the new procedures. At the time of the accident, SWA’s planned implementation of its autobrakes procedures did not include a familiarization period with the use of the 85  See (a) S. Shiffrin and W. Schneider, “Controlled and Automatic Human Information Processing: II. Perceptual Learning, Automatic Attending and a General Theory,” Psychological Review, vol. 84, no. 2, pages 127-190, 1977; (b) G. Logan, “Toward an Instance Theory of Automatization,” Psychological Review, vol. 95, no. 4, pages 492-527, 1988; and (c) G. Logan and W.B. Cowan, “On the Ability to Inhibit Thought and Action: A Theory of an Act of Control,” Psychological Review, vol. 91, no. 3, pages 295-327, 1984. 86  See G. Logan, “On the Ability to Inhibit Complex Movements: A Stop-Signal Study of Typewriting,” Journal of Experimental Psychology: Human Perception and Performance, vol. 8, no. 6, pages 778-792, 1982.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 52 autobrakes,87 nor was one required by regulations.88 However, feedback from other SWA pilots should have alerted SWA management and the company’s FAA POI to the need for a familiarization or transition period. The Safety Board concludes that the pilots’ first use of the airplane’s autobrake system during a challenging landing situation led to the pilots’ distraction from the otherwise routine task of deploying the thrust reversers promptly after touchdown. Had SWA implemented an autobrake familiarization period in advance, such a period would have allowed pilots to become comfortable with the changed sequence of landing tasks. The Safety Board further concludes that the implementation of procedures requiring thrust reverser status confirmation immediately after touchdown may prevent pilots from inadvertent failure to deploy the thrust reversers after touchdown. Therefore, the Safety Board believes that the FAA should require all Part 121 and 135 operators of thrust reverser-equipped airplanes to incorporate a procedure requiring the non-flying (monitoring) pilot to check and confirm the thrust reverser status immediately after touchdown on all landings. The Safety Board notes that the timing and nature of this autobrake policy change was specific to SWA, based on its operation of a fleet of only one model airplane (the 737) and the company’s desire to implement the policy simultaneously throughout that fleet. After this accident, the company voluntarily amended its autobrake policy and training program, delaying the implementation date and requiring a familiarization period, which allowed SWA pilots to first use the autobrakes in good conditions and with large stopping margins.89 In addition, SWA provided its pilots with specific instructions that the monitoring pilot was to monitor the reverse thrust levers during the landing sequence and to make a specific callout in the event of deviation from SWA reverse thrust procedures. Landing Distance Assessments 2.3  Preflight landing distance calculations (assessments) are required by Federal regulation while arrival landing distance calculations (assessments) are not. This section discusses the differences between preflight and arrival landing distance calculations and evaluates the need for both. This section also discusses related content in the FAA’s proposed OpSpec, recent SAFO, and observed industry landing distance practices. 87  SWA had not initially planned to implement the new autobrake policy during the winter; however, delays associated with other procedures implemented simultaneously delayed the autobrake implementation date. 88  The FAA POI approved the SWA autobrakes policy in accordance with Federal regulations and guidelines. Guidance for POIs when reviewing these types of changes is general but requires the POI to consider the impact of such changes and the best training method suitable to the change. 89  Pilots were required to use autobrakes under certain conditions only after they completed at least four familiarization landings on dry runways with ample safety margins. Even under these circumstances, there were reported instances of pilot failure to immediately deploy the thrust reverse during initial landings with use of autobrakes.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 53 Preflight and Arrival Landing Distance Calculations/ 2.3.1  Assessments The FAA requires Part 121 operators to perform preflight landing distance calculations before they depart on a flight, in part, to determine the maximum takeoff weight at which the airplane can depart, travel to the destination, and safely land on the available landing distance at the destination and/or alternate airport. Although preflight landing distance assessments are standardized by Federal regulations, the assessments do not attempt to comprehensively account for the actual conditions, configuration, and pilot techniques that exist and/or occur at the time of arrival.90 The manufacturer’s flight test data upon which these calculations are based are primarily accumulated during demonstrated landings on a dry, smooth, hard-surfaced runway without the effects of reverse thrust. To account for variations in landing conditions, pilot techniques, and other operational uncertainties, the FAA requires operators to factor in a significant safety margin in excess of the demonstrated landing distance during their preflight landing distance assessments.91 The Safety Board’s review of SWA dispatch documents for the accident flight indicated that, based on preflight calculations, the accident airplane was legal to depart BWI intending to land at MDW. Arrival landing distance assessments assist pilots in ensuring that they will be able to land the airplane and safely stop on the intended runway given the arrival weather and runway surface conditions and the planned airplane configuration, landing technique, and use of deceleration devices. Like preflight landing distance calculations, arrival landing distance calculations/assessments are typically developed by an operator or contractor based on data provided by the manufacturer. However, unlike the preflight data, specific FAA approval is not required for the data used by operators in their arrival landing distance assessments because those assessments are not required. Although the FAA does not require operators to perform arrival landing distance assessments, many Part 121 operators (including SWA) do require their pilots to perform landing distance assessments before every landing. However, because the FAA does not require or standardize arrival assessments as it does preflight assessments, operators are allowed to set their own policies and use data from various sources (for example, the manufacturer, in-house personnel, an outside contractor, etc.). Depending on the source, the data used may be less conservative than the manufacturer’s data and may contain embedded assumptions related to landing and deceleration techniques, the airplane’s braking ability for a given runway surface condition report, and/or the application of additional safety margins. If pilots are unaware of these embedded assumptions, they might believe that they need less landing distance than they actually do or have an inaccurate perception of how much braking effort will be needed on landing. Depending on an operator’s policies, pilots may not be required to conduct arrival landing assessments; may conduct such assessments based on variable landing performance data sources, 90  Preflight landing distance calculations are based on conditions that are forecast for the destination at time of landing. 91  The FAA requires operators to factor safety margins of 67 and 92 percent (for dry and wet/slippery runways, respectively) into their preflight landing distance calculations.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 54 assumptions, and calculation methods; or may conduct such assessments based on data that include no additional safety margin. SWA required its pilots to perform arrival landing distance assessments for each landing and developed a system, primarily based on Boeing’s performance data, to account for actual conditions and planned procedures/techniques. However, FAA personnel did not approve the data or calculation methods developed by SWA. The resultant system used data that were less conservative than Boeing recommended for braking reports worse than good. Although SWA and FAA personnel were aware that actual arrival conditions cannot be perfectly defined, planned procedures cannot always be accomplished, and the resultant variations will not always yield a conservative safety margin, the data programmed into SWA’s OPC did not account for reasonable operational variations. This is of particular concern because SWA’s policies at the time of the accident and its new autobrake policy authorize landing with even the smallest of positive calculated stopping margins. The Safety Board notes that, although not required by the FAA, SWA’s arrival landing distance assessment practices exceeded those of many other operators; yet, the safety margin was inadequate to prevent this accident. The Safety Board notes that preflight safety margins alone may not be sufficient to ensure adequate stopping margins at arrival. This investigation has shown that an arrival landing distance assessment should be conducted before arrival and should incorporate the following six basic components: Approved aerodynamic performance data obtained from demonstrated flight • test landings; A set of defined operational procedures and assumptions (for example, • touchdown at 1,500 feet, reverse thrust deployment promptly after touchdown, etc.); Actual arrival condition data (weather, airplane configuration, runway surface • condition, etc.); A physics-based method for calculating airplane performance; • A minimum acceptable standard for correlating the airplane’s braking ability • to the runway surface condition; and A minimum acceptable safety margin/factor that accounts for reasonable • operational variations and uncertainties. At the time of the accident, SWA had incorporated the first four components into their arrival landing distance assessments and prescribed the fifth component. After the accident, SWA incorporated the sixth component by adding an additional 15 percent safety margin to account for operational variations and uncertainties into its arrival landing distance assessments.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 55 Safety Alert for Operators Discussion and Industry Practice 2.3.2  Regarding Landing Distance Assessments As previously noted, although the FAA is on record as advocating arrival landing distance assessments, there is currently no requirement, FAA-approved data, minimum correlation standards, or minimum safety margin for such assessments. As a result, operators remain free to choose whether and how they perform such assessments. As a result of the SWA flight 1248 accident, the Safety Board issued urgent Safety Recommendation A-06-16, which asked the FAA to prohibit all 14 CFR Part 121 operators from using reverse thrust credit in landing performance calculations. The stated intent of this recommendation was to ensure adequate landing safety margins on contaminated runways. In response, in June 2006, the FAA issued an advance notice of its intent to issue mandatory OpSpec N 8400.C082, which would have required all Part 121, 135, and 91 subpart K turbojet operators to conduct landing performance assessments (not necessarily a specific calculation) before every arrival based, in part, on planned touchdown point, procedures and data at least as conservative as the manufacturer’s, updated wind and runway conditions, and an additional 15 percent safety margin. However, the FAA subsequently decided not to issue the mandatory OpSpec at that time and, in August 2006, published SAFO 06012 as an interim guidance measure. SAFO 06012 addressed similar issues to the mandatory OpSpec, but operator compliance with the SAFO is, by definition, voluntary. Although the FAA published SAFO 06012 with the intent of pursuing rulemaking in the area of landing distance assessments, in the interim, operators are still not required to comply with its recommendations and, currently, many operators do not. For example, on February 18, 2007, a Shuttle America Embraer ERJ-170 ran off the end of snow-contaminated runway 28 at Cleveland Hopkins International Airport, Cleveland, Ohio.92 The investigation to date has revealed that Shuttle America did not require its pilots to perform (and therefore did not incorporate landing distance safety margins into) arrival landing distance assessments. About 2 months later, a Pinnacle Airlines Bombardier Regional Jet CL600-2B19 ran off the end of snow-covered runway 28 at Cherry Capital Airport in Traverse City, Michigan.93 By contrast, the investigation into this accident showed that Pinnacle’s OpSpecs required its pilots to perform arrival landing distance assessments (including a minimum 15 percent safety margin) per SAFO 06012;94 however, the pilots did not perform the required assessment before the accident landing. If an arrival landing distance assessment had been performed, given the existing conditions, Pinnacle’s OpSpecs would have dictated that a diversion was required. 92  This accident investigation is ongoing at the time of this writing. Additional information about this accident, CHI07MA072, is available on the Safety Board’s Web site at http://www.ntsb.gov/ntsb/query.asp. 93  More information on this accident, DCA07FA037, is available on the Safety Board’s Web site at . 94  The OpSpec developed by Pinnacle and approved by the FAA required pilots to perform arrival landing distance calculations taking into account actual runway conditions, expected deceleration means, and airplane configuration, and including a minimum safety margin of 15 percent when landing on a contaminated runway.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 56 The Safety Board is concerned that, because of operational and conditional variations, it is possible for an airplane to use more of the landing runway than preflight (dispatch) calculations predicted and for pilots to continue to run off the end of contaminated runways. During a January 2007 meeting, Safety Board, FAA, Boeing, SWA, and SWAPA personnel discussed landing distance assessment and runway surface condition issues. A subsequent Boeing document recommended that operators develop arrival landing distance assessment procedures for their flight crews to use to better ensure that a full-stop landing can be made on the arrival runway in the conditions existing at the time of arrival (weather and runway) and with the deceleration means and airplane configuration to be used, consistent with SAFO 06012. The circumstances of the flight 1248 accident (among others) demonstrate that conditions95 can change between dispatch and arrival and that there is a safety benefit to landing distance assessments at both times. The Safety Board notes that the FAA concluded in SAFO 06012 that operator compliance with preflight landing distance planning requirements alone “does not ensure that the airplane can safely land within the distance available on the runway in the conditions that exist at the time of arrival, particularly if the runway, runway surface condition, meteorological conditions, airplane configuration, airplane weight, or use of airplane ground deceleration devices is different than that used in the preflight calculation.” In addition, the FAA stated that “a landing distance assessment should be made under the conditions existing at the time of arrival in order to support a determination of whether conditions exist that may affect the safety of the flight and whether operations should be restricted or suspended.” Landing Distance Assessments Summary 2.3.3  Existing FAA regulations do not specify either the type of arrival landing distance assessment that should be performed or specify a safety margin that should be applied. The FAA-advocated minimum safety margin of 15 percent for arrival landing distance assessments published in SAFO 06012 is based on historic links to the FAA-mandated additional 15 percent factor for wet/slippery preflight planning requirements and the 15  percent factor embedded in the EASA and JAA operational requirements for contaminated runway landing performance. Although during public hearing testimony the FAA stated that the 15 percent landing safety margin has not been substantiated by a specific data collection and evaluation effort, the Safety Board is convinced that a defined landing safety margin is necessary for air carrier operations on contaminated runways. The Board was encouraged when the FAA proposed OpSpec N 8400.C082, which would have required operators of transport-category airplanes to incorporate a 15 percent safety margin in arrival landing distance calculations. The proposed 15 percent safety margin identified in FAA OpSpec N 8400.C082 would have satisfied the intent of Safety Recommendation A-06-16. However, the FAA subsequently sought voluntary operator implementation of such actions through SAFO 06012; although SAFO 06012 contains 95  For example, between SWA flight 1248’s dispatch from BWI and its arrival at MDW, the airplane’s landing conditions were affected by many factors, including continuing snowfall, the timing of runway clearing operations, and an updated landing weight.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 57 similar information to OpSpec N 8400.C082, compliance with the SAFO is not required by the FAA.96 Because the FAA has not required actions to address the Board’s urgent safety recommendation, flight crews of transport-category airplanes may still be permitted to land in wet, slippery, or contaminated runway conditions, without performing arrival landing distance assessments that incorporate adequate safety margins. As another winter season approaches, the urgent need for such margins becomes more critical. The Safety Board concludes that because landing conditions may change during a flight, preflight landing assessments alone may not be sufficient to ensure safe stopping margins at the time of arrival; arrival landing distance assessments would provide pilots with more accurate information regarding the safety of landings under arrival conditions. Further, the Safety Board concludes that although landing distance assessments incorporating a landing distance safety margin are not required by regulation, they are critical to safe operation of transport-category airplanes on contaminated runways. Therefore, the Safety Board believes that the FAA should require all 14 CFR Part 121, 135, and 91 subpart K operators to accomplish arrival landing distance assessments before every landing based on a standardized methodology involving approved performance data, actual arrival conditions, a means of correlating the airplane’s braking ability with runway surface conditions using the most conservative interpretation available, and including a minimum safety margin of 15 percent. The Board recognizes that development of such a standardized methodology will take time. Therefore, the Safety Board further believes that, until a standardized methodology as described in the previous recommendation can be developed, the FAA should immediately require all 14 CFR Part 121, 135, and 91 subpart K operators to conduct arrival landing distance assessments before every landing based on existing performance data, actual conditions, and incorporating a minimum safety margin of 15 percent. Because the objectives of this recommendation and Safety Recommendation A-06-16 are identical, the Safety Board classifies A-06-16 “Closed— Unacceptable Action/Superceded.” Because the FAA has had adequate time to require landing distance assessments and implement a landing distance safety margin, but has not, A-06-16 was classified “Open—Unacceptable Response” on May 8, 2007. The superceding safety recommendation will maintain the status of “Open—Unacceptable Response.” 96  The Safety Board is currently investigating two more recent runway overruns involving air carrier operators landing on snow-contaminated runways; landing distance calculations were not conducted in either of these cases.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 58 Runway Surface Condition Assessments 2.4  The Safety Board has long been concerned about runway surface condition assessment issues.97 During this investigation, the Safety Board reevaluated the three methods currently used to assess a runway’s surface condition before landing: 1) pilot braking action reports, 2) runway contaminant type and depth observations, and 3) ground surface vehicle friction measurements. The Board notes that all three methods have limitations and that, regardless of the method used, runway surface conditions may vary over time because of changes in precipitation, accumulation, traffic, direct sunlight, temperature, or as a result of runway maintenance/treatment. The Board further notes that no standardized and universally accepted correlation exists to define the relationship between the runway surface condition (using any of the three runway surface assessment methods) and an airplane’s braking ability. This section discusses the accuracy and limitations associated with each method of runway surface condition assessment. Pilot braking action reports, contaminant type and depth reports, and airport runway surface friction measuring devices are discussed in sections 2.4.1, 2.4.2, and 2.4.3, respectively. Runway surface condition assessments are summarized in section 2.4.4, and correlating runway surface condition to airplane landing performance/braking ability is discussed in section 2.4.5. Braking Action Reports 2.4.1  Pilot braking action reports are commonly used by arriving pilots to predict landing runway conditions. However, Safety Board safety recommendation communications, public hearing testimony, and flight 1248 accident evidence indicate that pilot braking action reports are subjective and can vary significantly depending on the reporting pilot’s experience level and the type of airplane in use. The FAA has frequently acknowledged (most recently in SAFO 06012) that pilot braking action reports are subjective and reflect individual pilot expectations, perceptions, and experiences. Further, braking action reports are sensitive to airplane type and the actual deceleration methods used to slow or stop the airplane. In addition, an arriving pilot may have to interpret mixed pilot braking action reports (for example, fair‑to- poor braking action reported on a landing runway) or conflicting runway condition 97  In 1983, the Safety Board issued a special investigation report titled, Large Airplane Operations on Contaminated Runways, which recommended that research be conducted to identify reliable and consistent methods for determining runway conditions. Although several industry working groups have convened to address this issue, no consensus has been reached to date regarding the preferred method for doing so, and no significant advances have been developed to eliminate the subjectivity or minimize the variances between reports. In addition, there is no standardized correlation between pilot braking action reports and runway contaminant type and depth, nor is there an internationally recognized and standardized terminology for braking action reports or contaminant type and depth reports. The Board classified Safety Recommendation A-82‑155, “Closed—Unacceptable Action.”

Analysis National Transportation Safety Board A I R C R A F T Accident Report 59 reports (for example, a pilot braking action report that conflicts with a runway friction measurement).98 In SAFO 06012, the FAA defined a reliable braking action report as a braking action report submitted from a turbojet airplane with landing performance capabilities similar to those of the airplane being operated. The FAA recommends in the SAFO that pilots should use all available information and make decisions based on experience and sound judgment; however, the FAA has not yet provided standardized procedures or specific criteria for pilots to use in the development and delivery of braking action reports.99 Since this accident, the FAA has hosted an industry workshop that attempted to address this issue. A mid-2006 industry working group produced guidance regarding runway surface condition assessments that has since been disseminated to all operators of Boeing turbojet airplanes in an August 2007 bulletin. SWA is incorporating the working group guidance into its materials and training and plans to publish related revisions in October 2007 (see figure 6).100 Contaminant Type and Depth 2.4.2  A field report or observation of the type and depth of contaminant on the runway, typically conducted by airport personnel, may also be used to assess the runway surface condition. However, these observations may also be subjective and dependent on the observer’s experience and vantage point, the timing of the observation, and rapidly changing conditions. The FAA has not established and defined a standard correlation between an airplane’s braking ability and reports of contaminant type and depth. The Safety Board notes, however, that many airplane manufacturers worldwide (for example, Airbus and Embraer) provide their operators with contaminant type and depth options for landing distance calculations. Further, European agencies (EASA and JAA) require operators to account for contaminated runway conditions and define a minimally acceptable standard that manufacturers can use to correlate contaminant type and depth to airplane landing performance. In practice (and as stated in SAFO 06012), the FAA considers the data developed for showing compliance with EASA and JAA contaminated runway certification or operating requirements acceptable for U.S. arrival landing distance assessments. 98  A postaccident Safety Board survey of seven operators (not including SWA) indicated that none of them provided their pilots with guidance regarding mixed and/or conflicting braking action or runway condition reports. However, most of the operators surveyed based landing distances on runway contaminant type and depth, not braking action reports. 99  The FAA does have standards and requirements for ATC’s delivery of a pilot’s braking action report to other pilots. 100  The draft industry product addressing landing distance assessments (see figure 6) contained winter operational guidance that was developed by a team of aviation industry representatives and included proposed braking action and contaminant type and depth terminology, definitions, and estimated correlations. The Safety Board’s review of this document indicated that it represents a good initial effort in the development of standardized guidelines for runway surface condition assessments.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 60 Airport Runway Surface Friction Measuring Devices 2.4.3  Runway friction measuring devices were originally developed for use by airports for runway maintenance purposes and were not intended for use in assessing airplane landing performance. Although the FAA funds purchase of these devices for airports and believes that measurements are useful in identifying trends in runway surface condition, FAA representatives have stated that these devices cannot be reliably correlated with airplane performance or pilot braking action reports. Specifically, FAA statements and testimony at the Safety Board’s public hearing on this accident indicate that ground surface vehicle friction measurements should not be used to predict airplane stopping performance, in part, because of 1) unresolved variability in equipment design and calibration; 2) changes over time in temperature, sunlight, precipitation, accumulation, and operating traffic; and 3) the results of maintenance and/or treatment of a runway. MDW friction readings were less conservative than the available braking action reports and the postaccident calculated runway 31C surface condition. The runway 31C friction measurement taken at MDW 30 minutes before the accident landing (immediately after the most recent runway cleaning) was 0.67, which a Transport Canada public hearing witness correlated with expected “bare and dry” runway surface condition performance. A measurement taken just after the accident was 0.40, which was considered fairly good according to a public hearing witness from NASA. According to CRFI data for various runway surface conditions, both measurements (0.67 and 0.40) were within the range of normal values observed with 3 mm or less of loose snow on the runway. Measurements for this surface condition ranged from 0.16 to 0.76 (see figure 7 in section 1.18.2.2.1). The broad range of measurements possible with a single contaminant demonstrates that this type of runway friction measurement device cannot reliably be used to predict airplane stopping performance under these contaminant conditions (3 mm or less of loose snow). The Safety Board has previously issued safety recommendations supporting efforts to correlate friction measurement device readings to airplane performance. Boeing does not attempt to correlate runway friction measurements to airplane performance; however, many operators (including SWA) have developed tables that correlate friction measurements to braking action reports. Internationally, Transport Canada provides CRFI tables that correlate ground surface vehicle friction survey measurements to airplane performance for certain contamination conditions; however, use of the CRFI is optional. The Canadian academic community and members of the international research community also support the use of the IRFI, which is not fully operational or widely supported by the aviation industry. For both the CRFI and the IRFI, runway friction measurements are subject to contaminant type and depth constraints. Runway Surface Condition Assessments Summary 2.4.4  The Safety Board concludes guidance on braking action and contaminant type and depth reports would assist pilots, ATC, operator dispatch, and airport operations personnel in minimizing the subjectivity and standardization shortcomings of such reports. Further, the Safety Board concludes that using the most conservative interpretation of runway

Analysis National Transportation Safety Board A I R C R A F T Accident Report 61 braking action or surface condition reports from mixed or conflicting reports (for example, a fair-to-poor braking action report or a pilot braking action report that conflicts with a runway friction measurement) would increase the landing safety margin. Therefore, the Safety Board believes that the FAA should develop and issue formal guidance regarding standards and guidelines for the development, delivery, and interpretation of runway surface condition reports. Correlating Runway Surface Condition to Airplane Landing 2.4.5  Performance The Safety Board is concerned that the FAA currently provides no minimally acceptable standard for U.S. operators to use to correlate runway surface condition reports to airplane braking ability.101 Although a draft AC, dated August 1989, proposed a correlation between runway condition (braking action) and an airplane’s braking ability, the FAA never published it. SAFO 06012, issued by the FAA in 2006, also advocated the use of a specific correlation between reported braking action and runway contaminant type and depth to predict turbojet landing/stopping performance but only if the manufacturer- supplied wet or contaminated runway data were unavailable. Operators need a method to relate any of the three runway surface condition reports and airplane braking ability to determine an airplane’s landing performance. However, because the FAA has defined no acceptable correlation standards, manufacturers, operators, and/or third-party suppliers develop their own standards to fulfill their needs.102 This practice results in variable estimates of an airplane’s actual landing performance capability and different landing safety margins being used across even operators of the same make and model airplane. The Safety Board notes that flight crews preparing to land similar airplanes on similar runways, under similar actual conditions should not obtain arrival landing distance results that permit one flight crew to land while the other flight crew cannot, based solely on the operator’s choice of how to correlate a runway surface condition report to the airplane’s braking ability. Further, required arrival landing distance assessments should include an additional safety margin to account for variations in actual landing conditions and operational techniques. The current lack of standards in manufacturer-supplied and operator-packaged arrival landing data complicates the validation of both the airplane’s basic landing performance capability and adequate safety margins. The Safety Board’s investigation of this accident revealed arrival landing distance implementation errors that resulted in latent safety risks at two air carriers. The Safety Board concludes that an 101  In Europe, EASA and JAA provide a default relationship between an airplane’s braking ability and contaminant type and depth. 102  The Safety Board notes that operators and third-party suppliers do not generally possess the expertise needed and should not be given license to define (or redefine) basic airplane performance capability. During its investigation of the SWA flight 1248 accident, the Safety Board noted several instances of manufacturer- supplied errors and operator use of outdated or otherwise inaccurate data for their landing performance calculations. Although manufacturers and operators should be allowed to base arrival landing distance assessments on more conservative airplane braking ability correlations, the use of less conservative data should be prohibited.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 62 adequate safety margin would account for operational variations and uncertainties when factored into arrival landing distance assessments. Further, the Safety Board concludes that establishment of a means of correlating the airplane’s braking ability with the runway surface condition would provide a more accurate assessment of the airplane’s basic landing performance capability. Therefore, the Safety Board believes that the FAA should establish a minimum standard for 14 CFR Part 121 and 135 operators to use in correlating an airplane’s braking ability to braking action reports and runway contaminant type and depth reports for runway surface conditions worse than bare and dry. Airplane-Based Friction Measurements 2.5  The circumstances of this accident demonstrate the need for a method of quantifying the runway surface condition in a more meaningful way to support airplane landing performance calculations.103 The Safety Board and industry practice of analyzing an airplane’s actual landing performance in the aftermath of an accident based on airplane-recorded data demonstrates that runway surface condition and braking effectiveness information can be extracted from recorded data.104 These practices have shown that if the necessary parameters are recorded, specific calculations and operational procedures performed at lower rollout speeds (for example, wheel brake application for several seconds below 60 knots) can be used to quantify the runway surface condition and estimate the airplane’s potential braking ability.105 Thus, airplane braking coefficient/ runway surface condition data derived from one type of landing airplane could be used to estimate another type of airplane’s braking ability and landing distance.106 During a postaccident meeting in January 2007, Boeing, FAA, SWA, and SWAPA personnel agreed that this approach to obtain runway surface condition and braking effectiveness data has technical merit. However, the technical and operational feasibility issues associated with an airplane-based friction measurement system have not been evaluated on a test bed or an in-service air carrier airplane to date. A measurement 103  The Safety Board has previously issued a safety recommendation on this subject (A-82-168), urging the FAA to conduct research to determine whether the characteristic variables of aircraft systems could be correlated to an airplane’s stopping ability and related information displayed to pilots for objective braking action reports. The Board did not believe that the FAA’s resultant actions were sufficient and subsequently classified Safety Recommendation A-82-168 “Closed—Unacceptable Action.” 104  Specifically, the Safety Board’s airplane performance study for this accident demonstrated the technical feasibility of calculating an airplane’s braking ability during the landing roll based on recorded FDR data (including accelerometer, attitude, speed, control input, control surface position, deceleration device usage, and air/ground logic parameters), the airplane configuration, and existing airplane simulation models. Conceptually, the calculation determines how much of the energy (initial energy and any added forward thrust) is dissipated by aerodynamic drag and reverse thrust forces acting during the landing rollout. The remaining energy is used together with airplane weight, aerodynamic lift, and any applicable thrust force data to derive the airplane braking coefficient. If wheel brakes are not applied, the calculated result should correspond to the rolling coefficient of friction, assuming no contaminant drag exists. 105  Operational procedures at lower rollout speeds could be used to estimate the maximum or bound the minimum airplane braking coefficient available. 106  The airplane braking coefficient report from the preceding airplane would be used to perform a rational arrival assessment for the trailing airplane, after correcting for known airplane type, loading, configuration, braked wheel configuration, and antiskid efficiency differences.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 63 system installed on in-service airplanes could provide runway surface condition data that would surpass information produced by methods currently in use (including ground friction surveys, pilot braking action reports, and type and depth reports), without interfering with traffic flow. Such a system could provide unparalleled runway surface condition quantification and trend information of direct use to pilots, ATC, and airport maintenance. The Safety Board concludes that development and implementation of an operationally feasible, airplane-based, airplane braking ability/runway surface condition measurement and communication system would provide high value information to subsequent landing airplanes; the benefits of such a system during inclement weather would likely meet or exceed all existing runway surface condition reporting systems, with no resultant interruption to traffic operations. Therefore, the Safety Board believes that the FAA should demonstrate the technical and operational feasibility of outfitting transport- category airplanes with equipment and procedures required to routinely calculate, record, and convey the airplane braking ability required and/or available to slow or stop an airplane during the landing roll. If feasible, the FAA should also require operators of transport-category airplanes to incorporate use of such equipment and related procedures into their operations. Runway Safety Areas 2.6  The Safety Board’s investigation of this accident revealed that FAA and MDW airport personnel had been discussing RSA improvements off the ends of MDW runways for about 5 years before the accident; however, no such improvements had been made when the accident occurred. Correspondence between the FAA and MDW personnel indicated that the option of acquiring land to develop dimensionally standard RSAs (which would extend 1,000 feet beyond the ends of the MDW runways) was determined to be both undesirable107 and economically infeasible. Further, realigning the runways on the available airport property was not possible, and shortening the runways to improve RSAs was not practical given the operational requirements of the airplanes operating at MDW. A practicability study contracted by MDW concluded that insufficient space existed for standard EMAS installations off the ends of MDW runways. The study did not address nonstandard EMAS installations, and, throughout most of the FAA/MDW correspondence, the FAA did not reference the installation of nonstandard EMAS beds off the end of MDW runways. However, although the FAA had no official guidance regarding nonstandard EMAS installations until 2005, agency personnel were aware of the feasibility of such installations and had approved nonstandard EMAS installations at several other airports at the time of the accident. The Board’s postaccident calculations indicated that even a nonstandard EMAS installation off the end of runway 31C at MDW would have stopped the accident airplane before it left airport property and thus would have prevented the collision with the automobile. 107  Acquisition of the required land would result in the forced relocation of businesses, residences, and roadways in the surrounding area.

Analysis National Transportation Safety Board A I R C R A F T Accident Report 64 Therefore, the Safety Board concludes that the absence of an EMAS installation in the limited overrun area for runway 31C contributed to the severity of the accident; even a nonstandard EMAS installation would have safely stopped the airplane before it left airport property. After the accident, the FAA approved the installation of nonstandard EMAS beds at the ends of runways 31C, 13C, 4R, and 22L at MDW. By early December 2006, the first portion (170 feet long and 170 feet wide) of an EMAS bed had been installed off the departure end of runway 31C, with an additional, 40-foot long portion planned. Airport and City officials indicated that the installation of EMAS beds at the ends of affected MDW runways would be completed by winter 2007, pending relocation of localizer antennas at the ends of runways 13C, 4R, and 22L.

National Transportation Safety Board A I R C R A F T Accident Report 65 Conclusions

Findings 3.1  The pilots were properly certificated and qualified under Federal regulations. No

evidence indicated any medical or behavioral conditions that might have adversely affected their performance during the accident flight. There was no evidence of flight crew fatigue. The accident airplane was properly certificated and was equipped, maintained, and

dispatched in accordance with industry practices. No evidence indicated any failure of the airplane’s powerplants, structures, or systems

that would have affected the airplane’s performance during the accident landing. The pilots had adequate initial and updated meteorological information throughout

the flight. Chicago Midway International Airport personnel monitored runway conditions and

provided appropriate snow removal service on the night of the accident. The Chicago Midway International Airport air traffic control tower controller did not

follow Federal Aviation Administration guidance when he did not provide all of the required braking action report information. Because the pilots did not use the more critical braking action term (poor) during their

arrival landing distance assessment (which, combined with the associated tailwind limitation, would have required them to divert), they were not in compliance with Southwest Airlines’ policies. If the pilots had been presented with stopping margins associated with the input winds

or had known that the stopping margins calculated by the on board performance computer for the 737-700 already assumed credit for the use of thrust reversers, the pilots may have elected to divert. If Boeing’s recommended airplane performance data were used in Southwest Airlines’

on board performance computer calculations, the resulting negative stopping margins for even fair braking action conditions would have required the pilots to divert. Presentation of the on board performance computer assumptions upon which landing

distance calculations are based is critical to a pilot’s decision to land. Southwest Airlines did not provide its pilots with clear and consistent guidance

and training regarding company policies and procedures in several areas, including

Conclusions National Transportation Safety Board A I R C R A F T Accident Report 66 interpretation of braking action reports and the assumptions affecting landing distance assessments. The pilots would have been able to stop the airplane on the runway if they had

commanded maximum reverse thrust promptly after touchdown and maintained maximum reverse thrust to a full stop. The pilots’ delay in deploying the thrust reversers cannot be attributed to mechanical

or physical difficulties. The pilots’ first use of the airplane’s autobrake system during a challenging landing

situation led to the pilots’ distraction from the otherwise routine task of deploying the thrust reversers promptly after touchdown. Had Southwest Airlines implemented an autobrake familiarization period in advance, such a period would have allowed pilots to become comfortable with the changed sequence of landing tasks. The implementation of procedures requiring thrust reverser status confirmation

immediately after touchdown may prevent pilots from inadvertent failure to deploy the thrust reversers after touchdown. Because landing conditions may change during a flight, preflight landing assessments

alone may not be sufficient to ensure safe stopping margins at the time of arrival; arrival landing distance assessments would provide pilots with more accurate information regarding the safety of landings under arrival conditions. Although landing distance assessments incorporating a landing distance safety margin

are not required by regulation, they are critical to safe operation of transport-category airplanes on contaminated runways. Guidance on braking action and contaminant type and depth reports would assist

pilots, air traffic control, operator dispatch, and airport operations personnel in minimizing the subjectivity and standardization shortcomings of such reports. Using the most conservative interpretation of runway braking action or surface

condition reports from mixed or conflicting reports (for example, a fair-to-poor braking action report or a pilot braking action report that conflicts with a runway friction measurement) would increase the landing safety margin. An adequate safety margin would account for operational variations and uncertainties

when factored into arrival landing distance assessments. Establishment of a means of correlating the airplane’s braking ability with the runway

surface condition would provide a more accurate assessment of the airplane’s basic landing performance capability. Development of an operationally feasible, airplane-based, airplane braking ability/

runway surface condition measurement and communication system would provide

Conclusions National Transportation Safety Board A I R C R A F T Accident Report 67 high value information to subsequent landing airplanes; the benefits of such a system during inclement weather would likely meet or exceed all existing runway surface condition reporting systems, with no resultant interruption to traffic operations. The absence of an engineering materials arresting system (EMAS) installation in the

limited overrun area for runway 31C contributed to the severity of the accident; even a nonstandard EMAS installation would have safely stopped the airplane before it left airport property. Probable Cause 3.2  The National Transportation Safety Board determines that the probable cause of this accident was the pilots’ failure to use available reverse thrust in a timely manner to safely slow or stop the airplane after landing, which resulted in a runway overrun. This failure occurred because the pilots’ first experience and lack of familiarity with the airplane’s autobrake system distracted them from thrust reverser usage during the challenging landing. Contributing to the accident were Southwest Airlines’ 1) failure to provide its pilots with clear and consistent guidance and training regarding company policies and procedures related to arrival landing distance calculations; 2) programming and design of its on board performance computer, which did not present inherent assumptions in the program critical to pilot decision-making; 3) plan to implement new autobrake procedures without a familiarization period; and 4) failure to include a margin of safety in the arrival assessment to account for operational uncertainties. Also contributing to the accident was the pilots’ failure to divert to another airport given reports that included poor braking actions and a tailwind component greater than 5 knots. Contributing to the severity of the accident was the absence of an engineering materials arresting system, which was needed because of the limited runway safety area beyond the departure end of runway 31C.

National Transportation Safety Board A I R C R A F T Accident Report 68 Recommendations

New Recommendations 4.1  As a result of this investigation, the National Transportation Safety Board makes the following recommendations to the Federal Aviation Administration: Immediately require all 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators to conduct arrival landing distance assessments before every landing based on existing performance data, actual conditions, and incorporating a minimum safety margin of 15 percent. (A-07-57) Urgent (Supercedes Safety Recommendation A-06-16 and classified “Open—Unacceptable Response.”) Require all 14 Code of Federal Regulations Part 121 and 135 operators to ensure that all on board electronic computing devices they use automatically and clearly display critical performance calculation assumptions. (A-07-58) Require all 14 Code of Federal Regulations Part 121 and 135 operators to provide clear guidance and training to pilots and dispatchers regarding company policy on surface condition and braking action reports and the assumptions affecting landing distance/stopping margin calculations, to include use of airplane ground deceleration devices, wind conditions and limits, air distance, and safety margins. (A-07-59) Require all 14 Code of Federal Regulations Part 121 and 135 operators of thrust reverser-equipped airplanes to incorporate a procedure requiring the non-flying (monitoring) pilot to check and confirm the thrust reverser status immediately after touchdown on all landings. (A-07-60) Require all 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators to accomplish arrival landing distance assessments before every landing based on a standardized methodology involving approved performance data, actual arrival conditions, a means of correlating the airplane’s braking ability with runway surface conditions using the most conservative interpretation available, and including a minimum safety margin of 15 percent. (A-07-61) Develop and issue formal guidance regarding standards and guidelines for the development, delivery, and interpretation of runway surface condition reports. (A-07-62)

Recommendations National Transportation Safety Board A I R C R A F T Accident Report 69 Establish a minimum standard for 14 Code of Federal Regulations Part 121 and 135 operators to use in correlating an airplane’s braking ability to braking action reports and runway contaminant type and depth reports for runway surface conditions worse than bare and dry. (A-07‑63) Demonstrate the technical and operational feasibility of outfitting transport-category airplanes with equipment and procedures required to routinely calculate, record, and convey the airplane braking ability required and/or available to slow or stop the airplane during the landing roll. If feasible, require operators of transport-category airplanes to incorporate use of such equipment and related procedures into their operations. (A-07-64) Previously Issued Recommendation Resulting From 4.2  This Accident Investigation and Classified in this Report As a result of the SWA flight 1248 accident investigation, the Safety Board issued the following urgent safety recommendation to the FAA on January 27, 2006: Immediately prohibit all 14 Code of Federal Regulations Part 121 operators from using reverse thrust credit in landing performance calculations. (A-06-16) This recommendation (previously classified “Open—Unacceptable Response” on May 8, 2007) is classified “Closed—Unacceptable Action/Superceded” by Safety Recommendation A-07-57 in section 2.3 of this report. BY THE NATIONAL TRANSPORTATION SAFETY BOARD Mark V. Rosenker

Deborah A. P. Hersman Chairman

Member Robert L. Sumwalt

Kathryn O’Leary Higgins Vice Chairman

Member

Steven R. Chealander

Member Adopted: October 2, 2007

National Transportation Safety Board A I R C R A F T Accident Report 70 Appendixes

Appendix A Investigation and Public Hearing Investigation The National Transportation Safety Board was notified about the accident on December 8, 2005, shortly after it occurred. A full go-team arrived at the accident scene early the next morning. The go-team was accompanied by representatives from the Safety Board’s Office of Transportation Disaster Assistance and Public Affairs and by then Chairman-designee Ellen Engleman Conners. The following investigative groups were formed during the course of this investigation: Structures, Systems, Powerplants, Air Traffic Control, Meteorology, Operations, Human Performance, Airport/Survival Factors, Airplane Performance, Flight Data Recorder, and Cockpit Voice Recorder. Parties to the investigation were the Federal Aviation Administration (FAA); Boeing Commercial Airplane Company; Southwest Airlines, Inc. (SWA); Southwest Airlines Pilots Association (SWAPA); National Air Traffic Controllers Association (NATCA); the City of Chicago; CFM International; SWA Employee Association Dispatch; Transport Workers Union #556; and SWA AMFA. The Safety Board received submissions on this accident from SWA, SWAPA, Boeing, and the City of Chicago. Public Hearing A public hearing was held on June 21 and 22, 2006, in Washington, D.C. Then- Acting Chairman Mark V. Rosenker presided over the hearing. The issues discussed at the public hearing were the accuracy and dissemination of runway friction measurements, the adequacy of runway safety areas on the ends of runways, and aircraft landing performance. Parties to the public hearing were the FAA, SWA, SWAPA, Boeing Commercial Airplane Company, and the City of Chicago.

National Transportation Safety Board A I R C R A F T Accident Report 71 Appendix B Cockpit Voice Recorder The following is a transcript of the Honeywell model 6022 cockpit voice recorder installed on Southwest Airlines flight 1248, a Boeing 737-74H, N471WN, which ran off the departure end of runway 31C after landing at Chicago Midway International Airport, Chicago, Illinois, on December 8, 2005.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 72 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT Start of Transcript 17:12:58.2 [start of recording] 17:13:15.9 CAM-2 I thought it said that read before fly said actually it was in the weather packet. (the) front page said don't do the new procedures until you post the change and then then have at it. 17:13:26.5 CAM-1 oh really? 17:13:28.2 CAM-2 there was a big long thing on it and it's not on there any more. 17:13:32.8 CAM-2 have to read that that little blurb again. 17:15:37.2 CTR Southwest twelve forty eight climb maintain flight level three three zero. 17:15:41.0 RDO-2 flight level three three zero Southwest twelve forty. 17:15:43.5 CAM-1 well? 17:15:43.6 CTR Southwest twelve forty eight contact Washington one one eight point zero two she'll have higher.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 73 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:15:48.2 RDO-2 eighteen oh two have a great night Southwest twelve forty eight. 17:15:50.7 CTR goodnight. 17:15:54.3 RDO-2 center Southwest twelve forty eight leavin' thirty for flight level three three zero. 17:15:57.6 CTR Southwest twelve forty eight Washington center roger climb maintain flight level three niner zero. 17:16:04.1 HOT-1 three nine zero now. 17:16:05.2 HOT-2 thirty nine. 17:16:13.6 CAM-1 (see) anything exciting in there? 17:16:16.2 CAM-2 if I knew how to read it would be a lot easier. 17:16:17.9 CAM-1 ahuh. 17:16:18.5 CAM-2 [sound similar to laughter].

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 74 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:16:21.6 CAM-2 you know we're gonna get rid of all the two, two hundred (stuff). that should make it (a) little bit skinnier. 17:17:53.3 HOT-1 talkin' to a buddy a mine $. said yesterday the winds, most they got were the winds hundred and eighty eight knots dead on their nose. 17:18:02.4 HOT-2 man. 17:18:03.0 HOT-1 yea. 17:18:03.7 HOT-2 the highest I ever saw and it made me wonder what the plane what the computer went up to we're over Atlanta like couple months ago and it was two seven zero at one ninety nine. we were goin' north to Baltimore but... 17:18:15.1 HOT-1 yeah yeah. 17:18:16.3 CAM-2 ...(that) made me wonder if it didn't go any higher, sure it does but. 17:18:27.2 HOT-2 its a lot a wind, that blows [sound similar to laughter].

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 75 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:18:29.7 HOT-1 yup. 17:19:58.5 CAM-1 gonna do it huh? 17:19:59.7 CAM-2 I don't want to but. 17:20:03.2 HOT-1 kinda light drinkin' the spittoon. 17:20:04.6 HOT-2 [sound similar to laughter]. 17:20:11.2 CAM [sound similar to altitude alert warning tone]. 17:20:12.7 HOT-1 (thirty) eight one fer thirty nine. 17:20:14.6 CAM-2 eight one thirty five. 17:20:39.9 HOT-1 same all the way up. 17:20:41.2 CAM-2 yea (looks), no penalty. 17:20:43.0 CAM-1 unchanged two sixty five oh one fifty. 17:20:48.8 HOT-1 for the last nine thousand feet. 17:20:50.8 HOT-2 man, well.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 76 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:20:59.5 CAM-2

• *.

17:21:01.6 CAM-1 yea. 17:21:02.7 CAM-1 (think) we have a ninety eight on board wow. 17:21:04.9 CAM-2 (that's good) we're supposed to only have fifty one right when we started? 17:21:07.6 CAM-1 yea it kept on gettin' more and more. 17:21:17.1 HOT-1 I’ll put three nine zero in there I don't know if we're goin' up or not but. 17:21:19.6 CAM-2 'kay. 17:21:23.5 HOT-1 yeah. 17:21:55.0 CAM-1 okay. 17:22:01.6 CAM-2 okay now or you want me to wait till we get (up)? 17:22:04.1 CAM-1 you can let 'em up. 17:22:04.6 CAM-2 okay cool I'll be right back.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 77 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:22:07.8 PA-2 and folks good evenin' ah again from the guys up front thank you so much for your patience this evenin' ah with our troubles with mother nature we sure do appreciate your understanding *

• * are at thirty nine thousand feet we're gonna make a slow

climb to forty thousand feet here in just a couple minutes our friends at air traffic controller (tell) us its gonna be a pretty smooth flight this evenin' [sound similar to seatbelt warning tone] the seatbelt signs comin' off so folks if you wanna get up and stretch your legs or move about you sure can do so well please folks while you're in your seats always stay buckled up just in case we do find a few unexpected bumps along the way. ah folks as long as the flight attendants are busy trying to get their service out you sure can do them a big favor by trying to keep those aisles clear they really do appreciate it and so do we

• no lines up by the forward lavatory and you can't stand up

in the forward galley area ah these are FAA security regulations and each of us want to thank you here in advance for complyin'. ahhh pretty strong headwinds right now folks are out of the West at about a hundred and fifty knots 'bout a hundred seventy five mile an hour right on the nose ah normal a normally our speed across the ground is close to about five hundred miles an hour right now it's only about three hundred and fifty or so so it's not gonna help us make up any time at all right now about four hundred and fifty miles to go. showin' us ah - touchin' down in Chicago at about and hour twenty minutes or so 'bout an hour twenty five minutes we should have you safely at the gate. folks as we get closer * we'll keep you posted get you up to date on the latest for the Chicago weather. for now folks again ah thanks so much for your patience and understanding this evening we really do appreciate it and finally folks one extra note ah we have three great flight attendants and I promise ya they didn't have a single thing to do with us gettin' off to the late start this evenin' so folks please be kind to them 'cause they’re gonna take excellent care of you thanks so much folks again and good evenin'.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 78 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:23:51.7 CAM-1 wow whaddya say? 17:23:53.8 CAM-2 yadda yadda yadda. yadda yadda yadda. good flight attendants yadda yadda. we like visitors yadda yadda. 17:24:01.6 CAM-1 wow. 17:24:03.7 CAM-2 I always give 'em the be good to our flight attendants 'cause it's not their fault we're late. they're they always say ohh that's so nice thank you. 17:24:13.9 HOT-1 huh. 17:24:14.2 HOT-2 it's all lies and garbage. 17:24:15.5 HOT-1 yeap. 17:24:17.0 HOT-2 windy windy windy. 17:25:01.0 HOT-1 big three hundred and thirteen knots a groundspeed. 17:25:04.2 HOT-2 man oh man. 17:25:11.6 HOT-1 hope this stays with us for the last day.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 79 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:25:14.0 CAM-2 yea no kidding. 17:25:14.9 CAM-1 although it doesn't matter. 17:25:16.3 CAM-2 that's true. 17:25:17.0 CAM-1 ain't no flights I can make. 17:25:18.6 CAM-2 yea me neither. 17:25:22.0 HOT-1 see. 17:25:23.4 HOT-2 it's not even close for me. 17:25:28.1 HOT-1 Albany? 17:25:29.2 HOT-2 I think it's like eight, actually Saturday it's earlier it's seven somethin'. 17:25:33.6 HOT-1 (no) it's five somethin' on Saturday. 17:25:35.5 HOT-2 five. 17:25:36.0 HOT-1 yeah.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 80 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:25:36.6 HOT-2 man. 17:25:37.3 HOT-1 (see) I better turn this off I guess (huh)? 17:25:38.8 HOT-2 [sound similar to laughter]. 17:25:40.4 HOT-1 (ah) it is off how 'bout that it's smarter than I think. 17:25:42.6 HOT-2 my battery's probably dead already. 17:26:32.5 CAM-1 wow wow wow. 17:26:35.2 CAM-2 big stuff right here. 17:26:36.4 CAM-1 yeah. 17:26:37.2 CAM-2 be sleep *. 17:26:37.9 CAM-1 be the next leg for me. 17:26:39.0 CAM-2 [sound similar to laughter]. 17:27:10.7 CAM-2 you know this is some heavy stuff. (think I'm) gonna be sorry I (got into this).

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 81 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:27:14.8 CAM-1 yup. 17:29:56.8 CTR Southwest twelve forty eight contact Indianapolis center one two zero point two seven. 17:30:01.4 RDO-2 twenty twenty seven have a great night Southwest twelve forty eight. 17:30:04.0 CTR 'kay. 17:30:21.4 RDO-2 and center Southwest twelve forty eight flight level three nine zero. 17:30:24.6 CTR Southwest twelve forty eight Indy center roger. 17:31:12.0 CAM [sound similar to ACARS chime]. 17:31:22.6 HOT-1 landin' north Salt Lake ten miles fifteen thousand. 17:31:28.3 HOT-2 alright nice from Vegas. 17:31:32.5 HOT-2 alright here's the autobrakes. autobrakes if operational will be used when min two stopping margin is less than five hundred feet and the reported or anticipated runway condition is not dry.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 82 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:31:49.1 CAM-1 alright. 17:31:50.8 CAM-2 use the lowest autobrake setting resulting in a stopping margin of five hundred feet or more. 17:31:56.7 CAM-2 if stopping margin of at least five hundred feet cannot be achieved with autobrake setting landing is still authorized using MAX provided a positive stopping margin is computed. 17:32:08.6 CAM-1 alright what does that mean? I cause I can't... 17:32:12.4 CAM-2 I have no idea. [sound similar to laughter]. 17:32:14.1 CAM-1 I gotta read it. 17:32:15.2 CAM-2 it (has it) in here I'll show you. (you) get a good idea now. 17:32:20.1 HOT-1 yeah. 17:32:22.0 CAM-2 I guess if you use MAX my buddy flew whales for Atlas and he said when you land at max it'll get your freakin' attention.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 83 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:32:30.3 HOT-2 I mean it's a mega-stop. it like throws ya for you know he said I when they used max he used to do the

• he never did the crotchstrap till he did his first

MAX. 17:32:36.1 HOT-1 yeah. 17:32:40.9 HOT-1 really? 17:32:41.4 HOT-2 yeah. 17:32:42.6 HOT-2 he said after that I use it every time. 17:32:53.7 HOT-2 let's see. 17:32:54.8 HOT-1 crossfeedin' the centers. 17:32:55.9 HOT-2 alright. 17:33:11.3 CAM [sound similar to ACARS chime]. 17:33:13.3 CAM-1 Romeo. Romeo Romeo where art thou? 17:33:17.7 HOT-2 half a mile snow freezing fog two hundred who hoo.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 84 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:33:22.3 CAM-2 you wanted to go first. 17:33:24.1 HOT-1 half a mile we can't do it can we? 17:33:26.6 HOT-2 three one center we can if they're using three one center. 17:33:32.3 CAM-2 you need three thousand RVR. 17:33:35.2 CAM-2 you prob - you probably won't get in but. 17:33:35.3 CAM-1

• *.

17:33:37.5 CAM-1 you got a different one? it says four thousand or three quarters unless you got a... 17:33:40.5 CAM-2 you can do that ILS-Z. 17:33:42.6 HOT-1 I haven't got that one. 17:33:43.8 HOT-2 you don't? 17:33:46.6 CAM-2 pretty sure it's a (V). 17:33:47.7 CAM-1 okay. it's a HUD one?

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 85 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:33:51.2 CAM-2 it's the same approach but. 17:33:53.2 CAM-1 yeah get a little lower. 17:33:55.4 CAM-1 no where it went. 17:33:55.8 CAM-2 I I don't know if we'll see it. 17:33:57.2 HOT-2 'cause there's no approach lights. 17:34:00.6 CAM-2 (see). 17:34:03.9 CAM-1 (two hundred broken). 17:34:04.4 CAM-2 there's a lead in that's it three one center. 17:34:07.7 CTR Southwest twelve forty eight cleared direct Fort Wayne. 17:34:10.5 RDO-2 wow direct Fort Wayne thanks Southwest twelve forty eight. 17:34:12.9 CTR you're welcome. 17:34:13.3 CAM-1 direct Fort Wayne.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 86 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:34:15.4 CAM-2 you had the the Zee. 17:34:17.8 CAM-1 well let me take a peak then how's that look direct Fort Wayne. 17:34:20.5 CAM-2 good to me. 17:34:22.6 CAM-2 here we go three thousand or five (E). 17:34:27.5 CAM-1 yeah. 17:34:31.5 HOT-2 (well) there's. 17:34:32.9 HOT-1 okay. 17:34:33.8 HOT-2 probably a two -- what's the -- 17:34:39.0 HOT-2 the so what's to altitude on it though a * two hundred. 17:34:41.7 HOT-1 eight seventeen. 17:34:42.7 HOT-2 two hundred and fifty. 17:34:43.6 HOT-1 two hundred and four.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 87 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:34:44.5 HOT-2 oh two oh four so we'll probably see it. 17:34:47.2 HOT-1 neh heh. 17:34:50.1 CAM-2 temperature. 17:34:52.3 CAM-1 but five eighths is not a half a mile. 17:34:54.9 CAM-2 no I know (the). 17:34:55.8 CAM-1 gotta have three thousand. 17:34:57.1 HOT-2 he sent me a a dispatch message. 17:35:00.3 HOT-1 okay. 17:35:00.8 HOT-2 and he said fair and three thousand RVR. 17:35:03.4 HOT-1 alright it's three thousand RVR we can do it. 17:35:09.5 CAM-2 I can type him a little message and see what he's got now. 17:35:11.3 CAM-1 nah 'at's all right.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 88 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:35:14.9 CAM-2

• .

17:35:18.9 CAM-2 so I'll do I'll do wet fair just for # and giggles. 17:35:29.5 CAM-? I'm with you. 17:35:34.9 HOT-2 four point five. 17:35:58.6 HOT-2 so the - the way I get it since this is the one that has five hundred. 17:36:03.9 HOT-1 yeah. 17:36:07.2 HOT-2 and you can't use one. 17:36:10.0 HOT-2 two is - min so you'd have to use ah three. 17:36:13.1 HOT-1 three. 17:36:14.7 HOT-2 that's the way I get it but. 17:36:15.9 HOT-1 okay. 17:36:19.1 HOT-2 if its ah.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 89 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:36:20.2 HOT-1 Hmmm. 17:36:21.0 HOT-2 use those. 17:36:21.2 HOT-1 I would I would agree with that. 17:36:22.4 HOT-2 yeah yeah I think that's what I get. 17:36:24.2 HOT-2 you can't use one so it starts at two. 17:36:26.5 HOT-2 like two three from MAX. 17:36:28.3 HOT-1 you got wet fair. 17:36:29.8 HOT-2 and then ah ice on. 17:36:32.0 HOT-1 okay. 17:36:34.0 HOT-1 'kay. 17:36:34.6 HOT-2 no clutter we'll see. 17:36:36.4 HOT-1 didn't say any clutter add some clutter if they got any. 17:36:37.7 HOT-2 yeah.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 90 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:36:38.7 HOT-2 yeah. 17:36:39.5 HOT-1 add some clutter see what it says. 17:36:40.8 HOT-2 okay ah. 17:36:44.1 HOT-1 please. 17:36:44.7 HOT-2 sure. 17:36:47.6 HOT-2 well lemee see. 17:36:49.7 HOT-2 do ya just do clutter fer ahhh. 17:36:53.9 HOT-1 (ten). 17:36:54.3 HOT-2 maybe you just do clutter for takeoff I think you just do... 17:36:56.2 HOT-1 yeah. 17:36:56.5 HOT-2 ...clutter. 17:36:57.4 HOT-2 but if it was wet poor we'll do wet poor and see.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 91 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:36:59.8 HOT-1 yeah we can. 17:37:05.3 HOT-1 hmm ha. 17:37:07.4 HOT-2 wow. wooo. if it's poor it's scary. 17:37:12.0 HOT-1 I ain't doin' it. 17:37:12.8 HOT-2 max is thirty that's really scary. 17:37:15.2 HOT-1 yeah. 17:37:16.5 HOT-1 naw that's no good. 17:37:21.1 CAM-2 six knot tailwind. 17:37:23.4 HOT-1 did ya put in ah go back to wet fair did ya put in a. 17:37:29.0 HOT-2 HGS? 17:37:29.9 HOT-1 yeah. 17:37:30.8 HOT-2 well do we? 17:37:32.9 HOT-1 says it's a requirement.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 92 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:37:34.1 HOT-2 it is? 17:37:36.7 HOT-2 I did less than four thousand. 17:37:39.7 HOT-2 *. 17:37:39.7 HOT-1 ah you did less than four okay. ah that's good enough. 17:37:41.7 CAM-2 when when you put in the HGS I've never seen that before. 17:37:45.6 CAM-1 runway limited. 17:37:47.2 CAM-2 maybe it maybe it 'cause I don't think we're... 17:37:50.4 HOT-1 yeah just do wet poor ah ah poor and then ah below four yeah not HGS though. 17:37:56.4 HOT-1 you just have to be HGS cert- certified. 17:37:57.3 HOT-2 ...maybe 'cause they don't have... we'll do it we'll see as we get the next one but. (oh).

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 93 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:38:02.2 HOT-1 alright it's gotta have the lead in gotta have the REIL gotta have the VASI gotta have the HIRL and RVR for three one center must be operating. and DME is required. 17:38:11.2 HOT-2 let's see if they got a the fi- there's a field condition one in here. 17:38:14.9 HOT-1 yeah. 17:38:16.7 HOT-2 it didn't have the RVR in there before but. 17:38:21.7 HOT-2 field METAR. 17:38:26.4 HOT-2 that's really the only reason I wanna look. 17:38:29.3 CAM-2 hate to have somethin' happen when ya got the. 17:38:38.1 HOT-2 then the only other stuffs that really is gonna (bra-). 17:38:40.7 HOT okay? [sound similar to ACARS chime] 17:38:41.1 HOT-2 yeah. 17:38:43.8 HOT-1 there's field conditions and the METAR too.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 94 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:38:47.0 HOT-2 field condition. 17:38:49.1 HOT-1 wet poor. 17:38:50.0 HOT-2 wow. 17:38:51.0 HOT-1 can't do it. 17:38:52.3 HOT-2 I (I oh). 17:38:53.1 HOT-1 wait a minute that was ah. 17:38:55.9 HOT-2 it says ya can but I don't wanna. [sound similar to laughter] 17:38:58.2 HOT-1 what's ah thirty one center though? wet snow no clutter wet poor. 17:39:04.3 HOT-2 so that I mean it the books says you can as long it's positive but man that's whoo. 17:39:09.6 HOT-1 yeah. 17:39:15.6 HOT-2 I mean it's (what is it) thirty feet at max braking whao #.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 95 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:39:20.1 HOT-1 I know. 17:39:20.2 HOT-2 know you're good but. 17:39:25.3 HOT-2 I mean that's really tight. 17:39:29.3 HOT-1 nope 17:39:30.8 HOT-2 and then you know what's funny like if if you know we got we got that thirty feet of stopping MAX. 17:39:36.1 HOT-1 ah ha. 17:39:36.5 CAM-2 no procedure if that sucker fails when you touch down? we just go through the fence? we never talk about any of that stuff ya know? 17:39:45.1 HOT-2 er if it fails on * on landing? 17:39:47.3 HOT-1 yeah. 17:39:47.7 HOT-2 you do I tell you to go around? what you know what what if it doesn't there's no guidance on it. 17:39:53.7 HOT-1 yeah I don't know stand on the brakes?

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 96 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:39:55.9 HOT-2 maybe there is once we get in here there might be something further down the road that. 17:40:01.3 HOT-2 that tells us what to do but. 17:40:24.1 HOT-1 what's the date on this thing? 17:40:29.7 HOT-2 it's August ah. 17:40:34.9 HOT-1 what's it say ah hey where's the date? 17:40:36.3 HOT-1 November ninth oh five. 17:40:38.8 HOT-1 what is it? 17:40:39.5 CAM-2 November ninth. 17:40:41.9 CAM-1 on these revisions? 17:40:43.4 CAM-2 yeah. 17:40:43.7 CAM-1 oh yea there it is down there. 17:40:45.4 HOT-1 #.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 97 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:40:48.6 CAM-1 we haven't had it that long. 17:40:49.9 CAM-2 no. 17:41:06.9 HOT-1 where's that sucker . 17:41:11.5 HOT-2 I'm hoping that in the like the normal. 17:41:14.5 CAM-2 or in the approach it might have some guidance on it. 17:41:21.9 HOT-1 zero eight zero at ten. huh. 17:41:26.8 HOT-2 yeah it's a eight knot tailwind. 17:41:28.3 HOT-1 #. 17:41:33.4 HOT-1 let's go ah. 17:41:38.1 HOT-1 one three zero at ten. 17:41:38.3 HOT-2 I put in fair. 17:41:43.4 HOT-1 wet fair landing *. 17:41:53.0 HOT-1 close to ten knots can't do it.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 98 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:41:55.2 HOT-2 ahmm did you check in HGS? 17:42:00.4 HOT-1 no. 17:42:01.3 HOT-2 did I not take it out? 17:42:02.9 HOT-1 RVR four thousand. 17:42:06.3 HOT-1 with one three zero at ah ten. 17:42:08.4 HOT-2 oh yeah. 17:42:08.8 HOT-2 yeah with a ten knot tailwind you can't do it. 17:42:10.6 HOT-1 yeah. 17:42:11.5 HOT-2 well (do I) eh ah that's a less than four thousand thing. 17:42:15.1 HOT-2 it's like a five with anything less than with wet poor I think it's a five knot tailwind. 17:42:15.1 HOT-1 okay. 17:42:20.0 HOT-2 if it's poor you can only have a five - oh.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 99 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:42:22.0 HOT-1 that would make sense. 17:42:22.7 HOT-2 yeah. I think. 17:42:23.1 HOT-1 (they). 17:42:24.6 HOT-2 I think it is. 17:42:24.7 HOT-1 how 'bout one three zero at nine? 17:42:28.4 HOT-2 peak gust tailwind brakin' poor five knots. 17:42:33.9 HOT-1 can't do it there either. 17:42:37.2 HOT-1 so what is our? 17:42:39.9 HOT-1 you had a zero eight zero at ah. 17:42:43.8 HOT-2 eh I can throw it back up quick. 17:42:48.8 HOT-2 the I think it was. ahhh. oh. 17:42:56.1 HOT-1 Romeo wasn't it? 17:42:57.1 HOT-2 (L M) P Q R I think it was Romeo.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 100 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:43:00.4 HOT-2 zero eight zero at ten, must be right on the limit. 17:43:17.4 HOT-1 that gives us six knots a tailwind. 17:43:20.5 CAM-2 and it still says it's legal? 17:43:20.6 CTR Southwest twelve forty eight contact Indy center one tree tree point seven seven. 17:43:25.8 RDO-2 thirty three seventy seven have a great night Southwest twelve forty eight. 17:43:28.7 CTR see ya. 17:43:29.6 HOT-2 *. 17:43:34.2 CAM-1 (but) like you say. 17:43:36.6 CAM-2 that thing says five knot tailwind. 17:43:38.2 CAM-1 yeah. so really. 17:43:39.6 RDO-2 howdy center Southwest twelve forty at flight level three nine zero.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 101 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:43:42.3 HOT-2 well that's kinda scary that that doesn't save your # you know? 17:43:46.7 CTR who's that checkin' in? 17:43:47.8 HOT-1 peak gust. 17:43:48.4 RDO-2 Southwest twelve forty eight at flight level three nine zero good evening. 17:43:51.1 CTR Southwest twelve forty eight ** rog. 17:43:57.2 HOT-1 that's braking poor. 17:43:59.7 CAM-1 braking fair is ten knots. 17:44:01.9 CAM-2 yeah but the field conditions was poor. 17:44:04.4 CAM-1 yeah. 17:44:04.8 HOT-2 which means we couldn't do it anyway. 17:44:06.3 HOT-1 right. 17:44:06.5 HOT-2 well * we could but -

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 102 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:44:08.2 CAM-2 I'm my butt's gonna be squeezed so tight * you never seen a butt squeezed tighter. 17:44:11.4 HOT-1 no. 17:44:12.1 HOT-2 [sound similar to laughter]. 17:44:14.0 HOT-1 we got too much tailwind we can't do it. 17:44:15.6 HOT-2 yea with six. 17:44:16.2 HOT-1 that's our savior. 17:44:17.4 HOT-2 yup. 17:44:17.6 HOT-1 [sound similar to laughter]. 17:44:18.1 HOT-2 get another one in a few. 17:44:19.7 HOT-1 ah huh. 17:44:21.0 HOT-2 let's see. 17:44:34.9 HOT-1 well you want your own copy?

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 103 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:44:36.8 HOT-2 yeah that'd be great. 17:44:45.5 HOT-2 ah I don't feel like doin' the rest of this. 17:44:47.9 HOT-2 we got the meat 'n potatoes. 17:44:50.3 HOT-2 let's see. 17:45:13.7 HOT-2 oh there is some more stuff in here. three nine one (that's). 17:45:20.4 CAM-2 kinda gives ya the -- 17:45:21.7 CAM-1 [sound similar to violent sneeze]. . 17:45:22.7 CAM-2 bless ya. 17:45:40.6 HOT-1 alright let me look in there. 17:46:00.4 HOT-1 alright. I said I sent ah. okay what is it? (Maryland’s) I'm Midway status for zero zero five zero ETA. 17:46:07.5 HOT-2 cool. 17:46:09.0 HOT-1 sent.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 104 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:46:42.1 HOT-2 ah it says you can put clutter in but if there is clutter you can only have a twenty knot crosswind limit. which that won't be a big deal. 17:46:51.5 HOT-1 'kay. 17:46:58.7 HOT-2 I got a PC next month ha ha this is good ha ha. 17:47:00.9 HOT-1 yah hah. 17:47:02.5 CAM-1 I gotta PT. 17:47:05.8 CAM-2 select autobrakes as required here's the operational part of it. 17:47:11.7 HOT-1 'kay. 17:47:14.8 HOT-2 if it's operational it must be used. use the lowest... 17:47:19.1 CAM [sound similar to ACARS chime]. 17:47:20.0 HOT-2 ...brake level that gets you five hundred feet. 17:47:24.6 CAM-2 if neither setting results in a stopping margin of five hundred feet or more *

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 105 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:47:29.3 HOT-1 huh oh. 17:47:30.8 CAM-1 not good back to you in a minute. 17:47:32.2 CAM-2 [sound similar to laughter]. 17:47:32.5 CAM-1 [sound similar to laughter]. 17:47:39.4 HOT-2 wow it says if neither setting results in a stopping margin of five hundred feet or more landing is still authorized using MAX provided a positive (starch) stopping margin is computed. 17:48:02.4 HOT-1 what are we hurryin' to get there for then? [sound similar to laughter]. 17:48:04.9 HOT-2 yeah really. 17:48:08.7 HOT-2 uh well that I see that's in here really. 17:48:28.2 CAM-1 I'm gettin' ri- rid of all these (received messages). 17:48:30.9 HOT-2 that's cool delete delete delete.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 106 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:48:51.4 CAM-1 well let's see here our alternate happens to be Kansas City or St. Louis. 17:48:57.0 CAM-2 think ah Kansas City was a little better weather. 17:49:02.3 CAM-1 let's look. ** 17:49:04.0 HOT-2 think a St. Louis was snowin' a little bit (I mean) either way. 17:49:13.3 HOT-1 let's look a St. Louie first that's the closest. 17:49:18.8 HOT-2 oh I can show you somethin' cool in here too you probably seen it before. 17:49:28.1 CAM [sound similar to ACARS chime]. 17:49:30.2 HOT-1 alright there's St Louis. alright five miles light snow mist twenty three hundred broken forty five hundred broken. twenty five thousand broken. 'kay. 17:49:55.7 HOT-2 okay if we touch down and we get this -- where's the auto -- 17:50:02.3 HOT-1 hang on hang on a second lets ah let's sit the passengers down a little bit here.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 107 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:50:07.1 HOT-2 okay. 17:50:07.9 HOT-1 since we're gettin' in that area. 17:50:10.6 PA-2 and folks from the guys up front a few bumps [sound of single chime] seatbelts signs comin' back on so please folks if you're up (and about) head on back to your seats and buckle up thanks so much. 17:50:15.9 HOT-1 **. 17:50:20.2 HOT-1 okay. 17:50:24.8 CAM [sound similar to ACARS chime]. 17:50:26.5 HOT-1 I'm gonna sit the flight attendants down too. 17:50:27.9 HOT-2 okay. 17:50:28.7 PA-1 ah flight attendants go ahead and take your seats for a few minutes as well. folks I've asked the flight attendants to take their seats so ah make sure that you're in your seats as well seatbelts fastened thank you. 17:50:39.4 CAM-2 (yeah).

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 108 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:50:40.8 HOT-1 Kansas City is - clear I like that. cold but clear. 17:50:44.6 HOT-2 clear. woo hoo. 17:50:47.9 HOT-2 that's alright aw I wanted to do this thirty eleven fer Midway. 17:50:51.3 HOT-1 alright. 17:51:07.4 HOT-2 this one. 17:51:08.9 HOT-1 okay get that on? 17:51:09.9 HOT-2 if that pops on it says you can achieve the OPC stopping distance by applying brakes as it would do so if it comes on you just jam 'em baby and. 17:51:21.3 HOT-1 hmm kay. 17:51:22.2 HOT-2 hold on. 17:51:26.4 HOT-1 sounds good I can do that except where it says a - 17:51:27.6 HOT-2 et cetera da da tada.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 109 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:51:32.3 CAM-1 maximum thirty feet. 17:51:34.0 CAM-2 yeah that's. 17:51:34.8 CAM-1 that's outside my limits. 17:51:36.2 CAM-2 yeah. 17:51:38.1 HOT-1 that plus the tailwind. 17:51:41.4 HOT-1 wet poor tailwind. 17:51:46.6 HOT-2 eh and it says like if you want it to disarm - wow that was a nice shooting star. 17:51:50.4 HOT-1 what was it? 17:51:50.9 HOT-2 once you land. 17:51:51.8 HOT-1 yeah. 17:51:52.2 HOT-2 if you want it to disarm ah if you start pushing on the brakes and it's not letting go it says you might have to go a little further to get it to to pop off.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 110 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:52:01.4 HOT-1 okay. 17:52:01.9 HOT-2 that's about the only thing that I see in here that's different. 17:52:20.0 CAM-2 it's in my flow now so if we use it hit me or remind me to turn that stupid thing off after we land. 17:52:37.1 HOT-1 okay I'm turnin' this off. 17:52:39.0 HOT-2 alright. 17:53:01.6 CAM-1 oh boy ah uh oh oh huh. 17:53:12.9 CAM-1 let's see here checking the just for the # of it here. 17:53:18.8 HOT-2 hey know we can do? 17:53:21.5 CAM-1 last I heard that was even worse. 17:53:24.1 HOT-2 yeah I heard 'em sayin' ah. ah they asked if there was a ground... 17:53:29.0 CAM-2 ...groundhold but it wasn't a groundhold.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 111 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:53:30.8 HOT-1 just delayed. 17:53:31.0 HOT-2 they had a little bit of a delay though. 17:53:33.0 CAM [sound similar to ACARS chime]. 17:53:37.9 CAM-1 quarter mile snow freezing fog. 17:53:40.2 CAM-2 wo hoo. 17:53:40.7 CAM-1

• *.

17:53:47.8 HOT-1 ILS five right approach in use. 17:53:52.1 HOT-2 I got mine out if you don't wanna dig. 17:53:53.7 HOT-1 Indy? 17:53:55.6 CAM-1 ah take a look and see what they got there they got a HGS I think. 17:53:58.9 CAM-2 yeah I think so. 17:54:00.3 HOT-2 five five *.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 112 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:54:02.5 CAM-1 five right. 17:54:03.7 CAM-2 *. 17:54:10.8 HOT-2 ah brakin' action advisories I'll pull in the field conditions for them too and see what the the brakin' action is. 17:54:19.3 HOT-1 'kay. 17:54:22.5 HOT-2 five right CAT two and CAT three eight forty one fifty foot seven hundred RVR. 17:54:30.4 HOT-1 okay yeah. 17:54:31.8 HOT-2 we'll see what this is. 17:54:35.1 HOT-2 ahhh. 17:54:35.7 HOT-1 one forty at ten there too. 17:54:37.5 HOT-2 yeah let's do this (field) 17:54:42.2 HOT-1 crosswind.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 113 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:54:43.1 HOT-2 here's some completely useless knowledge for ya. this is great when you have two alternates. 17:54:50.9 HOT-1 one right. 17:54:55.1 HOT [sound similar to ACARS chime]. 17:54:58.0 HOT-2 I didn't mean to have it on my side (but). this thing kicks # [sound similar to laughter] it'll give ya ETA and fuel from your present position. 17:55:07.7 HOT-1 alright. how about that how'd ya do that? 17:55:11.7 HOT-2 $ showed me that a long time ago he's a great guy outta Chicago. 17:55:14.1 HOT-1 huh. 17:55:15.7 HOT-1 huh. 17:55:16.2 HOT-2 I said how the # did you learn that he said I don't know somebody else showed me. 17:55:18.7 HOT-1 ahah.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 114 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:55:22.1 HOT-1 Indy field. 17:55:24.5 HOT-1 wet good. 17:55:25.0 HOT-2 wet good see that's not a bad alter- 17:55:27.4 CAM-1 no. 17:55:27.8 CAM-2 what was the ceiling? 17:55:29.4 HOT-2 do you remember? 17:55:29.9 HOT-1 four hundred. 17:55:30.7 HOT-2 now see that's not bad. 17:55:37.4 HOT-1 and that'll keep changin huh? 17:55:40.2 HOT-2 yeah. 17:55:40.5 HOT-2 I. 17:55:41.5 CAM-2 oh let's see thought it did. 17:55:49.0 CAM-2 is it clicking down?

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 115 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:55:50.1 HOT-1 (I don't). 17:55:50.6 HOT-2 yeah it is clicking down. 17:55:50.6 HOT-1 no. 17:55:52.2 CAM-2 St. Louis just *. 17:55:58.5 HOT-1 sixty seven five fifty seven. 17:56:00.7 CAM-2 takin' an awful long time. 17:56:03.9 CAM-2 (see if we) go out (then go) back. 17:56:09.0 HOT-1 sixty six. 17:56:12.8 HOT-2 guess maybe ya go back and forth. 17:56:14.5 CAM-2 but if you go between 'em 17:56:16.4 CAM-1 the (S) changed a minute earlier. 17:56:18.3 HOT-2 it also gives you ah like the closest airports. 17:56:21.7 HOT-1 'kay.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 116 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:56:22.6 HOT-2 it's kinda cool. 17:56:23.1 HOT-1 closest one is Columbus. 17:56:25.6 CAM-1 how did ya get to that point. 17:56:27.5 CAM-2 this. 17:56:28.2 CAM-1 say I'm right here. 17:56:29.4 CAM-2 yeah. 17:56:30.1 HOT-1 you have to do it on (both)? 17:56:30.1 HOT-2 ya have to. 17:56:31.2 CAM-2 yeah. 17:56:32.3 HOT-2

• I guess you can pay fer the software but we didn't

pay for it so you gotta do like jump through a bunch of hoops. 17:56:37.6 HOT-2 hit that INIT reference page.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 117 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:56:38.4 CTR Southwest twel- twelve forty eight descend maintain flight level three eight zero. 17:56:42.7 PA-2 flight level three eight zero Southwest. 17:56:45.4 RDO-2 flight level three eight zero Southwest twelve forty eight. 17:56:47.3 HOT-2 hate when I do that. 17:56:47.3 HOT-1 (three) eight zero. 17:56:48.7 CAM-2 people in the back know we're goin' to three eight zero. 17:56:50.2 HOT-1 ha ha. 17:56:51.9 HOT-2 if ya hit ya hit this button. 17:56:56.1 CAM-2 ya get to the index wa -- 17:56:58.5 HOT [sound similar to single chime]. 17:56:59.7 HOT-1 I'm sorry say eh which one?

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 118 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:57:01.0 HOT-2 hit the INIT REF. 17:57:01.6 HOT-1 initial reference at same time 17:57:03.3 CAM-2

• you don't have to a -- [sound similar to single

chime] the only thing you have to do at the same time is. 17:57:06.6 CAM-1 delete 'em. 17:57:07.4 CAM-2 so you can just go. go to the main index page. and go to the offset mode. 17:57:13.4 CAM-1 alright. 17:57:14.0 CAM-2 and then you can you can have this guy do it er have me do it or you can do it. and then go to offset. 17:57:17.6 CAM-1 go to offset alright and then what? 17:57:19.3 HOT-2 either side you just put in any offset. (just) one right er one left er. 17:57:21.3 HOT-1 okay.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 119 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:57:23.2 HOT-1 'kay. 17:57:24.6 HOT-2 and eh ya only have to do it in one. 17:57:26.3 HOT-2 the only thing you have to do at the same time is you have to hit erase right at the same time. 17:57:30.1 HOT-1 alright. 17:57:30.8 HOT-2 eh I think if you do yours a little bit quicker it'll put 'em on yer side if you do mine like a split second quicker. I'll try to do it on-. 17:57:36.0 HOT-1 alright. 17:57:39.5 CAM-2 see now I'll put it on your side. now you can kinda play back and forth. 17:57:43.1 CAM-1 alright. 17:57:43.9 CAM-2 there'll be a test later. [sound similar to chuckle]. 17:57:49.9 HOT-1 zero zero two one huh? to Columbus. 17:57:54.5 HOT-1 it's close.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 120 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:57:56.3 HOT-2 yeah. 17:57:58.5 CAM-2 we should be able to get the new weather now. 17:58:00.3 CAM-1 just passed over. 17:58:01.3 CAM-2 the bummer is like. 17:58:02.8 HOT-2 if you click out of that 'cause you wanna see a progress page you gotta do the whole thing again to get back to it. 17:58:08.0 HOT-1 yeah. 17:58:26.1 CAM [sound similar to ACARS chime]. 17:58:27.8 HOT-1 Sierra. 17:58:30.7 HOT-2 quarter mile. can't do that. 17:58:32.5 HOT-1 can't do it. 17:58:35.6 HOT-2 see. oh.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 121 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:58:40.6 HOT-1 well if they call that quarter mile and three thousand we can do it. 17:58:44.5 HOT-2 four left two two right three one only runway open's three one center. 17:58:47.6 HOT-1 yeah. 17:59:09.1 CAM [sound similar to ACARS chime]. 17:59:10.5 HOT-2 see what that has to say. 17:59:14.5 HOT-2 wet poor wet poor no clutter wet poor. 17:59:17.4 HOT-1 yeah but its what they tell us. 17:59:19.0 HOT-2 yeah. 17:59:21.5 HOT-1 verbally that counts. 17:59:22.8 HOT-2 yup. 17:59:27.0 CAM-2 well the weather outside. [in a sing song voice].

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 122 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 17:59:28.1 CTR Southwest twelve forty eight contact Indy center one two eight point seven seven. 17:59:32.0 RDO-2 two eight seven seven you have a great night Southwest twelve forty eight. 17:59:35.1 CTR you too. 17:59:37.8 RDO-2 howdy center Southwest twelve forty eight at flight level three eight zero. 17:59:40.6 CTR Southwest twenty forty eight Indy center roger. 17:59:45.4 HOT-1 [unintelligible vocalizations]. 17:59:49.3 HOT-2

• .

18:00:23.3 HOT-2 the weather outside is frightful [in a sing song voice]. 18:00:27.2 HOT-1 the weather outside is rosey. 18:00:29.4 HOT-2 [sound similar laughter]. 18:00:30.8 HOT-1 [sound similar to humming].

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 123 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:00:31.2 HOT-2 and I -- ten thousand at AWSUM. 18:00:40.0 HOT-2 oh'right. 18:00:50.1 CAM [sound similar to ACARS chime]. 18:00:51.4 CAM-2 uh oh there he is it's your friend dispatch. 18:01:02.2 CAM-1 well alright aloha. [sound similar to laughter] alright. 18:01:05.8 CAM-2 I'll ask him how's the RVR. 18:01:53.3 HOT-1 $. 18:01:54.9 HOT-2 [sound similar to laughter]. 18:01:57.5 CAM-1

• and $. [in a sing song voice]

18:02:09.2 CAM-2 the weather outside is. [in a sing song voice] 18:02:12.7 CAM [sound similar to ACARS chime]. 18:02:14.2 CAM-2 oh oh oh oh oh oh. [in a sing song voice] 18:02:23.9 HOT-2 right now it's at fifty five hundred.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 124 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:02:27.1 CAM-2 whoo. 18:02:28.5 CAM-1 alright that's good. 18:02:30.2 CAM-2 that's is das'n zere gud. 18:03:17.3 CAM-1 da da da da da. [in a sing song voice]. 18:03:22.3 HOT-2 you working Christmas $? 18:03:23.9 HOT-1 say again? 18:03:24.5 HOT-2 you working Christmas? 18:03:25.5 HOT-1 I am working Christmas. 18:03:26.8 HOT-1 be where ya gotta be. 18:03:28.5 CAM-1 I picked it up for a guy so he could be home with his three year old and ah six year old. 18:03:33.3 CAM-2 aren't you a nice guy. 18:03:35.9 CAM-2 where ya gonna be.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 125 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:03:37.5 CAM-1 ah I just do a turn. 18:03:39.0 CAM-2 oh cool. 18:03:39.9 CAM-1 back through Baltimore unfortunately. 18:03:42.4 CAM-1 there's nothin' there. 18:03:43.4 CAM-2 yeah. 18:03:45.9 CAM-2 you're a good man. 18:03:50.8 HOT-1 hmmm. 18:04:13.8 HOT-2 do you wanna let the girls up again. 18:04:15.4 HOT-1 oh yeah. 18:04:18.0 HOT-1 yeah go ahead. 18:04:18.6 HOT-2 I'll be right back. 18:04:20.7 HOT-2 let everybody up? 18:04:21.8 HOT-1 sure.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 126 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:04:23.2 HOT [sound similar to double chime]. 18:04:28.3 INT [non-pertinent conversation between pilots and flight attendants not transcribed]. 18:05:00.7 PA-2 hey folks and from the guys up front you have a few minutes if you need to get up again ah you sure can do so * into Chicago in ah about another thirteen minutes and that's when I'll turn the seatbelt sign back on thanks so much folks a total distance two hundred twelve miles looks good to be in the gate ah touchin' down at fifty after in the gate about fifty five past. thanks so much folks. 18:05:26.3 CAM-2 alright. 18:05:28.3 CAM-1 yeah. 18:05:37.5 CAM-2 one hundred at (nine). . 18:05:45.9 CAM-2

• *.

18:05:48.3 CAM-2 vertical visibility a hundred feet. woo hoo. 18:05:52.1 CAM-1 huh.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 127 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:05:53.6 CAM-2 *. go around thrust TOGA. [sound similar to laughter] 18:05:57.6 CAM-1 yeah. 18:05:59.6 CAM-2 ah they got four right open. 18:06:05.7 CAM-2 I'll put in ah well he said it was good I'll put in fair just for # and giggles. 18:06:10.5 HOT-1 okay. 18:06:11.6 HOT-1 yeah. 18:06:13.4 CAM-1 still snowin' isn't it? 18:06:14.5 CAM-2 yeah freezin' fog. 18:06:16.8 HOT-2 which means type four on the way out. 18:06:20.2 HOT-1 yup. 18:06:23.1 HOT-2 gonna be an expensive night tonight. 18:06:24.8 HOT-1 yeah that is.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 128 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:07:35.6 HOT-1 you I don't know if I'm comfortable usin' the autobrakes * in -- 18:07:39.2 HOT-2 yeah. 18:07:39.5 HOT-1 in ah in this ah situation. 18:07:43.4 HOT-2 first time. 18:07:44.3 CAM-1 you know havin' not even seen 'em operate before and then all of a sudden go in with a. 18:07:47.9 CAM-2 yeah. 18:07:50.7 CAM-2 it's MAX now. 18:07:51.3 CAM-1 number three. 18:07:52.8 CAM-2 yeah you gotta use MAX now. 18:07:55.6 CAM-2 to get five sixty it's a eight knot tailwind. 18:08:00.9 CAM-1 #. 18:08:02.9 CAM-2 we gotta check if it's fair.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 129 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:08:06.2 CAM-1 yeah. 18:08:07.1 CTR ah Southwest twelve forty eight descend and maintain flight level three six zero. 18:08:10.7 RDO-2 flight level three six zero Southwest twelve forty eight you have any complaints about the rides in the descent? 18:08:14.9 CTR I think what's - in this area anyway its ah twenty and below are the only bad rides. 18:08:21.1 RDO-2 okay thanks alot. 18:08:23.4 CAM-2 alright. 18:08:24.5 CAM-1 three six zero down. 18:08:31.2 CAM-2 this is wet fair. 18:08:35.1 CAM-1 wet good we don't need it right? 18:08:43.1 CAM-2 there's ten. 18:08:46.2 CAM-2 can't do poor.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 130 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:08:49.3 CAM [sound similar to metallic clank]. 18:09:03.7 CAM-2 (let me make) sure nothing's broke. 18:09:05.7 CTR *** if able cross three five ah thirty miles south of Fort Wayne at maintain flight level three zero zero. 18:09:13.1 CAM-2

• (percent) *.

18:09:13.2 RDO-2 thirty this side of (Fort Wayne). 18:09:17.1 CAM-1 (stay) this side at three zero zero. 18:09:18.9 CAM-2 should be able to do that. 18:09:20.4 CAM-1 so let me put ah I've already got twenty so another ten huh? 18:09:24.5 CAM-2 thirty this side of Fort Wayne not *. 18:09:26.2 CAM-1 oh Fort Wayne. 18:09:27.2 CAM-2 yeah. 18:09:27.4 CAM-1 oh yeah that's thirty nine miles.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 131 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:09:29.4 CAM-1 there ya go. 18:09:30.5 CAM-2 'at's. 18:09:33.9 CAM-1 three zero zero. 18:09:35.0 CAM-2 (got it). 18:09:39.1 HOT-1 (it's) *. 18:09:40.6 CAM-2 (operative). 18:09:50.9 HOT-2 why does it do that? 18:09:52.6 HOT-1 hm hm. 18:09:55.0 HOT-2 sometimes they. 18:09:55.8 CAM-1 well I got sixteen miles to get down I'll just get on (down). 18:09:58.5 CAM-2 it's really crazy sometimes I don't know why (yeah). 18:10:05.7 HOT-1 I can do it.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 132 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:10:07.7 CAM-2 (maybe it) won't let you the next one *. 18:10:10.5 HOT-2 yeah I don't know why ah. 18:10:15.7 CAM-1 oh well we're gonna make it. got fourteen miles to do it. 18:10:17.8 CAM-2 yeah. 18:10:19.0 CAM-2 yup. 18:10:20.1 CAM-1 (my side) ten fifteen (we're good). 18:10:23.0 HOT-1 not a problem. 18:10:23.8 HOT-2 nope. 18:10:25.0 HOT-2 it's sure not. 18:10:27.9 HOT-2 and he said below twenty it's kinda yucky. 18:10:30.2 HOT-1 yeah that's what I heard yeah. 'kay. 18:10:33.8 HOT-1 well. why don't ya hand me the doodly bopper there for a ILS zay Z.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 133 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:10:40.8 HOT-2 Zee. 18:10:41.2 HOT-1 and ah or should say. not much difference really. 18:10:46.6 HOT-2 nah. 18:10:49.2 CAM-1 twenty May oh five eleven seven. 18:10:55.3 HOT-1 ten miles. 18:10:55.9 CAM-?

• one thousand (three).

18:11:02.4 CAM-1 one oh nine nine three fifteen inbound seventeen hundred at HOBEL that's (ten ten) eighty seven. 18:11:07.9 HOT-1 eight seventeen the decision height two hundred we'll keep in the radar altimeter. 18:11:12.2 CAM-1 six thirteen is touchdown. 18:11:26.7 CTR Southwest twelve forty eight * speed your discretion (expect) vectors * comin' out. 18:11:34.7 HOT-1 'kay.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 134 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:11:35.3 RDO-2 okay where's everybody holdin'? 18:11:39.3 CAM-1 (alright) we'll slow 'er down. 18:11:43.4 HOT-1 so anyway six thirteen touchdown ah we got the minsafes there they're at twenty eight and thirty four north. 18:11:50.0 HOT-1 ahmm. 18:11:53.0 HOT-1 we got all those special aircrew certification required we got that ah lead in REILs VASIs HIRLs RVR three one center must be operating and DME required. ahmm need three thousand RVR three degree glideslope. if we have to go missed approach it's climb to eleven hundred feet then ah climbing left turn to twenty one via heading one five zero * the PEON VOR zero zero one until crossing the IGECY. 18:11:56.6 HOT [sound similar to ACARS chime]. 18:12:00.4 CAM [sound similar to altitude warning horn]. 18:12:31.2 HOT-2 you're at thirty. 18:12:31.9 HOT-1

• intersection then climb to twenty six. fracken a.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 135 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:12:35.8 HOT-2 (I know). 18:12:36.1 HOT-1 what a #. 18:12:38.0 HOT-1 so anyway what we'll do we'll (hook) it up. if we have to go around it's ah go around thrust TOGA flaps fifteen landing gear up. 18:12:48.9 CAM-2 L-NAV [sound similar to laughter]. 18:12:50.2 CAM-1 L-NAV [sound similar to laughter]. 18:12:52.7 CAM-2 yeah # it. 18:12:53.6 CAM-1 L-NAV # it and then we'll clean it up as required okay. 18:12:56.5 HOT-2 okay. 18:12:56.9 HOT-1 you double check that get a good IDENT. 18:12:59.3 HOT-2 I'll just write it down. 18:13:00.3 HOT-1 yeah.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 136 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:13:01.1 CAM-2 and you - since you're gonna be flying it. 18:13:04.7 CAM-2 eight seventeen. 18:13:09.1 CAM-1 and. 18:13:14.0 CAM-1 we'll probably take her down the end turn off see what the weather's like. [sound similar to chuckle] 18:13:20.5 HOT-1 flaps forty. 18:13:23.0 HOT-2 MAX brakin'. 18:13:28.5 CAM-1 ('kay) hold airspeed. 18:13:36.2 HOT-2

• *.

18:13:46.0 CTR Southwest twelve forty eight direct GOSHN descend and maintain flight level two eight zero. 18:13:51.5 RDO-2 direct GOSHN flight level two eight zero Southwest. 18:13:53.7 CAM-1 direct GOSHN how's that look? 18:13:55.1 CAM-2 yeah GOSHN (you can) .

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 137 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:13:56.6 CAM-1 two eight zero. 18:13:57.7 CAM-2 okay. 18:13:58.0 CAM-1 here we go. 18:14:11.2 CAM-2 ah we have this missed in here? ah three one center eleven hundred one fifty IGECY * . 18:14:19.7 HOT-1 and all the altitudes in there good. 18:14:21.5 HOT-2 ahhh what's the eight seventeen. we need three thousand. or five (eighths). okay. that's good enough for me. 18:14:40.5 HOT-1 I'll hold around two twenty does that sound good to you? 18:14:42.8 HOT-2 sure. 18:14:43.1 HOT-1 you know actually I don't need this anymore. 18:14:44.9 HOT-2 you don't need it? 18:14:46.1 HOT-1 I don't believe so.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 138 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:14:47.2 HOT-2 okay. 18:14:49.5 CAM-1 see. 18:14:52.9 CAM-2 I looked in the NOTAMS on the on the ATIS and it didn't say anything was out. 18:14:56.5 CAM-1 okay good. 18:14:57.1 CAM-2 it looks like all that stuff . 18:14:59.2 CAM-1 'kay. 18:14:59.5 CAM-2 if you want it 'cause you're flyin' it's cool I wrote it down. 18:15:01.6 HOT-1 no you need you need it. yeah you need it there. 18:15:03.9 HOT-2 okay. 18:15:04.2 HOT-1 I'm good with it. 18:15:05.1 HOT-2 okay. 18:15:05.5 HOT-1 I trust ya.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 139 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:15:06.3 HOT-2 whatever makes you happy I don't care. twenty nine twenty eight. 18:15:10.6 HOT-1 twenty nine twenty eight. 18:15:12.1 HOT-2 how we doin' here? 18:15:13.1 CAM [sound similar to altitude warning horn]. 18:15:14.9 CAM-?

• * .

18:15:47.2 CAM-1 and I think as far as the autobrakes go. 18:15:49.6 HOT-1 I think I will use ah manual braking. 18:15:53.8 CAM-? *. 18:15:54.7 HOT-1 yeah. 18:15:55.3 HOT-2 (okay). 18:15:55.3 HOT-1 we'll try 'em into Vegas. if that's alright with you. 18:15:59.7 HOT-2 do you really wanna?

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 140 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:16:01.0 HOT-1 huh? 18:16:01.5 HOT-2 you really wanna? 18:16:03.0 CAM-1 you want to try 'em into Midway? 18:16:04.9 CAM-2 I know they work better than we do at least that's what my buddy told me. he said they kick ass. like you'll be when you land in MAX you it it is gonna get maximum braking out of the aircraft. 18:16:14.8 CAM-1 yeah. 18:16:17.5 CAM-1 I you know I just I don't know I don't know what to do. like if it starts to and it starts. 18:16:18.8 CAM-2 [sound similar to laughter]. 18:16:25.4 CAM-2 yeah. 18:16:25.9 CAM-1 takin' us off course ya know? 18:16:27.7 CAM-2 yeah. 18:16:28.1 CAM-1 then I gotta come in ah brake it.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 141 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:16:31.1 CAM-1 I guess. 18:16:31.9 CAM-2 I *. 18:16:32.1 CAM-1 let me think about maybe we can do it. 18:16:34.1 CAM-2 eh I would be cool with whatever your decision is. 18:16:36.7 CAM-1 okay. 18:16:37.9 CAM-2 fine. 18:16:39.4 CAM-1 it's the old guys fear of. 18:16:41.3 CAM-2 [sound similar to laughter]. 18:16:42.1 CAM-1 [sound similar to laughter]. 18:16:42.5 CAM-2 they say it's better it's better than we could ever be. 18:16:45.4 CAM-1 yeah okay. 18:16:46.1 CAM-2 but that's cool I will you know what I'll be happy with whatever you decide.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 142 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:16:49.4 HOT-1 well keep talkin' I I I guess we could do it let's let's see what the conditions are up there. we'll do it. 18:16:58.7 HOT-1 if you're comfortable with that I am too. 18:17:00.8 CAM-2 I will be happy with whatever you decide. 18:17:08.3 CAM-1 if it goes to ah autobrake. 18:17:10.8 CAM [sound similar to ACARS chime]. 18:17:11.3 CAM-1 eh uh oh. 18:17:14.9 CAM-2 then you just jump on it as hard as you can. 18:17:17.0 HOT-1 yup. 18:17:19.5 CAM-2 if I'm not already there for ya. [sound similar to laughter] 18:17:21.2 HOT-1 yeah. 18:17:23.3 HOT-2 hey it's bumpy.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 143 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:17:24.5 CAM-2 Pennsylvania New Jersey Ohio Indiana Wisconsin my # Detroit. eastern Kentucky western Kentucky West Virginia Virginia. 18:17:34.3 HOT-2 code three one eight oh to three two oh. 18:17:37.8 HOT-1 'kay. 18:17:38.2 HOT-2 mostly below thirty. 18:17:45.7 HOT-2 well the weather -- [in a sing song voice] 18:17:46.6 HOT-1 the other part of my briefing is. 18:17:49.0 HOT-2 *. 18:17:49.4 HOT-1 on this day If we're all together here. if. sometimes when we do a descent checklist you know we're so far out that ya switch things around a little bit. 18:17:57.6 HOT-2 oh.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 144 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:17:58.0 HOT-1 so if I'm ever in a position down there and I'll do the same for you. on approach or whathaveyou and you would normally have the localizer course in or the frequency in and and I don't have it in there say sumpin'. 18:18:07.4 HOT-2 okay. 18:18:11.1 HOT-2 and ah you can't hurt my feelings you can try if I'm not doin' what - . 18:18:12.9 HOT-1 [sound similar to laughter]. 18:18:14.2 CTR Southwest twelve forty eight turn right heading three five zero for sequence maintain, two hundred and fifty knots. well what are you doing right now actually for knots? 18:18:23.2 HOT-1 two ten. 18:18:23.8 RDO-2 we're slowed to two ten we're heading right to three fifty for Southwest twelve forty eight. 18:18:27.6 CTR and Southwest twelve forty eight you can keep your current airspeed fly heading three five zero they're out of the hold they gotta sequence you now.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 145 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:18:33.0 RDO-2 okay great three fifty heading and two ten Southwest twelve forty eight. 18:18:38.4 CAM-1 two fifty heading. 18:18:39.3 CAM-2 if I'm not doin' what you asked me to do it's not because I'm disobeying you it's 'cause I'm stupid and so sometimes this this is the most effective thing that ya ha ha. 18:18:49.7 CAM-1 well sometimes I might not hear ya. 18:18:51.6 CAM-2 [sound similar to laughter]. 18:18:54.5 HOT-1 ya can't hurt my feelings by yelling. 18:18:56.1 HOT-2 you can feel free to smash me right over the head with that thing. 18:18:58.5 HOT-1 yeah. 18:19:02.0 CAM-1 now we're gonna pick up some speed. 18:19:03.7 CAM-2 yeah.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 146 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:19:05.9 CAM-2 I told you two ten not three ten. 18:19:08.0 CAM-1 uhuh. 18:19:08.4 CAM-2 [sound similar to laughter]. 18:19:10.8 CAM-1 alright three five zero come on baby. what's the story here? 18:19:14.3 CTR Northwest twelve forty correction Southwest twelve forty eight descend and maintain flight level * five zero. 18:19:19.7 RDO-2

• level two five zero Southwest twelve forty eight.

18:19:22.1 HOT-1 alright two five zero there we go. 18:19:23.6 CAM-1 go ahead and . 18:19:25.0 CAM-2 yeah. 18:19:27.7 HOT-1 five zero. 18:19:28.4 HOT-2 (three) fifty (now). 18:19:29.3 CAM-1 down to a two five.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 147 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:19:30.4 CAM-2 alright. 18:19:31.3 CAM-2 I'm gonna sit 'em down. . 18:19:32.9 CAM-1 okay yeah yeah. sounds good.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 148 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:19:36.4 PA-2

• * startin' our very gradual descent into Chicago

Midway airport [sound similar to single chime] ah seatbelt signs comin' back on so folks please if you're up and about head on back to your seats * for the duration. there's only a hundred and twenty three miles between us and the airport. ah that's the good news get our sequence into arrival * into Chicago ah out of the east a ten miles an hour ah low visibility due to on and off light snow and it's very chilly it's only twenty five degrees. folks again ah * this evenin' ah we sure do appreciate all your patience and understanding and all and we welcome you to Chicago folks if you're continuing ah da ah Las Vegas and then ah finally to Salt Lake City with us we're gonna be on the ground in Chicago hopefully for only about twenty five minutes and we're gonna get you (safely on your way) yeah folks thanks so much for your patience and understanding tonight (and we hope) everybody has a wonderful night on your way home buckle up drive safely and next time you're gonna go flying we'd sure love for you to come back and see us again here at Southwest thanks so much folks good night. 18:20:23.8 CTR Southwest twelve forty eight turn left heading three one zero. 18:20:27.6 RDO-1 three one zero Southwest ah twelve forty (eight).

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 149 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:20:48.7 HOT-1 down ta two four zero now. 18:20:50.3 HOT-2 twenty four I am back. 18:20:52.5 HOT-? 'kay. 18:21:04.2 CAM-2 try try to grab a gate. 18:21:06.4 CAM-1 okay. 18:21:06.6 CAM-2 I'll be right back. 18:21:07.8 CAM-1 we won't have one. 18:21:08.9 CAM-2 yeah. 18:21:09.6 CAM-1 [sound similar to laughter]. 18:21:09.6 RDO-2 hey Midway Twelve forty eight. 18:21:13.8 OPS twelve forty eight go ahead. 18:21:16.2 RDO-2 we're not on time I guess you probably knew that by now though we're gonna be there around fifty with thirteen eight.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 150 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:21:23.8 OPS okay your gate is Alpha eleven A eleven with gate services. 18:21:28.2 RDO-2 A eleven with the service ah you think it's gonna be open? 18:21:31.7 OPS ah yeah I mean the visibility is better ah the last one we had ah the braking action was was fair snow covered taxiways that's the last report I have. 18:21:40.7 RDO-2 it was fair you said? 18:21:42.1 OPS ah that's the last flight that came into Chicago that's how he reported it. 18:21:46.3 OPS okay thanks eh and I I meant d-do you know if eleven gonna be open? 18:21:46.7 CAM-1 she doesn't know, she doesn't know. 18:21:50.7 OPS ah yes it will. 18:21:52.0 RDO-2 great. 18:21:52.2 HOT-2 thanks.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 151 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:21:53.1 RDO-2 thank you. 18:21:54.4 CAM-2 yeah [sound of chuckle] we oughta get a little better report than hers. 18:21:58.0 CAM-1 well our. 18:22:00.5 HOT-2 she made it sound like there hasn't been anybody that landed for a while. 18:22:02.8 HOT-1 yeah our twenty one year old at at a a operations said it was poi fair. 18:22:07.9 CAM-2 [sound similar to laughter]. 18:22:08.5 CAM [sound similar to altitude warning horn]. 18:22:09.0 CAM-2 whaddya mean we did sumpin' wrong? 18:22:10.1 CAM-1 twenty four nine twenty four. 18:22:14.8 CAM-2 twenty four nine is twenty four. 18:22:23.7 CAM-1 Alpha eleven.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 152 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:22:25.2 CAM-2 yeah. 18:22:25.5 CAM-1 that's right way the # over there. 18:22:26.2 CAM-2

• *.

18:22:27.1 CAM-2 horrible Potbellies . 18:22:29.6 CAM-2 ah it's not so bad. 18:22:30.4 CAM-1 it's not so bad. 18:22:32.0 CAM-1 somebody had the number. 18:22:34.7 CAM-1 let me (ask 'em) * there. 18:22:40.1 CAM-1 what are you going to have? 18:22:41.7 CAM-2 ahhh. 18:22:44.9 INT-1 hello. 18:22:45.9 INT-1 hey you guys got the number to Potbellies? 18:22:48.2 FA no.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 153 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:22:49.7 INT-1 why not? 18:22:50.6 FA I don't know. 18:22:51.6 FA do you have the number to Potbellies? 18:22:53.5 FA (bummer) (good job) (I don't know how) * (I can't believe it). [sound similar to laughter] 18:22:53.9 CTR Southwest twelve forty eight cleared direct GOSHN

• * at two hundred and ten knots.

18:22:59.5 RDO-2 kay two hundred ten knots direct GOSHN Southwest *. 18:23:02.8 INT-1 ya don't have it. 18:23:03.8 FA nooo. 18:23:04.7 INT-1 okay well we'll just have ta we're goin' to A eleven. 18:23:12.0 CAM-1 direct GOSHN. 18:23:12.8 CAM-2 direct GOSHN two ten she said still .

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 154 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:23:16.3 INT-1 oh well all right we'll see ya later. bye. 18:23:17.3 FA *. 18:23:28.5 CAM-1 two ten. 18:23:33.6 RDO-2

• * Southwest twelve forty eight.

18:23:40.4 RDO-2 ...two hundred and ten knots. 18:23:41.9 CTR

• twelve forty eight * confirmed good evening descend

and maintain one six thousand and altimeter three zero one three. 18:23:49.3 RDO-2 Southwest twelve forty eight do you still *. 18:23:52.1 CTR ah now ah what do you wanna do? *. 18:23:55.3 CAM-1 (I don't know). 18:23:58.7 CTR ...how 'bout two fifty or less (from now)? 18:24:00.2 CAM-2 okay. 18:24:02.6 CAM-1 two fifty or less.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 155 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:24:06.9 CAM-1 okay sir we're goin' down to one six thousand. 18:24:09.8 CAM-2 (sixteen). 18:24:13.8 CAM-1

• slowly picked up speed.

18:24:15.4 CAM-2 ohhhh. 18:24:19.4 HOT-2 nice night up here. 18:24:41.9 HOT [sound similar to ACARS chime]. 18:24:43.6 HOT-2 Tango. 18:24:43.9 HOT-1 Tango another new one huh? 18:24:45.8 HOT-2 quarter snow freezin' fog hundred feet. 18:24:48.2 HOT-1 oh well. 18:24:51.8 HOT-1

man.

18:24:53.1 HOT-2 three thousand feet what's * . 18:24:57.1 HOT-1 [sound similar to laughter].

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 156 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:24:58.4 HOT-2 snow (inch) three ninths? 18:25:01.0 HOT-1 I don't know. 18:25:03.3 HOT-1 snow NCR? 18:25:04.6 HOT-2 [sound similar to laughter]. 18:25:07.9 HOT-1 what's that mean? 18:25:08.7 HOT-2 [sound similar to laughter] # if I know. 18:25:10.3 HOT-1 snow increasing. 18:25:12.2 HOT-2 snow increasing. 18:25:16.1 HOT-1 three to nine four to nine. 18:25:18.8 HOT-2 [sound similar to laughter]. 18:25:28.7 CAM-1 one hundred at nine? 18:25:30.7 CAM-2

I don't know.

18:25:31.4 CAM-1 alright anti-ice comin' on.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 157 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:25:40.1 CAM-2

• three thousand RVR *.

18:25:42.5 CAM-1 that what it says? 18:25:43.6 CAM-2 three thousand feet ah yeah. 18:25:44.9 CAM-1 oh three thousand feet. 18:25:46.7 CAM-2 snow increasing. 18:25:56.7 HOT-2 uh. hey now. 18:25:58.6 CTR Southwest twelve forty eight you can resume normal airspeed and cross AWSUM at and maintain one zero (ten) thousand. 18:26:04.2 RDO-2 Normal speed AWSUM at ten Southwest twelve forty eight. 18:26:07.5 HOT-2 AWSUM at ten. 18:26:08.5 CAM-1 'kay. got it AWSUM at ten. 18:26:13.3 HOT-1 well lets see. we aren't there yet. at eighteen but.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 158 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:26:33.9 CAM-1 nice. 18:26:46.4 CAM-2

• (it) up here *.

18:26:48.4 CAM-1 yeah. 18:26:49.9 CAM-1 ahhh (pickin') some out there. don't ya get the lights on there for a second. 18:26:54.4 HOT-2 you got it. 18:26:56.2 CAM-2 little bit. 18:26:56.9 CAM-1 eh let's put it on. 18:26:58.0 CAM-2 alright. 18:26:58.8 HOT-1 there we go. 18:27:11.7 HOT-2 one hundred and nine is a eight knot tailwind so if anybody says poor. we can't do it. 18:27:18.1 HOT-1 yeah. 18:27:22.9 HOT-1 it's comin' off it's comin' on.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 159 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:27:27.5 HOT-1 haven't gotten any on the outside on the very eh outer edge do we? 18:27:31.4 HOT-2 ah vee looks like ah on top -- 18:27:33.9 HOT-1 I mean we have it there but we don't have any anti- ice on there. 18:27:36.0 HOT-2 (anti-) no no. 18:27:38.8 HOT-2 not there the tail. bummer. 18:27:40.3 HOT-1 eh. 18:27:45.8 CTR

• three Kilo Fox forty eight they are plowing the

runway at Midway now so the next sector is in the hold you can expect to hold on the next frequency reaching one zero thousand slow to two hundred and fifty knots. 18:27:50.8 CAM-2 uh oh. 18:28:09.1 CAM-1 hmm. 18:28:09.2 CTR Southwest twelve forty eight reaching one zero thousand maintain a speed of two five zero.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 160 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:28:10.3 CAM-2

• *.

18:28:13.9 RDO-2 'kay two fifty knots at ten thousand Southwest twelve forty eight. 18:28:18.1 HOT-1 two fifty at ten. 18:28:21.6 HOT-1 'kay. 18:28:23.4 HOT-2 what do we say thirty thirty oh nine when we get there. 18:28:24.0 HOT-1 we can do that. 18:28:27.5 HOT-1 alright lets do it thirty oh nine 18:28:35.2 HOT-1 wow. 18:28:42.3 CAM-1 well let's see what kinda lights we got here and a descent check please. 18:28:46.8 CAM-2 altimeters and bugs. 18:28:48.8 HOT-1 well eight seventeen and ah altimeters and bugs set and crosschecked.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 161 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:28:54.6 HOT-2 Vref and target. 18:28:56.4 HOT-1 whadda we got here? 18:28:58.1 HOT-2 twenty. 18:28:59.3 HOT-1 we have -- 18:29:00.0 CTR Southwest twelve forty eight expedite your descent to one zero ten thousand please. 18:29:04.0 RDO-2 'kay we'll hurry down to ten Southwest twelve forty eight. 18:29:08.2 CAM-1 hurryin' down. alright let me see ah one twenty five one thirty? 18:29:13.0 CAM-2 yeah. 18:29:23.6 CAM-1 alright. 18:29:25.7 HOT-1 twenty five thirty set. 18:29:27.1 HOT-2 autobrake. [sound similar to laughter]

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 162 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:29:29.3 HOT-1 alright four ah three four? 18:29:31.3 HOT-2 four. 18:29:31.9 HOT-1 four. 18:29:32.4 HOT-2 the big boy. 18:29:33.3 HOT-1 four for now. 18:29:34.6 HOT-1 set #. 18:29:36.5 HOT-2 [sound similar to chuckle] hey to get there you have to pull it out. 18:29:39.0 HOT-1 alright. 18:29:40.3 HOT-1 that's what she said. 18:29:41.2 HOT-2 [sound similar to laughter] *. 18:29:43.8 HOT-1 are auto. 18:29:45.7 HOT-2 start switches.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 163 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:29:46.5 CAM-1 are continuous. 18:29:48.2 CAM-2 and a recall. 18:29:50.3 HOT-1 clear. 18:29:51.3 HOT-2 Alpha eleven. 18:29:53.0 CAM-1 alright. 18:29:55.6 HOT-2 descent check is complete. 18:30:02.1 HOT-1 oh no. 18:30:02.1 HOT-2

• * Elmo.

18:30:03.4 HOT-1 uh oh. 18:30:08.3 HOT-1 hm hm I don't like Elmo. 18:30:10.9 CAM-2 (usually) what follows Elmo. [sound similar to chuckle]. 18:30:10.9 CAM-1 Elmo's good.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 164 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:30:14.6 CAM-2 is a da da da da I got a four year old I love Elmo. 18:30:19.8 CAM-1 yeah Elmo's good. that respect. 18:30:22.5 HOT-2 how many kids did you have. 18:30:23.7 CAM-1 I have three ah --. 18:30:25.6 CTR -- two five zero. 18:30:27.0 HOT-1 two five zero. 18:30:27.2 RDO-2 heading two five zero Southwest twelve forty eight. 18:30:29.6 HOT-1 I have uhm. 18:30:33.2 CAM-1 yeah three children and two grandchildren. 18:30:37.5 HOT-2 two grandkids any more grandkids on the horizon? 18:30:39.9 HOT-1 nah not yet. 18:30:41.0 HOT-2 yeah. 18:30:41.8 CAM-1 although my oldest son got just got married so.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 165 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:30:44.9 HOT-2 ah that's cool. 18:30:45.4 HOT-1 and ah he (he) been married a little over a year so they're thinkin' about it. (they) weren't thinkin' about it before but they are now. 18:30:49.6 HOT-2 I. 18:30:51.0 HOT-2 yeah. 18:30:52.1 CAM-2 I never told the girls to sit either. 18:30:54.6 CAM-1 well * I know I haven't told 'em to clean up yet. 18:30:57.8 CAM-2 yeah. * too. 18:31:01.7 HOT-? *. 18:31:03.4 PA-1 ah flight attendants take your seat if you haven't already just keep your seats 'till we let ya up thanks. 18:31:19.8 HOT-1 well we're hurryin' down. 18:31:21.0 CAM-2 yeah.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 166 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:31:23.0 CAM-1 on the heading now. 18:31:29.4 HOT-1 (looks) good out there. 18:31:33.3 HOT-1 well let's see let's try it we'll turn it off turn the wing off for a minute. 18:31:37.6 HOT-2 looks pretty clean to me. 18:31:39.0 HOT-1 alright and then we'll look back a little bit later. 18:31:41.9 HOT-2 (go). 18:31:47.9 HOT-1 I don't want the people back there seein' it. 18:31:49.8 HOT-2 ah don't blame ya. 18:32:06.5 HOT-1 (that's) a little better. 18:32:07.8 HOT-2 yeah not too bad. 18:32:15.8 HOT-1 little bit of stuff out there uh? 18:32:17.5 HOT-2 yeah.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 167 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:32:28.2 HOT-1 let's see. 18:32:31.1 HOT-1 eh its stayin' off. 18:32:32.1 HOT-2 yeah much better than before. 18:32:35.6 HOT-2 eleven for ten. 18:32:37.4 HOT-1 eleven for ten. 18:32:40.7 HOT-1 huh huh huh. 18:32:43.1 HOT-2 zero three two. 18:32:59.0 CTR Southwest twelve forty eight maintain a speed of two five zero knots and contact Chicago center one three two point niner five goodnight. 18:33:05.1 RDO-2 two fifty and thirty two ninety five you have a good night too Southwest twelve forty eight. 18:33:11.2 RDO-2 hello Chicago Southwest twelve forty eight just levelin' a fifty .

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 168 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:33:17.1 CTR

• Midway altimeter (three) zero zero * and I have

holding instructions advise when you're able to copy. 18:33:22.7 RDO-2 thirty oh seven go ahead. 18:33:24.6 CTR Southwest twelve forty eight you're cleared to the LUCIT intersection via direct hold southeast as published expect further clearance zero zero five five and now maintain one zero thousand. 18:33:37.8 RDO-2 okay LUCIT hold southeast as published zero zero five five can you spell the fix for us? 18:33:38.3 CAM-1 spell it. 18:33:43.1 CTR and ah Southwest twelve forty eight LUCIT intersection is Lima Uniform Charlie India Tango ah and ah one zero mile DME (right) there . 18:33:52.3 RDO-2

• *.

18:33:58.2 CAM-2 (LUCIT). 18:33:59.8 CAM-1 LUCIT huh? one zero miles. 18:34:02.3 CAM-2 L-U-C.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 169 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:34:03.3 CAM-1 how ya spell it L? 18:34:05.3 CAM-2 L-U-C-I-T. 18:34:09.6 CAM-1 C-I-T. 18:34:14.0 CAM-2

• (to go).

18:34:14.2 CAM-1 forty three miles away. 18:34:15.5 CAM-2 (we're) okay. 18:34:16.9 HOT-2 so we can go direct to there. 18:34:18.3 HOT-1 alright and then we can hold there if you would set that I'm gonna put us LNAV into LUCIT. 18:34:41.6 CAM-2 so here's the Boiler Two. 18:35:08.7 CAM-1 alright can you (hit) that? 18:35:10.4 CAM-2 yeah. 18:35:11.4 CAM-1 I got LUCIT down here.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 170 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:35:13.9 CAM-2 hold. LUCIT 18:35:15.5 CAM-1 there ya are grab it. 18:35:16.9 CAM-2 southeast one fifty six outbound. 18:35:22.1 CAM-1 'kay. 18:35:22.6 CAM-2 right turns. ten DME legs. 18:35:23.8 CAM-1

• * okay.

18:35:28.3 CAM-2 zero zero five five. 18:35:42.2 HOT-1 'kay there it is then. 18:35:43.4 RDO-2 (Indy) Center Southwest twelve forty eight. 18:35:47.6 CTR ah Southwest twelve forty eight go ahead -- 18:35:49.2 RDO-2

• as well LUCIT you want us to hold as published

on the Boiler Two arrival? 18:35:54.2 CTR ah yes sir that is correct *...

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 171 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:35:56.8 RDO-2 ... * west twelve forty eight. 18:35:59.6 CAM-1 yup. 18:36:00.8 CAM-2

• we weren't on that arrival I mean you they kinda

give ya. 18:36:03.9 CAM-1 right turn is that the arrival LUCIT there? 18:36:06.6 CAM-2 yeah yeah. 18:36:07.3 CAM-1 okay. 18:36:07.8 HOT-2 I I'll back it up too for ya inbound the Chicago Heights fourteen two. and it is three thirty six inbound. 18:36:14.9 HOT-1 uhmm best speed is two oh seven but he gave us he gave two fifty didn't he? 18:36:18.8 HOT-2 yeah I'll ask him too. 18:36:20.3 RDO-2 hey center Southwest twelve forty eight. 18:36:22.1 CTR Southwest twelve forty eight go ahead.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 172 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:36:23.6 RDO-2 can we slow down as well? 18:36:25.0 CTR ah yes sir airspeed at your discretion sir. 18:36:27.5 RDO-2 okay thanks a lot. 18:36:28.9 RDO-2 you think the fifty five will be hard time? 18:36:32.6 CTR ah right now my understanding is ah they're just clearin' the runway and ah I should get an update here shortly it looks like I've got ah three jets from the west ah just starting to go in at this time. 18:36:45.4 RDO-2 okay thanks a lot and after we exit the hold do you want us to set the box up for the Boiler Two? 18:36:52.1 CTR ah yes sir that would be correct ahm ah it'll be right around (Midway). 18:36:56.2 CAM-1 okay good. 18:36:56.9 CAM-2 ** (thank you much). 18:36:59.0 CAM-1 alright very good.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 173 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:37:00.3 CAM-2 that's cool. I'll save that one ah ah little holding action. 18:37:02.0 CAM-1 alright. 18:37:11.1 HOT-2 L-U. 18:37:14.0 CAM-1 alright. 18:37:15.2 HOT-1 (can you) monitor the -- I'm gonna I'll talk to the folks real quick. 18:37:21.2 HOT-2 okay *.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 174 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:37:24.0 PA-1 well folks you've probably felt that ah we've slowed here ahm we're gonna have to hold here for about ah twenty minutes it looks like ah 'till they clear the runway off they've been off and on doing that ah as we've been flying into Chicago to get the braking action ah such that we can land. so ah it's still snowing so ah the plows are workin' on the runway we're gonna hold and let 'em do their job and then ah and then ah once they ah get then we'll be heading into Chicago so they gave us a fifty five after the hour expected approach clearance time and ah that's when we expect to ah leave the holding pattern and head to (Chicago) *. 18:38:12.3 FA ladies and gentlemen we are ah (about to make our) final approach into Chicago * make sure your seatbelts are fastened lean forward and press the silver button * ... 18:38:14.1 HOT-2 fer ah alternate forty seven. seventy seven. like eight thousand would be as low as you we could go that's probably what he's figuring out. maybe eight five hundred be extra *. 18:38:28.9 HOT-1

• ETA zero zero four three eh? alright then we'll have

about ah twelve minutes in the fix eleven twelve. ten thousand feet.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 175 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:38:42.0 HOT-2 we got a lot a extra gas so that's not. 18:38:43.6 HOT-1 got enough gas ah holding (avail) at one plus fifteen *. 18:38:46.8 CAM-1 before we go to. 18:38:56.6 CAM-2 (where we goin') to Kansas City? 18:38:59.5 CAM-1 (let's see our worst run) Kansas City. 18:39:02.0 CAM-2 we need ah . 18:39:08.6 CAM-2 just (checking) *. 18:39:17.6 CAM-1

• (thrown it away).

18:39:19.3 CAM-2 huh. 18:39:48.1 HOT-2 yeah. 18:40:15.9 CAM-1 well let's take a peek here. 18:40:17.3 CAM-2 yeah I (knew) while you were talkin'.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 176 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:40:18.4 CAM-1 eh it's still good. 18:40:19.7 CAM-2 yeah. 18:40:32.9 CAM-1 got us holdin' all over the place. 18:40:34.5 CAM-2 yeah. 18:40:42.3 HOT-1 alright what so us comin' in this way whaddya think it's gonna do? 18:40:46.7 CAM-1 left turn isn't it? 18:40:47.0 CAM-2 well let's see. 18:40:49.5 CAM-1 parallel? 18:40:50.1 CAM-2 outbound. (it is) one fifty six so it should be. right turn. parallel. 18:41:01.7 HOT-1 so right turn you think? then the seventy? 18:41:03.8 HOT-2 yeah should turn.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 177 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:41:04.6 CTR Southwest twelve forty eight expect further clearance zero one one five. 18:41:08.5 RDO-2 zero one one five thank you. 18:41:10.7 HOT-1 alright zero one one five now. #. 'kay. 18:41:17.9 CAM-2 I think it's gonna go. 18:41:20.1 CAM-1 right? 18:41:20.7 HOT-2 right turn so right now left should be a parallel it's gonna turn left there. 18:41:22.2 HOT-1 whadda we got here oh he's telling' us what we're gonna do. 18:41:27.0 CAM-1 yeah that’s gonna be my guess. 18:41:27.1 CAM-2 (should) should turn left to one fifty six. 18:41:30.2 CAM-1 there ya go look at it. 18:41:31.5 CAM-2 do another lap.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 178 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:41:32.3 CAM-1 ha ha ha. 18:41:33.8 CAM-1 I love it. 18:41:34.6 CAM-2 that’s cool. 18:41:38.1 CAM-2 the map this is this is such a great deal. man 18:41:40.1 CAM-1 yeah aw yeah. 18:41:44.4 HOT-2 such a great great great aw hey (let's see) ATIS Golf quarter mile and snow Indy is not a good idea. 18:41:45.1 HOT-1 I'm slowin' her down a little here. 18:41:51.7 HOT-1 naw Indy's not good. 18:41:53.4 CAM-2 so MCI? MCI was better right? 18:41:56.7 CAM-1 STL? 18:41:58.4 CAM-2 MCI? 18:41:59.0 CAM-1 yes MCI was great but that's a ways away.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 179 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:42:01.7 CAM-2 how much further though? 18:42:17.1 HOT-1 there he is. 18:42:17.6 HOT-2 (they're at nine). 18:42:22.0 CAM-2 (they're not). 18:42:33.8 HOT-2 nine miles at St Louis. 18:42:36.3 HOT-1 ah that's good. 18:42:37.2 HOT-2 yeah. 18:42:38.6 HOT-2 thirty right. 18:42:40.5 HOT-1 yeah we can do a St Louis that'd be best. 18:42:40.7 HOT-2 let's do this S-T-L. 18:42:44.9 HOT-1 two hundred five miles. 18:42:45.3 HOT-2 two oh five.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 180 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:42:47.0 HOT-2 well let's do this wa how many we don't really have two much time forty three. 18:42:49.9 HOT-1 ah let's just enter here. 18:42:51.1 HOT-2 I was gonna put in the # again but. two oh five so really. really this is even extra cautious 'cause I'm sure the alternate gas is all the way to Kansas City. 18:43:02.2 HOT [transients and sounds similar to telephone keypad touchtone]. 18:43:03.8 HOT-? *. 18:43:04.7 HOT-2 so if we did like eight or eighty five hundred we'd still have plenty ah gas to go. 18:43:09.3 HOT-1 yeah what does it say we're gonna go over there at? 18:43:12.1 HOT-2 forty seven and thirty two, seventy nine. plus whatever your fudge factor is. 18:43:21.3 CAM-1 'kay. 18:43:22.8 CAM-2 forty seven and then ah reserve.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 181 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:43:24.5 CAM-1 oh yeah yeah. 18:43:31.4 CAM-2 seems like they're startin' to get 'em goin'. 18:43:33.2 HOT-1 yeah. 18:43:38.5 HOT-2 you're gonna make some extra money tonight. 18:43:40.6 HOT-1 yeah. 18:44:03.2 HOT-1 here we go. 18:44:04.1 RDO-2 Southwest twelve forty eight's enterin' the hold at LUCIT ten thousand. 18:44:08.8 CTR Southwest twelve forty eight ah roger thanks. 18:44:12.8 HOT-2 my pleasure. 18:44:35.0 HOT-2 it shoulda showed right turn. 18:45:13.6 CAM-2 diversion plan uplink. wow. 18:45:18.5 CAM-2 eight point * point five so that's pretty about what we figured.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 182 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:45:23.0 CAM-1 that's to go where St. Louis? 18:45:24.6 CAM-2 yea that's pretty cool. 18:45:25.7 HOT-1 alright. 18:45:26.5 HOT-1 where did you get that? 18:45:27.7 CAM-2 it just said it on the bottom its. 18:45:29.1 HOT-1 huh. 18:45:30.7 CAM-2 'kay. 18:45:31.1 HOT-2 so I guess we accept. 18:45:36.0 HOT-1 hmm. 18:45:36.8 CAM-2 Detroit must be # too. 18:45:44.3 HOT-2 that'd be a lot closer too. 18:45:46.6 HOT-1 hmm oh yea some weather out here. 18:45:52.3 HOT-2 how we doing.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 183 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:45:52.4 HOT-1 the weather... thank you. the weather out here is rosey. 18:45:55.0 HOT-2 ohp sorry. 18:45:55.9 HOT-1 still good uh? 18:45:56.7 HOT-2 yea looks real good. 18:45:59.3 HOT-2 oh the weather out -- here's Detroit. 18:46:03.9 HOT-1 [sound of whistling]. 18:46:03.9 HOT-2 a one and a half. 18:46:08.2 HOT-1 light snow there. 18:46:09.7 HOT-2 yeah (fourteen it may not send it). 18:46:10.6 HOT-1 did they send that to us too? 18:46:12.0 HOT-2 no I just typed that in. 18:46:13.1 HOT-1 okay

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 184 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:46:15.3 HOT-2 light to moderate rime. 18:46:16.3 CTR and Southwest twelve forty eight ah are you flyin' inbound ahm on the Chicago Heights one fifty (*) radial ah right hand turns or do ya are you set up for somethin' else. 18:46:27.1 RDO-2 uh that that’s what we're set up for we're doin' a parallel entry so we're gonna make a left turn back to the fix in about four more miles. 18:46:35.1 CTR Southwest twelve forty eight roger thanks. 18:46:41.8 HOT-1 very good. 18:46:42.6 HOT-2 we're not doin' a parallel the mighty box is. 18:46:45.1 HOT-1 yeah. 18:46:47.7 HOT-2 I always check and I hate when they give you fixes that aren't on your route because then you gotta go diggin' through the charts to see how they're depicted. It would be easier if they just gave you the whole instruction. 18:46:52.2 HOT-1 yeah. yeah.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 185 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:47:01.9 HOT-1 here we go. 18:48:01.6 HOT-1 this is awesome. 18:48:02.7 HOT-2 [sound similar to laughter]. 18:48:05.7 HOT-2 we're in a three hundred it wouldn't be so awesome. 18:48:07.5 HOT-1 no. 18:48:16.5 CTR Southwest twelve forty eight descend and maintain seven thousand. 18:48:20.5 RDO-2 seven thousand Southwest twelve forty eight. 18:48:23.6 HOT-1 seven thousand. 18:48:24.2 HOT-2 seven. 18:48:26.5 HOT-2 glad we're not in a two hundred. 18:48:28.4 HOT-1 oh man. done enough of that. 18:48:31.5 HOT-2 yea I bet you have.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 186 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:48:43.0 HOT-1 let's see. we got ah okay AWSUM HALIE we probably can - get rid of those but we got - 18:48:50.4 HOT-2 yeah (he said he) ah. 18:48:52.2 HOT-1 bring bring HILLS up or something. 18:48:53.6 HOT-2 I was gonna put in COKED an HEIGHTS but. he said he'll probably take us to like a vector for the thirty one center or somethin'. 18:48:59.4 HOT-1 yea. 18:49:02.3 HOT-2 HEIGHTS we could do 'cause that’s really what's what's next. will it take you out of the hold though? 18:49:09.0 HOT-1 hmmm. 18:49:09.9 HOT-2 if we put in HEIGHTS now like in the discontinuity it'll take you out of the hold next time won't it? 18:49:14.8 HOT-1 I'm not sure. 18:49:16.3 HOT-2 I I think it does.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 187 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:49:22.4 HOT-2 I think it would draw a line. 18:49:26.6 HOT-2 ah no I guess it didn't. yea it did. 18:49:35.6 HOT-2 yea it draws the line so. 18:49:37.1 HOT-1 yeah its over there. 18:49:37.2 CTR Southwest three twenty one ah fly heading of a two seven five intercept three one center localizer cleared to Midway airport via radar vectors and maintain ah six thousand. 18:49:38.2 CAM-2 that’s right. yeah. 18:49:44.8 HOT-1 alright. 18:49:45.7 CAM-2 that's good. 18:49:48.4 CAM-2 we're next they're at six thousand. 18:50:12.9 HOT-2 ah we might get one more. 18:50:20.7 HOT-1 alright. eh.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 188 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:50:25.8 HOT-2 what ya do before? where did you fly before? 18:50:29.0 HOT-1 what'd I fly before? 18:50:30.0 HOT-2 yeah. 18:50:30.4 HOT-1 I was Air Force guy. 18:50:31.6 HOT-2 how how long, did you retire? 18:50:32.9 HOT-1 eight for seven. 18:50:33.8 HOT-1 I was ah I been ah here eleven years so. 18:50:36.7 HOT-2 eleven years. 18:50:37.4 HOT-1 yeah. 18:50:38.8 CAM [sound similar to altitude warning horn]. 18:50:38.9 HOT-1 on my eleventh year. 18:50:42.0 CAM-2 how long did you stay in the Air Force for? 18:50:43.6 HOT-1 twenty six.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 189 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:50:44.4 CAM-2 twenty six years how old are you? 18:50:46.8 HOT-1 I'm fifty nine. 18:50:47.9 HOT-2 are you serious? 18:50:48.5 HOT-1 yeah. 18:50:49.2 HOT-2 jeeze you'd never freakin' know it you gonna make it its gonna change? (whaddya). 18:50:52.8 HOT-1 I don't know if the if they cha- I a November I've got ah till November eight. 18:50:58.5 CAM-2 I hope it does. 18:51:00.2 HOT-1 yeah I hope so. 18:51:00.9 HOT-2 some of my favorite people had to go and it was too bad $ he was * awesome guy to fly with outta Chicago. 18:51:07.6 HOT-2 I flew ah with $ his second to last night. 18:51:11.9 HOT-1 is that right?

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 190 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:51:12.6 CAM-2

there's some good guys and it just # to see 'em go.

18:51:14.9 HOT-1 you ever fly with ah $? 18:51:22.8 CAM-2 fifty nine man. you'd never know it. 18:51:25.7 HOT-1 ha tell me about it. 18:51:27.6 CAM-2 my #. 18:51:31.3 CAM-1 seven thousand feet here we are. 18:51:33.4 CAM-2 seven. 18:51:52.1 HOT-2 ah I'm gonna give em a quick update since we told 'em fifty. 18:51:54.2 HOT-1 'kay.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 191 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:51:56.4 PA ah folks just to give you a fast update we are estimating one more turn in the hold they're accepting aircraft back in ah Chicago Midway right now I think we're about three or four in the stack so hopefully we'll be heading that way as soon as we are we'll get back to ya but in the meantime folks thanks so much for your patience and hopefully we'll have you headin' towards the airport here in just a couple a minutes thanks. 18:52:18.6 HOT-1 well eighteen thirty's goin'. 18:52:21.9 HOT-2 yea and there is one more behind them and eh I thought they're at six the guys in front of us but. 18:52:26.4 HOT-1 yeah. 18:52:33.0 HOT-1 the other two seven zero. 18:52:34.7 HOT-2 yeah they're heading back up. 18:52:46.1 HOT-2 it's good that they're plowin'. 18:52:58.9 HOT-1 Uniform. 18:53:00.5 HOT-2 yeah that's another new one.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 192 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT DCA06MA009 18:53:03.4 HOT-2 zero zero two four 18:53:03.9 HOT-1 light snow three quarter mile three hundred alright. 18:53:08.4 HOT-2 zero nine zero at eleven I think I'm gonna put that in there. 18:53:10.3 CAM [sounds similar to two very faint clicks]. 18:53:12.3 HOT-1 alright. 18:53:13.3 CAM-2 just in case. 18:53:19.2 CAM-2 well this this for sure kills Salt Lake City for me. 18:53:23.5 CAM-1 yeah. 18:53:32.7 HOT-2 zero nine zero at eleven. 18:53:40.3 HOT-2 thirty oh seven now oh we got that. 18:53:44.8 HOT-1 on the altimeter? okay. 18:53:44.8 HOT-2 three zero zero seven.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 193 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:53:49.0 HOT-2 at three quarters I could probably undo the RVR less than four thousand. we'll leave it in just in case. 18:53:53.1 HOT-1 ahhhh well leave it in for now yeah that’s the worst case. 18:54:02.6 HOT-1 well yeah. 18:54:04.4 HOT-2 eight knot tailwind. 18:54:10.4 CTR Southwest ah twelve forty eight fly heading of ah two two zero. 18:54:14.8 RDO-2 heading two two zero Southwest twelve forty eight. 18:54:17.4 HOT-1 two two zero here we go. 18:54:39.9 CAM [sound similar to two loud clicks] 18:54:47.5 HOT-2 HILLS that sounds good. 18:54:47.6 HOT-1 I got a HILLS up there but. 18:54:53.5 CAM-1 I guess we can do that and extend it.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 194 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:54:56.4 CAM-2 cool. 18:55:06.8 HOT-2 two fifty. 18:55:07.3 HOT-1 'kay. 18:55:07.8 CTR Southwest twelve forty eight maintain ah two one five knots please. 18:55:11.6 RDO-2 okay ah two fifteen on the knots Southwest twelve forty eight. 18:55:14.3 HOT-1 three one five. 18:55:16.6 HOT-1 how's that look to you. 18:55:17.8 CAM-2 s'good. 18:55:18.8 CAM-1 'kay. 18:55:28.7 HOT [Morse code signal for G S H]. 18:55:28.8 HOT-1 fifteen. 18:55:43.4 HOT-1 (oh).

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 195 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:55:44.0 CAM-2 my side's up (the) DME for thirty one center. 18:55:44.0 HOT [Morse code signal for I M X T]. 18:55:47.1 HOT-1 okay. 18:55:50.2 HOT-2 and (then) my side ID's. 18:55:52.5 HOT-1 I might as well come over there with ya. 18:55:57.8 CTR Southwest twelve forty eight turn further right heading zero one zero. 18:56:01.7 RDO-2 heading zero one zero southwest twelve forty eight. 18:56:03.7 CAM-1 wow right turn zero one zero. 18:56:05.9 CAM-2 yeah. 18:56:15.4 HOT [Morse code signal for I M X T]. 18:56:19.6 CAM-2 your side ID's so I'm gonna take off just for real quick second. 18:56:22.3 CAM-1 'kay.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 196 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:56:23.6 RDO-2 hey Midway twelve forty eight. 18:56:25.5 HOT-1 lookin' good, still lookin' good okay. 18:56:26.1 OPS twelve forty eight go. 18:56:27.7 RDO-2 hey guys ha sorry for the late update looks like about ten after now they're just lettin' us leave holding now. 18:56:36.1 OPS okay copy that sir. 18:56:37.5 RDO-2 thank you. 18:56:40.7 PA and folks good news we're headin' towards the airport forty seven miles to go should be in the gate by about ten after thanks so much. and again everybody have a great night thanks so much for your patience. 18:56:50.1 HOT-2 I'm back. 18:56:51.2 HOT-1 okay. 18:56:52.2 CTR Southwest twelve forty eight turn further right heading zero two zero.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 197 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:56:55.9 RDO-2 zero two zero Southwest twelve forty eight. 18:56:57.9 HOT-1 zero two zero now. 18:57:00.2 HOT-2 whohoo. 18:57:10.1 HOT-1 they're everywhere they're everywhere, okay. 18:57:11.2 HOT-2 I know it. 18:57:13.1 HOT-1 well I'll be sittin' up lookin'. 18:57:27.1 HOT-1 we're gonna have a ah zero eight zero. or was it one zero zero? 18:57:32.4 HOT-2 uhm you know what I'm sorry I didn't (even) write it down. 18:57:34.1 CTR Southwest twelve forty eight turn right heading zero five zero. 18:57:37.5 RDO-2 zero five zero for Southwest twelve forty eight. 18:57:39.5 HOT-1 zero five zero.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 198 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:57:40.4 HOT-2 it was. 18:57:41.0 HOT-1 one hundred. at nine. 18:57:41.8 HOT-2 yea * I think it was ninety. T-U-V. 18:57:45.3 HOT-1 zero five zero. 18:57:47.6 HOT-2 zero nine zero at eleven. 18:57:48.8 HOT-1 alright zero nine zero so. 18:57:50.3 HOT-2 little bit of a right crosswind. 18:57:51.5 HOT-1 right cross so. comin' like this so I'll be lookin out this way here. little bit *. 18:57:57.4 HOT-2 yeah. 18:58:05.7 HOT-1 we'll be kinda doin' HUD. * doin' it on the HUD. once we get down there. 18:58:09.9 HOT-2 yeah HGS. 18:58:14.6 HOT-2 whatta we got six?

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 199 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:58:15.3 HOT-1 two hundred. 18:58:16.8 HOT-2 six thirteen. 18:58:18.5 HOT-1 at six thirteen sixty five twenty two at three degrees. 18:58:20.9 HOT-2 three degrees and three one center is sixty five twenty two. 18:58:27.6 HOT-2 alright. 18:58:30.2 HOT-2

this is a long Chicago flight.

18:58:33.6 HOT-2 I probably could have finished that revision. 18:58:36.2 HOT-1 yeah so what'll they do ma- a stop ya here? 18:58:39.8 CAM-2 I don’t know ah say we got out a here by it would be stupid to push us back have a half hour de-icing and then have it be a four hour five minute. 18:58:49.6 CAM-2 right now nineteen. its four hours and five minutes of block to Vegas. so say nineteen forty five at the earliest.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 200 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT DCA06MA009 18:59:00.2 CAM-1 Hmmum. 18:59:05.6 CAM-2 so it'll be nineteen *. 18:59:11.0 CAM-2 yea I could go to Vegas I'd have twenty five minutes extra. even if we get out by twenty hundred. 18:59:18.5 HOT-1 twenty hundred outta hear? 18:59:19.8 CAM-2 That'd be five about five minutes early. and I. 18:59:22.5 CAM-1 you got an hour. 18:59:23.5 CAM-2 if it's. 18:59:24.8 CAM-1 to get outta here. 18:59:26.0 CAM-2 yea. that would give us five minutes. if it was. 18:59:30.3 HOT-2 I mean if it was five minutes on the other end would you care if we called it in early so I didn't make a big problem? you know. 18:59:36.5 HOT-1 no no I don't have a problem.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 201 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 18:59:37.3 HOT-2 if it's gonna be close then. 18:59:38.6 HOT-1 yea do whatever you got the pencil. 18:59:41.5 HOT-2 okay. 18:59:42.2 HOT-1 [sound similar to laughter]. 18:59:48.2 HOT-2 looking good. 18:59:48.3 HOT-1 we're looking good man. 18:59:50.1 CAM-2 looking good Billy Ray. 18:59:54.4 CAM-2 feeling good Mortimer. 19:00:23.1 CAM-2 I bet they're gonna switch me here and do something else. 19:00:26.0 CAM-1 think so? 19:00:26.7 CAM-2 probably. 19:00:28.6 CAM-1 I don't know if they've got that far ahead --

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 202 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 19:00:30.5 CAM-2 yea. 19:00:30.7 CAM-1 they can think that far ahead today. 19:00:40.0 CAM-1 you might wanna call 'em I don't know. 19:00:41.1 CAM-2 yea I'm gonna just give 'em a (call). 19:00:44.9 CAM-2 he said call me at Midway. 19:00:45.5 CTR Southwest twelve forty eight fly heading of ah zero three zero. 19:00:48.8 RDO-2 zero three zero southwest twelve forty eight. 19:00:52.6 HOT-1 zero tree zero here we go. 19:00:54.5 HOT-2 yeah V-P-Z Valperazo. 19:01:11.7 HOT-1 he might take us through uh. 19:01:13.4 HOT-2 yea I'm going to hard altitude these. 19:01:15.9 CTR Southwest twelve forty eight descend and maintain six thousand.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 203 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 19:01:19.3 RDO-2 six thousand Southwest twelve forty eight 19:01:21.4 HOT-1 down to six. 19:01:24.1 CAM-2 six. 19:01:27.3 CAM-2 seven for six. 19:01:33.9 CAM [sound similar to altitude warning horn]. 19:01:35.5 HOT-1 six point nine for six. 19:01:41.3 HOT-1 its alive we're gonna go through it, yea. 19:01:43.1 HOT-2 yea. 19:01:53.1 RDO-2 you don't want us Southwest twelve forty eight to join do ya? 19:01:55.5 CTR ah not yet sorry about that vector through the localizer fly heading of ah three six zero please. 19:02:01.0 RDO-2 heading three six zero no problem Southwest twelve forty eight.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 204 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 19:02:06.0 HOT-1 three six zero. 19:02:27.1 CTR Southwest twelve forty eight turn further left heading of ah three er correction a two niner zero intercept three one center localizer. 19:02:35.1 RDO-2 heading two nine zero to join three one center loc Southwest twelve forty eight. 19:02:39.0 HOT-1 two nine zero to intercept. 19:02:40.2 CAM-2 two ninety. 19:03:02.6 EXEC 902 ah yes sir do you know if the runway is contaminated at Midway? 19:03:05.7 CAM-2 [sound similar to laugh]. 19:03:06.8 CTR it is contaminated? 19:03:08.7 EXEC 902 that's the question is it contaminated? 19:03:13.0 HOT-1 don't even think that. [sound similar to laughter]. 19:03:13.9 CTR exec jet nine zero two standby.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 205 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 19:03:15.2 HOT-2 there's the ah extended if you wanna use the L-NAV again. 19:03:19.2 HOT-1 okay. 19:03:24.0 HOT-1 we'll pick one. 19:03:25.3 HOT-2 [sound similar to laughter]. whichever one it likes better. 19:03:31.6 CTR Southwest twelve forty eight contact Chicago approach one one eight point four. 19:03:35.5 RDO-2 eighteen four you have a great night Southwest twelve forty eight. 19:03:39.5 HOT-1 it's alive. 19:03:40.6 HOT-2 yea. 19:03:41.6 RDO-2 hello Chicago Southwest twelve forty eight at six thousand. 19:03:44.3 APR Southwest twelve forty eight Chicago approach Victor current intercept three one center localizer runway three one center RVR five thousand five hundred.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 206 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 19:03:50.3 HOT-1 alright. 19:03:50.7 RDO-2 thanks alot southwest twelve forty eight we'll get Victor. 19:03:53.2 CAM-2 we're on Victor? 19:03:53.3 CAM-1

• backup.

19:03:57.5 HOT-2 time we got. 19:04:06.0 HOT-2

• capture.

19:04:06.9 CAM-1 alright capturing. 19:04:08.8 CAM-1 victory. 19:04:11.0 CAM-2 half a mile four hundred over thirty o' six. 19:04:12.8 APR Southwest twelve forty eight is one eight miles from GLEAM cross GLEAM at four thousand cleared ILS three one center approach maintain ah you're doin' two ten correct? 19:04:14.3 CAM-1 I don't think that means - they can't keep up *.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 207 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 19:04:17.4 CAM-1 fifty five hundred (is the). 19:04:20.2 HOT-1 beautiful day. 19:04:20.7 RDO-2 we're at two ten cleared for the ILS three one center * missed altitude if you gave us one. 19:04:24.8 APR ah four thousand cross GLEAM and two ten speed. 19:04:28.3 RDO-2 GLEAM at four thousand two ten speed and we're cleared for the ILS three one center southwest twelve forty eight. 19:04:32.5 CAM-1 alright here we go. 19:04:32.6 APR Southwest twelve forty eight braking action reported fair except at the end its ah poor. 19:04:37.1 RDO-2 okay thanks. 19:04:38.8 HOT-1 we got fair in there right? 19:04:40.2 HOT-2 yea. 19:04:40.7 HOT-1 we got the max?

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 208 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 19:04:42.6 HOT-2 [sound similar to laughter] we're all we're all counting on you. 19:04:44.2 HOT-1 [sound similar to laughter]. 19:04:48.8 HOT-2 picked the wrong day to stop sniffin' glue. 19:04:51.0 HOT-1 yea. 19:04:52.4 CAM [sound similar to two clicks]. 19:04:53.3 HOT-2 one more look for good measure. 19:04:56.3 HOT-2 I think you look good and clean my man. 19:04:58.0 HOT-1 alright. 19:05:02.4 HOT-2 four until GLEAM. 19:05:03.3 HOT-1 cleared the approach huh? 19:05:04.8 HOT-2 yea. 19:05:12.8 HOT-1 HILLS at four GLEAM at four.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 209 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 19:05:14.1 HOT-2 well yea he said GLEAM at four so we just have to make sure it doesn't wanna take you lower than GLEAM. lower than four at GLEAM. 19:05:20.4 HOT-1 yea okay. 19:05:22.7 HOT-2 I don't think it does but. 19:05:26.6 HOT-1 cleared the approach though. 19:05:31.0 HOT-2 one hundred at eleven. 19:05:33.7 HOT-2 that's just about a *. 19:05:34.1 HOT-1 [sound similar to autopilot disconnect warning horn]. 19:05:38.5 HOT-1 well that was nice. 19:05:39.5 HOT-2 yea. 19:05:40.0 HOT-1 [sound similar to laughter]. 19:05:42.6 CAM [sound similar to altitude warning horn]. 19:05:44.0 HOT-1 alright forty nine for four.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 210 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 19:05:46.2 HOT-2 forty nine for four. 19:05:47.3 HOT-1 try it again. 19:05:51.2 HOT-1 alright. 19:05:51.8 HOT-2 yea it's I remember this you were here for a while weren't ya. 19:05:55.8 HOT-2 were you based in Chicago for a while? 19:05:57.0 HOT-1 yea. 19:05:58.0 HOT-2 is that where I'd flown with you? 19:06:00.1 HOT-1 it was ah buh five years ago. 19:06:02.2 HOT-2 five but I wasn't I wasn't here that long. 19:06:20.7 HOT-1 what is it gonna be bumpy too or what? 19:06:22.2 HOT-2 [sound similar to laughter] what Chicago sheee.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 211 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 19:06:44.2 APR southwest nineteen fifty two Chicago approach intercept three one center localizer Victor's current the runway three one center RVR now four thousand five hundred. 19:06:51.5 HOT-2 forty five hundred. 19:06:54.6 HOT-1

[sound similar to laughter].

19:06:56.8 APR Southwest twelve forty eight reduce speed one seven zero to RUNTS contact the tower at RUNTS. 19:07:01.4 RDO-2 one seventy to RUNTS tower there have a great night southwest twelve forty eight. 19:07:04.1 HOT-1 alright slowin'. 19:07:05.1 APR Southwest nineteen fifty two last report I had for runway three one center on the braking was ah braking fair except at the end it was poor. 19:07:10.5 HOT-1 go flaps to ah five please. 19:07:12.9 HOT-2 flap-o de cinco. 19:07:19.1 APR southwest ninety fifty two you copy last?

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 212 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 19:07:20.8 SW1952 I'm sorry sir no. 19:07:22.3 APR yea braking action on runway three one center is fair and then poor at the end as reported by company seven three. 19:07:51.2 HOT-1 let's see there's sixteen miles. 19:07:54.1 HOT-1 still GLEAM is at eleven uh? 19:07:55.5 HOT-1 yea. 19:08:00.8 CAM-2 once we get over to tower I'll tell him that you wanna circle to two two left. [sound similar to laughter]. 19:08:05.7 CAM-1 yea. 19:08:18.7 SW1952 and ah was that braking action ah was that that poor was just or the fair was just at the end or what was the main part of the runway? 19:08:25.0 APR okay braking action was fair except at the end it was poor. 19:08:31.8 APR and we're just havin a Citation land now I'll get a new pilot report.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 213 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 19:08:34.5 HOT-1 oh we don't want him. 19:08:35.5 HOT-2 no [sound similar to laughter]. 19:08:37.4 HOT-2 if it's poor we don't wanna hear it. 19:08:38.8 HOT-1 no. 19:08:42.2 HOT-2 GLEAM at four. 19:08:44.3 HOT-2 after GLEAM you can go to twenty five. 19:08:45.0 HOT-1 alright landing gear down here sir. 19:08:47.8 HOT-2 landing gear down. 19:08:50.0 HOT-1 down to twenty five here we go. 19:08:55.0 HOT-1 at eleven point two huh? yea. 19:08:56.2 HOT-2 yea after GLEAM. 19:08:57.2 HOT-1 yea alright. 19:08:57.5 HOT-2 you're close.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 214 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 19:08:58.5 HOT-1 ah we're close. 19:09:00.0 HOT-2 I'll never tell. 19:09:00.8 HOT-1 yea I know. 19:09:08.0 HOT-1 close enough. 19:09:09.0 HOT-2 yea. 19:09:10.6 HOT-2 and after RUNTS we go to seventeen. 19:09:13.1 HOT-1 I'll follow the glideslope down here. 19:09:14.9 HOT-2 that's cool. 19:09:41.6 HOT-1 alright let's go flaps to ah fifteen. 19:09:43.8 HOT-2 flaps fifteen. 19:09:44.2 CAM [sound similar to metallic click]. 19:09:46.4 CAM [sound similar to altitude warning horn]. 19:09:53.4 HOT-1 hmm.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 215 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 19:09:53.7 RDO-2 Southwest twelve forty eight three one center. 19:09:57.6 TWR Southwest twelve forty eight Midway tower continue for three one center the winds zero nine zero at nine brakin' action reported good for the first half, poor for the second half. 19:10:06.2 RDO-2 thank you. 19:10:07.6 HOT-1 'kay. 19:10:09.4 HOT-2 glideslope's good I'm gonna throw a twenty one for the missed. 19:10:09.7 HOT-1 good for the first half. 19:10:11.9 HOT-1 RUNTS is six point seven alright. 19:10:16.2 HOT-1 alright glideslope looks like it's captured. 19:10:18.3 HOT-2 yea and twenty one's the missed approach altitude. 19:10:21.1 HOT-1 say again twenty one. 19:10:21.8 HOT-1 okay.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 216 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 19:10:21.9 HOT-2 that's the missed if we need it. 19:10:22.8 HOT-1 alright. 19:10:25.0 HOT-1 ah let's go flaps to thirty sir. 19:10:27.0 HOT-2 flaps thirty. 19:10:38.3 CAM-1 yea good old tailwind *. 19:10:39.9 CAM-2 yea. 19:10:41.2 TWR Gulfstream three Kilo Foxtrot say brakin' action. 19:10:41.4 CAM-1 alright flaps forty. 19:10:43.5 HOT-2 flaps forty. 19:10:46.0 G3KF fair to poor. 19:10:47.6 TWR Three Kilo Foxtrot than ah thank you very much can you make a left on Alpha? 19:10:52.8 G3KF standby.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 217 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 19:10:54.1 HOT-1 before landing check. 19:10:54.7 TWR if unable just let me know and go to the end. 19:10:56.1 CAM-2 speedbrake. 19:10:56.5 G3KF yea we can make a left on Alpha. 19:10:57.1 HOT-1 armed green light. 19:10:58.1 HOT-2 landing gear. 19:10:59.2 HOT-1 down three green. 19:10:59.9 HOT-2 flaps 19:11:00.4 HOT-1 forty green light. 19:11:01.4 HOT-2 before landing checks complete. 19:11:03.9 HOT-1 thank you. 19:11:04.4 CAM-2 no landing clearance yet. 19:11:05.9 HOT-1 nope.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 218 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 19:11:16.7 HOT-1 I got (a) A three just disregard the ah approach warning if we get one. 19:11:20.4 CAM-2 got it. 19:11:31.3 HOT-1 'kay. 19:11:34.6 CAM-2 comin' over HOBEL at seventeen. 19:11:37.0 HOT-1 alright and a thousand feet one thirty six sink is a nine hundred. 19:11:42.2 HOT-2 you can see the ground already. 19:11:43.4 HOT-1 (yea) * (good). 19:11:44.5 HOT-2 (one). 19:11:46.5 HOT-1 no peaking. 19:11:47.1 HOT-2 we're almost up to a thousand feet. 19:11:50.0 HOT-2 now we're at a thousand feet.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 219 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 19:11:51.9 HOT-1 alright yea you're right thousand feet. one thirty two sink is ah eight fifty. 19:11:53.2 HOT-2 I always. 19:11:57.4 CAM [sound similar to autopilot disconnect warning]. 19:12:00.3 HOT-2 we're all counting on you. 19:12:01.6 HOT-1 uhmhmm. 19:12:02.2 HOT-2 [sound similar to laughter]. 19:12:07.8 CAM [sound similar to two clicks]. 19:12:16.9 HOT-1 never autobraked here huh? 19:12:18.3 HOT-2 yeah. hang on tight [sound similar to laughter]. 19:12:21.6 HOT-1 yeah. 19:12:25.3 HOT-2 five hundred. 19:12:26.6 RDO-2 landing clearance for Southwest twelve forty eight.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 220 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 19:12:28.4 TWR Southwest twelve forty eight runway three one center cleared to land wind zero nine zero at nine brakin' action fair to poor. 19:12:35.3 HOT-2 four hundred. 19:12:36.3 HOT-1 alright. 19:12:37.2 HOT-2 five green lights cleared to land. 19:12:41.0 HOT-2 approaching minimums. 19:12:42.4 HOT-1 goin' outside. landing sir. 19:12:45.6 HOT-2 alright. 19:12:46.3 CAM [sound of thump]. 19:12:47.2 HOT-1 might help. 19:12:49.9 HOT-2

• a touch high on the glideslope.

19:12:50.6 CAM [sound similar to two thumps]. 19:12:56.5 HOT-2 one hundred.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 221 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 19:13:01.4 HOT-2 fifty. thirty. ten. 19:13:02.7 CAM [sound similar to click]. 19:13:07.1 CAM [sound similar to click and squeak]. 19:13:07.8 CAM [sounds similar to aircraft touchdown]. 19:13:08.5 HOT-1 oh baby I guess it comes on. 19:13:11.5 HOT-1 come on baby. 19:13:13.4 CAM-2 about two thousand feet to go. 19:13:14.7 HOT-1 feel it. 19:13:15.9 HOT-2 you jumpin' on the? 19:13:16.3 HOT-1 son of a #. 19:13:17.3 HOT-2 jump on the brakes are ya? 19:13:18.4 HOT-1 ah huh. 19:13:19.5 HOT-2 I'm ahnna.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 222 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 19:13:21.2 CAM-2 whaddya. 19:13:22.3 HOT-1 #. 19:13:23.2 CAM [sound similar to double clunk]. 19:13:23.4 HOT-1 get that back there. 19:13:25.3 HOT-1 we aint goin' man. 19:13:27.5 HOT-2 we're #. 19:13:28.7 HOT-1 we are #. 19:13:30.6 HOT-1 alright keep it straight. 19:13:31.2 CAM [sound similar to increased engine noise]. 19:13:35.0 HOT-2 #. 19:13:35.4 HOT-1

hang on.

19:13:35.9 HOT-2 hang on. 19:13:36.5 CAM [sound similar to impact].

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 223 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 19:13:37.3 HOT-2 *. 19:13:39.0 CAM [sound similar to impact]. 19:13:39.4 HOT-2 oh #. 19:13:42.2 HOT-2 [sound similar to groan]. 19:13:43.3 HOT-1 [sound similar to grunt] # me. 19:13:46.5 HOT-2 #. 19:13:47.1 HOT-1 #. 19:13:47.5 TWR what was that? Southwest twelve forty eight are you cleared three one center? 19:13:48.1 CAM [sound similar to stick shaker]. 19:13:49.1 CAM [sound similar to chime]. 19:13:51.0 CAM [sound similar to clunk]. 19:13:51.4 RDO-2 Southwest twelve forty eight went over the end.

Appendix B National Transportation Safety Board A I R C R A F T Accident Report 224 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME (CST) SOURCE CONTENT TIME (CST) SOURCE CONTENT 19:13:53.5 TWR say again. 19:13:54.3 RDO-2 we went off the end of the runway. 19:13:54.4 HOT-1 shut down. 19:13:58.4 HOT-2 #. 19:14:00.6 HOT-1 shuttin' down. [end of recording] 19:14:01.3 End of Transcript

National Transportation Safety Board A I R C R A F T Accident Report 225 Appendix C FAA Safety Alert For Operators 06012 Approved by AFS-1

Page 1 SAFO

Safety Alert for Operators U.S. Department SAFO 06012 of Transportation DATE: 8/31/06 Federal Aviation Administration Flight Standards Service Washington, DC http://www.faa.gov/other_visit/aviation_industry/airline_operators/airline_safety/safo A SAFO contains important safety information and may include recommended action. SAFO content should be especially valuable to air carriers in meeting their statutory duty to provide service with the highest possible degree of safety in the public interest. Subject: Landing Performance Assessments at Time of Arrival (Turbojets)

1. Purpose. This SAFO urgently recommends that operators of turbojet airplanes develop

procedures for flightcrews to assess landing performance based on conditions actually existing at time of arrival, as distinct from conditions presumed at time of dispatch. Those conditions include weather, runway conditions, the airplane’s weight, and braking systems to be used. Once the actual landing distance is determined an additional safety margin of at least 15% should be added to that distance. Except under emergency conditions flightcrews should not attempt to land on runways that do not meet the assessment criteria and safety margins as specified in this SAFO.

1. Discussion: This SAFO is based on the FAA’s policy statement published in the Federal

Register on June 7, 2006, and incorporates revisions based on public comments received by the FAA. Accordingly, the FAA has undertaken rulemaking that would explicitly require the practice described above. Operators may use Operation/Management Specification paragraph C382 to record their voluntary commitment to this practice, pending rulemaking. Operators engaged in air transportation have a statutory obligation to operate with the highest possible degree of safety in the public interest.

1. Applicability:

a. This SAFO applies to all turbojet operators under Title 14 of the Code of Federal Regulations (14 CFR) parts 121, 135, 125, and 91 subpart K. The intent of providing this information is to assist operators in developing methods of ensuring that sufficient landing distance exists to safely make a full stop landing with an acceptable safety margin on the runway to be used, in the conditions existing at the time of arrival, and with the deceleration means and airplane configuration that will be used. The FAA considers a 15% margin between the expected actual airplane landing distance and the landing distance available at the time of arrival as the minimum acceptable safety margin for normal operations. b. The FAA acknowledges that there are situations where the flightcrew needs to know the absolute performance capability of the airplane. These situations include emergencies or abnormal and irregular configurations of the airplane such as engine failure or flight control

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Page 2 malfunctions. In these circumstances, the pilot must consider whether it is safer to remain in the air or to land immediately and must know the actual landing performance capability (without an added safety margin) when making these evaluations. This guidance is not intended to curtail such evaluations from being made for these situations. c. This guidance is independent of the preflight landing distance planning requirements of part 121, section 121.195, part 135, section 135.385, and part 91, section 91.1037. d. This 15% safety margin should not be applied to the landing distance determined for compliance with any other OpSpec/MSpec requirement. The landing distance assessment of this guidance is independent of any other OpSpec/MSpec landing distance requirement. The minimum landing distance should comply with all applicable landing distance requirements. Hence, the minimum landing distance at the time of arrival should be the longer of the landing distance in this guidance and that determined to be in compliance with any other applicable OpSpec/MSpec. e. This guidance does not apply to Land and Hold Short Operations (LAHSO).

1. Definitions: The following definitions are specific to this guidance and may differ with those

definitions contained in other published references. a. Actual Landing Distance. The landing distance for the reported meteorological and runway surface conditions, runway slope, airplane weight, airplane configuration, approach speed, use of autoland or a Head-up Guidance System, and ground deceleration devices planned to be used for the landing. It does not include any safety margin and represents the best performance the airplane is capable of for the conditions. b. Airplane Ground Deceleration Devices. Any device used to aid in the onset or rate of airplane deceleration on the ground during the landing roll out. These would include, but not be limited to: brakes (either manual braking or the use of autobrakes), spoilers, and thrust reversers. c. At Time of Arrival. For the purpose of this guidance means a point in time as close to the airport as possible consistent with the ability to obtain the most current meteorological and runway surface conditions considering pilot workload and traffic surveillance, but no later than the commencement of the approach procedures or visual approach pattern. d. Braking Action Reports. The following braking action reports are widely used in the aviation industry and are furnished by air traffic controllers when available. The definitions provided below are consistent with how these terms are used in this guidance. Good – More braking capability is available than is used in typical deceleration on a non- limiting runway (i.e., a runway with additional stopping distance available). However, the landing distance will be longer than the certified (unfactored) dry runway landing distance, even with a well executed landing and maximum effort braking. Fair/Medium – Noticeably degraded braking conditions. Expect and plan for a longer stopping distance such as might be expected on a packed or compacted snow-covered runway.

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Page 3 Poor – Very degraded braking conditions with a potential for hydroplaning. Expect and plan for a significantly longer stopping distance such as might be expected on an ice- covered runway. Nil – No braking action and poor directional control can be expected. NOTE: Conditions specified as “nil” braking action are not considered safe, therefore operations under conditions specified as such should not be conducted. Do not attempt to operate on surfaces reported or expected to have nil braking action. e. Factored Landing Distance. The landing distance required by 14 CFR part 25, section 25.125 increased by the preflight planning safety margin additives required by the applicable operating rules. (Some manufacturers supply factored landing distance information in the Airplane Flight Manual (AFM) as a service to the user.) f. Landing Distance Available. The length of the runway declared available for landing. This distance may be shorter than the full length of the runway. g. Meteorological Conditions. Any meteorological condition that may affect either the air or ground portions of the landing distance. Examples may include wind direction and velocity, pressure altitude, and temperature. An example of a possible effect that must be considered includes crosswinds affecting the amount of reverse thrust that can be used on airplanes with tail mounted engines due to rudder blanking effects. h. Reliable Braking Action Report. For the purpose of this guidance, means a braking action report submitted from a turbojet airplane with landing performance capabilities similar to those of the airplane being operated. i. Runway Surface Conditions. The state of the surface of the runway: either dry, wet, or contaminated. A dry runway is one that is clear of contaminants and visible moisture within the required length and the width being used. A wet runway is one that is neither dry nor contaminated. For a contaminated runway, the runway surface conditions include the type and depth (if applicable) of the substance on the runway surface, e.g., standing water, dry snow, wet snow, slush, ice, sanded, or chemically treated. j. Runway Friction or Runway Friction Coefficient. The resistance to movement of an object moving on the runway surface as measured by a runway friction measuring device. The resistive force resulting from the runway friction coefficient is the product of the runway friction coefficient and the weight of the object. k. Runway Friction Enhancing Substance. Any substance that increases the runway friction value. l. Safety Margin. The length of runway available beyond the actual landing distance. Safety margin can be expressed in a fixed distance increment or a percentage increase beyond the actual landing distance required. m. Unfactored Certified Landing Distance. The landing distance required by section 25.125 without any safety margin additives. The unfactored certified landing distance

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Page 4 may be different from the actual landing distance because not all factors affecting landing distance are required to be accounted for by section 25.125. For example, the unfactored certified landing distances are based on a dry, level (zero slope) runway at standard day temperatures, and do not take into account the use of autobrakes, autoland systems, head-up guidance systems, or thrust reversers.

1. Background: After any serious aircraft accident or incident, the FAA typically performs an

internal audit to evaluate the adequacy of current regulations and guidance information in areas that come under scrutiny during the course of the accident investigation. The Southwest Airlines landing overrun accident involving a Boeing 737-700 at Chicago Midway Airport in December 2005 initiated such an audit. The types of information that were evaluated in addition to the regulations were FAA orders, notices, advisory circulars, ICAO and foreign country requirements, airplane manufacturer-developed material, independent source material, and the current practices of air carrier operators. This internal FAA review revealed the following issues: a. A survey of operators’ manuals indicated that approximately fifty percent of the operators surveyed do not have policies in place for assessing whether sufficient landing distance exists at the time of arrival, even when conditions (including runway, meteorological, surface, airplane weight, airplane configuration, and planned usage of decelerating devices) are different and worse than those planned at the time the flight was released. b. Not all operators who perform landing distance assessments at the time of arrival have procedures that account for runway surface conditions or reduced braking action reports. c. Many operators who perform landing distance assessments at the time of arrival do not apply a safety margin to the expected actual landing distance. Those that do are inconsistent in applying an increasing safety margin as the expected actual landing distance increased (i.e., as a percentage of the expected actual landing distance). d. Some operators have developed their own contaminated runway landing performance data or are using data developed by third party vendors. In some cases, these data indicate shorter landing distances than the airplane manufacturer’s data for the same conditions. In other cases, an autobrake landing distance chart has been misused to generate landing performance data for contaminated runway conditions. Also, some operators’ data have not been kept up to date with the manufacturer’s current data. e. Credit for the use of thrust reversers in the landing performance data is not uniformly applied and pilots may be unaware of these differences. In one case, there were differences found within the same operator from one series of airplane to another within the same make and model. The operator’s understanding of the data with respect to reverse thrust credit, and the information conveyed to pilots, were both incorrect. f. Airplane flight manual (AFM) landing performance data are determined during flight- testing using flight test and analysis criteria that are not representative of everyday operational practices. Landing distances determined in compliance with 14 CFR part 25, section 25.125 and published in the FAA-approved AFM do not reflect operational landing distances (Note: some manufacturers provide factored landing distance data that addresses operational requirements.) Landing distances determined during certification tests are aimed at demonstrating the shortest

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Page 5 landing distances for a given airplane weight with a test pilot at the controls and are established with full awareness that operational rules for normal operations require additional factors to be added for determining minimum operational field lengths. Flight test and data analysis techniques for determining landing distances can result in the use of high touchdown sink rates (as high as 8 feet per second) and approach angles of -3.5 degrees to minimize the airborne portion of the landing distance. Maximum manual braking, initiated as soon as possible after landing, is used in order to minimize the braking portion of the landing distance. Therefore, the landing distances determined under section 25.125 are shorter than the landing distances achieved in normal operations. g. Wet and contaminated runway landing distance data are usually an analytical computation using the dry, smooth, hard surface runway data collected during certification. Therefore, the wet and contaminated runway data may not represent performance that would be achieved in normal operations. This lack of operational landing performance repeatability from the flight test data, along with many other variables affecting landing distance, are taken into consideration in the preflight landing performance calculations by requiring a significant safety margin in excess of the certified (unfactored) landing distance that would be required under those conditions. However, the regulations do not specify a particular safety margin for a landing distance assessment at the time of arrival. This safety margin has been left largely to the operator and/or the flightcrew to determine. h. Manufacturers do not provide advisory landing distance information in a standardized manner. However, most turbojet manufacturers make landing distance performance information available for a range of runway or braking action conditions using various airplane deceleration devices and settings under a variety of meteorological conditions. This information is made available in a wide variety of informational documents, dependent upon the manufacturer. i. Manufacturer-supplied landing performance data for conditions worse than a dry, smooth runway is normally an analytical computation based on the dry runway landing performance data, adjusted for a reduced airplane braking coefficient of friction available for the specific runway surface condition. Most of the data for runways contaminated by snow, slush, standing water, or ice were developed to show compliance with European Aviation Safety Agency and Joint Aviation Authority airworthiness certification and operating requirements. The FAA considers the data developed for showing compliance with the European contaminated runway certification or operating requirements, as applicable, to be acceptable for making landing distance assessments for contaminated runways at the time of arrival.

1. Recommended Action:

a. A review of the current applicable regulations indicates that the regulations do not specify the type of landing distance assessment that must be performed at the time of arrival, but operators are required to restrict or suspend operations when conditions are hazardous. b. 14 CFR part 121, section 121.195(b), part 135, section 135.385(b), and part 91, section 91.1037(b) and (c) require operators to comply with certain landing distance requirements at the time of takeoff. (14 CFR part 125, section 125.49 requires operators to use airports that are adequate for the proposed operation). These requirements limit the allowable takeoff weight to that which would allow the airplane to land within a specified percentage of the landing distance available on: (1) the most favorable runway at the destination airport under still air conditions;

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Page 6 and (2) the most suitable runway in the expected wind conditions. Sections 121.195(d), 135.385(d), and 91.1037(e) further require an additional 15 percent to be added to the landing distance required when the runway is wet or slippery, unless a shorter distance can be shown using operational landing techniques on wet runways. Although an airplane can be legally dispatched under these conditions, compliance with these requirements alone does not ensure that the airplane can safely land within the distance available on the runway actually used for landing in the conditions that exist at the time of arrival, particularly if the runway, runway surface condition, meteorological conditions, airplane configuration, airplane weight, or use of airplane ground deceleration devices is different than that used in the preflight calculation. Part 121, sections 121.533, 121.535, 121.537, part 135, section 135.77, part 125, section 125.351, and part 91, sections 91.3, and 91.1009 place the responsibility for the safe operation of the flight jointly with the operator, pilot in command, and dispatcher as appropriate to the type of operation being conducted. c. Sections 121.195(e) and 135.385(e), allow an airplane to depart even when it is unable to comply with the conditions referred to in item (2) of paragraph 5b above if an alternate airport is specified where the airplane can comply with conditions referred to in items (1) and (2) of paragraph 5b. This implies that a landing distance assessment is accomplished before landing to determine if it is safe to land at the destination, or if a diversion to an alternate airport is required. d. Part 121, sections 121.601 and 121.603, require dispatchers to keep pilots informed, or for pilots to stay informed as applicable, of conditions, such as airport and meteorological conditions, that may affect the safety of the flight. Thus, the operator and flightcrew use this information in their safety of flight decision making. Part 121, sections 121.551, 121.553, and part 135, section 135.69, require an operator, and/or the pilot in command as applicable, to restrict or suspend operations to an airport if the conditions, including airport or runway surface conditions, are hazardous to safe operations. Part 125 section 125.371 prohibits a pilot in command (PIC) from continuing toward any airport to which it was released unless the flight can be completed safely. A landing distance assessment should be made under the conditions existing at the time of arrival in order to support a determination of whether conditions exist that may affect the safety of the flight and whether operations should be restricted or suspended. e. Runway surface conditions may be reported using several types of descriptive terms including: type and depth of contamination, a reading from a runway friction measuring device, an airplane braking action report, or an airport vehicle braking condition report. Unfortunately, joint industry and multi-national government tests have not established a reliable correlation between runway friction under varying conditions, type of runway contaminants, braking action reports, and airplane braking capability. Extensive testing has been conducted in an effort to find a direct correlation between runway friction measurement device readings and airplane braking friction capability. However, these tests have not produced conclusive results that indicate a repeatable correlation exists through the full spectrum of runway contaminant conditions. Therefore, operators and flightcrews cannot base the calculation of landing distance solely on runway friction meter readings. Likewise, because pilot braking action reports are subjective, flightcrews must use sound judgment in using them to predict the stopping capability of their airplane. For example, the pilots of two identical aircraft landing in the same conditions, on the same runway could give different braking action reports. These differing reports could be the result of differences between the specific aircraft, aircraft weight, pilot technique, pilot experience in similar conditions, pilot total experience, and pilot expectations. Also, runway surface conditions can degrade or improve significantly in very short periods of time dependent

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Page 7 on precipitation, temperature, usage, and runway treatment and could be significantly different than indicated by the last report. Flightcrews must consider all available information, including runway surface condition reports, braking action reports, and friction measurements. (1) Operators and pilots should use the most adverse reliable braking action report, if available, or the most adverse expected conditions for the runway, or portion of the runway, that will be used for landing when assessing the required landing distance prior to landing. Operators and pilots should consider the following factors in determining the actual landing distance: the age of the report, meteorological conditions present since the report was issued, type of airplane or device used to obtain the report, whether the runway surface was treated since the report, and the methods used for that treatment. Operators and pilots are expected to use sound judgment in determining the applicability of this information to their airplane’s landing performance. (2) Table 1 provides an example of a correlation between braking action reports and runway surface conditions: Braking Action Dry (not reported) Good Fair/Medium Poor Nil Contaminant Dry Wet Dry Snow (< 20mm) Packed or Compacted Snow Wet Snow Slush Standing Water Ice Wet ice Table 1. Relationship between braking action reports and runway surface condition (contaminant type) NOTE: Under extremely cold temperatures, these relationships may be less reliable and braking capabilities may be better than represented. This table does not include any information pertaining to a runway that has been chemically treated or where a runway friction enhancing substance has been applied. f. Some advisory landing distance information uses a standard air distance of 1000 feet from 50 feet above the runway threshold to the touchdown point. Unfactored dry runway landing distances in AFMs reflect the distances demonstrated during certification flight testing. These unfactored AFM landing distance data include air distances that vary with airplane weight, but are also nominally around 1000 feet. A 1000 foot air distance is not consistently achievable in normal flight operations. Additionally, the use of automatic landing systems (autoland) and other landing guidance systems (e.g., head-up guidance systems) typically result in longer air distances. Operators are expected to apply adjustments to this air distances to reflect their specific operations, operational practices, procedures, training, and experience. g. To ensure that an acceptable landing distance safety margin exists at the time of arrival, the FAA recommends that at least a 15% safety margin be provided. This safety margin represents the minimum distance margin that must exist between the expected actual landing distance at the time of arrival and the landing distance available, considering the meteorological and runway surface conditions, airplane configuration and weight, and the intended use of airplane ground deceleration devices. In other words, the landing distance available on the

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Page 8 runway to be used for landing must allow a full stop landing, in the actual conditions and airplane configuration at the time of landing, and at least an additional 15% safety margin. h. Operator compliance can be accomplished by a variety of methods and procedurally should be accomplished by the method that best suits the operator’s current procedures. The operator’s procedures should be clearly articulated in the operations manual system for affected personnel. The following list of methods is not all inclusive, or an endorsement of any particular methods, but provided as only some examples of methods of compliance. • Establishment of a minimum runway length required under the worst case meteorological and runway surface conditions for operator’s total fleet or fleet type that will provide runway lengths that comply with this guidance. • The requirements of this paragraph could be considered along with the other applicable preflight landing distance calculation requirements and the takeoff weight adjusted to provide for compliance at the time of arrival under the conditions and configurations factored in the calculation. This information, including the conditions/configurations/etc. used in the calculation, would be provided to the flightcrew as part of the release/dispatch documents. (However, this method may not be sufficient if conditions/configurations/etc. at the time of arrival are different than those taken into account in the preflight calculations; therefore, the flightcrew would need to have access to the landing performance data applicable to the conditions present upon arrival. • Tab or graphical data accounting for the applicable variables provided to the flightcrew and/or dispatcher as appropriate to the operator’s procedures. • Electronic Flight Bag equipment that has methods for accounting for the appropriate variables. NOTE: These are only some examples of methods of compliance. There are many others that would be acceptable.

1. Summary of Recommendation.

a. Turbojet operators have procedures to ensure that a full stop landing, with at least a 15% safety margin beyond the actual landing distance, can be made on the runway to be used, in the conditions existing at the time of arrival, and with the deceleration means and airplane configuration that will be used. This assessment should take into account the meteorological conditions affecting landing performance (airport pressure altitude, wind velocity, wind direction, etc.), surface condition of the runway to be used for landing, the approach speed, airplane weight and configuration, and planned use of airplane ground deceleration devices. The airborne portion of the actual landing distance (distance from runway threshold to touchdown point) should reflect the operator’s specific operations, operational practices, procedures, training, and experience. Operators should have procedures for compliance with this guidance, absent an emergency, after the flightcrew makes this assessment using the air carrier’s procedures, if at least the 15% safety margin is not available, the pilot should not land the aircraft.

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Page 9 (1) This assessment does not mean that a specific calculation must be made before every landing. In many cases, the before takeoff criteria, with their large safety margins, will be adequate to ensure that there is sufficient landing distance with at least a 15% safety margin at the time of arrival. Only when the conditions at the destination airport deteriorate while en route (e.g., runway surface condition, runway to be used, winds, airplane landing weight/configuration/speed/deceleration devices) or the takeoff was conducted under the provisions described in paragraph 5 (c) of this guidance, would a calculation or other method of determining the actual landing distance capability normally be needed. The operator should develop procedures to determine when such a calculation or other method of determining the expected actual landing distance is necessary to ensure that at least a 15% safety margin will exist at the time of arrival. (2) Operators may require flight crews to perform this assessment, or may establish other procedures to conduct this assessment. Whatever method(s) the operator develops, its procedures should account for all factors upon which the preflight planning was based and the actual conditions existing at time of arrival. b. Confirm that the procedures and data used to comply with paragraph 6 (a) above for actual landing performance assessments yield results that are at least as conservative as the manufacturer’s approved or advisory information for the associated conditions provided therein. Although the European contaminated runway operations requirements are applied differently than the requirements of this guidance, the operator may choose to use data developed for showing compliance with the European contaminated runway operating requirements for making these landing distance assessments for contaminated runways at the time of arrival. c. A safety margin of 15% should be added to the actual landing distance and require that the resulting distance be within the landing distance available of the runway used for landing. Note that the FAA considers a 15% margin to be the minimum acceptable safety margin. d. If wet or contaminated runway landing distance data are unavailable, the factors in Table 2 should be applied to the pre-flight planning (factored) dry runway landing distances determined in accordance with the applicable operating rule (e.g., sections 91.1037, 121.195(b) or 135.385(b). Table 2 should only apply when no such data are available. The factors in Table 2 include the 15% safety margin recommended by this guidance, and are considered to include an air distance representative of normal operational practices. Therefore, operators do not need to apply further adjustments to the resulting distances to comply with the recommendations of this guidance.

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Page 10 Runway Condition Reported Braking Action Factor to apply to (factored) dry runway landing distance* Wet Runway, Dry Snow Good 0.9 Packed or Compacted Snow Fair/Medium 1.2 Wet snow, slush, standing water, ice Poor 1.6 Wet ice Nil Landing is prohibited Table 2. Multiplication factors to apply to the factored dry runway landing distances when the data for the specified runway condition are unavailable.

• The factored dry runway landing distances for use with Table 2 must be based on landing

within a distance of 60% of the effective length of the runway, even for operations where the preflight planning (factored) dry runway landing distances are based on landing within a distance other than 60% of the effective length of the runway (e.g., certain operations under part 135 and subpart K of par t91). To use unfactored dry runway landing distances, first multiply the unfactored dry runway landing distance by 1.667 to get the factored dry runway landing distance before entering Table 2 above. NOTE: These factors assume maximum manual braking, autospoilers (if so equipped), and reverse thrust will be used. For operations without reverse thrust (or without credit for the use of reverse thrust) multiply the results of the factors in Table 2 by 1.2. These factors cannot be used to assess landing distance requirements with autobrakes. e. The landing distance assessment should be accomplished as close to the time of arrival as practicable, taking into account workload considerations during critical phases of flight, using the most up-to-date information available at that time. The most adverse braking condition, based on reliable braking reports or runway contaminant reports (or expected runway surface conditions if no reports are available) for the portion of the runway that will be used for the landing should be used in the actual landing performance assessment. For example, if the runway surface condition is reported as fair to poor, or fair in the middle, but poor at the ends, the runway surface condition should be assumed to be poor for the assessment of the actual landing distance. (This example assumes the entire runway will be used for the landing). If conditions change between the time that the assessment is made and the time of landing, the flightcrew should consider whether it would be safer to continue the landing or reassess the landing distance. f. The operator’s flightcrew and dispatcher training programs should include elements that provide knowledge in all aspects and assumptions used in landing distance performance determinations. This training should emphasize the airplane ground deceleration devices, settings, and piloting methods (e.g., air distance) used in determining landing distances for each make, model, and series of airplane. Elements such as braking action reports, airplane configuration, optimal stopping performance techniques, stopping margin, the effects of excess speed, delays in activating deceleration devices, and other pilot performance techniques should be covered. All dispatchers and flightcrew members should be trained on these elements prior to operations on contaminated runway surfaces. This training should be accomplished in a manner consistent with the operator’s methods for conveying similar knowledge to flight operations

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Page 11 personnel. It may be conducted via operations/training bulletins or extended learning systems, if applicable to the operator’s current methods of training. g. Procedures for obtaining optimal stopping performance on contaminated runways should be included in flight training programs. All flight crewmembers should be made aware of these procedures for the make/model/series of airplane they operate. This training should be accomplished in a manner consistent with the operator’s methods for conveying similar knowledge to flight operations personnel. It may be conducted via operations/training bulletins or extended learning systems, if applicable to the operator’s current methods of training. In addition, if not already included, these procedures should be incorporated into each airplane or simulator training curriculum for initial qualification on the make/model/series airplane, or differences training as appropriate. All flight crewmembers should have hands on training and validate proficiency in these procedures during their next flight training event, unless previously demonstrated with their current employer in that make/model/series of airplane.

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FD07334 ｜ 2007_美国_NTSB_AAR0901_In_flight_Fire_Emergency_Descent_and_Crash_in_a_Residential.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2007 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

In‐flight Fire, Emergency Descent  and Crash in a Residential Area  Cessna 310R, N501N  Sanford, Florida  July 10, 2007          Aircraft Accident Summary Report NTSB/AAR-09/01/SUM PB2009-910401

National Transportation Safety Board

NTSB/AAR-09/01/SUM PB2009-910401 Notation 7943B Adopted January 28, 2009

Aircraft Accident Summary Report In-flight Fire, Emergency Descent and Crash in a Residential Area Cessna 310R, N501N Sanford, Florida July 10, 2007

National Transportation Safety Board

490 L’Enfant Plaza, S.W. Washington, D.C. 20594

National Transportation Safety Board. 2009. In-flight Fire, Emergency Descent, and Crash in a Residential Area, Cessna 310R, N501N, Sanford, Florida, July 10, 2007. Aircraft Accident Summary Report NTSB/AAR-09/01/SUM. Washington, DC.

Abstract: This report explains the July 10, 2007, accident involving a Cessna 310R, N501N, operated by the National Association for Stock Car Auto Racing corporate aviation division as a personal flight. The airplane crashed while performing an emergency diversion to Orlando Sanford International Airport, Orlando, Florida, after an in-flight fire. The flight had been released despite a known unresolved maintenance discrepancy. Safety issues discussed in this report relate to the resetting of circuit breakers, the inspection and maintenance of electrical systems in general aviation aircraft, and the establishment of safety management systems in general aviation corporate operations. Safety recommendations regarding these issues are addressed to the Federal Aviation Administration.

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