06_境外及港澳台调查报告_part12.md

06_境外及港澳台调查报告 · 整合分片 part12

本片含 38 份报告。

FD07360 ｜ 2009_美国_AAR0906.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2009 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

Loss of Control and Crash  Marlin Air  Cessna Citation 550, N550BP  Milwaukee, Wisconsin  June 4, 2007          Accident Report NTSB/AAR-09/06 PB2009-910406

National Transportation Safety Board

This page intentionally left blank.

NTSB/AAR-09/06 PB2009-910406 Notation 8152 Adopted October 14, 2009

Aircraft Accident Report Loss of Control and Crash Marlin Air Cessna Citation 550, N550BP Milwaukee, Wisconsin June 4, 2007

National Transportation Safety Board

490 L’Enfant Plaza, S.W. Washington, D.C. 20594

National Transportation Safety Board. 2009. Loss of Control and Crash, Marlin Air Cessna Citation 550, N550BP, Milwaukee, Wisconsin, June 4, 2007. Aircraft Accident Report NTSB/AAR-09/06. Washington, DC.

Abstract: This report describes the circumstances of an accident involving a Cessna Citation 550, which impacted Lake Michigan shortly after departure. The safety issues discussed include pilot actions and coordination, the need for image recording equipment on airplanes not equipped with flight data recorders, autopilot panel design, control yoke wiring installations, identification of circuit breakers for use in emergencies, aural and visual alerts to pitch trim-in-motion, aileron trim power and sensitivity, human factors in airplane design, Federal Aviation Administration (FAA) appointment of check airmen, the scope of Regional Aviation Safety Inspection Program inspections, avenues for expressing safety concerns to Federal authorities, and the safety ramifications of operators’ financial health. Safety recommendations to the FAA and the American Hospital Association are included.

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 NTSB 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 Internet at http://www.ntsb.gov. Other information about available publications also may be obtained from the website or by contacting:

National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, SW Washington, DC 20594 (800) 877-6799 or (202) 314-6551

NTSB publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2009-910406 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 NTSB reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

NTSB Aircraft Accident Report Contents Contents .......................................................................................................................................... i  Figures ........................................................................................................................................... iv  Abbreviations .................................................................................................................................v  Executive Summary ................................................................................................................... viii 

1. Factual Information ...................................................................................................................1 
2. 1  History of the Flight .................................................................................................................1 
3. 2 Injuries to Persons ......................................................................................................................5 
4. 3 Damage to Airplane ...................................................................................................................5 
5. 4 Other Damage ............................................................................................................................5 
6. 5 Personnel Information ................................................................................................................5 
7. 5.1 The Captain ......................................................................................................................5 
8. 5.2 The First Officer ..............................................................................................................8 
9. 6 Airplane Information ...............................................................................................................10 
10. 6.1 General ...........................................................................................................................10 
11. 6.2  Airplane Systems .........................................................................................................10 
12. 6.2.1  Flight Control Trim Systems .........................................................................10 
13. 6.2.1.1  Pitch Trim System Information ........................................................... 11 
14. 6.2.1.2  Aileron Trim System Information ....................................................... 12 
15. 6.2.1.3  Rudder Trim System Information ....................................................... 13 
16. 6.2.2  Autopilot System ...........................................................................................14 
17. 7 Meteorological Information .....................................................................................................18 
18. 8 Aids to Navigation ...................................................................................................................19 
19. 9 Communications ......................................................................................................................19 
20. 10 Airport Information ................................................................................................................19 
21. 11 Flight Recorder Information ..................................................................................................19 
22. 11.1 Cockpit Voice Recorder ...............................................................................................19 
23. 11.2 Flight Data Recorder ....................................................................................................20 
24. 12 Wreckage and Impact Information .........................................................................................20 
25. 12.1 Airplane Systems Wreckage Information ....................................................................20 
26. 12.1.1  Airplane Trim Systems ..................................................................................20 
27. 12.1.2  Autopilot System Components......................................................................21 
28. 12.2 Control Yoke and Related Switches .............................................................................22 
29. 12.2.1  Control Column/Yoke Electrical Wiring .......................................................23 
30. 13 Medical and Pathological Information ...................................................................................24 
31. 14 Fire .........................................................................................................................................24 
32. 15 Survival Aspects ....................................................................................................................24 
33. 16 Tests and Research .................................................................................................................25 
34. 16.1 Airplane Simulation and Performance Studies ............................................................25 

i

NTSB Aircraft Accident Report 1.16.1.1  Pitch Trim Runaway ......................................................................................25  1.16.1.2  Inadvertent Autopilot Engagement ................................................................25  1.16.2 Assessment of Likely Aileron Trim Inputs and Forces ................................................26  1.17 Organizational and Management Information .......................................................................26  1.17.1 Marlin Air General Information ...................................................................................26  1.17.2 Marlin Air and University of Michigan Information ...................................................27  1.17.3 Marlin Air Financial Information .................................................................................27  1.17.4 Federal Aviation Administration Oversight .................................................................28  1.17.4.1  Operational Oversight of Marlin Air .............................................................28  1.17.4.2  Appointment of Marlin Air’s Check Airman ................................................29  1.17.4.3  Pre and Postaccident FAA Inspections of Marlin Air ...................................30  1.17.4.4  Available FAA Alert Programs ......................................................................31  1.18 Additional Information ...........................................................................................................31  1.18.1 Previously Issued Safety Recommendations ...............................................................31  1.18.1.1  Crew Resource Management ........................................................................31  1.18.1.2  Pitch Trim Issues ...........................................................................................32  1.18.1.3  Human/Aircraft Interface Issues ...................................................................34  1.18.1.4  Recording Information on Aircraft ................................................................35  1.18.1.5  FAA Postaccident Inspections .......................................................................36  1.18.1.6  Check Airman Program Guidance .................................................................37  1.18.1.7  Airplane Upset Recovery Training Aid .........................................................38  1.18.2 FAA Check Airman Appointment Information ............................................................39  1.18.3 Related Wiring Issues and Cessna Service Bulletin ....................................................40  1.18.4 Aileron Trim Requirements .........................................................................................40  1.18.5 Previous Citation 550 Aileron Trim Events .................................................................41 

1. Analysis .....................................................................................................................................42 
2. 1 General .....................................................................................................................................42 
3. 2  Accident Flight Sequence .......................................................................................................42 
4. 2.1  Possible Initiating Event Accident Scenarios ..............................................................43 
5. 2.1.1  Inadvertent Autopilot Engagement Scenario .................................................44 
6. 2.1.2  Runaway Pitch Trim Scenario .......................................................................45 
7. 2.1.3  Accident Scenario Analysis and Discussion .................................................47 
8. 2.2  Safety Issues.................................................................................................................48 
9. 2.2.1  Autopilot Panel Design .................................................................................48 
10. 2.2.2  Airplane Wiring .............................................................................................49 
11. 2.2.3  Runaway Pitch Trim ......................................................................................50 
12. 2.2.4  Human Factors in Aircraft Design ................................................................52 
13. 2.2.5  Aileron Trim Sensitivity and Responsiveness ...............................................52 
14. 3  Pilot Communications and Coordination ...............................................................................54 
15. 4  FAA Oversight .......................................................................................................................56 
16. 4.1  Check Airman Appointment Guidance ........................................................................56 
17. 4.2  Regional Aviation Safety Inspection Program Guidance and Procedures ...................57 
18. 4.3  Mechanisms for Alerting the FAA to Potential Operator Problems ............................58 
19. 5  Operators with Financial Difficulties .....................................................................................59 
20. Conclusions ...............................................................................................................................61 

ii

NTSB Aircraft Accident Report 3.1 Findings....................................................................................................................................61  3.2 Probable Cause.........................................................................................................................64  4.  Recommendations ..................................................................................................................65  4.1  New Recommendations ..........................................................................................................65  4.2  Previously Issued Recommendations Reiterated and Reclassified in This Report ................67  4.3  Previously Issued Recommendations Classified in This Report ............................................67  5.  Appendixes..............................................................................................................................69  Appendix A: Investigation and Public Hearing .............................................................................69  Appendix B: Cockpit Voice Recorder ...........................................................................................70 

iii

NTSB Aircraft Accident Report Figures Figure 1. The accident airplane’s ground track from liftoff to impact, based on radar data. Selected CVR excerpts are shown. ................................................................................................. 4  Figure 2. Photograph showing the pitch trim control wheel and the white pitch trim position indicator on the left side of the throttle console of a representative Citation, as viewed from the captain’s seat. ................................................................................................................................ 11  Figure 3. Photograph showing the aileron and rudder trim wheels and indicator tabs on the aft face of a representative Cessna 550 throttle console. ................................................................... 13  Figure 4. Photograph of a representative Citation 550 cockpit, with the autopilot control panel and the pilots’ control-yoke-mounted autopilot disconnect buttons indicated. ............................ 15  Figure 5. Photograph showing a closer view of the autopilot control panel at the aft end of the center console’s upper surface, between the pilots’ seats. ............................................................ 16  Figure 6. Photograph of the sections of the first officer’s control yoke and mounting shaft with associated wiring. .......................................................................................................................... 22  Figure 7. Illustration of the wiring and bolts in the control yoke mounting shaft. ...................... 23 

iv

NTSB Aircraft Accident Report v Abbreviations AAMS Association of Aeromedical Services AC advisory circular AD airworthiness directive AFM airplane flight manual agl above ground level AHA American Hospital Association ALJ administrative law judge ATC air traffic control ATCT air traffic control tower ATP airline transport pilot CAMTS Commission on Accreditation of Medical Transport Services CFM company flight manual CFR Code of Federal Regulations cg center of gravity

NTSB Aircraft Accident Report vi CRM crew resource management CVR cockpit voice recorder EDT eastern daylight time EMS emergency medical services EUROCAE European Organization for Civil Aviation Electronics FAA Federal Aviation Administration FBO fixed-base operator FDR flight data recorder

FSDO flight standards district office FSI Flight Safety International IFR instrument flight rules KIAS knots indicated airspeed MKE General Mitchell International Airport msl mean sea level MVFR marginal visual flight rules NASIP National Aviation Safety Inspection Program

NTSB Aircraft Accident Report NPRM notice of proposed rulemaking NTSB National Transportation Safety Board OIG Office of Inspector General OSIP Office Safety Inspection Program POI principal operations inspector PRIA Pilot Records Improvement Act RASIP Regional Aviation Safety Inspection Program SAIB special airworthiness information bulletin SB service bulletin TSO technical standard order UM University of Michigan YIP Willow Run Airport vii

NTSB Aircraft Accident Report viii Executive Summary On June 4, 2007, about 1600 central daylight time, a Cessna Citation 550, N550BP, impacted Lake Michigan shortly after departure from General Mitchell International Airport, Milwaukee, Wisconsin (MKE). The two pilots and four passengers were killed, and the airplane was destroyed. The airplane was being operated by Marlin Air under the provisions of 14 Code of Federal Regulations Part 135 and departed MKE about 1557 with an intended destination of Willow Run Airport, near Ypsilanti, Michigan. At the time of the accident flight, marginal visual meteorological conditions prevailed at the surface, and instrument meteorological conditions prevailed aloft; the flight operated on an instrument flight rules flight plan. The National Transportation Safety Board determined that the probable cause of this accident was the pilots’ mismanagement of an abnormal flight control situation through improper actions, including failing to control airspeed and to prioritize control of the airplane, and lack of crew coordination. Contributing to the accident were Marlin Air’s operational safety deficiencies, including the inadequate checkrides administered by Marlin Air’s chief pilot/check airman, and the Federal Aviation Administration’s (FAA) failure to detect and correct those deficiencies, which placed a pilot who inadequately emphasized safety in the position of company chief pilot and designated check airman and placed an ill-prepared pilot in the first officer’s seat. The safety issues discussed in this report include pilot actions and coordination, the need for image recording equipment on airplanes not equipped with flight data recorders, autopilot panel design, control yoke wiring installations, identification of circuit breakers for use in emergencies, aural and visual alerts to pitch trim-in-motion, aileron trim power and sensitivity, human factors in airplane design, FAA appointment of check airmen, the scope of Regional Aviation Safety Inspection Program inspections, avenues for expressing safety concerns to federal authorities, and the safety ramifications of an operators’ financial health.

NTSB Aircraft Accident Report 1

1. Factual Information
2. 1 History of the Flight

On June 4, 2007, about 1600 central daylight time,1 a Cessna Citation 550, N550BP, impacted Lake Michigan shortly after departure from General Mitchell International Airport, Milwaukee, Wisconsin (MKE). The two pilots and four passengers were killed, and the airplane was destroyed. The airplane was being operated by Marlin Air under the provisions of 14 Code of Federal Regulations (CFR) Part 135, and departed MKE about 1557 with an intended destination of Willow Run Airport (YIP), near Ypsilanti, Michigan. At the time of the accident flight, marginal visual meteorological conditions prevailed at the surface and instrument meteorological conditions prevailed aloft; the flight operated on an instrument flight rules (IFR) flight plan.2 On the day of the accident, the pilots reported for duty at YIP about 1000 eastern daylight time (EDT) for an 1100 EDT departure for MKE. The accident flight was a medical/air ambulance flight under contract to the University of Michigan (UM) Health System and was transporting a medical transplant team to MKE so they could harvest an organ and return to YIP for an organ transplant at UM Medical Center. According to the cockpit voice recorder (CVR),3 as the airplane approached MKE, the first officer stated that he would request weather information from MKE air traffic control tower (ATCT) personnel, and the captain replied, “no, no, because if they give us…below minimums then we’re…really screwed.”4 When the pilots were instructed to contact MKE ATCT, the captain reminded the first officer not to ask about the weather. The pilots checked in at the MKE fixed-base operator (FBO) about 1153. According to FBO personnel, the pilots helped the medical transplant team to a waiting van and then ate lunch and awaited the team’s return. A pilot who had interviewed for a job with Marlin Air encountered the accident pilots at the MKE FBO while they waited for the medical team to return. He stated that the pilots appeared relaxed and in good spirits; they talked about future business prospects for Marlin Air, and the accident captain indicated that he hoped to acquire more airplanes for the company. The pilot stated that the captain received a telephone call advising him (in his capacity as Marlin Air’s chief pilot) that the other Marlin Air/UM charter flight scheduled for that day had

1 Unless otherwise indicated, all times are central daylight time, based on a 24-hour clock. 2 The public docket for this accident (National Transportation Safety Board identification number CHI07MA160) is available online at http://dmssvr/dms/public/search. 3 The CVR recorded the last 30 minutes and 57 seconds of cockpit communications before the accident. See appendix B for a transcript of the CVR recording. 4 Federal regulations do not permit a flight operating under 14 CFR Part 135 to begin an instrument approach unless the latest weather report indicates conditions at or above the authorized IFR minimums for that airport. Therefore, the pilots would not have been able to initiate the approach to MKE if they had received a weather report indicating conditions that were below instrument landing requirements. Thus, they would have had to deviate to an alternate airport. Despite the captain’s concerns, surface weather observations showed that conditions at MKE were above the authorized minimums at the time of the flight’s arrival.

NTSB Aircraft Accident Report 2 been canceled because of mechanical problems and a ferry permit would be needed to return the airplane for maintenance. (For additional information, see section 1.17.2.) The medical team returned to MKE with the transplant organ about 1530, and the pilots prepared for departure. About 1546, the pilots received an IFR clearance for the flight from MKE to YIP. The pilots taxied to the departure runway (runway 1L). According to the CVR transcript, the pilots discussed some tasks that were on preflight checklists but did not perform a formal challenge-response checklist procedure as they were leaving MKE.5 About 1556:36, the pilots received clearance for takeoff, with instructions to climb to 2,000 feet mean sea level (msl) and then turn right to a heading of 050°. The National Transportation Safety Board’s (NTSB) review of CVR evidence showed that, about 1557:34, the airplane accelerated on the runway and rotated. About 4 seconds later, the captain stated, “positive rate gear up,” and the first officer confirmed, “yup.” About 1557:40, the CVR recorded the captain stating, “lights off, yaw damper on.” About 1557:51, while the first officer radioed MKE controllers to advise them that the pilots were starting the airplane’s turn from the runway heading to the air traffic control- (ATC)-assigned heading of 050°, the captain asked, “why am I fighting the controls here?” At 1557:57, the captain again stated, “I’m fighting the controls…” as the CVR recorded the first officer stating, “[unintelligible word] I had it on.” Then, the captain confirmed with the first officer that the landing gear was up and instructed him to retract the flaps. About 1558:07, the captain made his third mention of an unspecified control problem, stating, “what the [expletive]’s going on? I’m fighting the controls.” About 1558:13, the first officer asked, “how’s your trim set? Is that the way you want it?” About 1558:21, the captain began to describe the control problem more specifically, stating, “I’m fighting the controls. It wants to turn hard left,” and the first officer again asked, “how’s your trim down here?” The captain’s response, which began, “trim has nothing…” was interrupted when the first officer erroneously responded to an ATC transmission intended for another airplane. About 1558:45, the CVR recorded the captain stating, “… something is wrong with the trim…the rudder trim…” The captain questioned the altitude clearance, the first officer stated they were cleared to 3,000 feet msl, and the captain stated, “all right, something is wrong with our rudders. And I don’t know what.” At 1559:04, the first officer asked the captain what he wanted to do; then, at 1559:07, the first officer asked, “how’s that, any better?” The CVR recorded the captain stating, “huh, no, we got a trim problem…[sound of grunt6]…tell ‘em we got to come back and land.” At 1559:19, the CVR recorded the captain saying, “she’s rolling on me. Help me, help me,” and the first officer responded, “I am.” At 1559:24, the captain asked the first officer to pull the autopilot circuit breakers, and the first officer responded, “where is it?” About 1559:29, the CVR recorded the captain stating, “tell ‘em we got a control problem,” and at 1559:30, the first officer advised the MKE departure controllers that they had

5 During postaccident interviews, the owner of Marlin Air described the accident captain as being “quick with the checklist,” and a company pilot described the captain as “working on getting unnecessary callouts/chatter removed from some of the checklists.” 6 The NTSB’s investigation showed that when this sound was recorded, the airplane had accelerated to about 245 knots.

NTSB Aircraft Accident Report “a control problem, we’ve got to come back in.” The first officer used an incorrect airplane identification number on this transmission, and the captain promptly corrected him. At 1559:44, the first officer transmitted, “Milwaukee, we got…a runaway trim, we got an emergency.” According to the CVR transcript, about 1559:50, the first officer asked, “what circuit breakers?” About 1559:57, the CVR recorded the captain telling the first officer, “answer her…” in response to an ATC query, and “keep turning.” The captain then advised the MKE departure controller, “zero bravo pap[a] declaring an emergency, yes.” About 1600:12, the first officer repeated that they were “coming back to Milwaukee,” and the captain added, “landing any runway at…Milwaukee. Guide us in please, zero bravo pap[a].” At 1600:26, the captain transmitted to MKE, “I don’t know what’s wrong,” then, at 1600:30, the captain stated to the first officer, “I don’t know what’s wrong…I see the airport. Keep [unintelligible words].” At 1600:36, the CVR recorded the captain stating, “you hold it, I’m gonna try to pull circuit breakers…” Beginning at 1600:40, the captain stated, “…we’re not…holding it.” The first officer stated, “I’m pulling,” and, at 1600:43, the CVR recorded the captain stating, “awww [expletive]…” The CVR recording ended at 1600:45. The fragmented airplane wreckage was recovered from Lake Michigan during multiple dives. Physical evidence indicated that the airplane impacted Lake Michigan at a speed of about 243 knots, in a steep (about 42°) nose-down, left-wing-low attitude. Figure 1 shows the accident airplane’s ground track, based on radar data, from liftoff to impact, with selected CVR quotes shown. 3

NTSB Aircraft Accident Report

Figure 1. The accident airplane’s ground track from liftoff to impact, based on radar data. Selected CVR excerpts are shown. (Figure not to scale.) 4

NTSB Aircraft Accident Report 5 1.2 Injuries to Persons Table 1. Injury chart. Injuries Flight Crew Cabin Crew Passengers Other Total Fatal 2 0 4 0 6 Serious 0 0 0 0 0 Minor 0 0 0 0 0 None 0 0 0 0 0 Total 2 0 4 0 6 1.3 Damage to Airplane The airplane was destroyed when it impacted Lake Michigan. 1.4 Other Damage No other damage was reported. 1.5 Personnel Information 1.5.1 The Captain The captain, age 59, applied for Marlin Air’s chief pilot position7 on February 7, 2005, and was hired by Marlin Air as a line pilot on February 21, 2005. Marlin Air management subsequently designated him the company’s chief pilot and then, effective August 15, 2005, he was appointed by the Federal Aviation Administration (FAA) as Marlin Air’s check airman in Cessna Citation 500/550 airplanes.8 He held a multiengine airline transport pilot (ATP) certificate with type ratings in the Citation 500, 550, and 650 airplanes and the McDonnell-Douglas DC-9.9 He completed his most recent 14 CFR Part 135 recurrent training at a commercial flight training facility that provided simulator-based training in November 2006, and he completed his most recent Part 135 proficiency and line checks in a Marlin Air Citation

7 According to documents describing Marlin Air’s organization, the chief pilot’s duties included supervising company line pilots; establishing and maintaining ground and flight training programs; assisting and advising the company’s director of operations in managing flight operations; and maintaining company manuals. 8 A check airman is authorized to conduct proficiency or competency checks, line checks, and special qualification checks; to supervise the reestablishment of landing currency; and to supervise the initial operating experience requirements of 14 CFR 121.434 and 135.244. A check airman may conduct flight training in the operator’s approved program. 9 The captain’s Citation 650 type rating provided second-in-command privileges only.

NTSB Aircraft Accident Report 6 on April 24, 2007. The captain held a first-class FAA airman medical certificate, dated March 29, 2007, with the restrictions that he “must wear corrective lenses for distant vision,” and “not valid for any class after March 31, 2008.”10 According to FAA and Marlin Air records,11 at the time of the accident, the captain had flown about 14,000 total hours, including about 12,000 hours as a professional pilot in a variety of airplanes, including the Learjet, Citation, Mitsubishi MU-2, DC-8 and -9, and Airbus 320. The captain’s total flight time included about 300 hours in Citation 500/550 airplanes. Marlin Air records show that the captain had flown about 206, 51, and 31 hours in the 90, 60, and 30 days, respectively, before the accident. Company records showed that the captain was off duty on May 30, May 31, and June 1. On June 2, he was on duty from 0000 to 0330, during which time he flew 1.5 hours. On June 3, he was on duty from 1000 to 1900, during which time he flew about 1.5 hours. As previously stated, the captain reported for duty about 1000 on June 4, in preparation for the flight from YIP to MKE that preceded the accident flight. A search of FAA records revealed that, on August 13, 1987, the FAA issued an Order of Revocation against the captain’s commercial pilot certificate because of the captain’s March 27, 1987, conviction for “conspiracy to import methaqualone” into the United States from Canada in violation of federal law.12 The Order of Revocation was upheld on appeal before an NTSB administrative law judge (ALJ) on February 12, 1991. In September 1992, while appealing the ALJ’s decision upholding the revocation order, the captain successfully completed the required tests and was issued an ATP certificate.13 On July 9, 1993, the NTSB Board Members affirmed the earlier ALJ decision and upheld the FAA’s Order of Revocation. The captain’s subsequent petition that the NTSB reconsider its decision was denied in NTSB Order EA-4015, dated November 4, 1993; however, in accordance with existing procedures, the pilot was allowed to apply for new pilot certificates after he surrendered the revoked certificates. FAA records show that the captain surrendered his pilot certificates to the FAA on December 8, 1993. At the time of the captain’s conviction, regulations did not dictate permanent certificate revocation under these circumstances.14 Therefore, after the captain surrendered his pilot certificates to the FAA, new certificates were issued to him after he successfully completed the required practical tests. On December 17, 1993, the captain applied for and was issued a student pilot certificate. On December 19, 1993, the captain was issued private and commercial pilot certificates with instrument and multiengine land ratings after he successfully completed the required practical tests. On May 6, 1994, the captain successfully completed the applicable practical tests and was issued an ATP certificate.

10 The captain had an authorization for special issuance of a medical certification for his diabetes, controlled on oral medications, that required annual follow-up. 11 The captain’s current pilot logbook was likely on the accident airplane, and it was not found in the wreckage. 12 The captain was convicted of piloting an airplane containing about 2,100 pounds of methaqualone into the United States from Canada on the night of October 13-14, 1981, and was sentenced to 28 months in prison as a result. 13 A pilot can obtain additional certificates while a case is under appeal. 14 Current federal regulations specify a lifetime revocation of pilot privileges for a criminal conviction involving transportation of controlled substances.

NTSB Aircraft Accident Report 7 Records show that, on June 12, 2001, the captain applied for a Citation 500 type rating, which was initially denied because he “ran off [the] runway” while demonstrating a crosswind takeoff during the simulator checkride. The captain subsequently reapplied for the type rating the same day, successfully demonstrated a crosswind takeoff, and was issued an ATP certificate with a Citation 500 type rating. Records further indicate that, on June 8, 2004, the captain applied for a DC-9 type rating, which was initially denied because he was unable to successfully complete the weight and balance portion of the practical test oral exam. On June 21, 2004, the captain successfully completed the practical tests and was issued a DC-9 type rating. Marlin Air management personnel told investigators that when they hired the captain in February 2005, they obtained background information about the captain in accordance with the Pilot Records Improvement Act (PRIA) of 1996, which requires operators to obtain and evaluate safety-related background information regarding prospective pilots. The PRIA information should include airman and medical certification records, closed enforcement actions within the previous 5 years, and all past or current certificate revocations.15 FAA records showed that, on March 29, 2006, the captain failed a 14 CFR Part 135 proficiency checkride after he deployed the thrust reversers prematurely during landing, causing the airplane to become airborne again after touchdown. The inspector who conducted the proficiency checkride commented that the captain did not have the knowledge of the airplane’s systems needed for a check airman. The inspector also noted that the captain did not demonstrate an acceptable understanding of IFR operations and requirements. The captain subsequently successfully completed a retest on the same day.16 Records indicate that, on October 18, 2006, the captain applied for and successfully completed the practical test for a Citation 650 type rating with second-in-command privileges. During postaccident interviews, several pilots who had flown with the captain indicated that although he was a capable pilot, the captain lacked in-depth airplane systems knowledge and did not always adhere to company procedures or comply with regulations. Several former Marlin Air pilots commented that the captain seemed to focus on business issues rather than on flight operations and safety. One pilot stated that, as Marlin Air’s chief pilot, the captain wanted company pilots to stay longer at higher altitudes to save fuel. Another pilot stated that he had flown with the captain once when the captain intentionally took off, and subsequently landed, in an airplane that was loaded beyond allowable takeoff and landing weight limits because he was “tankering” inexpensive fuel.17 On another occasion, after experiencing a mechanical problem

15 Review of the documentation provided by the PRIA vendor showed that the information given to Marlin Air accurately reflected the captain’s background and certificate revocation. However, Marlin Air personnel stated that they were unaware of the captain’s background and certificate revocation. 16 Federal regulations (14 CFR Part 135.301[b]) do not prohibit a pilot who fails any of the required maneuvers during a Part 135 checkride from practicing and then being retested on the failed maneuver. However, the regulations restrict that pilot from acting as a flight crewmember in Part 135 operations until he or she has satisfactorily completed the checkride. 17 The term “tankering” refers to the practice of loading the airplane with more fuel than needed for an intended flight by buying from less expensive vendors and then carrying that fuel onboard until it is needed.

NTSB Aircraft Accident Report 8 (collapsed landing gear strut) on a flight, the captain proposed flying the return leg of the trip with the landing gear extended to avoid contract penalties that would be incurred if another company completed the trip. In addition, several pilots stated that the captain was actively trying to expand the company and was trying to obtain another airplane for charter operations. (During the investigation, NTSB investigators reviewed a partnership agreement that the first officer proposed to the owner of Marlin Air. The draft agreement proposed that the first officer would purchase 49 percent of Marlin Air stock at a price to be determined and that the captain would receive company stock from the owner and the first officer, such that the captain would have a 25-percent stake in the company at the end of 5 years.)18 The NTSB examined records for the three most recent training flights conducted by the captain. These flights included a company pilot training flight on May 4 and proficiency checkrides for the accident first officer and another newly hired pilot on May 23 and June 2, respectively. The training times recorded on all three training records (3.5, 3.1, and 1.5 hours, respectively) differed from the times recorded by the airplanes’ hour-recording meters (0.8, 0.6, and 0.3 hours, respectively). Marlin Air and FAA personnel were unable to explain these discrepancies. During postaccident interviews, the newly hired pilot involved in the June 2 training at first stated that he had never flown with the accident captain/chief pilot and then later indicated that he had flown briefly with the accident captain, to perform a “couple of takeoffs and landings.” This pilot held a Citation type rating but indicated that he had not flown a Citation in years. A search of the National Driver Register found no record of driver’s license suspension or revocation. 1.5.2 The First Officer The first officer, age 65, was not a full-time professional pilot but, rather, was a businessman who flew commercially part time. Records showed that he had previously worked as a part-time pilot for Marlin Air between December 1998 and August 2002 and was subsequently rehired by Marlin Air during the weeks before the accident. The first officer held a multiengine ATP certificate with type ratings in the Citation 500 and 550, Mitsubishi MU-300, and Raytheon Beechcraft BE-400. He also held a first-class FAA airman medical certificate, dated August 7, 2006, with the restriction that the “[h]older shall wear correcting lenses while exercising the privileges of his airman certificate.” According to FAA and Marlin Air records, the first officer had flown about 9,200 total hours, including about 420 hours in Citation 500/550 airplanes.19 Company records indicate that

18 Marlin Air personnel stated that, although the first officer had proposed an investment agreement, the company had not taken any action with regard to that agreement at the time of the accident. 19 This calculation of the first officer’s Citation 500/550 flight time was based on a June 2000 pilot record form for Marlin Air’s insurance provider; no updated documentation regarding his flight in the accident make and model was available.

NTSB Aircraft Accident Report 9 the first officer completed basic indoctrination training related to his rehire with Marlin Air on May 15, 2007, and that the accident captain, acting in his role as FAA-designated check airman, administered the first officer’s subsequent flight training and checkride in a Marlin Air Citation on May 23, 2007. (The first officer’s most recent simulator-based training was accomplished in May 2006, in a King Air simulator at a commercial flight training facility. His most recent Citation-specific simulator training occurred in November of 2001.) The associated FAA airman checkride documentation provided to the NTSB after the accident showed a checkride flight time of 2.5 hours;20 however, the airplane records showed that the airplane was actually flown a total of 0.6 hour flight time during the flight training and checkride. The first officer had flown about 1.1 hours since that logged training flight, all on the day of the accident. He had not flown during the 3 days before the day of the accident. He worked at a business not related to aviation on Friday, June 1, then remained near home over the weekend and reportedly arrived for duty well rested on Monday, June 4. He had been on duty about 7 hours when the accident occurred. FAA records indicated that, in December 2002, the first officer was involved in an accident involving a loss of electrical power on takeoff.21 The NTSB’s investigation of this accident revealed that the first officer inadvertently took off with the electrical generator switches in the “off” position and did not follow approved emergency landing gear extension procedures during the resultant (gear-up) forced landing.22 The NTSB conducted postaccident interviews with several pilots who had flown with the first officer during his previous employment with Marlin Air. One of these pilots characterized the first officer as “a nice guy who had no idea how the airplane operated” and added that he would act without thinking. These interviews revealed that the first officer would get overloaded easily and had difficulty flying a stabilized approach without coaching. One interviewed pilot recalled an occurrence in which the first officer was unable to properly tune the airplane’s radios. He stated that the first officer did not know which radio he was transmitting on or with which ATC facility he was communicating. Two other pilots who had flown with the first officer during his previous employment with the operator reported that the first officer inadvertently turned off the airplane’s avionics while attempting to switch the engine ignition settings from “on” to “norm” in accordance with after-takeoff procedures. (The ignition and avionics power switches were located adjacent to each other on the panel.) According to two former Marlin Air pilots, when the first officer left the company in August 2002, he was in captain upgrade training and was not performing to the required standards; they had informed Marlin Air’s owner that they could not recommend the first officer for the captain checkride. One of these pilots stated that the first officer was subsequently enrolled in upgrade training at Flight Safety International (FSI), and one of the FSI instructors

20 The checkride documentation showed that the first officer had satisfactorily completed all required tasks, including airwork, such as steep turns, approaches to stalls, emergency procedures, and two instrument approaches (one precision, one nonprecision). 21 This accident occurred on December 15, 2002, in Jackson, Michigan. Additional information about this accident, NTSB identification number CHI03LA039, can be found on the NTSB’s website at http://www.ntsb.gov/ntsb/query.asp. 22 Marlin Air’s principal operations inspector (POI) was the FAA inspector who reexamined the first officer after the 2002 accident. The POI subsequently rented one of the helicopters owned by the first officer when the POI wanted to take his son for a helicopter ride.

NTSB Aircraft Accident Report 10 did not believe that the first officer would successfully complete that program. Subsequently, the first officer was not upgraded to a captain position. The accident trip was the first officer’s first revenue flight since Marlin Air rehired him. CVR evidence indicates that he did not act as the flying pilot on either the outbound or return leg of the trip. The CVR also recorded the first officer being unaware that he had selected an improper standard instrument departure page (about 1547:35), being confused about taxi instructions (1549:30; 1550:03; and 1552:15), responding to an ATC communication for another aircraft (1558:08.3), and misstating the accident airplane’s call sign during three radio communications (1546:41; 1547:16; and 1559:38). A search of the National Driver Register found no record of driver’s license suspension or revocation. 1.6 Airplane Information 1.6.1 General The accident airplane, serial number 550-246, was manufactured by Cessna in 1981. In April 2003, after numerous ownership changes and modifications to the avionics and structure, the airplane was purchased by Toy Air, Inc. Toy Air made additional avionics and structural modifications23 and then leased the accident airplane to Marlin Air, Inc. At the time of the accident, the airplane had accumulated about 4,402 total flight hours. The airplane was equipped with two Pratt & Whitney Canada JT-15D-4 turbofan engines, both of which had been operated about 4,000 total hours. According to postaccident calculations, the airplane’s takeoff weight for the accident flight (assuming nominal fuel burn on the flight from YIP to MKE) was about 12,310 pounds and the calculated center of gravity (cg) was 280.5 inches; both parameters were within the required limits. 1.6.2 Airplane Systems 1.6.2.1 Flight Control Trim Systems The accident airplane had separate trim control systems for pitch (elevator), roll (aileron), and yaw (rudder). Each system included a manual hand-wheel in the cockpit and control cables attached to trim tabs at the related flight control surfaces. Each trim system had two cable loops,

23 The airplane records showed that modifications to the accident airplane included strengthening the landing gear, cutting the fuselage for a wider cabin door (for stretcher accessibility) and the installation of the CVR, an enhanced ground proximity warning system, a global positioning system, a satellite telephone, and emergency locator systems.

NTSB Aircraft Accident Report 11 one connecting the hand-wheel in the cockpit to the trim control surface and one connecting the trim control surface to its trim position indicator in the cockpit. 1.6.2.1.1 Pitch Trim System Information The pitch trim system is the only Citation 550 flight control trim system that is equipped with an electric servomotor and offers pilots the option of adjusting the elevator trim setting manually or electrically. The manual pitch trim mechanism is a large, black, vertically oriented wheel located along the left side of the throttle console, next to the captain’s right knee. (Figure 2 shows the pitch trim control wheel and the white position indicator as viewed from the captain’s seat in a Citation 550 airplane similar to the accident airplane.)

Figure 2. Photograph showing the pitch trim control wheel and the white pitch trim position indicator on the left side of the throttle console of a representative Citation, as viewed from the captain’s seat. Either pilot could input electrical pitch trim commands through a toggle switch on his control yoke.24 After engagement of the autopilot, the autopilot computer could also make pitch

24 Activation of the electric pitch trim system requires both a switched source of power and a switched path to ground. The single toggle button on each control yoke actuates a set of double-pole double-throw switches to achieve the required power and ground paths.

NTSB Aircraft Accident Report 12 trim inputs through a relay to relieve the load on the electric autopilot servomotor. Once engaged, the autopilot would disconnect if either pilot used their electric pitch trim switch.25 Marlin Air’s Citation 550 pilots’ abbreviated checklist contained the following item on the taxi checklist: “electric elevator [pitch] trim—check.” Marlin Air’s Citation 550 airplane flight manual (AFM) further described this taxi checklist item as follows: Electric Elevator Trim – CHECK; operate electric elevator trim nose up and push AP/TRIM DISC switch. Verify elevator trim wheel stops rotating. Repeat check for nose down trim. The CVR recorded no evidence that the pilots performed these system checks during the accident airplane’s ground operations.26 During postaccident investigations in a representative airplane, it was noted that the captain’s right knee or his right hand or arm while gripping the right side of the control yoke could obstruct his vision of pitch trim wheel movement. The pitch trim wheel was painted black, and movement of the wheel was largely inconspicuous. Investigators also noted that the electric pitch trim operated quietly and that an aural trim-in- motion warning is not required by the FAA. The “Abnormal Procedures” section of the Citation 550 AFM included the following instructions for a jammed elevator trim condition during a takeoff or go-around maneuver: Reduce power as necessary to maintain 120 [knots indicated airspeed] or less. Do not change flap position…Do not retract landing gear. Land as soon as practical. 1.6.2.1.2 Aileron Trim System Information During postaccident discussions, Cessna personnel initially indicated that the Citation 550 aileron trim, which has +/- 20° of authority, was designed to relieve control wheel forces in the event of an engine failure. However, Cessna personnel recognized that, because of the Citation’s design (low-wing with fuselage-mounted engines) and rudder and aileron effectiveness, this amount of aileron trim authority is not needed to counter an engine failure. Cessna personnel subsequently stated that the airplane’s aileron trim capability was originally designed for some other failure condition but that records from the time of the design did not identify that condition. The Citation 550 aileron trim system is mechanical, without an electric trim or autopilot function. It consists of a trim knob mechanism in the cockpit that is connected by cables to jackscrews located forward of the ailerons in the wings. The cockpit aileron trim knob is a relatively small, knobbed wheel that is vertically oriented on the aft face of the throttle console and is oriented perpendicularly to the airplane’s longitudinal axis. Clockwise or counterclockwise movement of the trim knob results in right-wing-low or left-wing-low aileron trim tab adjustments, respectively. The aileron trim indicator slot is 2.5 inches wide and has an

25 The autopilot could also disconnect if its internal monitoring system detected an uncommanded servomotor engagement. 26 Between 15:55:15 and 15:57, the CVR recorded the pilots citing some checklist items that were on the airplane’s abbreviated checklist; however, the cited items were incomplete and not in the listed order.

NTSB Aircraft Accident Report 13 associated 0.20-inch wide white position indicator tab. (Figure 3 shows the aileron and rudder trim wheels and indicators on the aft face of a Cessna 550 throttle console.)

Figure 3. Photograph showing the aileron and rudder trim wheels and indicator tabs on the aft face of a representative Cessna 550 throttle console. Based on postaccident observations in a similar airplane, investigators noted that a centered aileron trim indicator would appear not to be centered when viewed from either pilot’s seat, due to parallax.27 For additional information regarding Cessna Citation aileron trim, see section 1.18.4. 1.6.2.1.3 Rudder Trim System Information The Citation 550 rudder trim system is mechanical, without an electric trim or autopilot function. It consisted of cables that connect a hand-wheel mechanism in the cockpit to sets of

27 Parallax is when an object seems to change direction because the observer has changed position and, thus, has a new line of sight.

NTSB Aircraft Accident Report 14 jackscrews in the vertical stabilizer. The cockpit rudder trim wheel is a horizontal, knobbed wheel that is located in a slot on the aft face of the throttle console, below the aileron trim indicator slot; movement of the hand-wheel adjusts the rudder trim tab accordingly. The rudder trim indication slot is 1.70 inches wide and has an associated 0.20-inch wide, white position indicator tab. (See figure 3.) As they had with the aileron trim indicator, investigators noted that a centered rudder trim indicator in a similar airplane would appear not to be centered when viewed from either pilot’s seat, due to parallax. 1.6.2.2 Autopilot System The accident airplane was equipped with a Honeywell SPZ-500 integrated autopilot system, which used a computer to collect information from various sensors and control inputs and then to position electric-clutched servomotors at each of the primary flight controls (elevator, aileron, and rudder). When engaged, the autopilot computer could also provide input to the electric pitch trim system to relieve a sustained load on the autopilot’s pitch servomotor. The rudder servomotor and an internally segregated portion of the autopilot computer also functioned as the yaw damper, providing a limited amount of rudder authority to the rudder servomotor to offset minor yaw motions. The individual-toothed faces of the servomotor clutch discs (which resemble poker chips) are held apart by springs until the autopilot system is engaged, at which time the servomotor clutch assembly brings the two discs together and the disc teeth mesh. When engaged, the autopilot servomotors can provide limited amounts of force to the primary flight controls, based on inputs from the autopilot computer.28 If the flight guidance system is not coupled to the autopilot computer when the autopilot is initially activated, the autopilot computer’s default settings engage in the “magnetic heading hold/pitch attitude hold” mode. While engaged in this mode, the autopilot could apply up to the motor’s limits of force to resist any effort to change the airplane’s heading or pitch. However, according to Cessna and Honeywell, the electrical motor selected for the Citation autopilot servos limited the amount of force that each could generate, allowing a pilot to overpower the full force produced by a servomotor with relative ease in the event of a malfunction.29 The Citation 550 autopilot control panel is located on the aft surface of the center control console in the cockpit, between the pilots’ seats, aft of the seats’ forward edges. The two buttons that are used to either fully or partially engage the autopilot system (the autopilot and yaw damper buttons, respectively) are located on the aft portion of this control panel almost directly above the aileron and rudder trim indicators. The autopilot and yaw damper buttons are directly adjacent to each other on the panel and are identical except for their left/right orientation and the labeling text beneath them (AP and YD, respectively). Figure 4 is a photograph of a representative Citation 550 cockpit, with the autopilot control panel and the pilots’ control-yoke-

28 Pilots can provide control inputs to the autopilot directly through knobs on the autopilot control panel or through inputs to the flight guidance system. The autopilot computer can provide control inputs to the autopilot through its interpretation of flight guidance system information and inputs. 29 Flight test data showed that (at an altitude of 12,000 feet msl and 150 knots) 25, 30, and 70 pounds were required to overpower the aileron, elevator, and rudder servomotors, respectively.

NTSB Aircraft Accident Report mounted autopilot disconnect buttons indicated. Figure 5 is a closer view of the autopilot control panel at the aft end of the console’s upper surface, between the pilots’ seats. (This photograph also shows the aileron and rudder trim control wheels and position indicators.)

Figure 4. Photograph of a representative Citation 550 cockpit, with the autopilot control panel and the pilots’ control-yoke-mounted autopilot disconnect buttons indicated. 15

NTSB Aircraft Accident Report

Figure 5. Photograph showing a closer view of the autopilot control panel at the aft end of the center console’s upper surface, between the pilots’ seats. During the investigation of this accident, several Citation 550 pilots told NTSB investigators of times when they had inadvertently engaged the autopilot instead of the yaw damper. The NTSB previously addressed the issue of inadvertent autopilot activation in its report on the October 25, 2002, accident involving a King Air A100 in Eveleth, Minnesota. The Eveleth investigation showed that the selection of the autopilot instead of the yaw damper after a 16

NTSB Aircraft Accident Report 17 previous takeoff resulted in an unanticipated control response (abrupt nose-down pitch), which might have had dramatic consequences if the problem had gone unrecognized by the pilots.30 The ability to differentiate among controls has safety implications. As described in Human Factors in Engineering and Design,31 “[a]lthough the correct identification of controls is not critical in some circumstances, there are some situations…in which their correct and rapid identification is of major consequence—even life or death…. One characteristic of a good control system is that every control must be detectable and discernable from other controls.” FAA airworthiness standards in 14 CFR 25.777, “Cockpit Controls,” require that cockpit controls be located and arranged for easy access and operation and to prevent confusion and inadvertent operation. Section 25.781, “Cockpit Control Knob Shape,” requires specific control shapes for engine, landing gear, and flap controls to provide for tactile identification of controls as a secondary identification method beyond the visual. Marlin Air’s Citation 550 pilots’ abbreviated checklist contained the following item on the taxi checklist: “autopilot—check.” Marlin Air’s Citation 550 AFM further described this taxi checklist item as follows: Autopilot—check; engage autopilot; check pitch and roll command, heading mode, and altitude mode. Push autopilot test button and hold. The AP TORQUE annunciator will illuminate, the AUTOPILOT OFF annunciator will illuminate and the autopilot disconnect horn will sound. If all annunciators do not illuminate, autopilot may not be functional. The Citation AFM stated that the autopilot and yaw damper were to be off for takeoff and landing. Marlin Air’s Citation 550 checklists also included in the after-takeoff—climb checklist: “yaw damper—as required”32 and included in the before-landing checklist: “autopilot and yaw damper—off.”33 Marlin Air’s Citation 550 checklists reflected the more detailed guidance contained in the Citation AFM and Operating Manual. The CVR recorded no evidence that the pilots performed any of these autopilot or yaw damper system checks during the accident airplane’s ground operations. The Citation AFM outlined procedures for autopilot malfunctions involving an autopilot servomotor failure to high torque and an autopilot hardover;34 in both cases, the procedures

30 For additional information, see Loss of Control and Impact with Terrain, Aviation Charter, Inc., Raytheon (Beechcraft) King Air A100, N41BE, Eveleth, Minnesota. October 25, 2002, Aviation Accident Report NTSB/AAR-03/03 (Washington, DC: National Transportation Safety Board, 2003). 31 M.S. Sanders and E.J. McCormick, Human Factors in Engineering and Design. (New York: McGraw Hill 1987). 32 According to the Citation Operating Manual, “with the yaw damper engaged, airplane control is improved and passenger comfort is enhanced.” 33 The Citation Operating Manual stated, in part, “If the yaw damper is not turned off it will attempt to override pilot rudder input during touchdown and roll out. Utilize the APTRIM DISC button on either control [yoke].” 34 An autopilot hardover is defined as any autopilot failure that results in rapid and sustained displacement of an aircraft aerodynamic control surface.

NTSB Aircraft Accident Report 18 required the pilots to disconnect the autopilot using the AP/TRIM DISC switch on the control yoke. According to the Citation 550 operations manuals, the autopilot is normally disengaged by: • depressing the AP/TRIM DISC switch on either control yoke; • electrically trimming the elevator trim system; or • depressing the go-around button on the throttle lever. The manuals stated that, if the autopilot is disengaged by any of these methods, a warning tone sounds for 1 second and the amber AUTOPILOT OFF indicator light on the instrument panel illuminates for 1 second. The manuals further stated that, if the pilots disengage the autopilot by any method other than the normal disengagement procedures listed above, the warning tone will still sound for 1 second but the amber AUTOPILOT OFF indicator light will illuminate and remain illuminated.35 In addition, the autopilot servomotor engagement clutches can be temporarily disengaged by holding down the touch control steering button on either pilots’ control yoke. This method of disengagement would not result in a warning tone or instrument panel indicator light; however, the autopilot engagement light in the autopilot panel pushbutton would remain lit while the control yoke switch was held down. The autopilot cannot be disengaged by applying an overriding force to the control yoke; however, as previously noted, the engaged autopilot servomotors require a maximum force of 25, 30, and 70 pounds to overpower the aileron, elevator, and rudder servomotors, respectively, which a pilot would be able to counter easily. 1.7 Meteorological Information On the day of the accident, National Weather Service surface analysis charts showed a deep low-pressure system and associated cold fronts moving across the region, producing an area of IFR to marginal visual flight rules (MVFR) conditions36 with rain showers and thunderstorms. Surface weather observations from MKE showed MVFR conditions with rain and multiple cloud layers, with a broken ceiling at 3,000 feet above ground level (agl) and an overcast cloud layer at 3,500 feet agl reported at the time of the accident.

35 Other methods that might be used to disengage the autopilot included pulling the circuit breakers for the autopilot computer, autopilot clutch, or pitch trim; or removing generator power or otherwise interrupting signals from required system components. 36 IFR conditions are defined as a ceiling or lowest layer of clouds reported as broken or overcast, or the vertical visibility into a surface-based obscuration of less than 1,000 feet above ground level (agl) and/or visibility less than 3 statute miles. MVFR conditions are defined as a ceiling between 1,000 and 3,000 feet agl inclusive and/or visibility 3 to 5 miles inclusive. Based on the accident site weather observations, the pilots would not have had visual reference to the ground when the airplane was above 3,000 feet during the accident flight.

NTSB Aircraft Accident Report 19 1.8 Aids to Navigation No problems with any navigational aids were reported. 1.9 Communications No communications problems were reported. 1.10 Airport Information MKE is located about 5 miles south of Milwaukee, Wisconsin, at an elevation of about 723 feet. Runway 1L, the active runway at the time of the accident, is 9,690 feet long by 200 feet wide. 1.11 Flight Recorder Information 1.11.1 Cockpit Voice Recorder The accident airplane was equipped with a solid-state Universal CVR-30B designed to record the most recent 30 minutes of cockpit audio information obtained from four channels.37 The CVR was sent to the NTSB’s laboratory in Washington, DC, for examination, readout, and evaluation. Although the CVR exhibited external structural damage, audio information from the four channels was downloaded successfully. The accident CVR contained fair and good quality38 audio information. The recording started at 1138:26, and it captured the inbound portion of the airplane’s arrival at MKE, including the approach, landing, and ground operations; the recording ended at 1600:45.5, after the accident departure. (The airplane was not powered for about 3 hours and 51 minutes between flights, and during that time, the CVR was not operating.) Review of the CVR indicated that the captain was the flying pilot on both the inbound and outbound flights. A transcript was prepared of the 30-minute, 57-second recording and is available in appendix B.

37 The four channels of audio information recorded by the accident CVR included one channel for each flight crewmember, the cockpit area microphone, and a duplicate of the captain’s channel. 38 The NTSB uses the following categories to classify the levels of CVR recording quality: excellent, good, fair, poor, and unusable. A fair quality recording is one in which the majority of crew conversations were intelligible, and a good quality recording is one in which most of the flight crew conversations could be accurately and easily understood. The audio information recorded on the three pilots’ channels was fair, whereas that recorded on the cockpit area microphone was good.

NTSB Aircraft Accident Report 20 1.11.2 Flight Data Recorder The airplane was not equipped, and was not required to be equipped, with a flight data recorder.39 1.12 Wreckage and Impact Information As previously noted, physical evidence indicates that the airplane impacted Lake Michigan at a high speed, in a steep nose-down, left-wing-down attitude. The recovered wreckage was severely fragmented; however, in general, the damage observed on the recovered wreckage was more severe on the left side of the airplane than the right. Recovered debris included an airspeed indicator that exhibited impact marks extending from the center of the indicator to an airspeed indication of about 243 knots, and a partially-crushed standby attitude indicator that indicated an attitude of about 42° nose down, with about 115° left roll. The angle of the observed impact damage corresponded to this roll attitude, which would have resulted in the airplane’s left wingtip and nose striking the water almost simultaneously. The airplane wreckage was located in water about 62 feet deep east of Milwaukee, Wisconsin. After the wreckage was recovered from the lake, it was initially documented on a dock at the U.S. Coast Guard Station in Milwaukee and then transported to an airport hangar for reconstruction and lay-out. There was no evidence of lack of flight control continuity before impact. Physical examination of the flight control wreckage indicated that the elevators were generally positioned with the trailing edge down (airplane nose down) at impact; the ailerons were generally in a left-wing-down orientation, and the rudder trailing edge was left of its center, or streamlined, position. Wreckage examination indicated that the landing gear and flaps were in their retracted positions and the engines were producing power at impact. None of the airplane’s master warning annunciation light bulbs contained stretched or deformed filaments.40 1.12.1 Airplane Systems Wreckage Information 1.12.1.1 Airplane Trim Systems The NTSB examined the recovered trim systems, including their jackscrews, and related cockpit trim position indicators.41 Examination of the recovered aileron (roll) trim system revealed that the recovered black housing from around the white aileron trim position indicator had a white smear that extended from a half-needle width left of the center of the indicator slot,

39 According to 14 CFR Part 91.609(c)(1), an approved flight recorder is required for multiengine, turbine- powered airplanes manufactured after October 11, 1991, that have passenger seating configurations of 10 or more. The accident airplane was equipped with 8 passenger seats. 40 Tungsten filaments in a hot light bulb are malleable and may be stretched or deformed if illuminated at impact, unlike cold filaments, which are brittle. 41 Impact forces that result in flight control cable separation (as occurred in this case) can render jackscrew positions and cockpit indications inconclusive.

NTSB Aircraft Accident Report 21 which correlated to about 7-percent left wing down input. (Postaccident tests in another Citation showed that this trim position appeared to be centered when viewed from the first officer’s seat.) The cable-driven aileron trim jackscrew was found extended 1.2 inches, near its full left-wing-down extension. Examination of the recovered rudder (yaw) trim system revealed that the rudder trim jackscrew (recovered from the tail section) and the rudder trim cockpit indicator showed nearly identical indications of about 50 percent of full left rudder travel. Examination of the recovered rudder showed that it had impacted the airplane’s vertical stabilizer to the left of center. Examination of the recovered pitch trim system components revealed that the cockpit pitch trim indicator was found at the forward end of the range of travel, indicating a full nose- down position, with corresponding scratches on the side of the adjacent pedestal structure. The trim tab on the right elevator was twisted and bent but generally oriented in an airplane nose- down position. Pitch trim jackscrew measurements also indicated that the pitch trim was at or near its full nose-down position. There was no evidence of preimpact mechanical malfunction; however, the pitch trim wiring showed evidence of a short circuit. (For additional information, see section 1.12.2.) 1.12.1.2 Autopilot System Components The autopilot servomotor clutches that were connected to the primary control cables for the aileron, rudder, and elevator (pitch) systems were recovered and examined. The elevator autopilot servomotor clutch’s polymer gear teeth revealed no visible impact-related markings and showed little visible wear. Examination of the aileron autopilot and rudder servomotor clutches revealed damage to the clutch gear teeth that was consistent with an event that occurred while the clutch teeth were separated (disengaged). Some evidence of wear and repeated rubbing was observed at the roots of the aileron and rudder autopilot servomotor clutch gear teeth. Examination of the light bulbs that were in the recovered autopilot control panel from the throttle console revealed that the filament light bulb associated with the TRIM UP status light had stretched filaments that were partially wrapped around the support post within the bulb. This stretched filament indicated that the autopilot control panel (and the autopilot computer, which provided power to the autopilot control panel) was powered and functioning at impact.42 However, the autopilot pilot engaged light bulb filaments were not stretched; this bulb was tested and found functional after the accident. Examination of the yaw damper engaged bulb filaments revealed that they were more stretched than the AP ENGAGE status bulb filaments.

42Although the stretched light bulb filaments indicated that the autopilot control panel was powered and functioning (and thus performing continuous self-checks for proper operation) at impact, they did not indicate whether the servomotors were engaged. According to the autopilot’s design, if a servomotor had engaged when the light was illuminated, it should have resulted in a nose-up force on the pitch controls.

NTSB Aircraft Accident Report 22 1.12.2 Control Yoke and Related Switches The left and right side (captain’s and first officer’s, respectively) control yokes, with some associated switches and wiring, were recovered. Visual examination of the control yoke mounting shafts revealed that the shaft in the right side (first officer’s) control yoke had a sooty blackened appearance that was not evident in the shaft in the captain’s control yoke. (Figure 6 shows the sectioned first officer’s control yoke and mounting shaft with associated wiring.)

Figure 6. Photograph of the sections of the first officer’s control yoke and mounting shaft with associated wiring. The NTSB examined the control yoke-mounted switches (including the pitch trim and autopilot switches) and wiring from the recovered control yokes and mounting shafts. Each control yoke-mounted pitch trim system comprised a handgrip-mounted switch that had a plastic toggle to operate two double-pole double-throw internal microswitches43 and associated wiring. For the pitch trim motor to operate, two circuits needed to be completed: one providing power to

43 The microswitches, each of which had two sets of three contacts, could create nose-up or nose-down pitch trim commands, depending on the movement of the center reed and its subsequent contact with either the electrical contacts on either side of the reed. Depending on which direction the reed moved, such contact would result in either nose-down or nose-up commands.

NTSB Aircraft Accident Report 23 the motor, the other to a ground path for the motor. Wreckage examination also showed that, sometime before the accident, at least two short circuits occurred in a bundle of wires in the first officer’s control yoke/column. Investigators also found evidence of heat damage consistent with the short circuits and found chafing on some unrelated wires in this area.44 One of the short circuits occurred between the pitch trim power supply wire and the adjacent steel surface of the first officer’s control yoke shaft;45 the recovered wires were chafed around the area where the exposed wire had become welded to the steel of the control shaft. In addition, a possible ground path was found in the pitch trim microswitch assembly from the first officer’s control yokes. Although one of the normally-fixed contacts was found bent toward the center reed and the switch appeared to be closed when visually inspected, after rinsing silt from the switch, electrical tests found no continuity. 1.12.2.1 Control Column/Yoke Electrical Wiring Investigators recovered wires from both control yokes/columns. Examination of the wires revealed some wires that were enclosed in sleeves where repairs had previously been accomplished and several instances of damaged, chafed, or punctured wire insulation. Damage was observed on individual wires, as well as wires contained in flat ribbon cable bundles that were 0.38-inches wide and 0.07-inches thick. Two such ribbon cables were routed through each of the control yoke mounting shafts, along with individual wires. In addition, two mounting bolts passed through the control yoke mounting shaft at its widest point, restricting the available space in that part of the shaft to less than the 0.38-inch dimension of the ribbon wire, creating at least four potential chafe locations. (Figure 7 is an illustration of the wiring and bolts in the control yoke mounting shaft.) Postaccident examination also revealed some individual wires that had been folded back among the wires and pressed into the shafts, apparently when they were reinstalled after

44 Evidence and maintenance records showed at least two instances in which the wires in the first officer’s control yoke/column had been previously repaired. 45 There was also evidence of a short circuit on the power wire for the autopilot clutches. Figure 7. Illustration of the wiring and bolts in the control yoke mounting shaft. (Figure not to scale.)

NTSB Aircraft Accident Report maintenance. (Anecdotal information indicates that such wiring installations in control shafts are common.) Other recovered wires were found stretched and severed at the ends of the shafts. The observed wiring installations were inconsistent with the wiring practices described in FAA Advisory Circular (AC) 43.13-1B and -2A. After the right side control yoke and shaft were bisected, detailed examination revealed several areas of damaged wiring and that remnants of copper wire had adhered to the interior of the steel yoke mounting shaft. For example, the pitch trim system power wire had an extensive area of exposed copper core that had previously melted and resolidified, with some missing copper strands, signs of a mechanical imprint, and a kink that was not observed in other wires from that area. This portion of the pitch trim system power wire was found near an area of copper deposits, similar in shape and appearance, that had adhered to the inner wall of the steel mounting shaft. Additionally, wires adjacent to this portion of the pitch trim system power wire exhibited extensive insulation damage. In addition, the autopilot clutch power wire that was routed to the first officer’s control yoke exhibited two types of damage: 1) localized “poke-type” damage that penetrated the insulation and 2) a more wide-spread area of damage that contained a surface scratch, ripped insulation, torn copper strands, and three distinct areas of previously melted and resolidified copper, but none were as extensive as the damage to the pitch trim wire. 1.13 Medical and Pathological Information Toxicology tests were performed by the FAA’s Civil Aeromedical Institute on tissue specimens from both pilots. The tests detected low levels of ethanol in both pilots’ specimens, which were consistent with postmortem ethanol production. The specimens tested negative for a wide range of drugs, including major drugs of abuse such as marijuana, cocaine, phencyclidine, amphetamines, and opiates. The Milwaukee County Medical Examiner determined that the cause of death for the airplane occupants was multiple blunt force injuries. 1.14 Fire No evidence of an in-flight or a postcrash fire was found. 1.15 Survival Aspects The accident was not survivable due to impact forces. 24

NTSB Aircraft Accident Report 25 1.16 Tests and Research 1.16.1 Airplane Simulation and Performance Studies The NTSB conducted an airplane performance study to determine the accident airplane’s approximate flightpath, orientation, airspeed, and other performance parameters throughout the accident flight. Performance calculations were largely based on MKE airport surveillance radar data (with some support from two distant radar sites), and local weather information. The NTSB also conducted simulator tests to recreate two potential accident scenarios: runaway pitch trim and inadvertent autopilot activation. The NTSB’s airplane performance study noted that all of the pilots who attempted to fly the accident airplane’s flight scenario in the simulator indicated that a reduction in power (and resultant reduction in airspeed) was required to successfully control the airplane during the return to the airport. The study stated that without the power reduction, control forces were excessive and the aural overspeed warning sounded as the airplane’s airspeed exceeded its limits. The airplane performance study indicated that a power reduction shortly after the pilots declared an emergency and began to turn back to MKE was consistent with the accident airplane’s flightpath.46 1.16.1.1 Pitch Trim Runaway According to the airplane performance study, during a nose-down pitch trim runaway event, the pilots would have had to counter peak column forces as high as 140 pounds and average forces of about 80 pounds during the last minute of flight. The NTSB performance study indicated that, although the airplane would have been controllable in the event of a pitch trim runaway, it would have required a significant physical effort by both pilots working together to keep the airplane upright for the last minute of flight. 1.16.1.2 Inadvertent Autopilot Engagement If the pilots had inadvertently engaged the autopilot instead of the yaw damper after takeoff, the autopilot would have attempted to hold the airplane heading that existed when the autopilot was engaged, which was likely close to the runway’s magnetic heading of 009°. Trying to fly the airplane manually with the autopilot engaged would result in dynamically changing airplane handling characteristics. The NTSB’s performance study showed that during an inadvertent autopilot engagement, the pilots may have encountered control wheel forces of about 25 pounds right wing down during the first 2 minutes or so of the accident flight, with increased forces during the last minute of flight. The effectiveness of airplane trim surfaces is a function of the airplane’s airspeed squared. Thus, the tendency of aileron or rudder trim to roll the airplane would increase with

46 Such a power reduction was not detected by the NTSB’s CVR Sound Spectrum Study, nor did the CVR record the aural overspeed warning.

NTSB Aircraft Accident Report 26 speed. According to the performance study report, in an inadvertent autopilot engagement accident scenario, a pilot beginning to experience unexpectedly high roll-control forces while trying to manually control the airplane under these circumstances might add aileron trim in an attempt to ease those forces. The study also noted that the Citation’s aileron trim is highly sensitive and effective and that the effect of the added trim would increase as the airplane accelerated. 1.16.2 Assessment of Likely Aileron Trim Inputs and Forces As a result of this accident, simulator and flight tests were conducted to evaluate possible aileron trim inputs and their effects during the accident sequence. The tests revealed that aileron trim inputs resulted in a dramatic airplane-rolling tendency. Both simulator and flight-test data showed that the Citation 550 aileron trim is highly sensitive and effective. After examining the aileron trim test data,47 Cessna engineers estimated pilot wheel forces of 150 to 160 pounds for full aileron trim input at 250 knots. federal certification requirements limit wheel forces to 5 and 50 pounds for prolonged and temporary application, respectively. 1.17 Organizational and Management Information 1.17.1 Marlin Air General Information Marlin Air provided on-demand air taxi and air medical transportation services under 14 CFR Part 135, as authorized by the FAA. The company was privately owned, and the owner/president served as the director of operations. At the time of the accident, the company employed nine pilots, including the accident captain. Of those pilots, five were employed full time, and four part time. Five pilots were assigned to the UM Survival Flight contract. Marlin Air operated two Cessna Citation 550 airplanes (N435UM and N550BP) and one Beech C-90 King Air. The accident airplane, N550BP, was owned by Toy Air and made available to Marlin Air on a dry lease48 arrangement. In addition to on-demand charters, the accident airplane was used as a back-up aircraft for UM Medical Center’s organ procurement flights. Citation N435UM was owned by Marlin Air and leased under contract to the UM Medical Center. This airplane was configured in a medical transport configuration and was available for the exclusive use of UM Medical Center.

47 Examination of the aileron trim test data revealed that at 150 knots, the maximum aileron trim deflection of 20° resulted in a wheel force of approximately 50 pounds. At 90 percent of maximum aileron trim, or 18°, and 200 knots, 70 pounds of wheel force was measured. Only about 50 percent, or 11.5°, of aileron trim was introduced at 250 knots. At this speed, the recorded wheel force was 65 pounds. 48 A dry lease involves the lease of the basic aircraft without insurance, crew, maintenance, or other services.

NTSB Aircraft Accident Report 27 1.17.2 Marlin Air and University of Michigan Information Marlin Air had provided medical transport services for the UM Survival Flight Program under successive contracts for about 19 years before the accident. The current Marlin Air/UM contract was effective beginning October 1, 2004, and was scheduled to terminate on September 30, 2009.49 (The contract was terminated after the accident because of clauses for termination based on injuries to UM personnel and Marlin Air’s failure to perform.) During postaccident interviews, UM personnel told investigators that in the past they had felt comfortable with the operator and had confidence in Marlin Air’s pilots; however, they stated that, about 1½ years before the accident, UM management began to hear complaints about Marlin Air from UM medical crews. In general, these complaints reflected concerns about safety of flights and the number of maintenance-related cancellations. (At the time of the accident, UM also had an emergency medical services (EMS) contract with a hospital-based helicopter operator, and UM management personnel told investigators that maintenance-related cancellations with that operator were relatively rare.) UM’s Marlin Air program manager was responsible for EMS dispatch functions, and her main point of contact with Marlin Air was the captain/chief pilot. The individual selected as UM’s program manager had experience in critical care nursing and health care management; however, she was not familiar with flight operations. In addition, UM personnel, including the UM Marlin Air program manager, were not aware of the FAA safety hotline or that they could bring concerns about an operator to the attention of the overseeing FAA principal operations inspector (POI). The UM Marlin Air program manager told investigators that she had been concerned about Marlin Air’s financial condition before the accident, in part because upgrades requested by the University (for example, upgrades to the stretcher system and an intercom system to ease communications between pilots and medical crews) were not accomplished. Additionally, Marlin Air attempted to obtain additional revenue from UM by adding various supplemental charges to the contract. Further, UM’s program manager told investigators that she was disturbed to learn shortly before the accident that Marlin Air had not renewed its membership with the Association of Aeromedical Services (AAMS). She stated that she believed that Marlin Air’s lack of membership in AAMS could jeopardize the accreditation and standing of the UM Survival Flight Program in industry programs. 1.17.3 Marlin Air Financial Information The investigation revealed indications that Marlin Air had been experiencing financial difficulties in recent years.50 For example, a representative of a YIP-based fuel supplier that had

49 Postaccident interviews indicated that one of the other bidders for this contract was a start-up operator composed of former Marlin Air pilots with whom UM personnel were at least equally familiar and comfortable. However, UM management ultimately renewed the contract with Marlin Air because of financial considerations. 50 As a result of its investigation of the December 2005 Chalk’s Ocean Airways accident, the NTSB examined the association between an operator’s safety and its financial condition. The NTSB specifically evaluated the FAA’s

NTSB Aircraft Accident Report 28 contracted with Marlin Air for about 6 years stated that his company terminated its contract with Marlin Air about 2 or 3 years before the accident because the operator was behind in its payments. The representative stated that Marlin Air’s payments had been irregular for “a couple of years” before the contract was terminated but that Marlin Air subsequently repaid most of what was owed, and the fuel supplier wrote off the remaining balance. After that fuel contract was canceled, Marlin Air purchased fuel from a second YIP-based fuel supplier. A representative from this company stated that Marlin Air was initially billed on a monthly basis; however, when the operator began to miss required payments, the fuel vendor required immediate credit card payment for all purchases. They reported no further payment issues. In addition, two of the Marlin Air pilots interviewed after the accident reported experiencing problems with company paychecks being returned because of insufficient funds during the year before the accident. Further, on October 19, 2006, a landlord-tenant judgment related to nonpayment of hangar rent at Marlin Air’s YIP facility was entered against the operator. Marlin Air agreed to make an initial payment toward unpaid rent, with the promise of a subsequent payment within 90 days but defaulted on the subsequent 90-day payment. 1.17.4 Federal Aviation Administration Oversight 1.17.4.1 Operational Oversight of Marlin Air The Detroit flight standards district office (FSDO) was responsible for oversight of Marlin Air’s operations;51 like Marlin Air, the FSDO offices were located at YIP. Marlin Air’s POI had been assigned to the company’s certificate for about 8 years. The POI stated that he was required to observe all check airmen under his surveillance in performance of their duties at least once every 2 years. Records showed that the POI observed a checkride performed by the accident captain/check airman once, in June 2006.52 (Although FAA inspectors had performed about 20 percent of the Marlin Air checkrides during the 2 years preceding the accident,53 the POI did not recall whether FAA inspectors observed any checkrides conducted by the check airman during that time.)

oversight of operators experiencing financial difficulty. For additional information, see 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, Aviation Accident Report NTSB/AAR-07/04 (Washington, DC: National Transportation Safety Board, 2007). 51 The Detroit FSDO provided oversight for Marlin Air’s maintenance and operations; however, this section only addresses oversight of the company’s operations because the investigation did not reveal any maintenance program deficiencies. 52 During postaccident interviews, the POI stated that because Marlin Air did not notify the FAA of upcoming check airman-conducted checkrides, the POI did not have an opportunity to spontaneously observe such checkrides. The POI also stated that this was typical of the Part 135 operators he surveilled and that he had not addressed the issue with Marlin Air personnel. 53 Records indicated that of the Marlin Air checkrides conducted during the 2 years preceding the accident, FAA inspectors performed about 20 percent, Marlin Air check airmen performed about 40 percent, and outside training centers performed the remaining about 40 percent.

NTSB Aircraft Accident Report 29 At the time of the accident, the POI was responsible for 15 operator certificates (including Marlin Air), all of which were local operators. During postaccident interviews, the POI told investigators that it was a challenge to manage the 15 certificates and characterized his workload as “busy.”54 He estimated that he devoted about 5 percent of his time to routine surveillance of Marlin Air and stated that he would only provide additional oversight to any operator as a result of an incident or accident or in response to complaints alleging safety issues or regulation violations. The POI stated that his normal points of contacts within Marlin Air were the chief pilot and director of operations; he did not routinely talk with Marlin Air’s line pilots nor did he conduct checkrides for Marlin Air pilots because he was not current in the Cessna Citation. During postaccident interviews, the POI stated that he was uncertain about Marlin Air’s pilots’ workload, the competitiveness of pilot compensation, or the financial condition of the company. Specifically, the POI told investigators that he was unaware of the financial issues revealed during the investigation; he added that FAA inspectors would not typically inquire about an operator’s financial condition unless such an inquiry was prompted by discussions with the operator’s management or with outside parties.55 The POI’s supervisor at the FSDO stated that the POI was performing his oversight duties well; he had satisfactorily completed all of the inspection items on the Marlin Air work program, and the supervisor had received no complaints from or about the company. There had been no enforcement actions against Marlin Air in the 5 years before the accident, and the POI had not brought any issues related to Marlin Air to his supervisor’s attention. The supervisor, who was a point of contact for FAA hotline complaints, indicated that he was aware of no hotline complaints regarding Marlin Air. 1.17.4.2 Appointment of Marlin Air’s Check Airman About 2 years before the accident, Marlin Air’s POI reviewed a nomination letter requesting that the accident captain be appointed as a check airman for Marlin Air. The POI stated that he verified the captain’s pilot and medical certificate qualifications as required by FAA procedures. The POI stated that during the verification process he noted the captain’s prior airman certificate revocation; although the FAA’s database provided contact information for anyone interested in additional information regarding the nature and circumstances of the revocation, the POI did not pursue additional information because he did not believe it was necessary. The POI told investigators that he assumed that the revocation was the result of a personal issue with prescription medications. He did not seek to clarify the issue with the captain nor did he contact anyone within the FAA for additional information.56

54 During postaccident interviews, the FAA’s manager of the Flight Standards Certification and Surveillance Division stated that it would be a challenge for a POI to manage 15 certificates and that this workload would result in a limited depth of FAA surveillance. 55 For additional information as to how outside parties might communicate operator-related concerns to pertinent FAA personnel, see section 1.17.4.4. 56 The POI further stated that he recalled thinking that if FAA authorities had re-issued the captain’s pilot certificates, it would not be necessary to pursue the issue further.

NTSB Aircraft Accident Report 30 During postaccident interviews, an FAA Great Lakes region investigator told NTSB investigators that, in his opinion, because a pilot with a history of pilot certificate revocation related to a felony drug conviction would not be qualified to be hired as an FAA inspector, such a pilot should not be authorized to represent the FAA as a check airman. For information on official guidance regarding FAA appointment of check airmen, see section 1.18.2. 1.17.4.3 Pre and Postaccident FAA Inspections of Marlin Air In March 2002, the FAA conducted an Office Safety Inspection Program (OSIP) of Marlin Air and the UM’s hospital-based helicopter operator. Although the OSIP identified issues related to Marlin Air’s operating manual and recording of pilot flight times, the issues were corrected immediately, and both operators passed the audit. A Regional Aviation Safety Inspection Program (RASIP) was conducted after the accident.57 The RASIP team was made up of three inspectors from the FAA’s Great Lakes regional office and the three principal inspectors (operations, maintenance, and avionics) who were assigned to Marlin Air at the time of the accident. The inspection focused on Marlin Air’s policies and procedures and was conducted with input from the company’s director of operations and assistant chief pilot.58 Although the RASIP inspection report stated that “[training] records for all pilots were reviewed,” the RASIP team did not have access to the accident pilots’ training records. According to the RASIP inspectors, Marlin Air personnel told them that training records for the accident captain and first officer had been provided to the NTSB as a result of the ongoing investigation and were, thus, not available to RASIP inspectors. The RASIP report identified one adverse operational finding59 and indicated that there were no adverse findings in the area of pilot training. The NTSB’s postaccident review of Marlin Air records revealed three training discrepancies. One of these discrepancies (the improper recording of the first officer’s training flights and times) involved the accident pilots, and the related training documents were in the possession of the NTSB and, therefore, unavailable to the RASIP team. The two other training discrepancies (dated May 4 and June 2, 2007) identified by the NTSB and not identified during the RASIP involved other Marlin Air pilots whose training documents were available to the RASIP team. During postaccident interviews, an FAA Great Lakes regional inspector told investigators that the RASIP was intended to provide a “second set of eyes” on the operator. Because, according to the RASIP team leader, the inspection was not assessing the quality or adequacy of the FAA oversight by the operator’s principal inspectors, the operator’s principal inspectors were included on the RASIP team. (For additional information regarding postaccident inspections conducted by the FAA, see section 1.18.1.5.)

57 The FAA has since replaced its RASIP inspection program with a similar regional inspection program. 58 Marlin Air’s line pilots were not often available during the RASIP investigation because Marlin Air operations had been suspended after the accident. 59 The operational finding involved a Marlin Air operation that required two pilots but was operated with only one pilot.

NTSB Aircraft Accident Report 31 1.17.4.4 Available FAA Alert Programs During postaccident interviews, an FAA management and program analyst described the following four programs that the UM might have used to report concerns about or request additional surveillance of Marlin Air: 1) Administrator’s hotline.60 Developed in the late 1980s, this hotline provides FAA employees and outside organizations a way to raise issues to the FAA administrator. The FAA’s Flight Standards Division has 30 to 60 days to react to complaints received on this hotline. Callers who identify themselves will be advised of subsequent actions. Anonymous callers are not so advised. 2) Customer Service Initiative. The UM could have described safety concerns and lodged a complaint with the local FSDO. The FSDO would then have been required to investigate and, if possible, substantiate the complaint. If not satisfied by the FSDO’s response, the UM could have appealed to FAA regional management, the director, or the administrator. (This mechanism is typically used by operators rather than the public.) 3) Office of Inspector General (OIG) hotline. Used by the public, this hotline normally accepts information related to crimes, but it also accepts safety information. In the past 2 years, the OIG hotline was active in pursuing safety concerns related to the Southwest Airlines certificate. This hotline also pursued a complaint from a nurse involving a helicopter emergency medical services operator. She complained that the operation used by her hospital was unsafe. The FAA region sent in two teams and replaced the POI. 4) Safety hotline, Office of Accident Investigation. Complaints received through the safety hotline are typically received from pilots and are acted on by local regional offices and FSDOs. 1.18 Additional Information 1.18.1 Previously Issued Safety Recommendations 1.18.1.1 Crew Resource Management Between 1980 and 2003, the NTSB repeatedly recommended that the FAA revise 14 CFR Part 135 requirements to require on-demand charter operators that conduct operations with aircraft requiring two or more pilots to establish an FAA-approved crew resource management

60 Safety concerns may be reported to the administrator’s hotline by telephone at 1-800-255-1111 or 1-866-835-5322 (866-TELL-FAA) or online at http://www.faa.gov/contact/safety_hotline or http://www.faa.gov/about/office_org/headquarters_offices/avs/cust_service.

NTSB Aircraft Accident Report 32 (CRM) training program for their flight crews. Most recently, on December 2, 2003, the NTSB issued Safety Recommendation A-03-52 as a result of its investigation of the November 18, 2003, accident in which an Aviation Charter, Inc., King Air A100 airplane lost control and impacted terrain in Eveleth, Minnesota.61 Safety Recommendation A-03-52 asked the FAA to require that 14 CFR Part 135 on-demand charter operators that conduct dual-pilot operations establish and implement an FAA-approved CRM training program for their flight crews in accordance with 14 CFR Part 121, subparts N and O. Safety Recommendation A-03-52 was added to the NTSB’s Most Wanted List of Transportation Safety Improvements in November 2006. In April 2004, the FAA indicated that an aviation rulemaking committee had been tasked to revise Part 135 requirements, including a requirement for CRM training for Part 135 operators of airplanes with two pilots. The NTSB classified Safety Recommendation A-03-52 “Open— Acceptable Response” pending completion of the revisions to Part 135. However, as a result of its investigation of the November 28, 2004, Canadair, Ltd., accident in Montrose, Colorado, during which the NTSB determined that the captain and first officer demonstrated poor CRM, the NTSB reiterated Safety Recommendation A-03-52 and, as a result of the FAA’s continuing delays in addressing this issue, classified it “Open—Unacceptable Response” on May 2, 2006. In an April 3, 2008, letter, the FAA indicated that it had initiated a notice of proposed rulemaking (NPRM) to revise Part 135 requirements to include a requirement for CRM training for Part 135 operators of airplanes. On May 1, 2009, the FAA published in the Federal Register an NPRM titled “Crew Resource Management Training for Crewmembers in Part 135 Operations,” which proposed a rule that would require all Part 135 operators to include instruction in CRM in pilot and flight attendant training programs. The proposed rule requires initial and recurrent CRM training for crewmembers working for Part 135 on-demand operators. The proposed rule also specifies the minimum course content required for an approved CRM training program. However, the proposed rule exempts operators from providing initial training to those who have already completed training with another company. In comments submitted to the docket for this NPRM, the NTSB stated that it was supportive of the proposed rule, apart from that exemption because conditions and the specifics of training vary across operators such that crews should be trained by each operator with whom they work. The NTSB believed that, without this exception, the proposed rule would largely meet the intent of Safety Recommendation A-03-52. Pending issuance of appropriate revisions to Part 135, Safety Recommendation A-03-52 remains classified “Open—Unacceptable Response.” 1.18.1.2 Pitch Trim Issues The NTSB previously addressed issues related to Cessna Citation pitch trim, such as the need for an aural trim-in-motion warning, better visual trim-in-motion cues, and a collared pitch

61 Aircraft Accident Report NTSB/AAR-03/03. For information on additional CRM-related safety recommendations, see Safety Recommendations A-80-42, A-94-196, and A-02-12, which are available on the NTSB website at http://www.ntsb.gov.

NTSB Aircraft Accident Report 33 trim circuit breaker,62 in a recommendation letter concerning the July 22, 2003, accident involving a Citation 525 that ditched in the waters of Penn Cove, in Coupeville, Washington, after a loss of elevator trim control that resulted in an uncommanded nose-down pitch attitude.63 The recommendation letter stated the following: Because the Cessna Citation 525 is not equipped with a clear indication or warning for an electric elevator trim runaway (such as an aural[64] or visual trim- in-motion warning), the accident pilot had only indirect indications to assist in identifying the condition, and these indications were insufficient to allow timely recognition of the problem… The [NTSB] is concerned that, when the Citation 525 is in autopilot mode, the available cues for an electric elevator trim runaway…do not provide pilots with a salient and reliable means to detect this unsafe condition in a timely manner….it is critical to alert a pilot to a trim runaway condition before the associated control forces exceed what a single pilot can manage.

On September 13, 2007, the NTSB issued Safety Recommendations A-07-52 and-54, which asked the FAA to do the following: Require Cessna to modify the Citation 525 to incorporate an aural trim-in-motion warning and the addition of contrasting color bands on the pitch trim wheel to provide the pilot with more timely recognition of a trim runaway condition before control forces become unmanageable. (A-07-52) Require Cessna to replace the pitch trim circuit breaker on the Citation 525 with a collared circuit breaker to aid the pilot in quickly identifying it if necessary. (A- 07-54) In its response letter, dated November 20, 2007, the FAA indicated that it believes that the combination of the normal cues of undesired trim motion and the issuance of Airworthiness Directive (AD) 2004-14-20 (which addressed the specific failure mode identified in the Penn Cove accident investigation by requiring the replacement of the trim printed circuit board) correct the unsafe conditions identified during the investigation of the July 22, 2003, Penn Cove accident, rendering the action recommended in Safety Recommendations A-07-52 and -54 unnecessary. The NTSB’s response letter, dated June 11, 2009, disagreed with the FAA’s assertion that no action was required. With regard to Safety Recommendation A-07-52, the NTSB’s letter

62 The NTSB also discussed clear identification of critical circuit breakers in its report on the July 10, 2007, Cessna 310 accident in Sanford, Florida. For more information, see 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 (Washington, DC: National Transportation Safety Board, 2008) 63 The brief for this accident, NTSB identification number SEA03FA147, can be found on the NTSB’s website at http://www.ntsb.gov/ntsb/query.asp. 64 Several manufacturers equip their airplanes with aural alerts for stabilizer or pitch trim motion.

NTSB Aircraft Accident Report 34 stated that, had the Penn Cove pilot received conspicuous warning of the pitch trim runaway condition earlier in the accident sequence, he would have been able to complete the related checklist procedure and pulled the pitch trim circuit breaker before the pitch control forces became unmanageable. Pending action by the FAA to require Cessna to incorporate an aural trim-in-motion warning and the addition of contrasting color bands on the pitch trim wheel, the NTSB classified Safety Recommendation A-07-52, “Open—Unacceptable Response.” With regard to Safety Recommendation A-07-54, the FAA agreed with the NTSB’s belief that a collared pitch trim circuit breaker would improve a pilot’s ability to quickly locate the pitch trim circuit breaker in an emergency situation but indicated that the FAA lacked sufficient basis for regulatory action on the issue. As an alternative response to this safety recommendation, the FAA proposed issuing guidance, such as a special airworthiness information bulletin (SAIB), on the subject. Pending issuance of an SAIB or similar guidance recommending replacement of the pitch trim circuit breaker on the Citation 525 with a collared circuit breaker to aid the pilot in quickly identifying it if necessary, the NTSB classified Safety Recommendation A-07-54, “Open—Acceptable Alternate Response.” 1.18.1.3 Human/Aircraft Interface Issues In its 2006 study of the aircraft certification process,65 the NTSB made the following two recommendations to the FAA concerning human/aircraft issues in the certification of aircraft: Amend the advisory materials associated with 14…[CFR] 25.1309 to include consideration of structural failures and human/airplane system interaction failures in the assessment of safety-critical systems. (A-06-37) Require a program for the monitoring and ongoing assessment of safety-critical systems throughout the life cycle of the airplane. … Once in place, use this program to validate that the underlying assumptions made during design and type certification about safety-critical systems are consistent with operational experience, lessons learned, and new knowledge.” (A-06-38) In its September 12, 2007, response, the FAA indicated that it was incorporating more standardized consideration of human factors into new certification projects and planned to develop new regulations and advisory materials and a human factors design guide. Additionally, the FAA stated that it intended to formalize a process for monitoring and assessing safety critical systems throughout the life cycle of an airplane. Pending the FAA’s related actions, the NTSB has classified Safety Recommendations A-06-37 and -38, “Open—Acceptable Response.”

65 Safety Report on the Treatment of Safety-Critical Systems in Transport Airplanes, Safety Report NTSB/SR- 06/02 (Washington, DC: National Transportation Safety Board, 2006).

NTSB Aircraft Accident Report 35 1.18.1.4 Recording Information on Aircraft The NTSB has issued numerous recommendations addressing the need to record information on all turbine-powered, nonexperimental airplanes that are not required to be equipped with a flight data recorder (FDR) and are operating under 14 CFR Part 135 (such as the accident airplane). In addition, the NTSB included “automatic information recording devices” on its Most Wanted List from 2001 to 2008 and has included “require image recorders” on its Most Wanted List for 2009. Most recently, the NTSB noted these issues in its report on the July 27, 2007, midair collision involving electronic news gathering helicopters in Phoenix, Arizona.66 Because the FAA had not yet taken appropriate action in response to the NTSB’s earlier recommendations, in its January 2009 report on the Phoenix midair collision, the NTSB classified several previous safety recommendations,67 “Closed—Unacceptable Action/Superseded,” superseding them with updated recommendations, including Safety Recommendation A-09-11, which asked the FAA to do the following: Require all existing turbine-powered, nonexperimental, nonrestricted-category aircraft that are not equipped with a [FDR] and are operating under 14 [CFR] Parts 91, 121, or 135 to be retrofitted with a crash-resistant flight recorder system. The crash-resistant flight recorder system should record cockpit audio (if a cockpit voice recorder is not installed), a view of the cockpit environment to include as much of the outside view as possible, and parametric data per aircraft and system installation, all to be specified in European Organization for Civil Aviation Equipment document ED-155, “Minimum Operational Performance Specification for Lightweight Flight Recorder Systems,” when the document is finalized and issued. (A-09-11) On April 17, 2009, the FAA issued a response letter, which described the FAA’s participation in two proof-of-concept studies that evaluated the installation of image recorders on (1) an FAA airplane that was compliant with European Organization for Civil Aviation Electronics (EUROCAE) document ED-112 and (2) a transport-category Boeing 737 flight simulator. The findings that resulted from these studies provided valuable information on the potential uses of cockpit image recording systems on airplanes that are currently not required to carry any type of data-recording equipment. The working group incorporated this information into EUROCAE document ED-155, “Minimal Operational Performance Specification for Lightweight Flight Recorder Systems,” which was published in August 2009. Pending the FAA’s issuance of a technical standard order (TSO) that includes the specifications of ED-155, Safety Recommendation A-09-11 is classified “Open—Acceptable Response.”

66 For additional information, see Midair Collision of Electronic News Gathering Helicopters, KTVK-TV Eurocopter AS350B2, N613TV, and U.S. Helicopters Eurocopter AS350B2, N215TV, Phoenix, Arizona, July 27, 2007, Aviation Accident Report NTSB/AAR-09/02 (Washington, DC; National Transportation Safety Board, 2009). 67 Safety Recommendations A-03-62, -64, and –65 were classified “Closed—Unacceptable Action/Superseded” in this report.

NTSB Aircraft Accident Report 36 The NTSB notes that the accident airplane was not required to have an FDR installed; however, had the FAA implemented previous NTSB recommendations, the airplane would have been subject to the requirements for a cockpit image recorder. 1.18.1.5 FAA Postaccident Inspections The NTSB has issued several safety recommendations regarding the quality of inspections conducted by the FAA and the need for an evaluation of an operator’s principal inspectors during such inspections. For example, on July 21, 1989, as a result of the 1988 Aloha Airlines accident,68 the NTSB issued Safety Recommendation A-89-64, recommending that the FAA “[e]valuate the quality of FAA surveillance provided by the principal inspectors as part of the National Aviation Safety Inspection Program [NASIP].” In its response, dated June 21, 1991, the FAA indicated that NASIPs regularly resulted in an evaluation of FSDO personnel responsible for surveillance of inspected operators. On July 13, 1991, the NTSB classified Safety Recommendation A-89-64, “Closed—Acceptable Action” but also indicated that the FAA should consider issuing formal documentation of its related policies to ensure their consistent and continued implementation. On July 23, 1991, as a result of a fatal runway collision involving two Northwest Airlines airplanes,69 the NTSB issued Safety Recommendation A-91-65, recommending that the FAA do the following: Require that an assessment of local FAA surveillance effectiveness be a formal part of NASIP inspections, so that NASIP findings can be used to correct observed deficiencies of local inspectors as well as those of the airline. In its response, dated October 25, 1993, the FAA stated that its existing procedures involved routine internal evaluations of certificate-holding FSDOs to determine the effectiveness of the office surveillance programs and that any related NASIP results would be used in conjunction with this evaluation. On March 9, 1994, the NTSB classified Safety Recommendation A-91-65, “Closed—Acceptable Alternate Action.” Most recently, on April 8, 2005, as a result of a fatal accident involving an Air Sunshine Cessna 402C,70 the NTSB issued Safety Recommendation A-05-08, recommending that the FAA do the following:

68 For additional information, see Aloha Airlines, Flight 243, Boeing 737-200, 73711, near Maui, Hawaii, April 28, 1988, Aviation Accident Report NTSB/AAR-89/03 (Washington, DC; National Transportation Safety Board, 1989). 69 For additional information, see Northwest Airlines, Inc. Flights 1482 and 299, Runway Incursion and Collision, Detroit Metropolitan/Wayne County Airport, Detroit, Michigan, December 3, 1990, Aviation Accident Report NTSB/AAR-91/05 (Washington, DC; National Transportation Safety Board, 1991). 70 For more information, see In-Flight Engine Failure and Subsequent Ditching, Air Sunshine, Inc., Flight 527, Cessna 402C, N314AB, About 7.35 Nautical Miles West-Northwest of Treasure Cay Airport, Treasure Cay, Great Abaco Island, Bahamas, July 13, 2003, Aircraft Accident Report NTSB/AAR-04/03 (Washington DC; National Transportation Safety Board, 2004).

NTSB Aircraft Accident Report Review the procedures used during its oversight of Air Sunshine, including those for the Surveillance and Evaluation Program and [RASIP], to determine why the inspections failed to ensure that operational and maintenance issues that existed at the company were corrected. On the basis of the findings of this review, modify 14 [CFR] Part 135 inspection procedures to ensure that such issues, including maintenance record keeping and practices, are identified and corrected before accidents occur. In its response letter dated August 15, 2005, the FAA indicated that it would review FAA inspector procedures and programs and revise inspector handbooks and FAA orders as necessary. In subsequent responses, the FAA indicated that its southern region conducted a focused oversight inspection of Air Sunshine. As a result of this inspection, the FAA revised its oversight procedures for Air Sunshine and revised the following related sections of FAA Order 8900.1: • Volume 2, Chapter 1, Section 2, “Assignment of Federal Aviation Administration Responsibilities” (paragraph 2-30) • Volume 6, Chapter 2, Section 32, “Inspect Part 91 Subpart K Program Manager or Part 135 (Nine or Less) Air Carrier” • Volume 6, Chapter 2, Section 35, “Inspect Section 135.422(a)(1) Operator’s Maintenance Records” On August 27, 2009, as a result of the FAA’s actions, the NTSB classified Safety Recommendation A-05-08, “Closed—Acceptable Action.” 1.18.1.6 Check Airman Program Guidance On October 9, 1986, as a result of its investigation of three commuter air carrier accidents, the NTSB issued Safety Recommendation A-86-108, asking the FAA to do the following: Issue an Air Carrier Operations Bulletin-Part 135, requesting [POIs] to put special emphasis on their check airmen program to assure that company pilots are evaluated properly and that check airmen apply the training and checkride standards in a strict and standardized manner. On August 31, 1990, the FAA issued change 4 to its Handbook 8400.10, “Air Transportation Operations Inspector’s Handbook.” This change contained direction and guidance concerning the check airman program for Part 121 and 135 operators, including the role and purpose of the check airman, the regulatory requirements, qualifications, functional responsibilities, and the approval process and training requirements for check airmen. On August 1, 1991, based on these actions, the NTSB classified Safety Recommendation A-86-108, “Closed—Acceptable Action.” 37

NTSB Aircraft Accident Report 38 1.18.1.7 Airplane Upset Recovery Training Aid On October 18, 1996, as a result of three upset-related air carrier accidents, the NTSB issued Safety Recommendation A-96-120, asking the FAA to do the following: Require 14 [CFR] Part 121 and 135 operators to provide training to flight crews in the recognition of and recovery from unusual attitudes and upset maneuvers, including upsets that occur while the airplane is being controlled by automatic flight control systems, and unusual attitudes that result from flight control malfunctions and uncommanded flight control surface movements. The NTSB recognized that although pilots receive unusual attitude and upset training during all phases of basic pilot training, pilots would benefit from additional and recurrent training related to airplane attitudes and/or control system failures not normally associated with air carrier flight operations. In a response letter dated August 11, 1999, the FAA expressed agreement with the intent of the recommendation and indicated that it would initiate an NPRM proposing revision of 14 CFR Part 121, Subparts N and O, to include the recommended training. However, the FAA took no regulatory action for more than 8 years after this safety recommendation was issued (and had never proposed revision of 14 CFR Part 135 regulations, as recommended). Thus, in October 2004, the NTSB classified Safety Recommendation A-96-120 “Open—Unacceptable Response.” Although the FAA has not taken regulatory action regarding upset recovery training, an industry team, in response to an FAA request,71 developed an airplane upset recovery training aid designed to “increase the ability of pilots to recognize and avoid situations that can lead to airplane upsets and to improve their ability to recover control of an airplane that has exceeded the normal flight regime. This will be accomplished by increasing awareness of potential upset situations and knowledge of aerodynamics….” Although this aid was originally developed to address operations involving airplanes with 100 seats or more, the information it contains is directly applicable to most jet airplanes operating in environments similar to those used by Part 121 operators. The airplane upset recovery training aid indicates that there are myriad potential situations that pilots can experience while flying and that pilots should first gain control of the airplane and then determine and eliminate the cause of the upset. Specifically, the aid indicates that every upset recovery should include managing the energy (airspeed), arresting any flightpath divergence, and recovering to a stabilized flightpath. The airplane upset recovery training aid also states that there “could be confusion on the flight deck as to what exactly happened to cause the original upset” and that “inappropriate control inputs during one upset recovery can lead to a different upset situation.” On January 12, 2009, the FAA issued an NPRM titled, “Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers,” which, if adopted as a rule, would require minimum

71 The Upset Recovery Industry Team included representatives from airplane manufacturers, airlines, pilot associations, flight training organizations, and government and regulatory agencies. The upset recovery training aid was originally released in 1998, with a recommendation that it be incorporated into all air carrier training programs to improve aviation safety. Subsequent revisions were released in 2004 and 2008.

NTSB Aircraft Accident Report standards for Part 121 flight crewmember upset and loss of control training that references the airplane upset recovery training aid. The comment period for this NPRM closed on August 10,

1. In its comments on this NPRM, the NTSB indicated that it is pleased that the NPRM

includes Part 121 training on recognizing and recovering from sudden or unexpected aircraft upsets. The NTSB further noted that the special hazards training section of the NPRM addresses issues related to airplane malfunctions and human performance. However, the NTSB’s response stated that similar action for Part 135 operators will be needed before Safety Recommendation A-96-120 can be classified “Closed—Acceptable Action.” 1.18.2 FAA Check Airman Appointment Information According to FAA Order 8900.1, Flight Standards Information Management System, Chapter 20, titled, “Check Airman, Instructor, and Supervisor Programs for 14 CFR Parts 121 and 135 Certificate Holders,” a check airman is an airman who is approved by the FAA to perform the following functions for an operator: 1) ensure that a flight crewmember has met competency standards before that crewmember is released from training, and 2) ensure that those standards are maintained while the crewmember remains in service with the operator. According to the provisions of 14 CFR Part 135, a check airman is authorized to conduct proficiency or competency checks, line checks, and special qualification checks and to supervise the initial operating experience training within the operator’s approved program. According to FAA Order 8900.1, the check airman appointment process consists of the following five phases: 1) Operator familiarization with check airman requirements. (A check airman candidate must have the appropriate training, experience, and demonstrated ability to evaluate and to certify the knowledge and skills of other company airmen. Additionally, a check airman candidate must have achieved and maintained a favorable record as a flight crewmember.) 2) The operator submits the appropriate nominating documentation to the FAA. 3) The FAA reviews the nominating documentation. 4) The FAA evaluates the check airman candidate. 5) If appropriate, the FAA approves the check airman candidate for check airman status. FAA Order 8900.1 specifically stated that the approving POI will verify the check airman candidate’s pilot certificates and background using the Flight Standards Information System and that all required training must have been satisfactorily completed. Order 8900.1 does not contain any guidance regarding POI actions in the event that the background check contained negative information. However, the guidance stated that, once approved, a check airman’s manner and professional reputation should always reflect positively on the operator and the FAA. 39

NTSB Aircraft Accident Report 1.18.3 Related Wiring Issues and Cessna Service Bulletin Postaccident review of Marlin Air’s maintenance documents for its other Citation revealed a repair similar to those observed on the ribbon cables recovered from the accident airplane’s control column shafts. Subsequent interviews with avionics technicians and the NTSB’s review of related FAA service difficulty reports revealed that similar repairs to address damaged wiring/cables in control column shafts were common. At its widest point, the control yoke mounting shaft had an inside diameter of 0.625 inches. At that same point, the shaft had two 0.187-inch diameter bolts passing through it in a cross, which effectively reduced the inside diameter to less than 0.3 inch. (See figure 7 in section 1.12.2.1.) There was no chafe protection or physical restraint for the wires where they passed by the bolts. The design of the ribbon cable installations required lengthwise folds to fit past the bolts in the shaft, as was the case in the accident airplane. The wires within the control yoke shaft would not have been visible to flight crews or even to maintenance personnel without extensive disassembly. As a result of previous reports of failures of the wiring within Cessna Citations control column shafts, Cessna issued Service Bulletin (SB) 550-24-14, on January 17, 1992, advising Citation operators to replace the flat ribbon cable installed inside the control column shafts (which were found folded and damaged in the accident airplane control column) with a rounded type of sheathed wire bundle that would fit better and be better protected within the shaft. SB 550-24-14 had not been accomplished on the accident airplane. Compliance with SBs (which are issued by the manufacturer) is not mandatory as is compliance with FAA-issued ADs. According to FAA personnel, the agency did not issue an AD on this issue because it considered wiring short circuits a minor recurring service issue and because an unlikely double failure (for example, short circuits on the power and ground paths) would be necessary to elevate the problem beyond what it considered to be a nuisance level. According to Cessna representatives, after SB 550-24-14 was issued, Cessna had received seven customer reports of short circuits and cut wires in bundles of original control column wiring in various Citation models. 1.18.4 Aileron Trim Requirements Federal regulations require “powered” trim systems—systems in which an electric or hydraulic motor can drive the trim surface deflections—to be protected against the possibility of a runaway trim condition. AC 25-7A, “Flight Test Guide for Certification of Transport Category Airplanes,” provides guidance for demonstrating compliance with aileron trim system design standards. According to AC 25-7A, the aileron flight control forces experienced by the pilot must not exceed those defined in 14 CFR 25.143(d): 50 pounds for temporary application and 5 pounds for prolonged application. Because the Citation 550 aileron trim is an “unpowered” system (meaning that the only means of deflection are the manual inputs made by the pilots), the FAA does not require tests of surface deflections during airplane certification activities. However, during postaccident flight 40

NTSB Aircraft Accident Report tests conducted in July 2007, pilot control wheel forces in excess of 50 pounds were recorded when only 50 percent of the available aileron trim was applied at an airspeed of 250 knots. Cessna estimated that full aileron trim input would have resulted in pilot control wheel forces in excess of 150 pounds. 1.18.5 Previous Citation 550 Aileron Trim Events The NTSB’s investigation revealed several instances in which other Citation 550 pilots have experienced aileron trim-related control problems, as shown in the following examples: 1) The owner of the accident airplane told a NTSB investigator that when he flew the accident airplane just after maintenance a few months before the accident, control of the airplane during the takeoff roll and departure was “very challenging” even though the trim indicators appeared at first to be centered. He stated that he was able to counteract the challenging control forces by adjusting the aileron trim control knob and complete the flight without further incident. However, he noted that relatively minor adjustments of the aileron trim wheel resulted in control inputs that could be challenging to control and stated that those inputs would have been harder to control as the airplane’s speed increased. 2) On August 27, 2007, the pilots of a Cessna Citation declared an emergency and received vectors back to the departure airport after experiencing an uncommanded right roll during climbout. The captain reported that he had to use substantial pressure, using both of his hands and assistance from the first officer, to correct the uncommanded roll. A postflight inspection revealed that a mistrim in the roll axis resulted in an uncommanded roll at high speed when the autopilot disengaged.

41

NTSB Aircraft Accident Report

1. Analysis
2. 1 General

The captain and first officer were properly certificated and qualified under federal regulations to act in their respective roles during the accident flight. There was no evidence of any medical conditions that might have adversely affected the pilots’ performance during the accident flight. Although the captain’s pilot certificates had previously been revoked because of a felony conviction involving the illegal transport of drugs into the United States, the FAA had reissued his pilot certificates, and they were valid at the time of the accident. The accident airplane was properly certificated, was equipped and maintained in accordance with industry practices (except for the wiring installed in the pilots’ control yokes), and was within weight and cg limits. Evidence of preimpact electrical failures in the first officer’s control yoke is discussed in section 2.2.2.2. The following analysis discusses the accident flight, including possible accident scenarios; pilot actions and coordination; image recording equipment on airplanes not equipped with FDRs; autopilot panel design; control yoke wiring installations; identification of circuit breakers for use in emergencies; aural and visual alerts to pitch trim-in-motion; aileron trim power and sensitivity; FAA appointment of check airmen; the scope of RASIP inspections; avenues for expressing safety concerns to federal authorities; and the safety ramifications of an operators’ financial health. 2.2 Accident Flight Sequence According to the CVR recording, the captain recognized a flight control problem almost immediately after takeoff from MKE (about 1557:35), as he began to turn right from the runway heading of 009° toward the assigned departure heading of 050°. Beginning about that time (1557:51), the CVR recorded repeated comments indicating that the captain was struggling with a flight control problem. The captain repeatedly stated that he was “fighting the controls” (about 1557:51; 1557:57; 1558:07) and confirmed with the first officer that the landing gear had been retracted (about 1558:03). About 1558:21, the captain again stated that he was “fighting the controls,” this time adding, “It wants to turn hard left.” The captain allowed the airplane to accelerate and climb after takeoff consistent with the airplane’s assigned departure heading and altitude while he and the first officer tried to troubleshoot the control anomaly. Comments recorded by the CVR indicated that the pilots did 42

NTSB Aircraft Accident Report 43 not consult an emergency or abnormal procedure checklist.72 Further, CVR evidence indicated that, on at least one occasion, it is likely that the first officer made an unrequested trim input. About 1559, at the captain’s request, the first officer advised MKE air traffic controllers that they had a control problem and would be returning to the airport. For the remainder of the flight, the CVR recorded both pilots communicating on the radio. The CVR also recorded several instances in which the captain asked the first officer to help him maintain control of the airplane; the last such instance occurred about 1600:36, when the captain asked the first officer to hold the airplane’s flight controls so that he could try to pull circuit breakers. The last radar return was recorded moments later (just before 1601), about 8 to 9 seconds before the airplane hit the water in a steep nose-down, left-wing-low attitude. 2.2.1 Possible Initiating Event Accident Scenarios The NTSB evaluated several possible explanations for the initiating event experienced by the pilots and found that two of those possible explanations were most consistent with the abnormal control situation: 1) an inadvertent autopilot engagement, or 2) a runaway electric pitch trim. Examination of the available evidence, including the items described below, both supports and contradicts these scenarios. Without an FDR or image recorder on board, it was not possible to determine the exact cause of the initiating event or the pilots’ actions during the accident sequence. If the accident airplane had been equipped with crash-protected data- or image-recording equipment,73 the NTSB would also have had useful information regarding many other unresolved issues in this accident, including whether checklists were silently followed (partially or completely), whether and when the trim controls were used, and any other actions and flight control movements made by the pilots during the event. In Safety Recommendation A-09-11, issued in January 2009 as a result of the July 27, 2007, midair collision involving electronic news gathering helicopters in Phoenix, Arizona,74 the NTSB addressed the need for image recording equipment on aircraft that are not required to be equipped with an FDR and are operating under 14 CFR Part 135 (such as the accident airplane). In its April 17, 2009, response letter, the FAA described its participation in two studies that evaluated the installation of image recorders on an airplane and a flight simulator. Based on the results of these studies, the working group developed EUROCAE document ED-155, “Minimal Operational Performance Specification for Lightweight Flight Recorder Systems,” which was published in August 2009. Pending the FAA’s issuance of a TSO that includes the specifications outlined in ED-155, Safety Recommendation A-09-11 is classified “Open—Acceptable Response.” The NTSB concludes that if the accident airplane had been equipped with a recorder system that captured cockpit images and parametric data,

72 The pilots could have consulted the autopilot hardover or jammed elevator trim tab checklists, which would have called for pressing the autopilot/trim disengage switch or maintaining a reduced airspeed, respectively. There was no specific rudder-related emergency or abnormal procedure checklist. 73 The airplane involved in the Milwaukee accident was not required to have an FDR or image recorder installed; however, it would have been subject to the requirements for a cockpit image recorder had the FAA implemented previous safety recommendations. 74 For additional information, see Midair Collision of Electronic News Gathering Helicopters, KTVK-TV Eurocopter AS350B2, N613TV, and U.S. Helicopters Eurocopter AS350B2, N215TV, Phoenix, Arizona, July 27, 2007, Aviation Accident Report NTSB/AAR-09/02 (Washington, DC; National Transportation Safety Board, 2009).

NTSB Aircraft Accident Report 44 investigators would have been better able to determine the circumstances that led to this accident. 2.2.1.1 Inadvertent Autopilot Engagement Scenario The NTSB considered the possibility that the autopilot was inadvertently activated instead of, or at the same time as, the yaw damper, initiating the accident sequence. As previously noted, the autopilot and yaw damper engage buttons are identical and are located adjacent to each other on the autopilot console, and anecdotal evidence indicates that inadvertent activation of the autopilot when activation of the yaw damper is intended is not an uncommon occurrence.75 If the first officer had inadvertently engaged the autopilot instead of the yaw damper (which is not inconsistent with his limited proficiency in the accident airplane) and the situation went unnoticed (and, therefore, uncorrected) by the captain, the autopilot would have tried to hold the heading and climb pitch attitude on which it was engaged; the associated heading was likely on or about the runway’s magnetic heading of 009°. The autopilot inputs would result in a control wheel force toward that heading whenever the pilots tried to turn the airplane in a different direction. It is likely that, at some time during the accident sequence, the first officer manipulated the aileron and/or rudder trim in an effort to help the captain with the control problems he was experiencing. The CVR recorded several trim-related comments made by the first officer.76 The last of these comments, “how’s that. Any better?” occurred about 90 seconds after takeoff and after the captain complained about the trim and could plausibly have referred to an effort he made to assist the captain. The NTSB’s airplane performance study indicated that the airplane banked sharply after this statement. The CVR then recorded a grunting noise made by the captain, and the performance study indicated that the airplane subsequently returned to its previous heading. The CVR evidence indicates that the pilots did not coordinate with each other regarding trim inputs, and it is likely that the first officer’s trim inputs aggravated, rather than ameliorated, the situation. Almost immediately, the captain told the first officer to advise ATC that they were returning to MKE. (Pilot coordination will be discussed in section 2.3.) Because the captain would normally have hand-flown the initial portion of a flight, he would not have expected the autopilot to be engaged. Additionally, because he did not request trim adjustments, the captain would not have anticipated having to counter trim-related forces while haphazardly troubleshooting the problem. As a result, the captain’s troubleshooting during the accident sequence was confused. According to the NTSB’s performance study, the lateral and directional handling problems that would result from inadvertent autopilot activation and mistrim under these circumstances would result in control forces that were light at first and larger as the airplane accelerated and turned further from the runway extended centerline heading. The effects

75 The Citation 550 pilots involved with the simulator testing during the investigation stated that each, at one time in their careers, had inadvertently pushed the autopilot instead of the yaw damper buttons. 76 About 35 seconds after takeoff, after the captain made his third mention of an unspecified control problem, the first officer stated, “how’s your trim set? Is that the way you want it?” About 12 seconds later, after the captain stated that the airplane wanted to “turn hard left,” the first officer asked, “how’s your trim down here?” Finally, about 1 ½ minutes after takeoff, the first officer asked, “how’s that, any better?”

NTSB Aircraft Accident Report 45 of the autopilot turning the airplane toward the runway’s magnetic heading and the forces resulting from the mistrimmed condition ultimately would have demanded strenuous inputs from both pilots to maintain control. The performance study results were consistent with many aspects of this interpretation of the accident sequence. For example, the captain first complained of a control problem just moments after the airplane would have begun to turn from the initial autopilot engagement heading in accordance with the departure clearance, when an inadvertently activated autopilot would have been trying to return the airplane to the initial autopilot engagement heading. About 1 1/2 minutes later, after the control problem had escalated (likely as a result of the first officer’s trim inputs and the captain allowing the airplane to accelerate while he dealt with the unidentified control problem), the captain decided to declare an emergency and return to MKE. The final loss of control began about 1 minute later, just after the captain transferred the controls to the first officer to look for the autopilot circuit breaker. The performance study showed that the transfer of control occurred when the airplane was heading back towards MKE and passed through and moved away from the autopilot engagement heading, which, according to this scenario, would have resulted in dynamically changing forces on the control wheel as the autopilot reversed the direction of its input in an attempt to return to the runway heading. Other evidence was inconsistent with this scenario, however. For example, examination of the recovered autopilot servomotor clutches and the unstretched filaments in the cockpit autopilot-engaged light bulb (which was not illuminated at impact) suggested that, although the autopilot did have power at impact, it was likely not engaged at impact.77 Some stretching was observed in the yaw-damper-engaged bulb filaments. If the autopilot had been engaged, similar stretching should have been observed in the autopilot-engaged bulb filaments. 2.2.1.2 Runaway Pitch Trim Scenario Because of evidence of short circuits in the first officer’s control column wiring that could have affected the airplane’s pitch trim, the NTSB also considered the possibility that a runaway pitch trim resulted in uncommanded nose-down inputs,78 initiating the accident sequence. This scenario interprets the captain’s reactions as consistent with an increasing control force and efforts to decrease that force. These efforts would have been complicated by the first officer’s trim inputs. Actuation of the accident airplane’s electric pitch trim required completion of circuits providing power to the motor and to a ground path. Wreckage examination did reveal physical evidence that, sometime before impact, at least two short circuits occurred in a bundle of wires in the first officer’s control yoke/column. Investigators also found evidence of heat

77 Examination of the autopilot servomotor clutches indicated that they were not engaged at impact. Manufacturer testing showed that new servomotor clutches disengage within about 50 milliseconds, which was within the estimated 85 milliseconds that elapsed during the impact sequence. However, the servomotor clutch disengage times would degrade with time and use; therefore, it is likely that the accident airplane’s servomotor clutches would take longer than 50 milliseconds to disengage. 78 Physical evidence indicated that the airplane’s pitch trim was in the full nose-down position at impact. Because an engaged and normally functioning autopilot can also provide inputs to the electric pitch trim motor, this evidence could be consistent with either scenario.

NTSB Aircraft Accident Report 46 damage consistent with the short circuits and chafing on some of the wires in this area.79 One of the short circuits occurred between the pitch trim power supply wire and the adjacent steel surface of the first officer’s control yoke shaft;80 the recovered wires were chafed around the area where the exposed wire had become welded to the steel of the control shaft. This short circuit exposed the cores of multiple wires, providing a potential source of power to the pitch trim motor. This short circuit would also have caused the pitch trim circuit breaker to trip, which would render the electric pitch trim system unavailable for normal use by the pilots. Because the CVR recorded no pitch-trim-related complaints by the pilots during their approach to MKE, it is likely that this short circuit occurred after the pilots’ last use of the electric pitch trim during the airplane’s landing at MKE. Examination of the wreckage also revealed that a contact in one of the two switches in the first officer’s pitch-trim control was bent inward, eliminating the space between it and the center reed. In normal pitch trim operations, the center reed moves outward and contacts the fixed contact to complete the ground path circuit; this condition might have provided the pitch trim motor with the nose-down latent ground path. (Impact damage precluded positive identification of the ground path.) Other evidence is inconsistent with this scenario. For example, previous NTSB investigations involving pitch control problems81 indicate that pilots are typically immediately aware of the nature of pitch-related problems and struggle to keep the airplane upright.82 Because the captain would have routinely adjusted the pitch trim with each configuration change and in response to any unwanted trim forces experienced during departure, it is likely that he would have recognized a runaway pitch trim situation shortly after it began. Further, in this scenario, the pilots would have been struggling to keep the airplane from nosing over during the accident flight, yet there was no specific reference to “pitch” or “pull” by either pilot until about 5 seconds before impact.

79 Evidence and maintenance records showed at least two instances in which the wires in the first officer’s control yoke/column had been previously repaired. 80 There was also evidence of a short circuit on the power wire for the autopilot clutches. 81 For example, see (a) 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: National Transportation Safety Board, 2002); (b) Loss of Control on Takeoff, Emery Worldwide Airlines, Flight 17, McDonnell Douglas DC-8-71F, N8079U, Rancho Cordova, California, February 16, 2000, NTSB/AAR-03/02 (National Transportation Safety Board: Washington, DC, 2003); (c) Colgan Air (dba USAirways), Beechcraft 1900D, N240CJ, Yarmouth Massachusetts, August 26, 2003, NTSB/AAR-04/01 (National Transportation Safety Board: DC, 2001); and (d) 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 (National Transportation Safety Board: DC, 2004); (e) The factual report and probable cause statement for a September 1, 2008, accident (NTSB identification number CHI08MA270), available on the NTSB website at http://www.ntsb.gov/ntsb/query.asp. 82 In addition, during investigation-related simulation sessions, pilots indicated that a natural first response to a pitch-related problem would be to press the autopilot/trim disconnect button. No autopilot disconnect chime was recorded by the CVR.

NTSB Aircraft Accident Report 47 2.2.1.3 Accident Scenario Analysis and Discussion Although these two scenarios were the most likely explanations for the initiating flight control event, neither scenario was completely consistent with the investigative evidence. Therefore, the NTSB concludes that the accident sequence initiated as a result of a control problem that was related to either an inadvertent autopilot activation or a pitch trim anomaly, the effects of which were compounded by aileron and/or rudder trim inputs; however, it was not possible to determine the exact nature of the initiating event. Regardless of what the initiating event was, evidence from Cessna flight test records, postaccident simulator tests, and the NTSB’s postaccident performance study indicated that the result would have been controllable if the captain had not allowed the airspeed and resulting control forces to increase while he tried to troubleshoot the problem. Evidence showed that, despite the abnormal control situation, the captain was able to maintain control of the airplane without much exertion when the airplane was operating at a relatively slow airspeed shortly after takeoff, but he increasingly struggled as the airplane accelerated and the control forces increased. By allowing the airplane’s airspeed to increase while engaging in haphazard and poorly coordinated troubleshooting efforts, the pilots allowed an abnormal situation to escalate to an emergency. Therefore, the NTSB concludes that, regardless of the initiating event, if the pilots had simply maintained a reduced airspeed while they responded to the situation, the aerodynamic forces on the airplane would not have increased significantly; at reduced airspeeds, the pilots should have been able to maintain control of the airplane long enough to either successfully troubleshoot and resolve the problem or return safely to the airport. If the accident pilots had sought guidance for either of the potential scenarios in the airplane’s checklists or manuals, they would not have found it, because no such guidance existed. However, AFM guidance for a different control anomaly (a jammed elevator trim) suggests that, in the face of an unexpected and unidentified control problem, a pilot should maintain a configuration and airspeed already proven to be controllable.83 In partial response to an NTSB safety recommendation issued after a series of upset-related air carrier accidents (A-96-120), an industry team developed an airplane upset recovery training aid designed to “increase the ability of pilots to recognize and avoid situations that can lead to airplane upsets and to improve their ability to recover control of an airplane….” The FAA has issued an NPRM, which,84 if adopted as a rule, would require minimum standards for 14 CFR Part 121 flight crewmember upset and loss of control training that references the airplane upset recovery training aid. Although this aid was originally developed to address operations involving airplanes with 100 seats or more, the information it contains is directly applicable to most jet airplanes, such as the accident airplane, operating in environments similar to those used by Part 121 operators. In its comments on the NPRM, the NTSB stated that similar action for Part 135 operators will be needed before Safety Recommendation A-96-120 can be classified “Closed—Acceptable Action.”

83 The Citation 550 AFM guidance for a jammed elevator trim condition during takeoff condition advised pilots to maintain an airspeed of 120 knots or less, not to change the airplane’s configuration, and to land as soon as practical. Given enough time, the pilots might have consulted the AFM and discovered this procedure. 84 The NPRM was issued on January 12, 2009, and comments were due by August 10, 2009.

NTSB Aircraft Accident Report The NTSB recognized that although pilots receive unusual attitude and upset training during all phases of basic pilot training, pilots would benefit from additional and recurrent training related to airplane attitudes and/or control system failures not normally associated with air carrier flight operations. Therefore, the NTSB concludes that pilots would benefit from training and readily accessible guidance indicating that, when confronted with abnormal flight control forces, they should prioritize airplane control (airspeed, attitude, and configuration) before attempting to identify and eliminate the cause of the flight control problem. Therefore, the NTSB recommends that the FAA require all 14 CFR Part 91K and Part 135 operators to incorporate upset recovery training (similar to that described in the airplane upset recovery training aid used by many Part 121 operators) and related checklists and procedures into their training programs. Investigation of both possible initiating event scenarios identified safety issues that will be discussed in the remainder of this report. 2.2.2 Safety Issues 2.2.2.1 Autopilot Panel Design As previously noted, the yaw damper and autopilot engage buttons are identical in size, shape, type of operation (on/off pushbutton), and amount of force necessary to activate. Further, because of their physical location (adjacent to each other near the aft end of the cockpit center console, out of a pilot’s normal field of vision), the difference between the yaw damper and autopilot engage buttons may not always be readily apparent to pilots. Anecdotal evidence indicates that inadvertent activation of the autopilot when attempting to engage the yaw damper is not an uncommon occurrence. This would especially be of concern during times of competing visual demands and high pilot workload, such as takeoffs and landings. As discussed in section 2.2.1.1, if the first officer had inadvertently activated the autopilot when intending only to activate the yaw damper, it would likely have resulted in unanticipated, and possibly dramatic, consequences. FAA airworthiness standards require cockpit controls to be located and identified to prevent confusion and inadvertent operation. Additionally, human factors engineering principles indicate that, in a well-designed control system, every control must be detectable and discernable from other controls. The current design configuration of the Citation yaw damper/autopilot control push-button switches appears contrary to this standard. The switches present identical size, texture, mode of operation (on/off pushbutton), and actuation pressure to the pilot. Further, they are located immediately adjacent to each other, outside of the pilots’ normal range of vision, without an intervening divider or partition. In periods of high workload or other distractions, a pilot might be inclined to activate the yaw damper by feel and location; under such circumstances, it would be easy for a pilot to select the wrong switch. 48

NTSB Aircraft Accident Report 49 The NTSB concludes that the design and location of the yaw damper and autopilot switches on Cessna Citation series airplanes do not adequately protect against inadvertent activation of a system, which could have disastrous consequences. Therefore, the NTSB recommends that the FAA require Cessna to redesign and retrofit the yaw damper and autopilot switches on the autopilot control panel in Citation series airplanes to make them easily distinguishable and to guard against unintentional pilot activation. Further, because other airplanes may be equipped with similarly designed autopilot control panels and, therefore, may also be susceptible to inadvertent autopilot activation,85 the NTSB recommends that the FAA identify airplanes other than the Cessna Citation with autopilot control panel designs that may lead to inadvertent activation of the autopilot and require manufacturers to redesign and retrofit the autopilot control panels to make the buttons easily distinguishable and to guard against unintentional activation. 2.2.2.2 Airplane Wiring This investigation revealed documentation of previous instances in which the Cessna Citation series of airplanes had experienced failures of the wiring within the control column shafts.86 As a result of these wiring failures, Cessna issued SB 550-24-14 on January 17, 1992, advising Citation operators to replace the flat ribbon cable installed inside the control column shafts with a rounded type of sheathed wire bundle that would fit better and be better protected within the shaft. None of the accident airplane’s owners and/or operators since SB 550-24-14 was issued had accomplished the replacement suggested in SB 550-24-14; compliance with SBs is not mandatory. The flat ribbon cable installed in the accident airplane’s control column shaft was found in the wreckage, folded and damaged, with evidence of prior repairs. According to Cessna representatives, after SB 550-24-14 was issued, Cessna had received numerous customer reports of short circuits and cut wires in control columns in various Citation models. In each case where sufficient data were available, analysis indicated that the actions suggested in SB 550-24-14 would likely have alleviated the situation. The NTSB concludes that a rounded type of sheathed wire bundle would fit better and be better protected within the control column shaft than the currently installed flat ribbon cable; replacement of the flat ribbon cable with a rounded type of sheathed wire bundle could result in fewer short circuits and other electrical events. Therefore, the NTSB recommends that the FAA issue an AD mandating compliance with Cessna SB 550-24-14, “Control Wheel Electrical Cable Replacement,” which was issued on January 17, 1992.

85 For example, the NTSB’s investigation of the October 25, 2002, accident involving a King Air A100 in Eveleth, Minnesota, revealed that, on a previous flight, the King Air’s pilot had inadvertently activated the autopilot instead of the yaw damper after takeoff, which resulted in an abrupt nose-down pitch. 86 Review of documentation for these other instances revealed that in some cases multiple wires were damaged; however, there was no documentation of a dual failure (as may have occurred on the accident airplane) or resulting inappropriate pitch trim function.

NTSB Aircraft Accident Report 50 2.2.2.3 Runaway Pitch Trim The NTSB’s accident and incident database contains at least eight accidents involving Cessna Citation pitch trim or related failures. For example, the NTSB previously addressed runaway pitch trim issues as a result of the July 22, 2003, accident involving a Citation 525 that ditched in the waters of Penn Cove, Coupeville, Washington, after a loss of elevator trim control that resulted in an uncommanded nose-down pitch attitude. Based on this accident, the NTSB issued Safety Recommendations A-07-52 and -54, asking that the FAA require Cessna to equip its Citation 525 airplanes with an aural trim-in-motion warning, better visual trim-in-motion cues (for example, contrasting color bands) on the pitch trim wheel, and collars on the pitch trim and autopilot circuit breakers to provide pilots with the means for recognizing and correcting a runaway pitch trim condition before control forces become unmanageable. (Postaccident examination of Marlin Air’s other Citation 550 revealed that it had identification collars on the starter and alternating current inverter circuit breakers, but not on the pitch trim or autopilot circuit breakers. Investigators also noted that the Citation’s uncollared circuit breakers were difficult to grasp and pull and that the circuit breakers with identification collars were much easier to grasp and pull.) In its response letter, dated November 20, 2007, the FAA indicated that it believed that the combination of the normal cues of undesired trim motion and the issuance of AD 2004-14-20 (which addressed the specific single-point failure mode identified in the Penn Cove accident investigation by requiring the replacement of the trim printed circuit board) correct the unsafe conditions identified during the investigation of the July 22, 2003, Penn Cove accident, rendering the action recommended in Safety Recommendation A-07-52 unnecessary. The NTSB’s June 11, 2009, response letter disagreed with the FAA’s position, stating that, had the Penn Cove pilot received conspicuous warning of the pitch trim runaway condition earlier in the accident sequence, he would have been able to complete the related checklist procedure and pulled the pitch trim circuit breaker before the pitch control forces became unmanageable. Therefore, on June 11, 2009, the NTSB classified Safety Recommendation A-07-52, “Open—Unacceptable Response.” The NTSB notes that not only has the runaway trim problem not been satisfactorily addressed with regard to the Citation 525 model airplane involved in the Penn Cove accident, it also exists in other Citation model airplanes, such as the Citation 550 involved in the MKE accident. In a representative airplane, investigators observed that the movement of the large, black pitch trim wheel, which was located on the left side of the throttle console adjacent to the captain’s right leg, was not always apparent. The addition of contrasting color bands, as recommended in Safety Recommendation A-07-52, would facilitate a pilot’s recognition of the wheel’s movement during a runaway pitch trim situation. Additionally, if a pitch trim anomaly were the initiating event in either the Penn Cove or MKE accidents, an aural trim-in-motion warning would have allowed the pilots to promptly identify the nature of the problem and correct it.87

87 An aural pitch trim-in-motion would also have been recorded by the CVR and, therefore, would have benefited the accident investigation as well.

NTSB Aircraft Accident Report Therefore, the NTSB concludes that the incorporation of an aural pitch trim-in-motion warning and contrasting color bands on the pitch trim wheel in all Cessna Citation series airplanes would help pilots of those airplanes to more promptly recognize and correct runaway pitch trim situations before control forces become unmanageable. Therefore, the NTSB recommends that the FAA require Cessna to modify all Citation series airplanes by incorporating an aural pitch trim-in-motion warning and contrasting color bands on the pitch trim wheel to help pilots recognize a runaway pitch trim condition before control forces become unmanageable. This recommendation supersedes Safety Recommendation A-07-52, which the NTSB reclassifies, “Closed—Unacceptable Action/Superseded.” As an alternative response to the actions proposed in Safety Recommendation A-07-54, the FAA proposed issuing guidance recommending replacement of the pitch trim circuit breaker on the Citation 525 with a collared circuit breaker to aid the pilot in quickly identifying it if necessary. Pending the FAA’s issuance of such guidance, on June 11, 2009, the NTSB classified Safety Recommendation A-07-54, “Open—Acceptable Alternate Response.” The MKE accident demonstrates that identification-collared circuit breakers on critical systems that a pilot might need to access during an abnormal or emergency situation would also benefit pilots operating Citation models not affected by the single-point failure identified in the Penn Cove accident. Filament analysis of autopilot computer-related annunciator lights and evidence inferred from the CVR transcript indicated that the MKE accident first officer was not able to immediately locate and identify critical (possibly autopilot and pitch trim) circuit breakers during the accident sequence. In part, this may have been due to his lack of familiarity with the airplane; however, these critical circuit breakers were not easily distinguishable from the many other circuit breakers on the panel. As previously noted, postaccident examination of another Marlin Air Citation 550 revealed that it had identification-collared circuit breakers on the starter and the alternating current inverter. If the accident airplane had been equipped with identification-type collars on the autopilot and pitch trim circuit breakers, the accident pilots would have been better able to identify those breakers. In addition, after the pilots located those circuit breakers, the identification collars would have made the breakers easier to grasp and pull. Therefore, the NTSB concludes that if circuit breakers that a pilot might need to quickly access during an abnormal or emergency situation were equipped with identification collars, pilots would be able to locate them more readily and pull them more easily during such a situation. Therefore, the NTSB recommends that the FAA require Cessna to replace all Citation series airplanes’ pitch trim, autopilot, and any other circuit breakers for critical systems that a pilot might need to access during an emergency situation with easily identifiable and collared circuit breakers to aid a pilot in quickly identifying and easily pulling those circuit breakers if necessary. This recommendation supersedes Safety Recommendation A-07-54, which the NTSB reclassifies Safety Recommendation A-07-54, “Closed—Unacceptable Action/Superseded.” Additionally, because pilots should be able to easily identify and pull critical circuit breakers during an abnormal or emergency situations in any airplane, the NTSB recommends that the FAA require airplane manufacturers to develop guidance on the identification of circuit breakers that pilots need to identify quickly and pull easily during abnormal or emergency situations and to provide such guidance, once developed, to operators of those airplanes. Further, 51

NTSB Aircraft Accident Report the NTSB recommends that the FAA require operators to implement the manufacturer’s guidance asked for in recommendation A-09-119 regarding which circuit breakers pilots need to identify quickly and pull easily during abnormal or emergency situations in their airplanes. 2.2.2.4 Human Factors in Aircraft Design Several of the safety issues identified during this investigation (the autopilot panel design and the aileron trim sensitivity are two examples) reflect a lack of attention to human/airplane system interactions that was typical when the Citation cockpit was designed and certificated. However, the aviation industry has learned much about human factors issues in the years since the Citation was certificated, and it is now clear that areas of the airplane’s design would benefit from that knowledge. It is likely that many other aircraft that were designed and certificated in the last 3 decades would benefit from similar review and application of human factors principles. In its 2006 study of the aircraft certification process, the NTSB made two recommendations (Safety Recommendations A-06-37 and -38) to the FAA concerning human/aircraft issues in the certification of aircraft. In response to these recommendations, the FAA indicated that it was incorporating more standardized consideration of human factors into new certification projects and planned to develop new regulations and advisory materials and a human factors design guide. Additionally, the FAA stated that it intended to formalize a process for monitoring and assessing safety critical systems throughout the life cycle of an airplane. Pending the FAA’s related actions, the NTSB classified Safety Recommendations A-06-37 and -38, “Open—Acceptable Response” on September 12, 2007. This accident investigation revealed numerous human factors issues with the Citation cockpit design. Although this investigation revealed that many Citation pilots were aware of some of these issues (such as the potential for inadvertently pressing the wrong button when engaging the autopilot or yaw damper), the NTSB is not aware of any plans by Cessna or the FAA to change the design to address these issues. The FAA indicated to the NTSB that it was developing guidance on human factors issues in aircraft for use by its certification staff; however, the NTSB is not aware that this new guidance has been developed and distributed, nor that it would address the many issues identified in this accident. Therefore, the NTSB concludes that the circumstances of this accident demonstrate the importance of a program for the FAA to monitor and conduct ongoing assessments of safety-critical systems throughout the life cycle of an airplane; the FAA did not perform this task adequately for the Cessna Citation. Because the numerous human factors issues identified in the accident airplane’s cockpit design may have been identified and corrected if current human factors principles were applied even after certification, the NTSB reiterates Safety Recommendations A-06-37 and –38 and classifies both “Open—Unacceptable Response.” 2.2.2.5 Aileron Trim Sensitivity and Responsiveness As previously noted, the Citation 550 aileron trim system is a manual (unpowered) trim system in which small inputs on the manual trim wheel in the cockpit can have a 52

NTSB Aircraft Accident Report 53 disproportionate effect on aileron movement. Additionally, the trim position indicator may not accurately reflect the aileron trim surface position. Postaccident interviews indicated that many Citation pilots have been surprised by the disproportionate sensitivity and responsiveness of the Citation aileron trim control system. In addition, numerous Citation pilots (including the owner of the accident airplane)88 reported problems or even declared an emergency as a result of aileron trim issues. The anecdotal evidence indicates that it is easy to set the Citation aileron trim inappropriately, possibly resulting in a hazardous out-of-trim condition. The disproportionate sensitivity and responsiveness of this system would likely have compounded any aileron trim inputs made by the first officer during the accident flight and exacerbated an already challenging troubleshooting effort. The FAA’s certification requirements contained in 14 CFR 25.143(c) protect against a trim runaway for powered surfaces (no more than 50 pounds of force for temporary applications). However, the Citation’s aileron trim tab is unpowered, and the certification requirements do not protect against the forces that might result from excessive manual inputs. During accident-related flight tests, control wheel forces in excess of 50 pounds were measured when half of the available aileron trim was applied at an airspeed of 250 knots. Cessna estimated that application of full aileron trim at 250 knots would have resulted in control wheel forces in excess of 150 pounds. Therefore, the NTSB concludes that the control wheel forces resulting from adjustments to the Cessna Citation’s unpowered aileron trim could exceed the control force limits specified by regulations for powered aileron trim surfaces. The NTSB is concerned that the design of the Citation’s aileron trim system allows for trim forces that far exceed those needed during an emergency, such as a loss of engine power. Additionally, because of the relative sensitivity of the small aileron trim control knob, even a small aileron trim adjustment could result in trim forces that would require excessive control wheel inputs to counteract and keep the airplane’s wings level. Therefore, the NTSB concludes that limiting the deflection of the Cessna Citation’s manually operated aileron trim tab to the deflection certification limit for powered trim tabs and reducing the Citation’s aileron trim sensitivity (the unexpectedly significant aileron trim deflection that results from a relatively small amount of trim knob input) would help pilots avoid sudden and excessive aileron trim deflections. However, during postaccident interviews, Cessna personnel indicated that the Citation’s aileron trim capability was originally designed for a failure condition, but that records from the time of the design did not identify that failure condition. Therefore, the NTSB recommends that the FAA require Cessna to evaluate and limit the maximum aileron trim deflection on Citation series airplanes to that required to meet the certification control requirements for powered trim tabs, unless there is a design-justification to exceed those requirements. In addition, the NTSB recommends that the FAA require Cessna to reduce the aileron trim sensitivity (the unexpectedly significant aileron trim deflection that results from a relatively small amount of trim knob input) on Citation series airplanes to avoid sudden and

88 The owner of the accident airplane told investigators that months before the accident he experienced a “very challenging” aileron trim-related control situation just after takeoff during a postmaintenance flight. He stated that he was never concerned about losing control during the flight and was able to correct the situation with a half-turn of the aileron trim control wheel but added that a larger aileron mistrim would have been “really hard to control…as speed built you may not be able to [control the airplane].”

NTSB Aircraft Accident Report 54 excessive aileron trim deflections. (Safety Recommendations A-06-37 and -38, reiterated in this report, address this issue for other future-built airplanes.) These recommended changes to the Citation aileron trim system will take time to develop and implement. In the meantime, Citation pilots who are unaware of the aileron trim system’s potentially excessive sensitivity and responsiveness might unintentionally exacerbate an abnormal flight control situation. The NTSB concludes that if Cessna Citation pilots and operators were informed of the potential hazards related to the sensitivity and responsiveness of the airplane’s aileron trim system, they would be better able to avoid problematic aileron trim inputs until a more permanent solution (an aileron trim system retrofit) is in place. Therefore, the NTSB recommends that the FAA, as an interim measure (pending an available aileron trim system retrofit), notify Citation pilots and operators of the potential hazards related to the sensitivity and responsiveness of the airplane’s aileron trim system. 2.3 Pilot Communications and Coordination The CVR recorded the later portion of the flight inbound to MKE (including the approach, landing, and taxi to the FBO) and the entire accident flight. The CVR evidence showed that the captain performed the flying pilot duties during both flights and portrayed an instructor-student pilot atmosphere, with the captain routinely correcting the first officer, during both flights.89 The CVR transcript revealed a casual and undisciplined cockpit environment during both flights, with no indication that either pilot routinely referenced checklists. Further, neither pilot referenced a checklist for assistance in resolving the control anomaly during the accident flight. Rather, CVR evidence indicates that the pilots engaged in a haphazard and confusing troubleshooting process, which was often hindered by the pilots’ inadequate coordination and communication and the first officer’s lack of familiarity with the airplane. According to the CVR, when the captain decided to return to the departure airport, he stated again that the airplane was rolling on him and asked the first officer to pull the autopilot circuit breakers. The first officer could not find the circuit breakers and asked the captain where they were located. The captain did not respond to the first officer’s question; instead he instructed the first officer to declare an emergency and advise ATC of their intention to return to MKE. The first officer subsequently used an incorrect aircraft call sign in his radio transmission, and the captain corrected him. About 10 seconds before the end of the recording, the captain instructed the first officer to take control of the airplane while he, the captain, tried to pull circuit breakers. Seconds later, the captain stated, "…we're not holding it," and about 5 seconds later the recording ended. Performance data suggest that almost immediately after the first officer took control, the airplane rolled to the left and descended into the lake. It is clear that the captain had at least marginal

89 For example, when the pilots were inbound to MKE, the captain told the first officer, "Don't hesitate to ask a question…" When the first officer began to prematurely complete the before-landing checklist, the captain told him twice to wait until he talked with the control tower. Additionally, the captain coached the first officer to get the instrument landing system approach properly displayed on his flight instruments; then, during the landing rollout, the captain stated that they would forego the use of spoilers, indicating, "I should have called for 'em. I didn't want you being confused on it." As they taxied to the FBO after landing, the captain asked the first officer to call the FBO to announce the flight’s arrival; the first officer asked, "What switch do I use for com two?" The captain replied, "Number two. Turn your knob. There you go."

NTSB Aircraft Accident Report 55 control of the airplane, and the airplane had successfully reversed course to return to the airport until the captain transferred control to the first officer. It is possible that the captain believed that pulling circuit breakers was the best course of action to avert a loss of control. However, the captain’s efforts to maintain control of the airplane had been successful to that point, and he could have significantly eased the ongoing and increasing control problem by reducing airspeed. The first officer provided little or no support to the captain during either flight and was arguably a distraction because the captain had to monitor the first officer’s actions as well as perform flying pilot duties. In addition, as the emergency escalated, the captain began to take over the radio calls while he continued to handle the airplane and troubleshoot the control problem. Although these distractions might have been benign during a normal flight, they were critical during the accident sequence, especially the later stages. The NTSB concludes that, as a result of the first officer’s poor flying skills, his lack of airplane systems knowledge, and both pilots’ lack of communication and coordination, the first officer provided little help to, and likely hindered, the captain during his attempts to deal with the flight control anomalies during the accident flight. The NTSB has repeatedly recommended that the FAA revise Part 135 requirements to require on-demand charter operators to establish an FAA-approved CRM training program for their flight crews, similar to CRM training programs required for Part 121 operators. The most recent related safety recommendation, Safety Recommendation A-03-52,90 was added to the NTSB’s Most Wanted List in November 2006. On May 1, 2009, the FAA published an NPRM in the Federal Register titled “Crew Resource Management Training for Crewmembers in Part 135 Operations,” which proposed a rule to require all Part 135 operators to include instruction in CRM in pilot and flight attendant training programs. The proposed rule would require initial and recurrent CRM training for crewmembers working for Part 135 on-demand operators. The proposed rule also specifies the minimum course content required for an approved CRM training program. The proposed rule would also exempt operators from providing initial training to crew who have already completed training with another operator. In comments submitted to the docket for this NPRM, the NTSB stated that it was supportive of the proposed rule but not the exception because operations are sufficiently different from one another to require tailored training. The response stated that the NTSB believed that the rule, without the exception, would largely meet the intent of Safety Recommendation A-03-52. Postaccident interviews with FAA inspectors and pilots who had previously flown with the accident pilots indicated that both pilots lacked procedural knowledge and familiarity with the airplane’s systems. Several pilots who had previously flown with the first officer indicated that he did not understand airplane systems, would act without thinking, and would get overloaded easily. In addition, postaccident interviews indicated that the captain did not always adhere to procedures or comply with regulations, focused on business rather than safety concerns, and routinely abbreviated checklists. CVR evidence from the accident airplane support these assertions. Therefore, the NTSB concludes that the pilots’ lack of discipline, in-depth

90 Safety Recommendation A-03-52 was issued as a result of its investigation of the November 18, 2003, accident in which an Aviation Charter, Inc., King Air A100 airplane lost control and impacted terrain in Eveleth, Minnesota. For additional information, see Aircraft Accident Report NTSB/AAR-03/03. For information on additional CRM-related safety recommendations, see Safety Recommendations A-80-42, A-94-196, and A-02-12, which are available on the NTSB’s website at http://www.ntsb.gov.

NTSB Aircraft Accident Report 56 systems knowledge, and adherence to procedures contributed to their inability to cope with anomalies experienced during the accident flight. The NTSB further concludes that Marlin Air’s selection of the accident captain (who routinely failed to comply with procedures and regulations) to the positions of company chief pilot and check airman, with responsibility for supervision and training of all company pilots, contributed to an inadequate company safety culture that allowed an ill-prepared first officer to fly in Part 135 operations. 2.4 FAA Oversight 2.4.1 Check Airman Appointment Guidance As previously stated, the POI appointed the captain as Marlin Air’s designated check airman about 2 years before the accident. The FAA defines a check airman as an airman approved by the FAA who has the appropriate training, experience, and demonstrated ability to evaluate and to certify the knowledge and skills of other airmen. The roles of a check airman, as described previously, are (1) to ensure that the flight crewmember has met competency standards before the crewmember is released from training, and (2) to ensure that those standards are maintained while the crewmember remains in line service. A check airman candidate must have achieved and maintained a favorable record as a flight crewmember. Once approved, a check airman's manner and professional reputation should always reflect positively upon the employer and the FAA. When Marlin Air nominated the captain for check airman appointment, the POI reviewed the nomination letter and verified the captain's pilot and medical certificate qualifications as required by FAA procedures.91 The captain was eligible under federal regulations to serve as the company’s chief pilot and as an FAA-designated check airman, and the POI approved the designation. The POI stated that during his review process, he noticed that the captain had previously had his pilot certificates revoked because of a drug violation; however, the POI did not seek further information regarding the nature or circumstances of the revocation. He stated that he assumed the revocation was related to a personal issue with prescription medications. The POI further stated that he did not believe it would be necessary for him to pursue the issue because the FAA had reviewed the situation and reissued the captain’s pilot certificates. FAA guidance regarding appointment of check airmen requires POIs to verify the check airman candidate's “certificates and background.” Additionally, all required training must be completed, and the airman's training records must show satisfactory completion of initial, transition, or upgrade training, as applicable. The guidance does not specifically address POI actions when the background evaluation discloses negative information. This lack of guidance can result in the

91 In October 1986, as a result of its investigations into three commuter air carrier accidents, the NTSB issued Safety Recommendation A-86-108, asking the FAA to issue guidance regarding oversight of check airmen to all POIs for Part 135 operators. In response to this recommendation, on August 31, 1990, the FAA issued change 4 to its Handbook 8400.10, “Air Transportation Operations Inspector’s Handbook.” This change contained specific direction and guidance concerning the check airman program for Part 121 and 135 operators, including the role and purpose of the check airman, the regulatory requirements, qualifications, functional responsibilities, and the approval process and training requirements for check airmen. In March 1991, the NTSB classified Safety Recommendation A-86-108, “Closed—Acceptable Action.”

NTSB Aircraft Accident Report 57 appointment of check airmen who do not adhere to standards, possibly jeopardize flight safety, and generally do not represent the FAA well (as was the case with the accident captain). The FAA could address this issue by establishing procedures requiring POIs to provide heightened surveillance during a probationary period (and at other times if deemed necessary based on routine surveillance) for any check airman whose background or performance reveals negative information. The heightened surveillance would provide a check airman with an opportunity to demonstrate that they had reformed and would represent the FAA well, while providing the approving POIs with an opportunity to scrutinize the individuals’ manner and performance to ensure that they are consistent with the FAA’s standards for check airmen. In this case, the captain might have established the habit of operating according to proper standards as a check airman because he was aware of the scrutiny, or the POI might have noticed the captain’s tendency to be slipshod and rescinded the check airman appointment. The NTSB concludes that if the FAA guidance regarding check airman appointments and oversight contained procedures for POIs to follow (such as heightened surveillance) in cases where review of the pilot’s background or performance reveals negative information, checkride failures, or other performance-related deficiencies, the agency might prevent inadequate and/or undisciplined pilots from being appointed or retained as check airmen. The NTSB therefore recommends that the FAA revise check airman approval and oversight procedures to incorporate heightened surveillance during a probationary period and at other times, as warranted, for check airmen whose background evaluation uncovers a history of criminal convictions, certificate revocations, check-ride failures, or other performance-related deficiencies. 2.4.2 Regional Aviation Safety Inspection Program Guidance and Procedures The FAA’s postaccident RASIP of Marlin Air involved an inspection team that included three inspectors from the FAA's Great Lakes Regional office and the three principal inspectors assigned to the operator at the time of the accident. The Marlin Air RASIP team leader told NTSB investigators that RASIP inspections were not intended to assess the quality or adequacy of the principals’ oversight, but rather to provide additional surveillance of the operators. In the case of the Marlin Air RASIP, the FAA decided to include the principal inspectors on the RASIP team because their familiarity with the operator's policies and procedures could facilitate the inspection. The Marlin Air RASIP was focused on the operator's policies and procedures, including training. Because Marlin Air’s operations had been suspended at that time due to the accident, the RASIP team did not interview any company line personnel, but rather coordinated with the director of operations and the assistant chief pilot. The inspection revealed one finding related to operation of an airplane requiring two pilots under the operations specifications by only one pilot.92

92 As previously noted, the only other recent FAA inspection of Marlin Air was an OSIP that was accomplished in March 2002, more that 5 years before the accident. The OSIP findings were minor and were immediately corrected by Marlin Air.

NTSB Aircraft Accident Report Although the RASIP report indicated that the team reviewed training records for all Marlin Air pilots, Marlin Air personnel advised the RASIP team that the only copies of the accident pilots’ records had been furnished to NTSB investigators. Because Marlin Air did not retain copies of the pilots’ records (or obtain copies from the NTSB to fully comply with the RASIP team’s request), these records were not available for the RASIP team’s review. Yet the RASIP team’s report indicated that “records for all pilots were reviewed,” and issued no adverse findings. The RASIP report did not qualify its findings by indicating that some of the pilot records were not reviewed nor did it indicate that the team was unable to assess Marlin Air’s day- to-day operations because the company’s operations were suspended after the accident. Furthermore, it is understandable that the RASIP report did not reveal the training form irregularities for the first officer’s recent checkride approval if the inspection team had no information regarding him; however, it is not clear why the RASIP investigators did not discover the irregularities in two recent checkride forms pertaining to other Marlin Air pilots, irregularities that were subsequently discovered during the NTSB’s investigation. The NTSB has previously issued safety recommendations reflecting its concerns about the quality of inspections conducted by the FAA, repeatedly recommending that the FAA issue formal documentation to ensure consistent and continued implementation of these policies. The most recent of these recommendations, Safety Recommendation A-05-08, was issued in April 2005, as a result of a fatal accident involving an Air Sunshine Cessna 402C. In response to Safety Recommendation A-05-08, the FAA’s southern region conducted a focused oversight inspection of Air Sunshine. As a result of that inspection, the FAA revised its oversight of Air Sunshine and revised several related sections of FAA Order 8900.1. On August 27, 2009, the NTSB classified Safety Recommendation A-05-08, “Closed—Acceptable Action.” The NTSB concludes that the RASIP inspection conducted after this accident failed to uncover evidence of training irregularities and did not evaluate the quality of FAA surveillance provided before the accident. Therefore, the NTSB recommends that the FAA conduct a detailed review of the oversight provided to Marlin Air to determine why the oversight system failed to detect (before and after the accident) and correct Marlin Air’s operational deficiencies, particularly in the areas of pilot hiring, training, and adherence to procedures. Further, the NTSB recommends that the FAA, based on the review described in Safety Recommendation A-09-125, revise the oversight system and FAA Order 8900.1 as needed. 2.4.3 Mechanisms for Alerting the FAA to Potential Operator Problems Complaints from outside the FAA may alert the FAA to a variety of operator-related safety issues that the FAA can pursue through a formal investigation or increased oversight. This investigation revealed that although UM Survival Flight program personnel had felt comfortable with Marlin Air for most of the 19 years they had contracted with the operator, UM personnel had increasing reservations regarding Marlin Air’s operations in the couple of years preceding the accident. UM personnel stated that they began to hear complaints about Marlin Air and their pilots and had concerns related to the number of Marlin Air flights cancelled due to mechanical issues. According to the UM program manager, the number of trip cancellations had increased in the year preceding the accident and medical personnel were beginning to think that Marlin Air was unsafe. However, UM personnel did not relay any of these concerns to the FAA before the 58

NTSB Aircraft Accident Report 59 accident because they were not aware of the FAA safety hotline or other methods by which they might make their concerns known. An FAA representative of its Executive Office for Flight Standards stated that there were several FAA programs that might have been beneficial to the UM personnel in raising safety concerns. These included the Customer Service Initiative administered through the local FSDO or regional offices, the Safety Hotline administered by the Office of Accident Investigation, and the Administrator’s Hotline. Had the FAA been aware of UM’s concerns, FAA staff could have responded with increased oversight or a formal investigation. The NTSB concludes that customers (such as UM) who contract with aviation operators may not understand the FAA’s role in aviation safety or know how to contact FAA personnel when safety concerns arise. Therefore, the NTSB recommends that the FAA require all 14 CFR Part 135 and Part 91K operators to provide their customers, when a business agreement or contract is finalized, with FAA contact information identified as specifically for use in expressing concerns about flight safety thus providing customers with a clear means of communicating any safety concerns to the FAA. The American Hospital Association (AHA) is another source for updated medical/air ambulance industry information.93 AHA currently has more than 37,000 health care members and routinely publishes newsletters addressing current healthcare issues. The NTSB recommends that AHA inform its members, through its website, newsletters, and conferences, of the FAA’s role in aviation safety with respect to medical/air ambulance services and provide FAA contact information. Further, AHA should urge its members to communicate any safety concerns related to medical/air ambulance services to the FAA. 2.5 Operators with Financial Difficulties Marlin Air exhibited many signs of financial difficulties before the accident. For example, about 7 months before the accident, a court judgment was entered against Marlin Air for nonpayment of hangar rent. The company made an initial payment against the rent due but subsequently defaulted on the second payment. Additionally, a supplier that had previously provided Marlin Air with fuel on a contract basis terminated its contract with the company about 2 to 3 years before the accident because the operator fell behind in account payments. Another fuel supplier terminated its credit arrangement with Marlin Air due to nonpayment but continued to provide fuel, with payment required at the time of purchase. Postaccident interviews and CVR evidence showed that the captain occasionally focused on business issues at the expense of flight safety. For example, as previously stated, the captain intentionally took off, and subsequently landed, in an airplane that was loaded beyond allowable takeoff and landing weight limits because he was “tankering” inexpensive fuel to avoid paying for more expensive fuel elsewhere. In addition, CVR evidence showed that, during the accident airplane’s approach to MKE in marginal weather conditions, the captain advised the first officer

93 The AHA is the national organization that represents and serves all types of hospitals, health care networks, and their patients and communities.

NTSB Aircraft Accident Report not to ask for current weather information. Although asking for the most current weather conditions immediately before an instrument approach is not required by regulation, a specific decision not to do so is consistent with a willingness to attempt an approach to an airport that may be below minimums, thus decreasing the level of safety for the operation. Concerns about the cost of a go-around or diversion to another airport might have played a part in that decision. The UM program manager stated that the financial condition of Marlin Air appeared troubled before the accident because requested upgrades were not accomplished. The program manager was disturbed to learn shortly before the accident that Marlin Air had failed to pay its recent renewal dues to the AAMS. She felt this failure could potentially jeopardize the accreditation and standing of the UM program. The examples above clearly indicate that the operator was experiencing financial difficulties. However, current federal regulations and procedures require only Part 121 operators to report financial information to the FAA. The FAA detected none of the signs of Marlin Air’s financial hardship during the FAA’s routine surveillance of that company’s Part 135 operations. The POI and local FSDO management personnel reported that they were unaware of Marlin Air’s financial situation; had they known, they said they would have scrutinized the company’s operations more closely. The NTSB concludes that had FAA personnel been aware of Marlin Air’s financial situation, the FAA would have had an opportunity to increase surveillance of the company. Therefore, to provide inspectors with an opportunity to increase their oversight of operators who appear to be in financial distress, the NTSB recommends that the FAA require all 14 CFR Part 91K and Part 135 operators to notify the assigned POIs of specific adverse financial events, such as bankruptcy, court judgments related to nonpayment of recurring expenses, or termination of a credit agreement or contract by a vendor for reasons of late payment or nonpayment. Upon receipt of such information, inspectors should increase their oversight of operators who appear to be in financial distress. 60

NTSB Aircraft Accident Report

1. Conclusions
2. 1 Findings
3. The captain and first officer were properly certificated and qualified under federal

regulations to act in their respective roles during the accident flight. There was no evidence of any medical conditions that might have adversely affected the pilots’ performance during the accident flight.

1. Although the captain’s pilot certificates had previously been revoked because of a felony

conviction involving the illegal transport of drugs into the United States, the Federal Aviation Administration had reissued his pilot certificates, and they were valid at the time of the accident.

1. The accident airplane was properly certificated, was equipped and maintained in accordance

with industry practices (except for the wiring installed in the pilots’ control yokes), and was within weight and center of gravity limits.

1. If the accident airplane had been equipped with a recorder system that captured cockpit

images and parametric data, investigators would have been better able to determine the circumstances that led to this accident.

1. The accident sequence initiated as a result of a control problem that was related to either an

inadvertent autopilot activation or a pitch trim anomaly, the effects of which were compounded by aileron and/or rudder trim inputs; however, it was not possible to determine the exact nature of the initiating event.

1. Regardless of the initiating event, if the pilots had simply maintained a reduced airspeed

while they responded to the situation, the aerodynamic forces on the airplane would not have increased significantly; at reduced airspeeds, the pilots should have been able to maintain control of the airplane long enough to either successfully troubleshoot and resolve the problem or return safely to the airport.

1. Pilots would benefit from training and readily accessible guidance indicating that, when

confronted with abnormal flight control forces, they should prioritize airplane control (airspeed, attitude, and configuration) before attempting to identify and eliminate the cause of the flight control problem.

1. The design and location of the yaw damper and autopilot switches on Cessna Citation series

airplanes do not adequately protect against inadvertent activation of a system, which could have disastrous consequences. 61

NTSB Aircraft Accident Report

1. A rounded type of sheathed wire bundle would fit better and be better protected within the

control column shaft than the currently installed flat ribbon cable; replacement of the flat ribbon cable with a rounded type of sheathed wire bundle could result in fewer short circuits and other electrical events.

1. The incorporation of an aural pitch trim-in-motion warning and contrasting color bands on

the pitch trim wheel in all Cessna Citation series airplanes would help pilots of those airplanes to more promptly recognize and correct runaway pitch trim situations before control forces become unmanageable.

1. If circuit breakers that a pilot might need to quickly access during an abnormal or

emergency situation were equipped with identification collars, pilots would be able to locate them more readily and pull them more easily during such a situation.

1. The circumstances of this accident demonstrate the importance of a program for the Federal

Aviation Administration to monitor and conduct ongoing assessments of safety-critical systems throughout the life cycle of an airplane; the FAA did not perform this task adequately for the Cessna Citation.

1. The control wheel forces resulting from adjustments to the Cessna Citation’s unpowered

aileron trim could exceed the control force limits specified by regulations for powered aileron trim surfaces.

1. Limiting the deflection of the Cessna Citation’s manually operated aileron trim tab to the

deflection certification limit for powered trim tabs and reducing the Citation’s aileron trim sensitivity (the unexpectedly significant aileron trim deflection that results from a relatively small amount of trim knob input) would help pilots avoid sudden and excessive aileron trim deflections.

1. If Cessna Citation pilots and operators were informed of the potential hazards related to the

sensitivity and responsiveness of the airplane’s aileron trim system, they would be better able to avoid problematic aileron trim inputs until a more permanent solution (an aileron trim system retrofit) is in place.

1. As a result of the first officer’s poor flying skills, his lack of airplane systems knowledge,

and both pilots’ lack of communication and coordination, the first officer provided little help to, and likely hindered, the captain during his attempts to deal with the flight control anomalies during the accident flight.

1. The pilots’ lack of discipline, in-depth systems knowledge, and adherence to procedures

contributed to their inability to cope with anomalies experienced during the accident flight.

1. Marlin Air’s selection of the accident captain (who routinely failed to comply with

procedures and regulations) to the positions of company chief pilot and check airman, with responsibility for supervision and training of all company pilots, contributed to an inadequate company safety culture that allowed an ill-prepared first officer to fly in Part 135 operations. 62

NTSB Aircraft Accident Report

1. If the Federal Aviation Administration guidance regarding check airman appointments and

oversight contained procedures for principal operations inspectors to follow (such as heightened surveillance) in cases where review of the pilot’s background or performance reveals negative information, checkride failures, or other performance-related deficiencies, the agency might prevent inadequate and/or undisciplined pilots from being appointed or retained as check airmen.

1. The Regional Aviation Safety Inspection Program inspection conducted after this accident

failed to uncover evidence of training irregularities and did not evaluate the quality of Federal Aviation Administration surveillance provided before the accident.

1. Customers (such as the University of Michigan) who contract with aviation operators may

not understand the Federal Aviation Administration’s (FAA) role in aviation safety or know how to contact FAA personnel when safety concerns arise.

1. Had Federal Aviation Administration (FAA) personnel been aware of Marlin Air’s financial

situation, the FAA would have had an opportunity to increase surveillance of the company. 63

NTSB Aircraft Accident Report 3.2 Probable Cause The National Transportation Safety Board determines that the probable cause of this accident was the pilots’ mismanagement of an abnormal flight control situation through improper actions, including failing to control airspeed and to prioritize control of the airplane, and lack of crew coordination. Contributing to the accident were Marlin Air’s operational safety deficiencies, including the inadequate checkrides administered by Marlin Air’s chief pilot/check airman, and the Federal Aviation Administration’s failure to detect and correct those deficiencies, which placed a pilot who inadequately emphasized safety in the position of company chief pilot and designated check airman and placed an ill-prepared pilot in the first officer’s seat.

64

NTSB Aircraft Accident Report

1. Recommendations
2. 1

New Recommendations As a result of this investigation, the National Transportation Safety Board makes the following recommendations: To the Federal Aviation Administration: Require all 14 Code of Federal Regulations Part 91K and Part 135 operators to incorporate upset recovery training (similar to that described in the airplane upset recovery training aid used by many Part 121 operators) and related checklists and procedures into their training programs. (A-09-113) Require Cessna to redesign and retrofit the yaw damper and autopilot switches on the autopilot control panel in Citation series airplanes to make them easily distinguishable and to guard against unintentional pilot activation. (A-09-114) Identify airplanes other than the Cessna Citation with autopilot control panel designs that may lead to inadvertent activation of the autopilot and require manufacturers to redesign and retrofit the autopilot control panels to make the buttons easily distinguishable and to guard against unintentional activation. (A-09-115) Issue an airworthiness directive mandating compliance with Cessna Service Bulletin 550-24-14, “Control Wheel Electrical Cable Replacement,” which was issued on January 17, 1992. (A-09-116) Require Cessna to modify all Citation series airplanes by incorporating an aural pitch trim-in-motion warning and contrasting color bands on the pitch trim wheel to help pilots recognize a runaway pitch trim condition before control forces become unmanageable. (A-09-117) (This recommendation supersedes Safety Recommendation A-07-52 and is classified “Open—Unacceptable Response.”) Require Cessna to replace all Citation series airplane pitch trim, autopilot, and any other circuit breakers for critical systems that a pilot might need to access during an emergency situation with easily identifiable and collared circuit breakers to aid a pilot in quickly identifying and easily pulling those circuit breakers if necessary. (A-09-118) (This recommendation supersedes Safety Recommendation A-07-54 and is classified “Open—Unacceptable Response.”) Require airplane manufacturers to develop guidance on the identification of circuit breakers that pilots need to identify quickly and pull easily during abnormal or emergency situations and to provide such guidance, once developed, to operators of those airplanes. (A-09-119) 65

NTSB Aircraft Accident Report Require operators to implement the manufacturer’s guidance asked for in recommendation A-09-119 regarding which circuit breakers pilots need to identify quickly and pull easily during abnormal or emergency situations in their airplanes. (A-09-120) Require Cessna to evaluate and limit the maximum aileron trim deflection on Citation series airplanes to that required to meet the certification control requirements for powered trim tabs, unless there is a design-justification to exceed those requirements. (A-09-121) Require Cessna to reduce the aileron trim sensitivity (the unexpectedly significant aileron trim deflection that results from a relatively small amount of trim knob input) on Citation series airplanes to avoid sudden and excessive aileron trim deflections. (A-09-122) As an interim measure (pending an available aileron trim system retrofit), notify Citation pilots and operators of the potential hazards related to the sensitivity and responsiveness of the airplane’s aileron trim system. (A-09-123) Revise check airman approval and oversight procedures to incorporate heightened surveillance during a probationary period and at other times, as warranted, for check airmen whose background evaluation uncovers a history of criminal convictions, certificate revocations, check-ride failures, or other performance- related deficiencies. (A-09-124) Conduct a detailed review of the oversight provided to Marlin Air to determine why the oversight system failed to detect (before and after the accident) and correct Marlin Air’s operational deficiencies, particularly in the areas of pilot hiring, training, and adherence to procedures. (A-09-125) Based on the review described in Safety Recommendation A-09-125, revise the oversight system and Federal Aviation Administration Order 8900.1 as needed. (A-09-126) Require all 14 Code of Federal Regulations Part 135 and Part 91K operators to provide their customers, when a business agreement or contract is finalized, with Federal Aviation Administration (FAA) contact information identified as specifically for use in expressing concerns about flight safety, thus providing customers with a clear means of communicating any safety concerns to the FAA. (A-09-127) Require all 14 Code of Federal Regulations Part 91K and Part 135 operators to notify the assigned principal operations inspectors of specific adverse financial events, such as bankruptcy, court judgments related to nonpayment of recurring expenses, or termination of a credit agreement or contract by a vendor for reasons of late payment or nonpayment. Upon receipt of such information, inspectors should increase their oversight of operators who appear to be in financial distress. (A-09-128) 66

NTSB Aircraft Accident Report To the American Hospital Association: Inform your members, through your website, newsletters, and conferences, of the Federal Aviation Administration’s (FAA) role in aviation safety with respect to medical/air ambulance services and provide FAA contact information. Urge your members to communicate any safety concerns related to medical/air ambulance services to the FAA. (A-09-129) 4.2 Previously Issued Recommendations Reiterated and Reclassified in This Report As a result of its investigation of this accident, the National Transportation Safety Board reiterates the following safety recommendations to the Federal Aviation Administration: Amend the advisory materials associated with 14 Code of Federal Regulations 25.1309 to include consideration of structural failures and human/airplane system interaction failures in the assessment of safety-critical systems. (A-06-37) Adopt Society of Automotive Engineers [Aerospace Recommended Practice] 5150 into 14 Code of Federal Regulations Parts 21, 25, 33, and 121 to require a program for the monitoring and ongoing assessment of safety-critical systems throughout the life cycle of the airplane. Once in place, use this program to validate that the underlying assumptions made during design and type certification about safety-critical systems are consistent with operational experience, lessons learned, and new knowledge.” (A-06-38) Safety Recommendations A-06-37 and -38 are reiterated in section 2.2.2.4 of this report. In addition, Safety Recommendations A-06-37 and -38 are reclassified “Open—Unacceptable Response.” 4.3 Previously Issued Recommendations Classified in This Report The following previously issued recommendations are classified in this report: • Safety Recommendation A-07-52 (previously classified “Open—Unacceptable Response”) is classified “Closed—Unacceptable Action/Superseded” (replaced by Safety Recommendation A-09-117) in section 2.2.2.3 of this report. • Safety Recommendation A-07-54 (previously classified “Open—Acceptable Alternate Response”) is classified “Closed—Unacceptable Action/Superseded” (replaced by Safety Recommendation A-09-118) in section 2.2.2.3 of this report. 67

NTSB Aircraft Accident Report BY THE NATIONAL TRANSPORTATION SAFETY BOARD DEBORAH A.P. HERSMAN ROBERT L. SUMWALT Chairman Member

CHRISTOPHER A. HART

Vice Chairman

Adopted: October 14, 2009

68

NTSB Aircraft Accident Report

1. Appendixes

Appendix A Investigation and Public Hearing Investigation The National Transportation Safety Board (NTSB) was notified about the accident on June 4, 2007, shortly after it occurred. A partial go-team was launched, with an Investigator-in- Charge and specialists in Operations and Maintenance/Maintenance Records/Airworthiness. The following investigative groups were formed during this investigation: Maintenance/Maintenance Records/Airworthiness, Meteorology, Operations/Human Performance, Airplane Performance, and Cockpit Voice Recorder. 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 Pratt and Whitney Canada participated in this investigation. Parties to the investigation were the Federal Aviation Administration, Marlin Air, Cessna Aircraft Company, and Honeywell International. The NTSB received submissions regarding this accident from Marlin Air, Cessna Aircraft Company, and Honeywell International. Public Hearing No public hearing was held for this accident. 69

NTSB Aircraft Accident Report 70 Appendix B Cockpit Voice Recorder Transcript The following is a transcript of the Universal CVR-30B cockpit voice recorder (CVR) installed on the accident airplane, a Cessna 550 (Citation 550), N550BP, which impacted Lake Michigan shortly after it departed the General Mitchell International Airport (MKE), Milwaukee, Wisconsin on June 4, 2007. LEGEND CAM Cockpit area microphone voice or sound source HOT Flight crew audio panel voice or sound source RDO Radio transmissions from N550BP TAWS Sound identified as the terrain awareness and warning system TCAS Sound identified as the traffic collision and avoidance system -1 Voice identified as the captain -2 Voice identified as the first officer -3 Voice of unidentified passenger -? Voice unidentified * Unintelligible word

Expletive @ Non-pertinent word [ ] Editorial insertion Note 1: Times are expressed in central daylight time (CDT). 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.

NTSB Aircraft Accident Report 71

INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

11:38:26 START OF RECORDING START OF TRANSCRIPT

11:38:26 CAM-1

*** anti-ice.

11:38:35 CAM-2

six thousand feet to go. gonna be in the clouds all the way.

11:38:41 CAM-1

sixty five *.

11:38:53 CAM-?

three thousand *.

11:39:17 CAM-1

***.

11:39:21 CAM-2

I’ll check.

11:39:27 HOT-2

I’ll get—. I’ll ask 'em.

11:39:28 HOT-1

naw that's all right. don't worry about it.

11:39:29 HOT-2

no when I go to tower I’ll ask what the current weather is.

11:39:33 HOT-1

no no because if they give below minimums then we're—. we're really screwed.

11:39:36 HOT-2

okay.

NTSB Aircraft Accident Report 72 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

11:39:39 HOT-1

anti-ice is coming off.

11:39:43 RDO-2

two fifty—. two fif—. uh four thousand two fifty on the heading zero bravo pap.

11:39:48 HOT-1

four thousand?

11:39:51 HOT-1

all right get ahead of this stuff.

11:39:52 HOT-1

no. too dark out. too dark.

11:39:59 HOT-1

okay down to four thousand. we're still armed on the alt— altitude.

11:40:06 CAM-2

yes.

11:40:09 HOT-1

can't hear you. what?

11:40:09 HOT-2

• speed.

11:40:10 CAM

[sound similar to altitude alert tone]

11:40:16 HOT-1

darn me. okay we are doing uh. I’ll show you something else here too if I can find it.

11:40:24 HOT-1

DH here. up here. DH is two hundred feet above the ground.

NTSB Aircraft Accident Report 73 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

11:40:36 HOT-1

okay. comin' through ten thousand feet seatbelt sign's on. I’d put the extra lights on if I need it— if I thought it would do any good but it won't. and we are seventeen miles from CUTMO. down to four let's get her down.

11:40:58 HOT-1

normally I don't get down this fast but I want to be set up for this approach.

11:41:09 HOT-1

put the air conditioner back on.

11:41:15 HOT-1

** cold back there.

11:41:50 HOT-2

set the radar altimeter.

11:41:55 HOT-1

yeah two hundred feet. we don't need no damn turbulence right now either.

11:42:20 HOT-1

• we'll flatten out the descent a little bit.

11:42:28 HOT-1

six for four now.

11:42:43 HOT-1

you keep—.

11:42:46 RDO-2

two seven zero five five zero bravo pap.

11:42:52 HOT-1

two seven zero. okay you keep me honest now.

11:42:58 CAM-2

okay.

NTSB Aircraft Accident Report 74 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

11:42:58 HOT-1

don’t hesitate to ask a question. just try to keep it calm. I’m pretty comfortable with the airplane so—.

11:43:06 HOT-1

out of five for four.

11:43:07 CAM

[sound similar to altitude alert]

11:43:08 CAM-2

one to go.

11:43:10 HOT-1

startin’ to get the right signals here. there’s the glideslope. um.

11:43:35 HOT-1

okay altitude’s captured. she’ll level at four.

11:43:48 HOT-1

very good. yeah that’s our missed. okay we’ll slow to about two twenty. we get our vector I’ll slow a little more.

11:43:50 CAM-2

right.

11:44:03 HOT-1

we're six miles from the fix.

11:44:09 RDO-2

down to twenty-six hundred zero bravo pap.

11:44:12 HOT-1

set it for me. armed.

11:44:31 HOT-1

thousand feet to go.

11:44:33

NTSB Aircraft Accident Report 75 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

CAM [sound similar to altitude alert]

11:44:35 HOT-1

now we're going below the glide slope which we should be doing.

11:44:52 RDO-2

okay two six zero maintain two thousand six hundred till CUTMO five zero bravo pop.

11:45:01 HOT-1

cleared for the approach we arm it on both sides.

11:45:05 CAM-2

two ninety the heading *.

11:45:08 HOT-1

say what.

11:45:11 RDO-2

zero four zero five zero bravo pap.

11:45:16 HOT-1

all we need is a bad vector. approach flaps. approach flaps there one notch.

11:45:21 CAM

[sound similar to flap lever actuation]

11:45:22 CAM-2

speed check approach flaps out.

11:45:25 HOT-1

just what we need is a bad vector.

11:45:47 HOT-1

okay we're stable. flaps are out we're good. next call's gonna be gear but don't worry about it right now. ignitors are on that's a pre landing check. okay localizer's alive again. yup and captured.

11:45:55

NTSB Aircraft Accident Report 76 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

CAM-2 *.

11:46:00 CAM-2

you want the approach mode armed at all?

11:46:02 HOT-1

say what no? * I can't hear you @.

11:46:05 HOT-2

I’m sorry approach mo— mode armed?

11:46:07 HOT-1

yeah we're all set.

11:46:08 HOT-2

okay I’m sorry.

11:46:09 HOT-1

good catch good catch.

11:46:14 HOT-1

okey doke.

11:46:27 RDO-2

'kay over to tower lifeguard zero bravo pap. thanks for the help.

11:46:37 HOT-1

damn it.

11:46:43 HOT-1

don't ask her the weather.

11:46:44 CAM-2

I’m not. one dot gear up.

11:46:46 HOT-1

I see it. landing gear down.

11:46:49 CAM

[sound similar to landing gear handle actuation]

NTSB Aircraft Accident Report 77 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

11:46:49 CAM

[sound of increasing background noise]

11:46:59 HOT-1

landing flaps? landing checklist?

11:47:06 HOT-2

landing gear's down landing gear's down. * are on. landing lights on. flaps flaps—.

11:47:09 HOT-1

three green. yes.

11:47:10 HOT-1

no wait talk to tower now.

11:47:13 HOT-1

talk to tower. @ talk to tower.

11:47:17 RDO-2

• tower lifeguard uh five five zero bravo pap's on the ILS one zero.

11:47:23 CAM

[sound similar to switch being flipped]

11:47:25 CAM

[sound similar to altitude alert]

11:47:30 RDO-2

five zero bravo pap.

11:47:32 HOT-1

okay we're cleared to land lights are on go ahead with checklist.

11:47:36 HOT-2

landing lights?

11:47:37 HOT-1

on.

NTSB Aircraft Accident Report 78 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

11:47:38 HOT-2

okay gear's down ignition's on.

11:47:40 HOT-1

correct.

11:47:40 HOT-2

flaps landing lights?

11:47:42 HOT-1

on on on.

11:47:43 HOT-2

flaps autopilot yaw damper?

11:47:44 HOT-1

autopilot's comin' off in a minute.

11:47:46 HOT-2

okay.

11:47:47 HOT-1

okay I need you inside and out now okay @. let's get you armed and join me here.

11:47:50 HOT-2

okay.

11:47:51 HOT-1

oh # for some reason it didn't—. the one over here anything. no go to nav yeah go to nav go to nav. now hit the two buttons. armed.

11:48:02 HOT-1

okay. all right you've got a good ILS with a glideslope. okay we're shooting for nine oh four. we got a thousand feet to go or less. that—. that agrees there. that agrees here. okay autopilot's comin' off.

NTSB Aircraft Accident Report 79 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

11:48:05 HOT-2

right.

11:48:15 CAM

[sound similar to autopilot disconnect tone]

11:48:17 HOT-2

speed one thirty-five.

11:48:18 HOT-1

want to keep that pretty much all the way down.

11:48:20 CAM-2

okay.

11:48:24 HOT-1

just bleed it off very slowly. we got plenty of runway and we're going to the far end anyway.

11:48:32 HOT-1

I need you in and out real good okay….

11:48:33 HOT-2

I’ll do the best I can.

11:48:34 HOT-1

good man good man.

11:48:35 HOT-2

I show you on glideslope on localizer.

11:48:38 HOT-1

we're tryin' we're tryin'.

11:48:39 HOT-2

speed one thirty-five.

11:48:48 HOT-1

gettin' darker that's a good sign.

NTSB Aircraft Accident Report 80 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

11:48:58 HOT-2

okay I show you three hundred feet to minimums.

11:49:00 HOT-1

thank you.

11:49:02 TAWS

five hundred.

11:49:04 HOT-1

that's above the ground. that's fine.

11:49:05 HOT-2

right.

11:49:10 HOT-2

on glideslope on localizer. a little high— a little low rather.

11:49:13 HOT-1

workin' on it.

11:49:17 HOT-1

bleed the speed of a little bit with ground contact in my peripheral vision there.

11:49:18 HOT-2

okay.

11:49:24 HOT-1

comin' up on minimums. look for the runway please.

11:49:27 HOT-2

I got the lights straight ahead.

11:49:28 HOT-1

okay I’m flying. I’m landing. got your sight—. runway in sight.

11:49:30 CAM

[sound of unknown tones]

NTSB Aircraft Accident Report 81 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

11:49:31 CAM-2

airspeed one thirty-five.

11:49:33 HOT-1

okay we'll bleed the speed off nice and slow.

11:49:36 HOT-2

three green no red.

11:49:37 HOT-1

okey doke.

11:49:40 HOT-1

right down the chute. almost like I knew what I was doing.

11:49:41 HOT-2

fifty feet.

11:49:43 CAM-2

hey good job….

11:49:50 HOT-1

do a little float routine down here gotta go all the way to the end anyway.

11:49:55 CAM

[sound of unknown tones]

11:49:58 HOT-1

nice soft landing.

11:50:00 HOT-1

trying here.

11:50:11 HOT-2

your speed is ninty-five.

11:50:14 CAM

[sound similar to touchdown]

NTSB Aircraft Accident Report 82 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

11:50:15 HOT-2

ninety.

11:50:17 HOT-2

six lights.

11:50:18 HOT-1

we could get some spoilers out but don't worry about it I should have called for 'em. I didn't want you being confused on it.

11:50:25 HOT-2

Signa—. Signature.

11:50:32 RDO-2

'kay left at the end over to ground.

11:50:39 CAM

[sound of unknown tones]

11:50:40 HOT-1

we never called…with an inbound sorry. I should have. no big deal. yeah you got a frequency for them. go ahead I’ll watch ground. ground is twenty-one eight. yeah I’ll get the ground you just—. don't wor—. its on the flightplan actually too. thirty-one something or 'nother.

11:50:55 CAM-2

thirty-one twenty.

11:50:56 HOT-1

thirty-one zero. left at the end is what she told us.

11:50:58 CAM

[sound of unknown tones]

11:51:02 HOT-1

Signature's right here anyway.

11:51:13 CAM

[sound of unknown tones]

NTSB Aircraft Accident Report 83 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

11:51:14 CAM-2

what switch do you use for com two?

11:51:17 HOT-1

number two. turn your knob.

11:51:19 HOT-1

there you go.

11:51:22 RDO-2

and…lifeguard five five zero bravo pap.

11:51:25 CAM

[sound similar to switches being flipped]

11:51:30 RDO-1

ground five five zero bravo pap clear of uh zero one at the end going to Signature.

11:51:39 RDO-1

zero bravo pap.

11:51:40 RDO-2

and…lifeguard five five zero bravo pap is taxiing in.

11:51:43 HOT-1

we have an ambulance. there should be an ambulance or a cab or something waiting for them.

11:51:50 CAM-2

they're not answering. where do you want—.

11:51:54 HOT-1

they didn't answer. all right it looks like they heard us coming or something. there's a guy walking out. see the guy in the raincoat. I don't know where he's gonna park us but—.

11:52:01 CAM-2

yup.

NTSB Aircraft Accident Report 84 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

11:52:02 CAM

[sound of unknown tones]

11:52:05 HOT-1

see if you can figure out what direction he wants us to turn. looks like we're gonna get front line parking here next to the Citation. yeah I see it okay I got 'em facing east right. I shut right engine down.

11:52:11 HOT-2

yup see him over there.

11:52:15 HOT-2

okay.

11:52:16 CAM

[sound similar to decreasing engine rpm]

11:52:19 HOT-1

we can turn the fan and defog switch off.

11:52:23 CAM

[sound similar to switches being flipped]

11:52:24 CAM

[sound of unknown tones]

11:52:54 HOT-1

nosewheel nice and straight.

11:53:00 CAM

[sounds consistent with aircraft power down]

[Break in CVR recording while the airplane was unpowered at Milwaukee.] 15:44:32.0 CAM

[sound similar to switches being flipped]

15:44:34.0

NTSB Aircraft Accident Report 85 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

HOT-1 okay. ATIS is still on here correct?

15:44:41.4 CAM

[sound similar to switches being flipped]

15:45:11.7 CAM

[sound of unknown tones]

15:45:25.4 HOT-1

here's what I do. put destination in here.

15:45:28.5 HOT-2

uh huh.

15:45:31.4 HOT-1

get this *.

15:46:15.7 HOT-1

okay I’m gonna get the clearance

15:46:17.4 HOT-2

I’ll get it for you if you want me to.

15:46:18.3 HOT-1

all right number one's ready for it.

15:46:19.6 HOT-2

okay.

15:46:20.1 HOT-1

make sure you're switched on to it. down no down on you num— knob too. turn it no—. knob down. speaker down. down no next one. okay you got clearance on top radio.

15:46:26.4 HOT-2

okay. oop— that one.

15:46:30.9 HOT-2

okay.

NTSB Aircraft Accident Report 86 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

15:46:34.9 RDO-2

Milwaukee clearance lifeguard five five zero bravo pap.

15:46:40.8 RDO-2

zero pap has got to pick up an IFR clearance to yankee india papa. and we have uh quebec.

15:47:12.4 CAM-2

what was the squawk? Three two one—.

15:47:14.2 HOT-1

three two five one.

15:47:16.1 RDO-2

okay five five papa papa is cleared Br— Brew Three departure Grand Rapids Lansing Spartan arrival five thousand eight— nineteen uh nineteen sixty-five thirty-two fifty-one.

15:47:31.4 HOT-1

okay man. you got the Brew Three pulled?

15:47:32.1 RDO-2

zero pap.

15:47:33.3 CAM-2

yup.

15:47:34.5 HOT-1

all right that's not it.

15:47:37.6 HOT-1

there it is. okay. cool. all right I’m ready to taxi. let's turn to ground.

15:47:41.3 CAM-2

you want what runway?

15:47:42.5 HOT-1

we're on it.

NTSB Aircraft Accident Report 87 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

15:47:43.3 HOT-1

we haven't been assigned a runway yet. winds are—. winds are a little—. we can't take that runway. winds are too strong. all right tell her we're ready to taxi. wherever she sends us we'll go.

15:47:45.4 CAM-2

*** okay.

15:47:53.9 RDO-2

• ground lifeguard five five zero bravo pap at Signature with

quebec like taxi. 15:48:09.7 RDO-2

one left by zulu echo tango romeo.

15:48:27.9 RDO-2

okay that's foxtrot delta bravo romeo and want to get the progressive as we go thanks.

15:48:37.6 RDO-2

okay **.

15:48:41.4 HOT-1

yeah and uh you can try to pick it up somewhere. we're on the north side here so—. I see foxtrot there.

15:48:48.5 CAM-2

this is foxtrot here.

15:48:50.2 HOT-1

yeah we're on—. I guess we're on foxtrot. so foxtrot what?

15:48:55.2 CAM-2

delta down here.

15:48:57.9 HOT-1

okay.

15:49:02.1 HOT-1

got a long taxi here. all right just keep an eye on it. you can

NTSB Aircraft Accident Report 88 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

figure it out.

15:49:07.3 CAM-2

we're clear off to the right. how we doin' on the left.

15:49:09.5 HOT-1

uh we're clear as far as I can see. we are crossing—.

15:49:15.3 CAM-2

crossing runway.

15:49:16.4 HOT-1

okay foxtrot to what?

15:49:18.1 CAM-2

delta.

15:49:18.8 HOT-1

uh is that delta up ahead or do we turn here?

15:49:20.6 CAM-2

yup delta up ahead.

15:49:23.1 HOT-1

okay.

15:49:27.2 RDO-2

left turn *.

15:49:30.3 HOT-1

where? is this—. which one. you sure? this says charlie.

15:49:31.6 CAM-2

no keep going. no this is delta.

15:49:37.1 HOT-1

this is charlie.

15:49:44.2 RDO-1

okay **. okay we'll turn left on charlie then left again here.

NTSB Aircraft Accident Report 89 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

15:50:02.6 RDO-2

zero bravo pap.

15:50:03.1 HOT-1

all right keep an eye on things. come on @. you're worse than uh @.

15:50:09.3 HOT-1

***. let's get the fans on here.

15:50:16.5 HOT-1

stay on charlie. okay I’m following the lines.

15:50:19.8 CAM-2

• charlie. okay that'll take us to bravo.

15:50:23.5 HOT-1

she said cross some runway up here.

15:50:25.2 CAM-2

yup. crossing seven left.

15:50:28.6 HOT-1

turn your uh radar altimeter knob get that light off. yup right there. the other way. all the way to zero. there you go. no yellow lights. me no like 'em yellow lights.

15:50:45.5 HOT-1

okay she said cross seven left.

15:50:47.6 CAM-2

okay.

15:50:47.9 HOT-1

I don't see any taxiway on the other end.

15:50:49.1 CAM-2

clear to the right. this is bravo here.

NTSB Aircraft Accident Report 90 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

15:50:56.0 HOT-1

there's nobody around.

15:50:59.6 CAM-2

turn right. take bravo right.

15:51:02.9 HOT-1

okay.

15:51:03.2 CAM-2

take bravo to romeo.

15:51:05.9 HOT-1

if you say so.

15:51:07.3 CAM-2

** bravo to romeo.

15:51:10.2 HOT-1

some of our guys would stop. they'd stop.

15:51:14.8 CAM-2

**.

15:51:19.0 CAM-2

blocked off here. bravo's off this way.

15:51:22.3 HOT-1

okay. yup. looks like it to the right. I’ll follow. its gonna be on— on the terminal area. its through the terminal here. its in there somewhere.

15:51:32.2 CAM-2

*.

15:51:50.3 HOT-1

um what's the Brew Three while we're doing this now?

15:52:03.2 CAM-2

runway heading to two thousand.

NTSB Aircraft Accident Report 91 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

15:52:04.7 RDO-1

zero bravo pap.

15:52:05.8 HOT-1

okay runway heading to two thousand feet. got it.

15:52:08.1 CAM-2

okay.

15:52:09.2 HOT-1

then what?

15:52:10.1 CAM-2

turn to assigned heading. okay that's it.

15:52:12.9 CAM-2

** join.

15:52:14.5 HOT-1

uh left at delta she said? you're not paying attention @.

15:52:17.9 CAM-2

bravo romeo. bravo—.

15:52:20.1 HOT-1

no she changed it. she said due to a— due to an aircraft pushback.

15:52:23.3 CAM-2

I didn't catch that.

15:52:24.4 HOT-1

uhhh gotta see where.

15:52:27.0 CAM-2

• pushback.

15:52:28.0

NTSB Aircraft Accident Report 92 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

HOT-1 yeah but she wants us going left somewhere.

15:52:35.9 RDO-2

okay kilo then right turn on echo zero bravo pap.

15:52:40.9 CAM-2

here all the way down.

15:52:41.5 HOT-1

yup and that should take us all the way down. okay now you can look at the departure.

15:52:44.8 CAM-2

the departure basically two thousand feet to assigned heading.

15:52:47.1 HOT-1

okay put your intercom on.

15:52:49.3 HOT-2

okay I’m sorry. two thousand feet turn to assigned heading. okay?

15:52:49.4 HOT-1

I’m getting old stand here. okay.

15:52:55.7 CAM-1

okay and what altitude? is there a fix you can put in? what's our first fix from the clearance? go ahead and put that in there.

15:52:59.4 HOT-2

well—. okay its Lansing. Grand Rapids rather.

15:53:03.3 HOT-1

all right. put Grand Rapids in. there there you're already there. just keep plug it. start plugging.

15:53:07.1 HOT-2

there?

15:53:08.3

NTSB Aircraft Accident Report 93 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

HOT-1 nope up now turn the little knob and plug in Grand Rapids. G no no no K. Just the G-R-R.

15:53:09.8 HOT-2

all right. G-R-R?

15:53:15.6 HOT-1

yup.

15:53:21.3 HOT-1

okay.

15:53:29.3 RDO-1

zero bravo pap.

15:53:32.0 HOT-2

okay.

15:53:33.9 CAM-1

okay and then after Grand Rapids what's there?

15:53:35.6 HOT-2

Lansing.

15:53:36.0 CAM-1

all right well. let's get back. just put it in over yip. put the cursor over yip.

15:53:41.0 HOT-2

pardon.

15:53:44.0 CAM-1

damn it.

15:53:46.7 CAM-1

okay put Lansing.

15:53:56.2 CAM-1

that's good enough. now go ahead and enter—. yup. enter set yeah. that's good. now we'll plug— we’ll program the rest later

NTSB Aircraft Accident Report 94 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

15:54:04.1 HOT-2

right okay. check the Spartan arrival after Lansing.

15:54:13.7 CAM-1

okay uh look on your taxi chart and get tower frequency—.

15:54:15.9 HOT-2

I can't hear you….

15:54:18.5 HOT-1

look on your tow— uh taxi chart and get a tower frequency there.

15:54:21.6 HOT-2

okay.

15:54:22.3 HOT-1

get ready for that.

15:54:28.8 HOT-2

okay.

15:54:29.5 HOT-1

look on your taxi chart. taxi chart ground control frequency— or tower frequency.

15:54:34.4 HOT-2

okay tower is one nineteen one.

15:54:47.0 HOT-2

we tell 'em we're ready to go at the end?

15:54:53.6 RDO-2

okay number one and monitor tower thanks for your help today.

15:54:57.4 HOT-1

okay put your tower in monitor them and put your departure frequency in the bottom. no just monitor them is all she said.

15:54:57.9

NTSB Aircraft Accident Report 95 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

CAM-2 yup. yup.

15:55:06.0 HOT-1

departure you wrote down haven't you?

15:55:08.6 HOT-1

okay the squawk is in. what is the squawk?

15:55:11.2 CAM-2

three two five one.

15:55:12.0 HOT-1

three two five one is here.

15:55:13.5 CAM-2

okay.

15:55:15.1 HOT-1

I’m gonna put the transponder on. that's part of the checklist before takeoff.

15:55:17.9 CAM-2

okay right **.

15:55:22.4 HOT-1

that's way down at the bottom but—.

15:55:23.6 CAM-2

flaps you want at ten right?

15:55:24.6 HOT-1

flaps are good. they— they're fifteen actually.

15:55:31.3 CAM-2

exterior lights transponder. engine switch.

15:55:35.1 HOT-1

he said we were number one and now he says traffic will hold in position. he hasn't told us to hold yet. we will find out.

NTSB Aircraft Accident Report 96 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

15:55:36.7 CAM-2

right.

15:55:44.8 CAM-2

he knows we're ready to go?

15:55:52.1 RDO-2

okay position and hold five zero bravo pap.

15:55:56.0 HOT-1

yeah she said monitor tower so we don't have to call and tell 'em we're ready. you know be careful at busy airports like that New York and uh Chicago and all that. when they monitor tower just be ready when they call. yeah.

15:56:02.9 CAM-2

uh huh. just listen.

15:56:07.1 HOT-1

all set back there?

15:56:08.4 CAM-3

yes sir.

15:56:09.9 HOT-1

they're eatin' away man. they don't care. hey see if you can hand me my straps? am I sitting on them or what?

15:56:12.8 CAM-2

all right.

15:56:17.0 CAM-2

you get 'em both?

15:56:23.7 HOT-1

okay we got position and hold. you can go to final items on the checklist.

15:56:28.5 HOT-1

damn things [sound of grunt]. that's all right it just doesn't work.

NTSB Aircraft Accident Report 97 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

15:56:36.4 RDO-2

okay two thousand zero five zero cleared for takeoff five zero bravo pap.

15:56:41.9 HOT-1

okay final items for takeoff.

15:56:43.6 CAM-2

okay final items. p-heat? transponder? on.

15:56:46.2 HOT-1

its on.

15:56:46.9 CAM-2

okay * ignition?

15:56:50.0 HOT-1

put your PA. put your intercom on.

15:56:50.8 HOT-2

ignition?

15:56:51.8 HOT-1

they're on.

15:56:52.5 HOT-2

pitot heat?

15:56:53.9 HOT-1

who? pitot heat's on.

15:56:54.4 HOT-2

pitot heat.

15:56:55.2 HOT-2

anti-skid?

15:56:56.4 HOT-1

anti-skid is gonna get—. I’ll get it in a second.

NTSB Aircraft Accident Report 98 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

15:56:58.9 HOT-2

annunciators clear?

15:56:59.6 HOT-1

annunciators gonna be clear when I get anti-skid.

15:57:02.1 HOT-2

okay.

15:57:04.0 HOT-1

okay here comes anti-skid. we're clear to go two thousand feet we're turning right to zero five zero.

15:57:08.2 HOT-2

right.

15:57:09.3 HOT-1

okay here we go. you're watching my power ninety-six three or less.

15:57:12.6 CAM

[sound similar to increasing engine rpm]

15:57:15.2 HOT-1

okay you got it.

15:57:19.9 HOT-2

power set. airs—. airspeed—. airspeed alive.

15:57:22.8 HOT-1

okay.

15:57:26.8 HOT-2

eighty knots.

15:57:31.7 HOT-2

V one.

15:57:33.4

NTSB Aircraft Accident Report 99 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

HOT-2 rotate.

15:57:37.3 HOT-1

positive rate gear up.

15:57:38.3 HOT-2

yup.

15:57:39.0 HOT-1

lights.

15:57:39.4 CAM

[sound similar to switches being flipped]

15:57:40.5 HOT-1

lights off yaw damper on.

15:57:51.0 RDO-2

okay zero five zero and start my turn and thanks for the help.

15:57:51.3 HOT-1

why am I fighting the controls here? damn it.

15:57:57.1 HOT-1

I’m fighting the controls @.

15:57:58.5 CAM-2

** I had it on.

15:58:01.3 TCAS

traffic traffic.

15:58:03.2 HOT-1

gear up.

15:58:03.9 CAM-2

gear's up.

15:58:05.0 HOT-1

flaps up.

NTSB Aircraft Accident Report 100 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

15:58:06.9 HOT-1

what the hell's going on? I’m fighting the controls.

15:58:12.5 CAM-2

how's your trim set? is that the way you want it?

15:58:21.4 HOT-1

I’m fighting the controls. it wants to turn left hard.

15:58:24.3 CAM-2

how's— how's your trim down here?

15:58:26.1 HOT-1

trim is— *.

15:58:26.3 CAM

[sound similar to altitude alert]

15:58:27.4 HOT-1

trim has nothing—. I—. I—.

15:58:31.1 RDO-2

we’ll take a one eighty two thirty uh * twenty three for three.

15:58:33.9 HOT-1

all right you talk.

15:58:39.1 HOT-1

that's not us.

15:58:39.6 RDO-2

negative on that. wrong aircraft.

15:58:44.9 HOT-1

something is wrong with the trim.

15:58:47.6 CAM

[sound similar to altitude alert]

NTSB Aircraft Accident Report 101 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

15:58:48.4 HOT-1

the rudder trim. what— what's our altitude clearance?

15:58:52.1 CAM-2

three thousand three thousand.

15:58:57.4 HOT-1

all right something is wrong with our rudders. and I don't know what.

15:59:02.7 HOT-1

damn it.

15:59:03.8 HOT-1

@.

15:59:04.3 CAM-2

hey what do you want to do.

15:59:05.6 HOT-1

huh.

15:59:07.1 CAM-2

how's that. any better?

15:59:09.4 HOT-1

huh no we got a trim problem.

15:59:14.2 HOT-1

[sound of grunt]

15:59:16.0 HOT-1

tell 'em we got to come back and land.

15:59:18.2 HOT-1

#.

15:59:19.1 HOT-1

@ she's rolling on me. help me help me.

NTSB Aircraft Accident Report 102 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

15:59:22.4 CAM-2

I am.

15:59:24.1 HOT-1

the autopilot is—. pull circuit breakers on autopilot.

15:59:27.4 CAM-2

where is it?

15:59:28.6 HOT-1

tell 'em we got a control problem.

15:59:30.0 CAM-2

I am.

15:59:30.2 RDO-2

Milwauk—. eh approach Citation one bravo tango has got a control problem we’ve got to come back in.

15:59:34.9 HOT-1

….

15:59:37.5 CAM

[sound of high frequency tone that lasts 16 seconds]

15:59:38.3 RDO-2

one bravo tango.

15:59:39.9 HOT-1

zero bravo pap.

15:59:43.8 RDO-2

Milwaukee approach we got a—. Milwaukee we got uh a runaway trim. we got an emergency.

15:59:49.3 CAM-1

[sound of grunt] @ *.

15:59:50.4 CAM-2

which circuit breakers?

NTSB Aircraft Accident Report 103 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

15:59:52.7 CAM-1

zero bravo pap.

15:59:54.3 RDO-1

zero bravo pap.

15:59:57.0 CAM-1

yes ma'am. answer her @. keep turning *.

16:00:03.5 CAM-2

**.

16:00:03.7 CAM-1

yes.

16:00:05.0 RDO-1

zero bravo pap declaring an emergency yes.

16:00:06.2 HOT-1

we're coming back to Milwaukee.

16:00:08.2 CAM

[sound similar to altitude alert]

16:00:12.5 RDO-2

coming back to Milwaukee.

16:00:13.5 RDO-1

landing any runway at uh at Milwaukee. guide us in please. zero bravo pap.

16:00:26.1 RDO-1

I don't know what's wrong.

16:00:28.0 HOT-1

[sound of heavy breathing]

16:00:30.1 HOT-1

I don't know what's wrong @. I see the airport. keep **. son of a

NTSB Aircraft Accident Report 104 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME and SOURCE CONTENT TIME and SOURCE CONTENT

***.

bitch.

16:00:35.9 RDO-1

@ you hold it I’m gonna try to pull circuit breakers.

16:00:37.3 CAM-2

16:00:40.0 RDO-1

@ we’re not—.

16:00:40.1 HOT-1

holding it.

16:00:40.6 CAM-2

I’m pulling.

16:00:42.8 CAM-1

awww #.

16:00:45.4 CAM-1

no—.

16:00:45.5 END OF TRANSCRIPT END OF RECORDING

FD07361 ｜ 2009_美国_AAR0907.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2009 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

Crash During Approach to Landing of Maryland State Police Aerospatiale SA365N1, N92MD District Heights, Maryland September 27, 2008

Accident Report NTSB/AAR-09/07 PB2009-910407

National Transportation Safety Board

This page intentionally left blank.

ERRATA

AIRCRAFT ACCIDENT REPORT NTSB/AAR-09/07 (PB2009-910407)

CRASH DURING APPROACH TO LANDING OF MARYLAND STATE POLICE AEROSPATIALE SA365N1, N92MD, DISTRICT HEIGHTS, MARYLAND, SEPTEMBER 27, 2008

Pages 21 and 62 have been changed to indicate that the coordinates were in the form of degrees, decimal degrees.

The report originally stated that the coordinates were in the form of degrees, decimal minutes.

THE CORRECTION BELOW IS INCLUDED IN THIS REVISED VERSION OF THE DOCUMENT

NTSB/AAR-09/07 PB2009-910407 Notation 8067A Adopted October 27, 2009

Aircraft Accident Report Crash During Approach to Landing of Maryland State Police Aerospatiale SA365N1, N92MD District Heights, Maryland September 27, 2008

National Transportation Safety Board

490 L’Enfant Plaza, S.W. Washington, D.C. 20594

National Transportation Safety Board. 2009. Crash During Approach to Landing of Maryland State Police Aerospatiale SA365N1, N92MD, District Heights, Maryland, September 27, 2008. Aircraft Accident Report NTSB/AAR-09/07. Washington, DC.

Abstract: This report describes the circumstances of an accident involving an Aerospatiale SA365N1 that crashed on approach to landing during an emergency medical services flight operated by the Maryland State Police (MSP). The safety issues discussed include risk assessments, pilot performance and training, terrain awareness and warning systems, air traffic control deficiencies, MSP System Communications Center duty officer performance, and emergency response. Also discussed are patient transport decisions, flight recorder requirements, and Federal Aviation Administration (FAA) oversight. Safety recommendations concerning these issues are addressed to the FAA; the MSP; Prince George’s County, Maryland; all public helicopter emergency medical services operators, and six associations whose members are involved in search and rescue operations.

The National Transportation Safety Board (NTSB) 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 NTSB 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 Internet at http://www.ntsb.gov. Other information about available publications also may be obtained from the website or by contacting:

National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, SW Washington, DC 20594 (800) 877-6799 or (202) 314-6551

NTSB publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2009-910407 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 NTSB reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

NTSB Aircraft Accident Report iii Contents Figures .............................................................................................................................................v Tables ............................................................................................................................................ vi 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 Aircraft ...................................................................................................................7
5. 4 Other Damage ...........................................................................................................................8
6. 5 Personnel Information ..............................................................................................................8
7. 6 Aircraft Information ...............................................................................................................10
8. 7 Meteorological Information ...................................................................................................11
9. 7.1 Preflight Weather Information .....................................................................................12
10. 7.2 Department of Defense Weather Dissemination ..........................................................14
11. 7.3 Runway Visual Range Information .............................................................................15
12. 8 Aids to Navigation ..................................................................................................................15
13. 9 Communications .....................................................................................................................15
14. 10 Airport Information ................................................................................................................16
15. 10.1 Instrument Approach Procedures .................................................................................16
16. 11 Flight Recorders .....................................................................................................................17
17. 12 Wreckage and Impact Information .........................................................................................17
18. 13 Medical and Pathological Information ...................................................................................18
19. 14 Fire ..........................................................................................................................................19
20. 15 Survival Aspects .....................................................................................................................19
21. 15.1 Emergency Response ...................................................................................................20
22. 15.2 Additional Information on Emergency Response ........................................................23
23. 16 Tests and Research .................................................................................................................24
24. 16.1 Engine Examinations ...................................................................................................24
25. 16.2 Avionics Examinations ................................................................................................24
26. 16.3 Aircraft Performance Study .........................................................................................25
27. 16.3.1 TAWS Simulation .......................................................................................25
28. 17 Organizational and Management Information .......................................................................26
29. 17.1 Training ........................................................................................................................27
30. 17.2 Dispatch System...........................................................................................................28
31. 17.3 Operational Policies .....................................................................................................29
32. 17.3.1 Aviation Command Operational Policies ....................................................29
33. 17.3.2 SYSCOM Operational Policies ...................................................................31
34. 17.4 Previous Accidents Involving Maryland State Police .................................................32

NTSB Aircraft Accident Report iv 1.17.5 Maryland State Police Postaccident Actions ...............................................................33 1.17.6 Federal Aviation Administration Oversight .................................................................34 1.18 Additional Information ...........................................................................................................36 1.18.1 Public versus Civil Aircraft Operations .......................................................................36 1.18.2 Protocols for Medevac Helicopter Request .................................................................39 1.18.3 Previous Related Safety Recommendations ................................................................41 1.18.3.1 Safety of EMS Flights .................................................................................41 1.18.3.2 Safety of Public HEMS Flights ...................................................................43 1.18.3.3 National Guidelines for Selection of Emergency Transportation Modes ...44 1.18.3.4 Flight Recorder Systems .............................................................................44 1.18.3.5 Obstructive Sleep Apnea .............................................................................46 1.18.4 Minimum Safe Altitude Warning ................................................................................46

1. Analysis ...................................................................................................................................48
2. 1 General ...................................................................................................................................48
3. 2 Pilot‘s Decision to Accept the Flight .....................................................................................48
4. 3 Accident Sequence .................................................................................................................52
5. 4 Air Traffic Control .................................................................................................................56
6. 5 Instrument Training and Experience ......................................................................................57
7. 6 Fatigue ....................................................................................................................................59
8. 7 Survival Factors ......................................................................................................................60
9. 7.1 SYSCOM .....................................................................................................................60
10. 7.2 Emergency Response ...................................................................................................61
11. 7.2.1 Maryland State Police Search and Rescue ....................................................62
12. 7.2.2 Prince George‘s County Search and Rescue .................................................63
13. 7.2.3 FAA Search and Rescue Support ..................................................................64
14. 8 Other Related Issues ...............................................................................................................65
15. 8.1 Patient Transport Decisions .........................................................................................65
16. 8.2 Flight Recorder Systems ..............................................................................................66
17. 8.3 Oversight ......................................................................................................................67
18. Conclusions .............................................................................................................................71
19. 1 Findings ..................................................................................................................................71
20. 2 Probable Cause .......................................................................................................................73
21. Recommendations ..................................................................................................................74
22. 1 New Recommendations ..........................................................................................................74
23. 2 Previously Issued Recommendations Reiterated in this Report .............................................75
24. Appendix .................................................................................................................................77

Investigation and Public Hearing ...................................................................................................77 Investigation ...........................................................................................................................77 Public Hearing ........................................................................................................................77

NTSB Aircraft Accident Report v Figures Figure 1. Trooper 2 ground track indicated by yellow line. .......................................................... 3 Figure 2. ILS runway 19R published approach chart. ................................................................... 5 Figure 3. Aerial photograph of Walker Mill Regional Park, overlaid with the locations of Trooper 2. ........................................................................................................................................ 7 Figure 4. Photograph of an exemplar Aerospatiale SA365N1 helicopter.................................... 10 Figure 5. Photograph of the accident site. .................................................................................... 18 Figure 6. Map of search area. ....................................................................................................... 21 Figure 7. Comparison of Trooper 2‘s flightpath to the runway 19R glideslope. ........................ 52

NTSB Aircraft Accident Report vi Tables Table 1. Timeline of Events. .......................................................................................................... 6 Table 2. Injury Chart. ..................................................................................................................... 7 Table 3. Number of Patients Transported by Maryland State Police Aviation. ........................... 41

NTSB Aircraft Accident Report vii Abbreviations and Acronyms AC advisory circular ADS

• B

automatic dependent surveillance-broadcast ADW Andrews Air Force Base AFWA Air Force Weather Agency agl above ground level AIRMET Airman‘s Meteorological Information AOPA Aircraft Owners and Pilots Association ASOS Automated Surface Observing System ASR airport surveillance radar ATC air traffic control BMI body mass index CFR Code of Federal Regulations CVR cockpit voice recorder DCA Ronald Reagan Washington National Airport DME distance measuring equipment DO duty officer DoD Department of Defense DUAT Direct User Access Terminal EMS emergency medical services FAA Federal Aviation Administration

NTSB Aircraft Accident Report viii FDR flight data recorder FICEMS Federal Interagency Committee on Emergency Medical Services fpm feet per minute FSDO flight standards district office FY fiscal year GPS global positioning system HEMS helicopter emergency medical services Hg Mercury H-TAWS helicopter terrain awareness and warning system IFR instrument flight rules ILS instrument landing system IMC instrument meteorological conditions IPC instrument proficiency check LOC localizer MDA minimum descent altitude medevac medical evacuation MEL minimum equipment list METAR meteorological aerodrome report MIEMSS Maryland Institute for Emergency Medical Services Systems MSAW minimum safe altitude warning msl mean sea level MSP Maryland State Police

NTSB Aircraft Accident Report ix NOTAM notice to airmen NTSB National Transportation Safety Board NWS National Weather Service PAR power analyzer and recorder PCT Potomac Consolidated Terminal Radar Approach Control PG Prince George‘s PGH Prince George‘s Hospital Center PIC pilot-in-command PIREPS pilot weather reports rpm revolutions per minute RVR runway visual range SYSCOM System Communications Center TAF terminal aerodrome forecast TAWS terrain awareness and warning system TIS-B Traffic Information Service-Broadcast U.S.C. United States Code VFR visual flight rules VMC visual meteorological conditions

NTSB Aircraft Accident Report x Executive Summary On September 27, 2008, about 2358 eastern daylight time, an Aerospatiale (Eurocopter) SA365N1, N92MD, call sign Trooper 2, registered to and operated by the Maryland State Police (MSP) as a public medical evacuation flight, impacted terrain about 3.2 miles north of the runway 19R threshold at Andrews Air Force Base (ADW), Camp Springs, Maryland, during an instrument landing system approach. The commercial pilot, one flight paramedic, one field provider, and one of two automobile accident patients being transported were killed. The other patient being transported survived with serious injuries from the helicopter accident and was taken to a local hospital. The helicopter was substantially damaged when it collided with trees and terrain in Walker Mill Regional Park, District Heights, Maryland. The flight originated from a landing zone at Wade Elementary School, Waldorf, Maryland, about 2337, destined for Prince George's Hospital Center, Cheverly, Maryland. Night visual meteorological conditions prevailed for the departure; however, Trooper 2 encountered instrument meteorological conditions en route to the hospital and diverted to ADW. No flight plan was filed with the Federal Aviation Administration (FAA), and none was required. The MSP System Communications Center (SYSCOM) was tracking the flight using global positioning system data transmitted with an experimental automatic dependent surveillance-broadcast communications link. The National Transportation Safety Board determined that the probable cause of this accident was the pilot's attempt to regain visual conditions by performing a rapid descent and his failure to arrest the descent at the minimum descent altitude during a nonprecision approach. Contributing to the accident were (1) the pilot‘s limited recent instrument flight experience, (2) the lack of adherence to effective risk management procedures by the MSP, (3) the pilot‘s inadequate assessment of the weather, which led to his decision to accept the flight, (4) the failure of the Potomac Consolidated Terminal Radar Approach Control (PCT) controller to provide the current ADW weather observation to the pilot, and (5) the increased workload on the pilot due to inadequate FAA air traffic control handling by the Ronald Reagan National Airport Tower and PCT controllers. The safety issues discussed in this report involve risk assessments, pilot performance and training, terrain awareness and warning systems, air traffic control deficiencies, SYSCOM duty officer performance, and emergency response. Also discussed are patient transport decisions, flight recorder requirements, and FAA oversight. Safety recommendations concerning these issues are addressed to the FAA, the MSP, Prince George‘s County, all public helicopter emergency medical services operators, and six other organizations whose members are involved in search and rescue activities.

NTSB Aircraft Accident Report 1

1. Factual Information
2. 1

History of Flight On September 27, 2008, about 2358 eastern daylight time,1 an Aerospatiale (Eurocopter) SA365N1, N92MD, call sign Trooper 2, registered to and operated by the Maryland State Police (MSP) as a public medical evacuation (medevac) flight,2 impacted terrain about 3.2 miles north of the runway 19R threshold at Andrews Air Force Base (ADW), Camp Springs, Maryland, during an instrument landing system (ILS)3 approach. The commercial pilot, one flight paramedic (medic), one field provider,4 and one of two automobile accident patients being transported were killed. The other patient being transported survived with serious injuries from the helicopter accident and was taken to a local hospital. The helicopter was substantially damaged when it collided with trees and terrain in Walker Mill Regional Park, District Heights, Maryland. The flight originated from a landing zone at Wade Elementary School, Waldorf, Maryland, at 2337, destined for Prince George's Hospital Center (PGH), Cheverly, Maryland. Night visual meteorological conditions (VMC) prevailed for the departure; however, Trooper 2 encountered instrument meteorological conditions (IMC) en route to the hospital and diverted to ADW. A flight plan was not filed with the Federal Aviation Administration (FAA), and none was required. The MSP System Communications Center (SYSCOM) was tracking the flight using global positioning system (GPS) data transmitted via an experimental automatic dependent surveillance-broadcast (ADS-B)5 communications link. Review of SYSCOM audio recordings revealed that the SYSCOM duty officer (DO) received the medevac flight request at 2301:51. The pilot of Trooper 2, located at ADW, was notified of the flight at 2302:13 by the DO. The pilot asked where the flight was, and the DO responded that it was in Waldorf. The pilot stated, ―I don‘t know if we can get to the hospital,‖ to which the DO responded, ―well that‘s fine, if you can‘t make the mission you can‘t make the mission.‖ The pilot continued, ―they say College Park is 800 feet up there6…that is only a mile

1 Unless otherwise indicated, all times are eastern daylight time based on a 24-hour clock. 2 On March 13, 2009, the Federal Aviation Administration issued a memorandum classifying the accident flight as a public aircraft operation. For further information, see section 1.18.1. 3 The ILS is a precision approach system that consists of a localizer and a glideslope, which provide lateral and vertical guidance, respectively, to help the pilot align with the runway. 4 The field provider was a local emergency medical technician who was brought aboard the helicopter at the automobile accident site. When two patients are carried, a field provider is needed to assist the flight paramedic. 5 ADS-B is a surveillance system in which an aircraft is fitted with cooperative equipment in the form of a data link transmitter. The aircraft periodically broadcasts its GPS-derived position and other information, such as velocity, over the data link, which is received by a ground-based transceiver for use by air traffic control and other users. 6 The cloud ceiling at College Park Airport was 800 feet. The cloud ceiling is the height above the ground of the base of the lowest layer of cloud covering more than half the sky.

NTSB Aircraft Accident Report 2 north of the hospital, ah PG [Prince George‘s] is on fly by anyway.‖7 The DO subsequently confirmed that the hospital was no longer ―on fly by,‖ and the pilot responded, ―ok, we can give it a shot.‖ After a brief conversation regarding the coordinates of the landing zone, the pilot stated, ―maybe they will change their mind.‖ The DO responded ―well hold on, they ain‘t going to change their mind, if you tell them you will go, they want you to go…that‘s up to you, do you think you can fly it?‖ The pilot again stated that the ceiling at College Park Airport was 800 feet and added that the ceiling at Ronald Reagan Washington National Airport (DCA) was 1,200 feet. Additionally, the pilot remarked that he had just heard a medevac helicopter operated by a private company complete an interhospital transfer flight in the same area, and then said, ―if they can do it we can do it.‖ The DO responded, ―ok it is up to you,‖ and the pilot subsequently stated, ―yeah we ought to be able to do it…we‘re going to try it.‖ Trooper 2 departed ADW at 2310:22 to the automobile accident site to pick up the two patients. (See figure 1 on the following page.) The flight arrived at the landing zone about 2319 and departed about 2337 with the patients and the field provider aboard. Review of FAA air traffic control (ATC) radio recordings revealed that the pilot of Trooper 2 contacted DCA tower at 2337:45, reporting his departure from Waldorf en route to PGH. The tower controller approved the operation. ATC radar and ADS-B data indicated that Trooper 2 entered the Washington class B airspace8 about 2341 at an altitude of 1,000 feet mean sea level (msl) on a northerly heading. During the initial contact with Trooper 2, the DCA tower controller provided a pilot report from another helicopter9 that had ―… passed through the highway 210/295 area 30 minutes earlier, describing cloud bases at 900 feet that lowered further north.‖ About 2344:23, the pilot reported that ―...we just ran into some heavy stuff—I don't think we're gonna be able to make it all the way to the hospital. I'd like to continue on about three more miles and see what happens, and if I don't see a hole I'll have to go IFR [instrument flight rules] back to Andrews.‖ The controller advised the pilot that he could choose an altitude at his discretion and to advise of his intentions. Trooper 2 continued on a northerly heading at an altitude of 900 feet msl, and, about 2347, reached a point about 0.25 miles east of PGH. The pilot then began a 180° right turn. About 2347:28, Trooper 2 advised the DCA tower controller, ―it's solid up here. I'd like to climb to 2,000 feet and go over to radar and shoot an approach over at Andrews.‖ The controller responded, ―Trooper 2 approved as requested, contact approach on… 118.95.‖ There was no subsequent coordination about Trooper 2 between the DCA controller and the Potomac Consolidated Terminal Approach Control (PCT) controller.

7 According to MSP personnel, ―PG on fly by‖ meant the hospital was full to incoming patients by air. 8 Class B airspace surrounds the nation‘s busiest airports, typically extending from the surface to 10,000 feet. An ATC clearance is required for all aircraft to operate in the area. 9 This was the private medevac helicopter that the pilot referred to in his prelaunch conversation with the DO. This helicopter transferred a patient to Washington Hospital Center in Washington, D.C., from a hospital in La Plata, Maryland. La Plata is located about 6 miles south of the automobile accident site.

NTSB Aircraft Accident Report 3

Figure 1. Trooper 2 ground track indicated by yellow line.

NTSB Aircraft Accident Report 4 About 2348:01, Trooper 2 called PCT, the controller acknowledged, and at 2348:08 the pilot stated, ―we tried to make a medevac up at PG hospital, we're about 7 miles northwest of Andrews, like to climb to 2,000 feet and shoot an approach to runway 1L at Andrews.‖ The controller did not respond. At 2349:15, Trooper 2 called PCT again, the controller responded, and the pilot stated, ―Yes sir, I was waiting for a reply. Climbing to 2,000 feet and my course is uh… 200 degrees.‖ The controller responded, ―All right Trooper 2 present position 200 degrees is approved the altimeter 2991 Washington tower 120.75.‖ The pilot replied, ―No sir, I want to shoot the approach at Andrews.‖ The controller then transmitted, ―All right tell you what go direct to the you—you want to shoot the ILS 19 what runway?‖ The pilot asked, ―Are they using 19? Uh, runway 19R.‖ At 2350:01, the controller began vectoring Trooper 2 to the ILS approach for runway 19R. (See figure 2 on the following page.) After some discussion, the pilot stated that he wanted a single approach to a full stop at Andrews to drop off patients aboard. At 2351:49, the PCT approach controller advised Trooper 2 that ―the latest weather at Andrews is 7 miles uh 1,800 broken and the temperature uh right now is uh 21 dew point[10] 19.‖11 The pilot acknowledged. Vectoring to final approach continued, and at 2353:46 the approach controller transmitted, ―Trooper 2 mile and a half from the final approach fix turn right heading 1 uh 70 maintain 2000 until you're established on the localizer cleared ILS 1R [sic] approach into Andrews.‖ At the time, Trooper 2 was crossing to the east side of the localizer, and the 170° heading issued would not have resulted in a successful intercept. Review of radar data indicated that the pilot continued the turn to approximately 210°, which resulted in intercepting the localizer about 1 mile from the final approach fix. The controller asked Trooper 2 to report that the flight was established on the localizer, and the pilot did so. The pilot was then instructed to contact ADW tower. About 2355:12, Trooper 2 checked in with ADW, stating, ―Trooper 2's with you off uh on the localizer for runway 19R.‖ At this time, the helicopter was 6 nautical miles from the runway, at an altitude of 1,900 feet msl. The ADW controller responded, ―Trooper 2 roger runway 19[unintelligible] cleared for the option[12] wind 090 at 5.‖ About 2356:45, Trooper 2 reported, ―I'm not picking up the glideslope.‖ The controller replied, ―it's showing green on the panel but you're the only aircraft we've had in a long time so I don't really know if it's working or

10 Dew point is the temperature to which air must be cooled in order to be saturated with water vapor already in the air. The difference between the actual air temperature and the dew point is called the temperature/dew point spread. As the spread narrows, relative humidity increases, and relative humidity is 100 percent when the temperature and the dew point are the same. 11 Subsequent review of ADW weather reports showed that the weather information provided to the pilot had been issued at 1855 local time, and was almost 5 hours old. 12 ―Cleared for the option‖ is ATC authorization for an aircraft to make a touch-and-go, low-approach, missed-approach, stop-and-go, or full-stop landing at the discretion of the pilot.

NTSB Aircraft Accident Report 5

Figure 2. ILS runway 19R published approach chart.

NTSB Aircraft Accident Report 6 not.‖ About 2357:00, Trooper 2 requested an airport surveillance radar (ASR) approach,13 but the ADW controller replied that she was not current to provide that service.14 There were no further communications with Trooper 2. The last radar target for Trooper 2 was detected about 23:57:50, at 800 feet msl over Walker Mill Regional Park. The last ADS-B target for Trooper 2 was detected about 2358:04, at 325 feet msl near the accident site. Table 1 shows a timeline of the accident sequence. Table 1. Timeline of Events. Time (EDT) Event Elapsed Time Since Helicopter Dispatched 22:45:34 First of numerous 911 calls made to Charles County communications about

the auto accident

22:46:09

First group of fire department personnel arrived on-scene

23:01:51 Charles County called SYSCOM to request helicopter transport for two

patients to PGH

23:02:13 SYSCOM called Trooper 2 (T2) and asked if they could accept mission; T2 accepted 00:00:00 23:10:32 T2 radioed SYSCOM en route to landing zone 00:08:19 23:20:50 T2 arrived at landing zone 00:18:37 23:36:56 T2 departed with 2 patients and field provider 00:34:43 23:37:30 T2 radioed SYSCOM en route to PGH; 8 minute estimated time en route with 2 patients 00:35:17 23:44:23 Pilot of T2 reported to DCA "…we just ran into some heavy stuff” and stated he would continue for about 3 miles and if he "didn't see a hole," he would "go IFR" to ADW. 00:42:10 23:47:29 Pilot of T2 reported to DCA "it's solid up here" and requested an instrument approach at ADW. At this time, T2 was about 0.25 miles east of PGH. 00:45:15 23:58:00 ACCIDENT 00:55:47

The accident occurred about 3.2 miles from the threshold of runway 19R and along the extended runway centerline. The wreckage was found in a heavily wooded area of Walker Mill Regional Park at an elevation of about 200 feet msl. Figure 3 on the following page shows an aerial photo of the park.

13 An ASR approach is an approach wherein the air traffic controller instructs the pilot, based on aircraft position in relation to the final approach course and the distance from the end of the runway as displayed on the controller‘s radarscope. 14 The FAA requires controllers to complete three ASR approaches every quarter, including one no-gyro approach, to remain current (qualified) for that type of approach.

NTSB Aircraft Accident Report 7 1.2 Injuries to Persons Table 2. Injury Chart. Injuries Flight Crew Other Crew Passengers Other Total Fatal 1 2 1 0 4 Serious 0 0 1 0 1 Minor 0 0 0 0 0 None 0 0 0 0 0 Total 1 2 2 0 5 1.3 Damage to Aircraft The helicopter sustained extensive structural damage, separated components, and broken main rotor blades. Figure 3. Aerial photograph of Walker Mill Regional Park, overlaid with the locations of Trooper 2. Green dots show Trooper 2 locations recorded by ADS-B; the red dot is the last ADS-B target received.

NTSB Aircraft Accident Report 8 1.4 Other Damage No other damage was reported. 1.5 Personnel Information The pilot, age 59, held a commercial pilot certificate issued on June 28, 1979, with ratings for rotorcraft-helicopter and instrument helicopter. He also held a private pilot certificate with a rating for single-engine, land airplanes. In addition, the pilot held a flight instructor certificate initially issued on August 20, 1985, and most recently renewed on October 27, 2007, with ratings for rotorcraft-helicopters and instrument helicopters. The pilot was issued a second-class medical certificate on September 26, 2008, with the restriction ―must wear corrective lenses.‖ The pilot was hired by MSP as a state trooper on January 5, 1970, applied for a position in the aviation division on May 29, 1979, and began employment in that division on July 15,

1. All of the pilot‘s flight experience was accumulated as an MSP employee.

The pilot's most recent annual MSP flight evaluation was conducted on October 27, 2007. This evaluation was completed in 1.6 hours of flight time and included an instrument proficiency check (IPC), a biennial flight review, and a re-instatement of the pilot‘s flight instructor certificate. During the IPC portion of the flight, the pilot performed two approaches to runway 1L at ADW, an ILS approach and a nonprecision approach.15 According to the instructor who flew with the pilot, his instrument skills were ―slightly above average when compared to other pilots.‖ The pilot received his MSP ―Command Instrument Single Pilot Certification‖ during this evaluation and was signed off to act as ―Single Pilot PIC [pilot-in-command] for IFR Operations,‖ which allowed him to file a flight plan and fly in IMC, if necessary, to fly a patient to a trauma center, reposition the helicopter to a maintenance facility, return to base from a flight, or conduct a VIP (very important person) transport.16 The pilot‘s most recent IPC (which included training) was completed on May 13, 2008. This training included 1 hour of ground instruction and 1.4 hours of flight instruction. According to the pilot‘s training folder, he conducted an ILS approach and a nonprecision approach at ADW and a GPS approach at St. Mary‘s County Airport, Leonardtown, Maryland. The paperwork did not specify which ILS approach at ADW was performed; however, it stated both approaches were practiced coupled and uncoupled with the autopilot. According to the instructor pilot, there was nothing unusual about the flight and the pilot ―did pretty well.‖ He additionally reported that the accident pilot was ―above average‖ compared to other pilots and had ―no trouble‖ with instrument approaches.

15 A nonprecision approach is a standard instrument approach procedure in which no electronic glideslope is provided. 16 MSP pilots who have not received ―Command Instrument Single Pilot Certification‖ may not file and fly in IMC; they are signed off for ―Single Pilot PIC IFR Operations (Recovery Only).‖

NTSB Aircraft Accident Report 9 Review of the pilot's logbook revealed that he had 5,225.1 total flight hours of which 2,770 hours were in the accident make and model helicopter. The pilot had recorded 5,200.9 hours as PIC and 1,919.9 hours of night flight time. His last recorded night flight was on September 16, 2008. The pilot‘s total instrument flight experience is unknown.17 In the year prior to the MSP‘s change in their instrument training program,18 the pilot logged instrument time on 7 flights, accumulating 6.2 hours of instrument time and completing 20 approaches. After the change and in the year prior to the accident, the pilot logged instrument time on only 2 flights, which included 2.1 hours of instrument time and 4 instrument approaches. The pilot‘s most recent flight at night under instrument conditions took place on October 29, 2006, and the pilot completed 3 instrument approaches and logged 0.5 hours of simulated instrument time. During the 2 years preceding the accident, the pilot completed 25 instrument approaches: 20 approaches at ADW, 3 GPS approaches at nearby airports, and 2 unspecified approaches in a simulator. Out of the 20 ADW approaches, only 4 were nonprecision approaches. The nonprecision approaches practiced did not include the localizer approach to runway 19R. The pilot's last recorded instrument flight was on May 13, 2008, during his IPC. However, a medic reported that, a few days before the accident, the pilot practiced a GPS approach in VMC conditions for proficiency purposes during his return to base after a medevac flight. MSP reported that the pilot was off duty for 2 days before the accident and scheduled to work the late shift (1900 to 0700) on the day of the accident. The pilot‘s wife reported that he slept normally on the 2 days before the accident, waking between 0800 and 0830 and going to bed between midnight and 0100. On the day of the accident, the pilot woke about 0800 and reported for work about 1800 in preparation for his 1900 start of duty. The pilot‘s wife indicated that his activities and demeanor in the days before the accident were routine. According to his most recent airman‘s physical examination, the pilot was 6 foot 3 inches tall and weighed 293 pounds (resulting in a body mass index (BMI) of 36.6).19 His wife stated that the pilot had snored his entire adult life, and a colleague stated that he was notorious among coworkers for loud snoring. Obesity and snoring are two symptoms of obstructive sleep apnea, a disorder in which an individual‘s airway is repeatedly blocked during sleep, usually by soft tissue collapsing at the back of the throat.20 Interruptions in breathing can cause hypoxia, disturbed sleep architecture, and decrements in cognitive and psychomotor functioning.21

17 The pilot logbook examined by NTSB investigators was labeled ―logbook #3‖ and covered the period from June 17, 2006, to September 13, 2008. The pilot‘s family was unable to locate previous logbooks. There were no carried-over flight times listed for simulated or actual instrument experience. 18 See Section 1.17.1 for a discussion of MSP‘s instrument training program. 19 BMI is a person's weight in kilograms divided by his or her height in meters squared. The National Institutes of Health defines a person with a BMI of 30 or more as obese. 20 See, for example, O. Resta, et al., ―Sleep-Related Breathing Disorders, Loud Snoring and Excessive Daytime Sleepiness in Obese Subjects,‖ International Journal of Obesity and Related Metabolic Disorders, vol. 25, no. 5 (2001), pp. 669-75. 21See, for example, L. Ferini-Strambi, et al., ―Cognitive Dysfunction in Patients with Obstructive Sleep Apnea (OSA): Partial Reversibility after Continuous Positive Airway Pressure (CPAP),‖ Brain Research Bulletin, vol. 61, no. 1 (2003), pp. 87-92.

NTSB Aircraft Accident Report 10 1.6 Aircraft Information The Aerospatiale SA365N1 ―Dauphin‖ helicopter has twin engines, a single main rotor, and a retractable tricycle landing gear. As shown in figure 4 below, the helicopter has four doors, two on each side. The four-bladed main rotor is mounted on the main gearbox, which is directly above the cabin. Two Turbomeca Arriel 1C1 engines are mounted side by side aft of the main gearbox. The accident helicopter was equipped with two front seats with dual controls and an aftermarket medical interior including four seats and two litters.

The transport-category helicopter was manufactured in 1988. At the time of the accident, the helicopter had flown 8,869.1 total flight hours and had 34,575 total landings. The helicopter was equipped with a night vision imaging system, which was used for law enforcement flights and was not being used during the accident flight; a radar altimeter;22 and an autopilot that was capable of fully coupling to an ILS. The helicopter was not equipped with a terrain awareness and warning system (TAWS).

22 A radar altimeter uses the reflection of radio waves from the ground to determine the height of an aircraft above the surface. Figure 4. Photograph of an exemplar Aerospatiale SA365N1 helicopter.

NTSB Aircraft Accident Report 11 The helicopter had a standard airworthiness certificate and was being maintained in accordance with Eurocopter‘s recommended maintenance service requirements, using an approved aircraft inspection program. According to the aircraft logbook, a 100-hour airframe and engine inspection was accomplished on September 22, 2008, 3.2 flight hours before the accident. The No. 1 (left) and No. 2 (right) engines had accumulated calculated total times of 7,077.3 and 7,426.5 flight hours, respectively, at the time of the accident. The No. 1 and No. 2 engines had accumulated 1,120 and 574.7 hours since overhaul, respectively. An aircraft weight and balance form was completed prior to departure for the flight. According to the form, the helicopter departed ADW on the flight with 1,180 pounds of fuel. National Transportation Safety Board (NTSB) investigators estimated the fuel weight on board at the time of the accident was close to 880 pounds. Given these fuel weights, the helicopter was within weight and center of gravity limits throughout the flight. According to MSP Aviation Command personnel, the instrument approach charts were in a pouch on the right side of the pilot‘s seat, readily accessible to the pilot. 1.7 Meteorological Information There is an Automated Surface Observing System (ASOS) at ADW. Observations are augmented and verified by Air Force personnel who are qualified weather observers. The ASOS was in augmented mode at the time of the accident.23 The 2255 September 27, 2008, surface weather observation at ADW was wind 110° at 3 knots, visibility 7 miles, ceiling broken clouds at 1,300 feet, temperature 20° C, dew point 20° C, and altimeter setting 29.92 inches of mercury (Hg). The 2355 surface weather observation at ADW was wind 080° at 3 knots, visibility 4 miles in mist, scattered clouds at 200 feet, ceiling broken clouds at 500 feet, temperature 20° C, dew point 20° C, and altimeter setting 29.91 inches of Hg. The 0055 September 28, 2008, surface weather observation at ADW was wind 070° at 3 knots, visibility 4 miles in mist, ceiling broken clouds at 200 feet, overcast at 500 feet, temperature 20° C, dew point 20° C, and altimeter setting 29.91 inches of Hg. Visibility at ADW was reported to deteriorate rapidly after 0117, with visibility dropping to 1/4 mile at 0137. The fire chief on duty at ADW around the time of the accident indicated that the weather had been ―foggy‖ and ―soupy,‖ with estimated visibilities at 1/4 mile and, in some places, less.

23 Augmentation is the process of adding information from a trained weather observer to that which is observed automatically.

NTSB Aircraft Accident Report 12 However, he stated that, at the time, he could see the high intensity lights on the hangars on the opposite side of the field, about 1 mile from his location. The fire chief noted that, at the north end of the airport, the visibility was slightly better and he could see down to Suitland Parkway, which was about 1/2 mile from his location. The chief also noted that, about 2250, he was standing about 200 feet from the 13-story ADW tower24 and said that the top of the cab was ―shrouded in fog.‖ A homeowner who resided about 1.8 miles southwest of the accident site, stated that, between 2345 and 2400, he heard a helicopter approaching his home and that it flew over his house flying towards Walker Mill Regional Park and ADW. He went outside and observed the helicopter below the clouds in a descending attitude; he estimated the clouds were 100 to 150 feet above the trees. He stated that it was dark and there was a light mist of rain. He observed the helicopter until it disappeared from view. 1.7.1 Preflight Weather Information About 1851, when the pilot began his shift, he obtained and printed a weather briefing from the FAA‘s Direct User Access Terminal (DUAT) service.25 The information that the pilot obtained included trend weather observations, pilot reports, weather radar data, terminal forecasts, and wind aloft forecasts. The 1755 ADW surface weather observation and the ADW terminal forecast were included in the information. The 1755 surface weather observation at ADW was wind 090° at 5 knots, visibility 7 miles, a few clouds at 1,000 feet, temperature 21° C, dew point 20° C, and altimeter setting 29.90 inches of Hg. The ADW terminal forecast valid from 1800 on September 27, 2008, to 0100 on September 28 indicated wind 120° at 6 knots, visibility 7 miles, and scattered clouds at 2,000 feet. Between 0100 and 0200, the weather at ADW was expected to become wind variable at 6 knots, visibility 3 miles in mist, ceiling broken at 500 feet and overcast at 1,000 feet. The included DCA terminal forecast issued at 1330 indicated that by 2200 the weather was expected to be wind 150° at 5 knots, visibility 5 miles in light rain showers and mist, scattered clouds at 400 feet and ceiling overcast at 800 feet. There is no record of any further contacts with DUAT before the accident. The 1851 DUAT briefing did not include weather hazards because the pilot did not select them from the DUAT menu of products. If the pilot had included weather hazards, the briefing would have contained an Airman's Meteorological Information (AIRMET) for IFR conditions issued at 1645 and valid until 2300 that forecast ceilings below 1,000 feet and visibilities less than 3 miles in precipitation and mist for an area that began immediately north and east of ADW, extending over eastern Maryland, Delaware, eastern Pennsylvania, New Jersey and

24 The height of the ADW tower is 181 feet. 25 The DUAT service provides direct access to weather briefings, flight planning, and flight plan filing.

NTSB Aircraft Accident Report 13 New England.26 PGH was located within the boundaries of the AIRMET; ADW and the landing zone at Waldorf were not. An amended terminal forecast for DCA, issued at 1933, indicated that from 2000 on September 27, 2008, to 0200 on September 28, the weather was expected to be wind 70° at 3 knots, visibility greater than 6 miles, ceiling broken at 1,500 feet, broken clouds at 25,000 feet. Between 2000 and 2300, temporary changes were expected to visibility 3 miles in light rain showers, ceiling broken at 800 feet, overcast at 1,500 feet. A new AIRMET for IFR conditions was issued at 2245 and was valid until September 28, 2008, at 0500 and forecast ceilings below 1,000 feet, visibilities less than 3 miles in precipitation, and mist for an area that encompassed Maryland, the District of Columbia, and Virginia. The entire route of flight of Trooper 2 was located within the boundaries of the new AIRMET. The MSP Aviation Command has access to the helicopter emergency medical services (HEMS) weather tool.27 FAA Notice N 8000.333 describes the HEMS tool and explains that it is an experimental product. The notice states, with regard to Part 135 HEMS operators: The only approved use of this Tool is in VFR operations and then only in the context of supporting a ―no-go‖ decision.‖ Operators may not use the tool as the sole source for decisions to ―Go.‖ They may only use established primary products such as METARs [meteorological aerodrome reports], TAFs [terminal aerodrome forecasts], area forecasts, weather depiction charts, prognosis charts, etc., to make both ―Go‖ and ―No-Go‖ decisions. After the accident, another pilot, who arrived at the hangar about 0310 on September 28, the morning after the accident, noted that the pilots‘ computer was on and the HEMS weather tool was on the screen. He stated that most pilots read the weather directly from the HEMS weather tool before a flight. The SYSCOM DO stated that when he came on duty about 1800 on day of the accident, the HEMS weather tool indicated marginal visual flight rules (VFR) conditions throughout most of the state. 28 He noted that all MSP aviation bases were operating

26 AIRMETs are weather advisories issued concerning weather phenomena that are of operational interest to all aircraft and potentially hazardous to aircraft having limited capability because of lack of equipment, instrumentation, or pilot qualifications. An AIRMET for IFR conditions is issued when ceilings of less than 1,000 feet and/or visibilities less than 3 miles are forecast to affect a widespread area. 27 At the request of the FAA, the National Weather Service‘s Aviation Digital Data Service development team created a tool specifically designed to show weather conditions for the short-distance and low-altitude flights that are common for the HEMS community. 28 According to National Weather Service definitions, IFR conditions prevail when visibility is less than 3 miles and ceiling is less than 1,000 feet. Marginal VFR prevails when visibility is 3 to 5 miles and ceiling is 1,000 to 3,000 feet. VFR prevails when visibility is greater than 5 miles and ceiling is greater than 3,000 feet.

NTSB Aircraft Accident Report 14 under a flight-by-flight (―call by call‖)29 conditional response due to the weather conditions throughout the state. The HEMS weather tool is capable of displaying surface weather observations, terminal area forecasts, AIRMETs and pilot reports. Since HEMS weather tool data are not archived, it is impossible to confirm which of these items the pilot may have chosen to display. Surface weather observations for ADW, DCA, Fort Belvoir, Virginia, and College Park, Maryland, are normally available through the HEMS weather tool. Figure 1 shows the locations of these surface weather observation sites. About 2300, the HEMS weather tool would have displayed the 2252 DCA observation30 indicating 10 miles visibility and multiple cloud layers, with the lowest layer a few clouds at 1,400 feet, and the 2250 College Park observation31 indicating visibility of 10 miles and ceiling 800 feet overcast. Because of a technical failure in Department of Defense (DoD) communications, the current surface observations for ADW and Fort Belvoir were not available at 2300. The 2255 ADW observation was indicating visibility 7 miles and ceiling broken at 1,300 feet, and the 2255 Fort Belvoir observation32 was indicating visibility 1 1/4 miles in mist and a few clouds at 15,000 feet. 1.7.2 Department of Defense Weather Dissemination According to U.S. Air Force personnel, a data communications switch failure at Offutt Air Force Base, Nebraska, prevented the Air Force Weather Agency (AFWA) from transmitting military alphanumeric data to the National Weather Service (NWS). This prevented the display of military surface weather observations, including ADW ASOS observations, on nonDoD weather outlets, such as DUAT and the HEMS weather tool. On September 27, 2008, the last ADW observation noted on nonDoD weather outlets was for 1855, about 5 hours before the accident. Local dissemination of the ADW ASOS observations to the ADW tower was not affected. Replacement of the switch restored transmission capability. The outage of the circuit between the NWS and the AFWA lasted about 18 hours and 33 minutes.33 There was no backup procedure available to continue transmission of weather data during the outage. As of April 29, 2009, a backup procedure had been developed, tested, and implemented that would provide for the uninterrupted exchange of data between AFWA and NWS during a failure of this type.

29 When an MSP section is ―call by call,‖ the reported or observed weather is close to MSP VFR weather minimums. 30 The 2252 surface weather observation at DCA was wind calm, visibility 10 miles, a few clouds at 1,400 feet, 3,000 feet scattered, 11,000 feet scattered, ceiling 25,000 feet broken, temperature 22° C, dew point 19° C, altimeter setting 29.92 inches of Hg. 31 The 2250 surface weather observation at College Park was wind calm, visibility 10 miles, ceiling 800 feet overcast, temperature and dew point 21° C, altimeter setting 29.92 inches of Hg. 32 The 2255 surface weather observation at Fort Belvoir was wind calm, visibility 1 1/4 miles, mist, a few clouds at 15,000 feet, temperature and dew point 20° C, altimeter setting 29.91 inches of Hg. 33 The NWS reported the outage was from 1922 on September 27, 2008, to 1355 on September 28, 2008.

NTSB Aircraft Accident Report 15 1.7.3 Runway Visual Range Information The runway visual range (RVR)34 sensors along ADW runway 19R began reporting touchdown values below 6,000 feet about 40 minutes before the accident. Touchdown RVR values below 2,400 feet were reported from about 11 minutes before the accident through the time of the accident. According to FAA equipment logs, the edge and approach lights for runway 19R were set to their lowest intensity, step 1, while Trooper 2 was on approach. Step 1 is the normal setting at night when the visibility is above 5 miles.35 According to FAA technicians, because the RVR system measures the distance along the runway that the edge lights are visible, the reported value changes when the lights are turned up or down. When the edge lights are set to the lowest two settings, reported RVR values are not considered accurate and do not necessarily represent a specific level of fog or other obstruction to visibility. The ADW tower controller stated that the RVR display in the tower was not on because it is ADW practice not to activate the RVR display until the official weather observer reports visibility of 1 mile or less. The controller was therefore unaware of the RVR values detected by the system and did not increase the runway light intensity setting to get an accurate RVR value. 1.8 Aids to Navigation FAA technicians conducted a postaccident certification of the ILS for runway 19R on September 28, 2008, and found all certification parameters to be within tolerances. A flight check was conducted on September 29, 2008, and the system was again within tolerances. Review of maintenance and monitoring logs for the ILS for runway 19R showed no unusual maintenance or malfunctions recorded for the system. 1.9 Communications There were no known difficulties with communications equipment.

34 The RVR is the measurement of the visibility near the runway‘s surface. The measurement represents the horizontal distance that a pilot should be able to see down a runway from the approach end. 35 A high-intensity runway lighting system has 5 intensity steps. Step 1 is the lowest intensity, and step 5 is the highest. When visibility is less than 3 miles, the normal setting is at least 3. Settings are under the control of the tower.

NTSB Aircraft Accident Report 16 1.10 Airport Information ADW is owned and operated by the US Air Force. The ADW tower is operated by the FAA.36 The airport is located about 3 miles east of Camp Springs, Maryland, at an elevation of 280 feet. ADW has two runways: 1R/19L and 1L/19R. Runway 1L/19R is 9,300 feet long and 200 feet wide with a concrete surface. Runway 19R is equipped with a high-intensity approach lighting system with centerline-sequenced flashers; high-intensity runway edge lights; and a touchdown, midpoint, and rollout RVR system. The runway‘s touchdown zone elevation is 273 feet. 1.10.1 Instrument Approach Procedures There are 12 instrument approach procedure charts published for ADW. The ILS runway 19R approach and the localizer runway 19R approach are presented on a single approach chart, as shown in figure 2. The ILS runway 19R approach procedure requires aircraft to intercept and track the inbound localizer course of 190°, fly level until the glideslope is intercepted, and then descend along the glideslope. If the pilot does not see the runway environment or the runway by the time the aircraft reaches the decision altitude of 473 feet msl, which is 200 feet above the runway touchdown zone elevation, the pilot is required to perform a missed approach. According to the FAA‘s Aeronautical Information Manual Section 1-1-9 (j), when the glideslope fails, the ILS reverts to a nonprecision localizer approach. The localizer runway 19R approach procedure requires the aircraft to pass over the final approach fix, which is located 6.1 distance-measuring-equipment (DME)37 miles from the ADW VORTAC.38 After passing over the final approach fix, the pilot can descend to the minimum descent altitude (MDA) of 680 feet msl which is 407 feet above the runway touchdown zone elevation. The pilot cannot descend below the MDA unless the runway environment or the runway is visible. If the runway environment or the runway is not visible when the aircraft reaches the missed approach point, which is located 1.5 DME miles north of the ADW VORTAC, the pilot is required to perform a missed approach.39 The approach chart also provides the ASR runway 19R approach‘s MDA, which is 780 feet msl, or 507 feet above the runway touchdown zone elevation. According to information in the FAA‘s Instrument Flying Handbook and Aeronautical Information Manual, the procedure for an ASR approach, usually called a surveillance approach, requires the controller to provide radar vectors to establish the aircraft on the final approach path. The controller then advises the

36 The Federal Aviation Act of 1958 mandated that certain military bases, including ADW, have FAA-staffed control towers. The FAA has been operating the tower at ADW since 1961. 37 Distance measuring equipment is a pulse-type electronic navigation system that shows the pilot, by an instrument panel indication, the number of nautical miles between the aircraft and a ground station. 38 A VORTAC is a ground station that transmits navigation signals whereby the pilot of an aircraft equipped with appropriate receivers can determine distance and bearing to the station. 39 The ADW VORTAC is located near the middle of the airport. When an aircraft reaches the missed approach point for the localizer approach to runway 19R, it is 0.5 nautical miles from the runway threshold.

NTSB Aircraft Accident Report 17 pilot of the published MDA and missed approach point and then instructs the pilot when to begin descent to the MDA. On final approach, the controller provides vectors to keep the aircraft tracking on the extended runway centerline and advises the pilot of the distance from the missed approach point at each mile of the final approach. Guidance is provided all the way to the missed approach point where, unless the runway environment or the runway is visible, the pilot is required to perform a missed approach. 1.11 Flight Recorders The helicopter was not equipped, and was not required to be equipped, with a cockpit voice recorder (CVR) or a flight data recorder (FDR). 1.12 Wreckage and Impact Information Examination of the crash site revealed that the helicopter initially collided with the upper section of an 80-foot tree in a level, descending attitude on a heading of 191° magnetic. A debris path approximately 164 feet long extended from this tree to the main wreckage. The helicopter was separated into three main parts and many smaller pieces. All components of the helicopter were accounted for at the accident site. In addition, no evidence was identified of any preimpact mechanical failures or malfunctions of the aircraft‘s systems or the airframe. As shown in figure 5 below, the fuselage came to rest on its left side. The right side of the fuselage was crushed and exhibited horizontal scrape marks, and the cabin and cockpit areas were extensively damaged. The right-side pilot‘s door was located in a tree near the main wreckage.

NTSB Aircraft Accident Report 18

Figure 5. Photograph of the accident site. The radar altimeter bug40 was set to 300 feet, which is 573 feet above msl at the runway threshold. The horizontal situation indicator on the pilot‘s side of the instrument panel was set to 190°. Instrument approach charts, including the chart of the ILS runway 19R approach, were found scattered throughout the debris near the nose of the helicopter. 1.13 Medical and Pathological Information Autopsies were performed on the four fatally injured occupants by the state of Maryland, Office of the Chief Medical Examiner. The cause of death for all four individuals was listed as ―multiple injuries.‖ The FAA‘s Civil Aerospace Medical Institute performed toxicology tests on tissue specimens from the pilot. The results were negative for carbon monoxide, cyanide, ethanol, and a wide range of drugs, including major drugs of abuse. A review of the pilot‘s FAA airman

40 The radar altimeter bug is set by the pilot to a preselected altitude, and when the helicopter approaches and descends below that altitude, the radar altimeter generates visual and aural alerts.

NTSB Aircraft Accident Report 19 medical records revealed that his medical certificate had never been suspended, denied, or revoked. According to his wife, the pilot was in good health and had experienced no major changes in health in the past 12 months. The survivor sustained multiple traumatic injuries from the helicopter accident. She was hospitalized until November 5, 2008, and then discharged to a rehabilitation center. On November 26, 2008, she was discharged to her home. 1.14 Fire No in-flight or postcrash fire occurred. 1.15 Survival Aspects The pilot occupied the right front seat, and the left front seat was vacant. The medic occupied an aft-facing seat positioned just behind and between the two front seats. The field provider occupied a forward-facing seat positioned in the center of the aft bulkhead; the seat consisted of a seat cushion fitted into a depression in the floor and affixed to the aft bulkhead with a Velcro strip. The fatally injured patient was on the primary litter, located on the left side of the helicopter, and the surviving patient was on the secondary litter, located on the right side of the helicopter. The patients were placed onto the litters while already strapped to backboards provided by local emergency medical services (EMS) personnel, and the backboards were secured to the litters. The pilot‘s seat was found near its original location in the fuselage and was heavily damaged. The lap belt of the pilot‘s four-point harness was found buckled, and the webbing had been cut by first responders. Neither shoulder harness fitting was engaged in the central buckle. The aft-facing medic seat was found near its original location in the cabin and was heavily damaged. The four-point restraint for the medic seat was undamaged and unbuckled. The field provider seat cushion was found in the debris near the fuselage. The four-point restraint for the field provider seat was found buckled, and the lap belt and both shoulder harness webbings had been cut by first responders. The primary litter stayed in place within the cabin. It was undamaged except for a 4-inch section of aluminum plate that was bent upwards on the inboard side. The backboard was found detached from the litter, and the right-side handle at the head end of the board was fractured. The secondary litter was found in the debris field in multiple pieces. The lower portion of the litter was bent upward approximately 90°. The backboard was found detached from the litter, and both of the handles at the toe end of the board were fractured.

NTSB Aircraft Accident Report 20 1.15.1 Emergency Response The ADW controller noticed that Trooper 2 was missing almost immediately after radar contact was lost, and she began attempting to contact the pilot. At 2359:50, she also advised the ADW fire department chief, who was expecting to meet the helicopter, that she had lost radar contact with Trooper 2. The chief then contacted the PG County Communications Center and MSP Forestville barrack about the missing helicopter, and he then engaged in a ground search of ADW and the MSP hangar to locate Trooper 2. The ADS-B trip history report indicated that the SYSCOM DO logged Trooper 2 as landed at ADW at 0002:02. When he received a call at 0014:11 from MSP Forestville inquiring about the whereabouts of Trooper 2, the DO immediately responded, ―they landed at Andrews.‖ When informed by MSP Forestville that the ADW tower controller had lost Trooper 2 from radar,41 he was surprised. He then attempted to contact Trooper 2 by radio and got no response. The DO provided MSP Forestville with Trooper 2‘s last ADS-B coordinates. MSP personnel said that the equipment installed on the helicopters for ADS-B tracking ―does not function well at low levels.‖ There had been many instances when the ADS-B position stopped at the end of a runway even though the helicopter had actually landed at the other end of the runway or somewhere else. This, they said, led to a ―lack of confidence in the low-level position‖ and to ―conditioning‖ among personnel to assume that the helicopter had landed safely when the ADS-B signal was lost. According to MSP operational policy at the time of the accident, the troopers at each barrack were responsible for managing any incident that happened in their area of responsibility. Therefore, the shift supervisor on duty at the Forestville barrack became the incident commander for the search for the helicopter until the barrack commander arrived about 0100 and took over. The shift supervisor was not familiar with the flightpath to ADW and was unable to tailor the search to the area directly along the flightpath. He sent troopers to check the unpopulated areas that were about 2 miles north of ADW since, as he said in an interview, ―all the initial indications were that the helicopter went missing within 2 miles of ADW.‖ (The ADW tower controller had reported that the helicopter was within 2 miles of the airport.) The shift supervisor relied on ADW tower controllers or SYSCOM to provide him with the last known location of the helicopter. However, he said that he did not plot the coordinates that the SYSCOM DO gave him because he did not know ―what the coordinates meant.‖

About 0021:45, the DO provided PG County dispatchers with Trooper 2‘s last ADS-B coordinates by reading a string of numbers, ―three eight five two one seven, north was seven six five two two six.‖ The DO did not indicate that the numbers were in the form of degrees,

41 MSP Forestville had received this information from the ADW fire chief.

NTSB Aircraft Accident Report 21 minutes, seconds. The DO also added that the location of the coordinates was approximately 2 nautical miles southwest of FedEx Field.42 (See figure 6 below.) PG County dispatchers responded by sending patrol vehicles to the area southwest of FedEx Field. They also plotted the coordinates using an online mapping program, but the dispatchers assumed the coordinates were in the form of degrees, decimal degrees, which they were accustomed to using, so they entered the coordinates in that format. The location returned by the software program was near Calvert Cliffs, Maryland, located about 30 miles southeast of the accident site. This location raised confusion among PG County personnel and, about 0032:02, a county dispatcher called SYSCOM to verify the location. An operator at SYSCOM responded, ―okay I don‘t know where the duty officer got those [coordinates]….‖ The operator did not communicate with the DO to verify the coordinates given to PG County dispatchers. The misunderstanding about the format of the coordinates was not discovered, and confusion about the helicopter being near Calvert Cliffs persisted as the search continued. During the search, PG County dispatchers initiated an offer to ―ping‖ the cell phones of the troopers who had been on the helicopter and, thus, to possibly identify their location more

42 FedEx Field is a football stadium located in Landover, Maryland, in PG County. Figure 6. Map of search area (not to scale).

NTSB Aircraft Accident Report 22 accurately. MSP SYSCOM accepted the offer, and at 0036:19, the SYSCOM DO provided two cell phone numbers, one for the pilot and one for the medic. PG County dispatchers contacted the cellular service provider and went through the emergency process of finding the closest cell phone tower. At 0114:47, the cellular provider gave the street address of the tower but did not provide a distance or bearing from the tower. The address was immediately provided to PG County police officers and MSP Forestville, and numerous officers and troopers responded to that location. Approximately 10 minutes later, the Forestville MSP shift commander called PG County dispatchers and discovered that the best search area was probably within a 2- to 3- mile radius of the cellular tower. Meanwhile, about 0044:42, the medic of Trooper 8, based in Norwood, Maryland, about 20 miles northwest of the accident site, called SYSCOM and requested and received the last known ADS-B coordinates of Trooper 2. The medic stated that since Trooper 8 was ―down for weather,‖43 he and the Trooper 8 pilot were going to drive to the area where Trooper 2 was thought to have crashed. The medic said in a postaccident interview that he ―used the computer and plotted the coordinates near the north entrance to Walker Mill Regional Park.‖ He and the pilot arrived at the park‘s north entrance about 0100. There were several PG County police officers there, and they heard from them about ―pings‖ from one of the trooper‘s cell phones. Because they believed these ―pings‖ were giving a more accurate location, the pilot and the medic left Walker Mill Regional Park and drove to the address provided by the PG County police officers, arriving at a mall parking lot near the cell phone tower. About 0103:02, the DO called ADW tower and asked the controller for the time of the last contact with Trooper 2. The ADW controller stated that the time was about midnight. The DO asked, ―do you have a particular location, a north or west location?‖ The controller responded that she could not provide latitude and longitude coordinates and reported Trooper 2‘s last known position as 2 miles north of the runway. Again the DO asked, ―there‘s no way to get any kind of a bearing on what his location was, as far as north and west?‖ The ADW controller responded, ―I don‘t know how to do that.‖44 When the MSP Forestville barrack commander arrived at the barrack, she took over from the shift supervisor as the incident commander and set up a command post in the barrack‘s parking lot. About 0154:39, the barrack commander called MSP Forestville to request an aviation command unit to respond to the command post at Forestville, saying ―we‘ve got questions that we need them to answer about how things work.‖ About 0134, both PG County and MSP search efforts began to focus on a construction area located about 1.25 miles east of the accident site, where a witness reported seeing something come down. Visibility in the unlighted area was reported to be approximately 50 feet. About

43 Trooper 8 had been notified by the SYSCOM DO about 0025 that Trooper 2 was missing and requested to launch and head toward ADW. Trooper 8 departed Norwood, encountered low-level clouds about 2 miles south of Norwood, and aborted the flight. 44 The ADW controller had not received training on how to use a program called CountOps to obtain the coordinates of Trooper 2‘s last radar position. See Section 1.15.2 for more information on CountOps.

NTSB Aircraft Accident Report 23 0143:37, PG County personnel at the construction area reported needing ―true 4-wheel drive vehicles to search the area.‖ While the search of the construction area was proceeding, the pilot and medic of Trooper 8 met an MSP Aviation Command sergeant who had also responded to the mall parking lot. The sergeant asked them if anyone had talked to ADW tower. About 0142, Trooper 8‘s pilot called and spoke with the ADW tower controller, who reported losing radar contact with the helicopter about 2 miles out on approach to runway 19R. The pilot took out an ADC map45 and drew a straight line out from runway 19R; the line intersected with Walker Mill State Park, the same location where Trooper 8‘s medic had plotted the original coordinates. They immediately drove back to the park, arriving at the south end of the park about 0155. About 0158, the two troopers proceeded into the park on foot and located the wreckage and the survivor. 1.15.2 Additional Information on Emergency Response Interviews with MSP personnel at the Forestville barrack indicated that MSP road troopers performed their daily duties by referencing ADC grid maps and were not aware that those maps contained latitude and longitude coordinates. Some MSP patrol cars were equipped with laptop computers and software that allowed them to enter latitude and longitude coordinates, but none of the troopers interviewed had received any training on how to use this function. During a postaccident visit to PCT, NTSB investigators were shown an FAA system known as CountOps, an automated traffic count program that tracks the movement of aircraft through PCT airspace. Included in the items recorded by the system is the last observed position of aircraft under PCT control. CountOps was available on the night of the accident and could have been used by either the ADW controller or the operations manager on duty at PCT to obtain the latitude and longitude coordinates for the last radar position of Trooper 2. When interviewed, the operations manager on duty at PCT stated that he was not familiar with any way to obtain latitude and longitude coordinates for PCT traffic. Also, the location function of CountOps had not been part of training given on the system at ADW, so the ADW controller was unaware of it. Therefore, the system was not consulted during the search for Trooper 2.

45 ADC, of the Langenscheidt Publishing Group, publishes a popular series of maps, atlases, and guidebooks in the Mid-Atlantic region that are often used by Maryland troopers.

NTSB Aircraft Accident Report 24 1.16 Tests and Research 1.16.1 Engine Examinations The No. 1 and No. 2 engines were examined at the manufacturer‘s facility. A factory-supplied fuel control unit was installed on each engine,46 and the engine was run in a test cell. The No. 1 engine was run to 100 percent of the gas-producer turbine‘s rotational speed (N1). The engine ran with normal fuel consumption and normal oil consumption and did not exhibit any abnormal noises or vibrations. The No. 2 engine was run to 95 percent of N1. The engine ran with normal fuel consumption and normal oil consumption and did not exhibit any abnormal noises or vibrations. The engine was not run to 100 percent of N1 because multiple sparks were exiting the exhaust pipe. A borescope examination of the turbine assemblies revealed no defects, and the sparks were attributed to wreckage debris passing through the engine. The No. 1 and No. 2 fuel control units were examined at the manufacturer‘s facility and run on a test fixture after the impact-damaged parts of their controlling mechanisms were replaced. Both units performed adequately at all ranges of rpm. 1.16.2 Avionics Examinations The helicopter was equipped with a power analyzer and recorder (PAR) computer, which monitors and records turbine engine parameters for engine health trending and maintenance diagnostics. The PAR computer does not record data continuously; it records data only when certain discrete events occur, including engine starts and stops, engine parameter exceedances, and engine power checks. Examination revealed that the unit was slightly damaged but the internal components were intact. The memory was read, and the calibration of the unit was checked and found to be acceptable. The unit recorded no engine exceedances for the flight. The last event recorded was the loss of electrical power to the unit when the accident occurred. The final data recorded included engine torque values of 4.7 percent and 6.8 percent and N1 values of 77.4 percent and 78.4 percent for the left and right engines, respectively. Main rotor speed was recorded at 356 rpm (100 percent rpm); pressure altitude was recorded at 231 feet and indicated airspeed at 92 knots. The radar altimeter unit, both navigation receivers, both navigation control heads, and the DME transceiver were examined and tested at the manufacturer‘s facility. The examination revealed no discrepancies that would have prevented them from functioning normally and displaying proper indications during the accident flight. One of the navigation control heads was set to 111.5, the runway 19R localizer frequency. The other was set to 110.5, the runway 19L localizer frequency.

46 The fuel control units were replaced as both had sustained impact damage to their controlling mechanisms.

NTSB Aircraft Accident Report 25 It was not possible to determine the frequency set on the DME transceiver at the time of the accident. Normally, the frequency of the DME transceiver is automatically set to the same frequency as the navigation receiver. However, if the pilot switches the navigation receiver to another frequency but wants to keep the DME on the previous frequency, the pilot can select ―HOLD‖ by rotating a spring-loaded switch on the navigation control head. Because the switch springs back to the ―ON‖ position when it is released by the pilot, examination of the unit does not reveal whether the pilot selected the hold function. 1.16.3 Aircraft Performance Study NTSB investigators conducted an aircraft performance study using available ASR,47 ADS-B, and ATC transcript data. These data were used to define the aircraft‘s flightpath, ground track, ground speed, rate of climb, and ATC communication history. No aircraft acceleration, airspeed, attitude, engine, flight-control input, flight-control surface position, or external atmosphere parameters were recorded in the ADS-B or radar data. Investigators derived true altitude, calibrated airspeed, flightpath angle, estimated bank angle, and true heading parameters. The calculated Trooper 2 flightpath was compared to the runway 19R calculated glideslope parameters. The initial aircraft descent was consistent with the expected glideslope centerline guidance. About 2357:32, upon reaching an altitude of about 1,450 feet msl on the glideslope and a distance of about 4 miles north of the runway threshold, the helicopter‘s rate of descent increased rapidly from about 500 feet per minute (fpm) to greater than 2,000 fpm, and Trooper 2‘s flightpath began to deviate below the glideslope. The rapid descent continued until the end of the data. 1.16.3.1 TAWS Simulation At the request of NTSB investigators, Honeywell International Inc., a manufacturer of TAWS, used the ADS-B data to calculate the pilot alerts that would be expected if Trooper 2 had been equipped with TAWS. The simulation indicated that, had Trooper 2 been equipped with a Honeywell TAWS system,48 three terrain alerts would have been generated prior to initial impact, independent of glideslope signal operation. These aural alerts would have been ―Caution Terrain,‖ ―Warning Terrain,‖ and ―Pull-up,‖ given approximately 7, 4, and 2 seconds, respectively, before initial impact with the trees.49 Additionally, assuming a valid glideslope signal was being received, a ―Glideslope‖ aural alert would have been generated approximately 24 seconds before initial impact.

47 ASR systems are short-range (60-nautical-mile) radar systems that produce radar returns every 4.3 to 4.6 seconds for use in providing ATC services. 48 The system used was Honeywell‘s Mark 22 Helicopter Enhanced Ground Proximity Warning System. 49 The aural alert times from the Honeywell simulation were given in seconds before the end of the ADS-B data, and NTSB investigators correlated the end of the data with the helicopter‘s initial impact with the trees.

NTSB Aircraft Accident Report 26 1.17 Organizational and Management Information MSP Aviation Command is composed of eight sections located throughout Maryland. (There are four regions, with two sections in each region.) Aviation Command headquarters is located at Martin State Airport, Middle River, Maryland, collocated with one of the sections. At the time of the accident, MSP operated 12 Aerospatiale AS365 Dauphin helicopters. Trooper 2 was the designation for the helicopter assigned to the MSP Southern Region, Washington Section, located at ADW. The specific (N number) helicopter that flew as Trooper 2 could change from day to day, depending on helicopter availability. At the time of the accident, one helicopter and five pilots were based at Washington Section. MSP Aviation Command performs medevac, law enforcement, homeland security, search and rescue, and support flights. In calendar year 2007, MSP flew 8,607 flights; 5,769 of those were medevac flights in which a helicopter transported a patient from an accident site to a hospital. The Washington Section completed 1,201 medevac flights to accident sites, 29 interhospital transfers, 155 law enforcement flights, 79 homeland security flights, 50 search and rescue flights, and 122 support flights. The MSP Aviation Command is funded by the state of Maryland. The state legislature oversees and approves the MSP‘s budget, considers changes to the program introduced by legislators, and can order audits, conducted by state employees, of specific aspects of the program. However, the state legislature has no direct responsibility for the day-to-day operations of the MSP Aviation Command, nor do they have an aviation surveillance function similar to the FAA. According to interviews with MSP personnel, funding is independent of the number of flights flown. In the state of Maryland, all requests for medevac flights to accident scenes must be made to MSP first (through SYSCOM), before any private medevac operator. If MSP Aviation Command is not able to respond to a scene for any reason, SYSCOM notifies private medevac operators or other government agencies.50 When weather is the reason MSP is not able to accept the flight, private operators are generally also required to turn it down.51 The exception to this is when the weather is a localized phenomenon, for example a thunderstorm, and a private operator has an available helicopter that is not affected by the weather. Private operators based in Maryland primarily perform interhospital patient transports. MSP Aviation Command personnel stated that MSP operates under 14 Code of Federal Regulations (CFR) Part 91 and complies with its requirements pertaining to aircraft and pilot certification, aircraft maintenance, and pilot training. In addition, MSP has implemented a number of policies that mirror 14 CFR Part 135, including use of an operations manual,

50 MSP Aviation has memorandums of understanding (MOUs) with each of the three private operators in Maryland, as well as with the U.S. Park Police and the U.S. Coast Guard. They also have a mutual relationship with the Delaware State Police. 51 MOUs with these organizations reflect this agreement to eliminate pressure to launch.

NTSB Aircraft Accident Report 27 flight-hour requirements for new pilots, flight-crew duty time limitations, and flight-crew duty rest requirements. In 2008, the state legislature‘s Joint Legislative Audit Committee requested that the Office of Legislative Audits conduct an audit of certain aspects of MSP helicopter operations. The scope of the audit included a review of maintenance practices, but it did not include a review of flight operational practices. A report concerning the audit was completed in August 2008 and submitted to the requesting committee. Three of the report‘s major findings were (1) MSP helicopters were used almost exclusively for critical flights, (2) improved data systems and processes were needed to better manage MSP Aviation Command operations, including helicopter maintenance, and (3) staff turnover issues needed to be addressed. 1.17.1 Training MSP had three full-time flight instructors at headquarters and four part-time flight instructors in the field, one in each region. Each regional instructor provided recurrent and new-hire training for the seven to eight pilots assigned to their region. The regional instructor for the Southern Region, who had been employed by MSP as a pilot since 1994, stated that, prior to 2000, MSP pilots received ―more than enough‖ instrument training. After 2000, however, salaries for helicopter pilots in the civilian industry increased, and a high turnover of pilots began at MSP. The regional instructor stated that, due to the high pilot turnover, ―instructors currently spend most of their time training new hires and not enough time performing recurrent training.‖ On November 27, 2007, MSP Aviation Command changed its instrument training program. Before that date, pilots were required to perform six approaches every 6 months to maintain currency. After that date, pilots would receive two IPCs per year with instructor pilots in order to maintain FAA currency.52 According to MSP personnel, because MSP normally has just one pilot on duty at each base, the only opportunity pilots had to fly with each other was during a shift change or if they were at headquarters where another pilot might be located. According to the chief pilot, pilots were not conducting ―quality training‖ when practicing with other pilots, so he decided to change the training program. He felt that if the pilots flew with instructor pilots, the quality of the training would be better. His goal was to provide a more structured and consistent pilot training plan. When questioned about the November 2007 change to the instrument training program, the Aviation Command safety officer stated that the change was made for two reasons: to reduce the number of hours the helicopters were flown and to make the training more consistent. He felt that the new program provided ―better quality training.‖ He further stated that before the change, pilots would often perform the six required approaches on the last day of the sixth month ―just to document their currency.‖

52 Title 14 CFR 61.57 (d), ―Recent flight experience: Pilot in command,‖ requires a pilot to perform either 6 approaches during a 6-month timeframe or an IPC in order to maintain FAA currency.

NTSB Aircraft Accident Report 28 The Southern Region instructor reported that the rationale behind the change to the instrument training program was to ―save flight time plus it got an instructor in the cockpit.‖ He stated that he did not think two IPCs a year was enough training for pilots to maintain proficiency and that pilots needed to practice more than that. Before the November 2007 change, pilots could practice approaches more often, thus ―reinforcing learning.‖ On September 22, 2008, a pilot from the Cumberland Section sent a memorandum to the MSP Aviation Commander noting hazardous flying conditions in the Cumberland and Frederick sections, due to the mountainous terrain. In the memorandum, the pilot requested that helicopters assigned to these sections be equipped with TAWS. Additionally, he requested: Cumberland and Frederick Section pilots should be allowed to resume the previous instrument currency training: six practice or actual approaches every six months. Getting half the previous number of practice approaches and going six months between training opportunities provides neither the frequency nor the quantity of instrument practice needed for this demanding and hazardous flying environment. The pilot noted that instrument proficiency depended on the quality of initial instrument training, total instrument experience, time elapsed since last instrument experience, and quantity of recent instrument experience. According to MSP personnel, in response to the pilot‘s memorandum, the three MSP helicopters with TAWS are now assigned to the Cumberland and Frederick sections whenever possible. Also, in addition to the required IPC every 6 months, pilots with a ―Single Pilot PIC for IFR Operations‖ endorsement are encouraged to file an IFR flight plan and fly in IMC whenever possible to maintain their proficiency. 1.17.2 Dispatch System MSP uses SYSCOM for dispatch and flight-following functions. SYSCOM is a cooperative effort between the Maryland Institute for Emergency Medical Services Systems (MIEMSS)53 and the MSP. It controls and coordinates all aeromedical emergency responses in Maryland using a 24-hour operations center that provides central aircraft dispatching and emergency communications liaison among 911 centers, police stations or barracks, hospital systems, responding aircraft, and ground units. SYSCOM is staffed at all times with an MSP DO and two communications operators from MIEMSS. The duties of SYSCOM include processing calls, flight tracking, aircraft and crew accountability, and airspace coordination. According to the standard operating procedures, pilots are required to monitor the weather; however, if pilots are unable to obtain a weather update (for example, if they are already on a flight), the DO has

53 According to its fact sheet, MIEMSS ―oversees and coordinates all components of the statewide EMS educational programs, operates and maintains a statewide communications system, designates trauma and specialty centers, licenses and regulates commercial ambulance services, and participates in EMS-related public education and prevention programs.‖

NTSB Aircraft Accident Report 29 access to the HEMS weather tool and may assist pilots. Additionally, the DO is required to obtain a statewide forecast at the beginning of each 12-hour shift (0545 and 1745). At the time of the accident, SYSCOM DOs were not aviation-trained or certified. They did not have an active role in monitoring weather and determining whether to accept a flight. When a call came into SYSCOM from a 911 center requesting a helicopter transport, the DO notified the closest MSP aviation section. The pilot checked the weather, and the flight crew (pilot and medic) decided whether to accept the flight. If the flight crew accepted the flight, the DO then forwarded the crew a flight package and called the requesting 911 center to give them an estimated time of arrival for the helicopter. The flight package typically included incident type, number of patients, approximate age of patients, condition of patients, and landing zone information. SYSCOM uses ADS-B for tracking and flight following. The data are displayed on a screen at the DO‘s console and provide status, location, altitude, speed, and course of the aircraft. At the time of the accident, the software provided a view of the ADS-B data over a sectional aeronautical chart. When there was a loss of ADS-B signal, the icon showing the helicopter‘s last position turned red and there was an audible alert. In 2005, MSP performed an unannounced training drill for controllers at SYSCOM. In the exercise, a helicopter on a maintenance flight made an unexpected, unannounced landing (not at an airport) while en route to its destination. The goal was to see how and when SYSCOM personnel would ascertain that the helicopter was not where it was supposed to be. The drill identified deficiencies in the situational awareness of the three controllers on duty and led to the reassignment of one individual. A new operations supervisor was appointed approximately 3 months after that exercise. He concentrated on in-house practice sessions until the new ADS-B system went on line in late

1. For the next 2 years, the drill procedure involved the selection of a random site for the

center‘s staff to identify. After the geographic target was identified, the staff briefed a response plan. The supervisor noted that these drills ―did not involve direct interaction with a flight crew.‖ 1.17.3 Operational Policies 1.17.3.1 Aviation Command Operational Policies MSP provided a copy of the Aviation Command Operations Manual dated November

1. The manual was current at the time of the accident.

Under the heading ―Flight Crew Responsibilities,‖ the document stated, in part: ―Flight crews will call SYSCOM by telephone when they arrive at their office or destination when practical.‖ Under the heading, ―Radar Altimeter,‖ the document stated, in part:

NTSB Aircraft Accident Report 30 The Decision Height bug will be set on command aircraft Radar Altimeters to an altitude that will provide appropriate response time to alert crew members if they should have an unintentional descent near the water or ground. Under the heading ―Weather Briefings,‖ the document stated, in part: At the beginning of each shift, the pilot will obtain a full weather briefing, to include current and forecasted weather, all NOTAMS [notices to airmen], PIREPS [pilot weather reports] and forecasted winds aloft. In addition to an overall briefing, the pilot will ensure that he/she gathers information available to make him/her familiar with the weather situations throughout the state, as well as adjoining areas of neighboring states. The pilots will obtain, as necessary, sufficient weather information to ensure that the original weather briefing remains valid. The frequency of these additional weather checks will be determined by the severity of the existing or forecasted weather. However, if the section is call by call or weather down,[54] a check of the weather should be conducted at a minimum every two hours.

Under the heading ―Aviation Command Weather Minimums for Department Aircraft,‖ the document stated, in part (emphasis in the original): No helicopter VFR FLIGHTS will be initiated when the reported or observed weather at the departure, en route and/or destination is below the following:

1. Daylight Operations – Sunrise to Sunset if the ceiling is less than 600 feet

A.G.L. and/or the visibility is less than two miles.

1. Night Operations – Sunset to Sunrise if the ceiling is less than 800 feet A.G.L.

and/or the visibility is less than three miles.

1. In all cases, the helicopter must be capable of maintaining an altitude of at least

500 feet above ground level when operating under VFR, unless otherwise directed by Air Traffic Control or mandated by helicopter route charts.

1. The above minimums are in no way a must respond situation. Each crew will

apply the Risk Assessment Matrix as it pertains to Type of Mission Requested, Aircraft MEL [minimum equipment list] Status, All Weather Factors, Terrain the Mission is to be flown over (i.e. mountains), and Human Factors of crew on duty. Based on the crew‘s Risk Assessment, visibility and/or ceiling minimums will be increased to the crew‘s comfort level prior to accepting the mission.

54 When an MSP section is ―weather down,‖ the reported weather is below MSP VFR weather minimums.

NTSB Aircraft Accident Report 31 1.17.3.2 SYSCOM Operational Policies MSP personnel provided an undated document entitled, ―SYSCOM Ops Policies 1-08, Joint Operations Center Policy & Procedures DRAFT.‖ They explained that this document‘s draft status was primarily because flight operations policies and procedures in SYSCOM were going through a review and enhancement process. Because MSP Aviation Command believed that many areas would benefit from immediate improvement, they directed the SYSCOM DO to use these policies for normal operations pending the completion of the review. MSP confirmed that the policies included in the document were in place on the night of the accident. Under the heading, ―Flight Tracking,‖ the document stated, in part: The DO retains responsibility to insure that all MSP Aviation Command helicopters are positively identified & tracked throughout each mission. The flight tracking system (ADS-B) vehicle status alert function will remain fully functional at both the DO and SYSCOM-B work stations. This will allow positive status alert monitoring & resets to be completed in the event an operator or DO is temporarily unavailable. At no time will the audio level on the flight tracking work stations be altered to a point where alerts will not be detected at all stations within the center. Aircraft ADS-B failures will be identified and confirmed with flight crew. Loss of ADS-B position reporting will be identified and immediate contact made with flight crew to confirm status. Under the heading, ―Aircraft Emergency,‖ the document stated, in part: a. Loss of radio/flight track contact. SYSCOM will confirm aircraft condition, status and position. b. Establish contact or verify position by available means including ATC if in airport environment, local 911 center if on arrival to field incident. c. Other radio contact points. d. Presence of Traffic Information [Service -] Broadcast (TIS[-B]) target visible on last known aircraft heading & alt.[55]

55 The Traffic Information Service-Broadcast (TIS-B) is a ground-based broadcast service that provides traffic data derived from secondary surveillance radar. If an aircraft was in radar coverage, but its ADS-B data signal was not being received, a TIS-B data signal would be received over the ADS-B data link system.

NTSB Aircraft Accident Report 32 e. DO will initiate emergency services and Command staff alert notifications if unable to confirm position. f. DO will deploy available MSP and allied resources to assist in aircraft contact and location tasks. Appendix E of the MSP Aviation Command‘s Health and Safety Plan contained a ―Mishap Plan.‖ The plan provided the SYSCOM DO with a list of information that he was to obtain ―upon receiving notification that an aviation related incident/accident has occurred involving [d]epartment personnel, equipment or aircraft.‖ It also provided a list of notifications that the DO was to make. It did not provide the DO any guidance about how to deal with a missing or overdue aircraft. Appendix D of the Health and Safety Plan contained a ―Risk Assessment Matrix‖ that could be used by pilots for flight risk evaluation. However, according to the safety officer, the matrix was not being used by the pilots. The matrix included the statement that it was ―designed as a mental guide that is updated prior to flight, during flight and throughout the shift.‖ The safety officer stated that at the time of the accident there was no formal, documented process for pilots to evaluate risk before accepting a flight. Examination of the matrix revealed that it assigned risk levels of low, medium, and high to various parameters, such as type of flight, weather, and crew rest. For example, under the ―Mission Risk‖ category, a night medevac to an accident scene was assigned a low risk level, and under the ―Weather Factors‖ category, a dew point/temperature spread of 2° C or less was assigned a medium risk level. The overall risk assessment for a flight was the highest risk level assigned to any category. The matrix indicated that no flights were to be made if the risk level was high but provided no specific guidance concerning what actions should be taken by the pilot if the risk level was medium. 1.17.4 Previous Accidents Involving Maryland State Police The MSP reported that, since beginning to operate EMS helicopters in 1970, they had experienced five previous accidents, which occurred in 1971, 1972, 1973, 1986, and 1989. The most recent fatal accident occurred on January 19, 1986, when a Bell 206B3 helicopter, registered to and operated by the MSP, impacted terrain in Leakin Park, Baltimore, Maryland.56 The commercial pilot, who was not instrument rated, and the flight medic were killed, and the helicopter was destroyed. The accident occurred at night when the helicopter was on the return leg of a public medevac flight. The flight encountered IMC, the pilot initiated a 180° turn, and, during the turn, which was made over a dark, wooded area, the helicopter descended and impacted trees and terrain.

56 The NTSB participated in the investigation of this accident, which was assigned the accident number, BFO86FA014. A probable cause was not determined because, at the time, public aircraft were not within the NTSB‘s jurisdiction.

NTSB Aircraft Accident Report 33 After that accident, the MSP took the following corrective actions:  They replaced their nonIFR certified helicopters with Aerospatiale Dauphin helicopters with single pilot IFR capability.  Those MSP Aviation Command pilots who were not already instrument rated received the requisite instrument flight instruction and obtained a helicopter instrument rating.  Minimum requirements of 2,000 rotorcraft flight hours and a helicopter instrument rating became mandatory for all new pilots hired as of January 1, 1987. 1.17.5 Maryland State Police Postaccident Actions On March 18, 2009, MSP provided a memorandum to the NTSB investigator-in-charge detailing their postaccident actions. These actions included the following:  Designing a new mission-specific flight risk assessment tool.  Implementing new weather minimums that delineate cross-country from local flights and mountainous from non-mountainous flights.  Implementing new training requirements for pilots, including  One instrument approach in VMC per month on the return leg of a flight.  One instrument approach per month with another check pilot.  One training flight with an Aviation Command instructor pilot per year.  Two instrument proficiency check flights per year (one every 6 months) with an Aviation Command instructor pilot.  One annual evaluation flight with an Aviation Command instructor pilot.  Training and requiring SYSCOM DOs to be certified flight communicators through the National Association of Air Medical Communication Specialists.  Training all Aviation Command personnel and MSP field personnel on the use and interpretation of latitude and longitude.  Resuming unannounced missing aircraft exercises. During the course of the investigation, NTSB investigators learned of the following additional postaccident changes that were made by MSP:

NTSB Aircraft Accident Report 34  When a flight request is received, the DO evaluates the local and regional weather conditions displayed on the HEMS weather tool before allowing the request to proceed to the flight crew or making a no-go decision. The DO can make a no-go decision on a flight request based on weather conditions before the flight crew is notified.  Flight crews must notify SYSCOM within 5 minutes of landing. If landing confirmation is not received within 5 minutes of the estimated landing time, the DO will attempt to call the aircraft. If there is no contact after 10 minutes, the DO will initiate emergency procedures.  The software for ADS-B monitoring at all three SYSCOM workstations is capable of overlaying the ADS-B data on ADC street maps, terrain maps, satellite images, and aviation sectional charts.  The new risk assessment tool assigns low, medium, and high risk levels the colors green, yellow, and red, respectively. A percentage, as well as a color, is associated with the operational risk, and there is a range of percentages for green, yellow, and red. Red requires approval from the MSP Director of Flight Operations or a designee before a flight can be accepted. Yellow indicates heightened operational risk, but does not require approval prior to accepting the flight. If the flight crew's operational risk percentage puts the flight request in the ―high yellow‖ range for a particular flight request, SYSCOM must be informed by the flight crew that any change during flight, such as deteriorating weather, could put them into the ―red‖ and approval would be required to continue the flight or the flight would be cancelled. Moreover, SYSCOM would also notify the requesting agency that the estimated arrival time could be increased and/or the flight cancelled due to an increase in operational risk as determined by the flight crew. 1.17.6 Federal Aviation Administration Oversight During the NTSB‘s February 2009 public hearing on the safety of HEMS operations,57 FAA representatives testified that, with the exception of operations within the National Airspace System, the FAA has no statutory authority to regulate public aircraft operations. Title 49 United States Code (U.S.C.) Section 44701 is the primary authority for federal aviation regulations. This section instructs the FAA administrator to ―promote the safe flight of civil aircraft in air commerce‖ through regulations and standards prescribed in the interest of safety. Unless a government-owned (public) aircraft is engaging in a civil operation, it is not subject to civil aircraft and pilot requirements pertaining to certification, maintenance, and training. For further discussion of public versus civil aircraft operations, see section 1.18.1.

57 In response to the increase in fatal accidents involving HEMS operations in 2008, the NTSB conducted a public hearing from February 3 through 6, 2009, to critically examine safety issues concerning this industry. Details of the hearing can be found on the NTSB‘s website at the following link: http://www.ntsb.gov/events/hearing-hems/default.htm. For further information about safety recommendations issued following this hearing, see Section 1.18.3.2.

NTSB Aircraft Accident Report 35 FAA Order 8900.1,58 Chapter 14, Section 2 Public Aircraft Operations and Surveillance Government Aircraft Operations Versus Civil Aircraft Operations, dated September 13, 2007, states that ―government-owned aircraft operators holding any type of FAA certification will be included in the normal surveillance activities such as spot inspections of the aircraft and aircraft records.‖ It further states that ―any aircraft or operation certificated by the FAA is subject to this surveillance regardless of whether they are operating as public or civil.‖ Additionally, it states that ―government-owned aircraft operators that are conducting public aircraft operations should be included in the FSDO‘s [Flight Standards District Office‘s] annual planned surveillance activities to ensure that the operator‘s status remains unchanged.‖ A search of FAA surveillance records of MSP Aviation Command revealed that, during the year before the accident, the FAA performed no surveillance inspections of MSP‘s flight operations. Specifically, there were no en route inspections, base inspections, station inspections, simulator inspections or checks, manual reviews, training program reviews, ramp inspections, or records inspections. Surveillance inspections of the MSP 14 CFR Part 145 maintenance repair station were routinely performed during the year prior to the accident. In April 2009, MSP notified the FAA‘s Baltimore FSDO that it would like to seek 14 CFR Part 135 certification. On May 4, 2009, the commander of MSP Aviation Command discussed MSP‘s request with the manager of the Baltimore FSDO. According to the commander, the FSDO manager advised him that ―the FAA now considers public helicopter operations ineligible for Part 135 certification; therefore, this new policy change precludes MSP Aviation Command from becoming Part 135 certified.‖ The FSDO manager further advised the commander that he was awaiting further guidance on this issue from his superiors. In response to a request from the NTSB to explain why it considered MSP ineligible for Part 135 certification, the FAA provided a copy of a June 9, 2009, electronic mail message from the FSDO manager to other FAA personnel. In the message, the FSDO manager stated that he told the commander ―that our Policy Divisions in FAA Headquarters were in the process of amending our guidance and that MSP Aviation Command may not be eligible to apply for or to hold a 135 Air Carrier Certificate.‖ Additionally, the FAA provided a copy of a June 26, 2009, letter from the Associate Administrator for Aviation Safety to MSP, which stated, in part: The information from the Baltimore Flight Standards District Office (FSDO) that the Maryland State Police (MSP) Aviation Command was not eligible to hold a 14 CFR part 135 operating certificate may not be correct. The letter also stated that MSP could begin the process of obtaining a Part 135 certificate by submitting a Preapplication Statement of Intent to the Baltimore FSDO and suggested that MSP could, while waiting for the FAA to process its certificate request, ―immediately adopt, and comply with, the more stringent 14 CFR part 135 regulations required by the FAA for 14 CFR part 135 air carriers without having such a certificate.‖

58 FAA Order 8900.1 contains aviation safety policy used by aviation safety inspectors in performance of their official duties.

NTSB Aircraft Accident Report 36 1.18 Additional Information 1.18.1 Public versus Civil Aircraft Operations Helicopter EMS operations are conducted by both civil and public operators. Civil operators conduct these operations for hire under 14 CFR Part 135. Forty public operators currently provide air medical transportation using helicopters in the United States.59 Unless such transportation results in compensation, these public operators are not required to hold an FAA air carrier certificate.60 Public aircraft are exempt from many FAA regulations applicable to civil aircraft. However, Public Law 103-411, the Independent Safety Board Act Amendments of 1994, redefined ―public aircraft.‖ The statute, which became effective April 23, 1995, narrowed the definition of public aircraft with the intent that government-owned aircraft that operate for commercial purposes or engage in transport of passengers be subject to the regulations applicable to civil aircraft. In testimony supporting passage of the law, as recorded in the Congressional Record: October 3, 1994, Congressman Norman Mineta stated, in part: It is intended to require, for the first time, that the Federal Aviation Administration regulations apply to aircraft operated by government entities. This requirement does not apply to certain governmental functions, such as firefighting, search and rescue, and law enforcement. Rather, it is intended to apply to all operations in which government officials or other individuals are transported on government-owned aircraft. It is expected that if public use aircraft are required to adhere to the Federal Aviation regulations, the safety of these operations will be enhanced. Also, in the Congressional Record: October 6, 1994, in regard to the purpose of the law, Senator Larry Pressler stated, in part: Its purpose is to advance the safety of travel on public aircraft; that is, aircraft used exclusively in the service of federal, state, and local governments. Under current law, public use aircraft are not subject to Federal Aviation Act safety regulations to the extent imposed on civil aircraft. My provision would amend the definition of public use aircraft to mandate that FAA safety regulations, directives and orders issued for civil aircraft be made applicable to all government-owned, nonmilitary aircraft engaged in passenger transport. Title 49 U.S.C. Section 40102(a)(16) states that ―civil aircraft‖ means an aircraft except a public aircraft. As defined in 49 U.S.C. Section 40102(a)(41)(C), a ―public aircraft‖ includes

59 NTSB staff determined this number by combining information provided by the Association of Air Medical Services, the Airborne Law Enforcement Association, and the Helicopter Association International. 60 The NTSB is aware of one public operator—Lee County Division of Public Safety, Fort Myers, Florida— that holds a Part 135 air carrier certificate.

NTSB Aircraft Accident Report 37 An aircraft owned and operated by the government of a State, the District of Columbia, or a territory or possession of the United States or a political subdivision of one of these governments, except as provided in section 40125(b). Title 49 U.S.C. Section 40125(b) states that an aircraft described in subparagraph (C) of Section 40102(a)(41) does not qualify as a public aircraft ―when the aircraft is used for commercial purposes or to carry an individual other than a crewmember or a qualified non- crewmember.‖ Title 49 U.S.C. Section 40125(a) defines ―commercial purposes‖ as ―the transportation of persons or property for compensation or hire.‖ It defines a ―qualified non-crewmember‖ as ―an individual, other than a member of the crew, aboard an aircraft … whose presence is required to perform, or is associated with the performance of, a governmental function.‖ A ―governmental function‖ is defined as ―an activity undertaken by a government, such as national defense, intelligence missions, firefighting, search and rescue, law enforcement (including transport of prisoners, detainees, and illegal aliens), aeronautical research, or geological resource management.‖ According to FAA Advisory Circular (AC) 00-1.1, ―Government Aircraft Operations,‖ dated April 19, 1995, the status of an aircraft as a ―public aircraft‖ or ―civil aircraft‖ depends on its use in government service and the type of operation that the aircraft is conducting at the time. Government agencies may conduct both public and civil aircraft operations with the same aircraft. The AC states, ―rather than speaking of particular aircraft as public aircraft or civil aircraft, it is more precise to speak of particular operations as public or civil.‖ On the subject of ―Medical Evacuation,‖ the AC states: While this term is not considered synonymous with ―search and rescue,‖ it may be an included governmental function, depending on the particular circumstances of the operation. Again, the use of an aircraft must be essential to the successful performance of the mission. It is unlikely that the use of an aircraft would be essential for a medical evacuation operation in an urban area where other means of transportation are routinely available. Regarding medevac flights, FAA Order 8900.1, Chapter 14 Public Aircraft, Section 1, ―General Information on Public Aircraft Operations,‖ dated September 13, 2007, states, in part: The term ―search and rescue‖ does not include routine medical evacuation of persons due to traffic accidents and other similar incidents or hospital-to-hospital patient transfers. The order further states: Medical evacuation, as a general matter, is not considered a government function unless:

1. The nature of the operation requires the use of an aircraft with special configurations,

which may not be eligible for a standard airworthiness certificate,

1. The victim cannot be accessed by ground transportation,

NTSB Aircraft Accident Report 38

1. Insufficient number of properly certified and equipped civil aircraft operating under

the appropriate rule, are available to complete the mission, or

1. Other, similar nonroutine factors are present.

When the accident occurred, the MSP considered Aviation Command medevac flights to be civil aircraft operations. A memorandum from the commander addressed to all Aviation Command personnel on the subject of ―Public Aircraft (Use) vs. Civil Aircraft (Part 91) Operations,‖ dated March 5, 2008, was issued ―to provide background information and to clarify our operational status as it relates to our mission profile and the airworthiness of our aircraft.‖ After discussing Public Law 103-411 and the material in AC 00-1.1, the memorandum‘s conclusion section states, in part (underlining in the original): When Aviation Command pilots are involved in a flight operation that would be considered a ―civil aircraft‖ operation, i.e. medevac operations, VIP transports, training flights, mechanic transports, photo flights, etc.: we are operating under [Federal Aviation Regulations] part 91, as well as our policy and procedures outlined within the Command‘s Operations, Active Policies, and Standardization Manuals. When Aviation Command pilots are involved in a flight operation that would be considered ―public aircraft‖ operation (and the mission meets the operational definition of same), i.e. search and rescue mission and law enforcement support/homeland security operations, etc.; we are operating within the standard operating procedures and standards outlined within the Aviation Command‘s Operations, Active Policies and Standardization Manuals for that particular operation. However, while Public Law 103-411 and AC 00-1.1 does allow government agencies to conduct both ―civil‖ and ―public‖ aircraft operations with the same aircraft, operators of aircraft used for ―dual purposes,‖ as is the case with MSP Aviation Command, the government agencies are required to maintain the airworthiness of the aircraft in accordance with the appropriate regulations applicable to civil aircraft operations as outlined in [Federal Aviation Regulations P]art 43 and 91, as applicable. On January 28, 2000, the FAA‘s regional counsel for the Great Lakes region, responded to a letter from Washington Hospital Center requesting an opinion regarding certain operations being conducted by MSP aircraft. In addressing the question of whether the interhospital air transfer of patients is a public or civil operation, the FAA‘s letter stated, in part: The information you provided states that the Maryland State Police operates aircraft under [14 CFR] Part 91 of the Federal Aviation Regulations. This would seem to indicate that the aircraft and pilots meet the requirements for civil aircraft operation. Therefore, so long as the MSP does not receive compensation from the hospital or patients for the air transportation portion of the interhospital transfers, these flights may be conducted as civil aircraft operations under Part 91. On December 3, 2008, NTSB investigators made a written request for the FAA to render its opinion on the public aircraft status of Trooper 2. A memorandum dated March 13, 2009, from FAA‘s Office of the Chief Counsel stated, ―we believe the flight to have been a public aircraft operation within the meaning of the statute and FAA guidance material.‖ The memorandum referenced the definition of public aircraft in 49 U.S.C. Section 40102(a)(41)(C) and the exception provided in 49 U.S.C. Section 40125(b). The memorandum stated, in part:

NTSB Aircraft Accident Report 39 The exception in section 40125(b) states that an aircraft does not qualify as public when it is used for commercial purposes or to carry an individual other than a crewmember or a qualified non-crewmember. The operation of Trooper 2 does not meet the exception as being used for commercial purposes. Our understanding is that the funding for the Maryland State Police helicopter operations is public, through fees and other taxes, and does not fall within the meaning of ―for compensation or hire‖ under the statute (section 40125(a)(1)). The recipients of the service provided by the Maryland State Police (in this case, the accident victims) do not pay for the service in any manner that could be construed as compensation or hire, and are considered ―qualified non-crewmembers‖ as they are individuals who are ―associated with the performance‖ of a governmental function. While the statute contains examples of governmental function, it does not specifically call out flights for medical evacuations. However, the FAA considers helicopter emergency medical services as akin to the ―search and rescue‖ function used as an example in the statute, and as falling within the statutory intent of governmental function. Additionally, the memorandum stated that the FAA was ―aware that internal agency materials may not be consistent in the consideration of the statutory factors or historical decisions‖ and that these materials were being updated. 1.18.2 Protocols for Medevac Helicopter Request Through its EMS Board, MIEMSS provided guidance to medical responders in Maryland for choosing between helicopter or ambulance transport. The guidance was given in the form of a trauma decision tree developed by the American College of Surgeons and adopted by the state of Maryland. This tree provided standards based on mortality and injury evidence for responders to classify four levels of serious injury consistent with required treatment at a trauma center, from ―A‖ (the most serious) to ―D‖ (the least serious). The tree also provided guidance concerning when to use helicopter transport. For patients in categories A and B, it stated, ―Consider helicopter transport if quicker or of clinical benefit.‖ For patients in categories C and D, it stated, ―Patients within a 30-minute drive time of the closest appropriate trauma/specialty center shall go by ground unless there are extenuating circumstances. Consider helicopter transport if of clinical benefit.‖ Responders to the automobile accident from the Waldorf fire station, who were among the first at the scene, confirmed that they were all familiar with the trauma decision tree and employed it in their evaluations of the accident victims. They had received training on recent upgrades to the trauma decision tree through a 60- to 90-minute video presented at their station house between January and May 2008, and their use of the tree was regularly reinforced at station safety reviews.

NTSB Aircraft Accident Report 40 In the case of the automobile accident, paramedics classified the victims as category C61 and decided they required treatment at a trauma center because of two factors: intrusion of the passenger compartment greater than 18 inches and patient complaints of back and neck pain. Helicopter transport was requested because the responders recognized that driving to the nearest trauma center, located at PGH, would take more than 30 minutes on wet and slippery roads. Based on a postcrash investigation, MIEMSS determined that the automobile accident site was a 48-minute drive from PGH and concluded that the decision to request helicopter transport to a trauma center was appropriate. As a result of the helicopter accident, MIEMSS updated the trauma decision tree in the state of Maryland to require consultation with a local emergency room or trauma center for victims classified as C or D in order to reach agreement on the most appropriate mode of transport. According to the executive director of MIEMSS, the dispatch center (SYSCOM) has coordinated these consultations efficiently and there have been more joint decisions to use ground transportation. MIEMSS will evaluate mortality trends to judge the effectiveness of this new rule. In addition to its internal postaccident review, MIEMSS and the Governor of Maryland convened an expert panel to conduct a review of the HEMS program operated in Maryland.62 With regard to the physician consultation rule for Category C and D patients, the panel‘s November 2008 report stated, ―it appears to be a prudent and reasonable approach to curtail air transport of more minor trauma patients.‖ The panel reported that during the first 7 weeks after the protocol change, there was a marked reduction in HEMS usage in the state of Maryland. However, the panel pointed out that it was premature to judge the effect of this change on patient outcomes. Further, in 2004, in response to increasing helicopter use, MIEMSS initiated development of a quality assurance procedure to assist local jurisdictions in evaluating the need for helicopter transports. Using satellite imagery, MIEMSS generated plots of each trauma center in the state with shaded zones around the trauma center representing areas within about 15 to 30 minutes driving time and dots to show the locations where medevacs to accident scenes had been performed. In 2007, these plots were shared with the local jurisdictions, and whenever helicopter transport had been requested from a shaded zone, MIEMSS asked the local jurisdiction to review the launch decision. According to the executive director of MIEMSS, the response from the local jurisdictions was positive, and requested helicopter launches have declined by about 23 percent since this program began. The executive director stated that he believed the use of satellite mapping for quality assurance, as well as the use of a consultation rule, might be useful for national standards and suggested a forum, which might be sponsored by the Office of Injury Control within the Centers for Disease Control and Prevention and by the National Highway Traffic Safety Administration, be held to review national standards on the use of aeromedical services in the transport of trauma victims.

61 The patients were initially classified as category D when the helicopter request was made. 62 The Expert Panel Review of Helicopter Utilization and Protocols in Maryland can be found online at http://www.miemss.org/home/LinkClick.aspx?fileticket=Wc3WFoQSevY%3d&tabid=161&mid=569.

NTSB Aircraft Accident Report 41 Review of usage data obtained from MIEMSS shows a steady decline in the number of patients transported on MSP medevac flights each fiscal year (FY) from 2005 to 2008, followed by a marked reduction in FY 2009 (July 1, 2008 to June 30, 2009). (See table 2.) Between FY2005 and FY2008, there was a 19.7 percent reduction in the number of patients transported by MSP. Between FY2008 and FY2009, there was a reduction of 42.7 percent. Table 3. Number of Patients Transported by MSP Aviation. Year Scene Medevacs Percent Decline from Prior Year Percent Decline from FY2005 FY2005 5,126 patients

FY2006 4,874 patients 4.9% 4.9% FY2007 4,634 patients 4.9% 9.6% FY2008 4,114 patients 11.2% 19.7% FY2009 2,356 patients 42.7% 54.0%

The NTSB recently issued a recommendation to the Department of Homeland Security‘s Federal Interagency Committee on Emergency Medical Services (FICEMS)63 recommending that it develop national guidelines for the selection of appropriate emergency transportation modes for urgent care. See section 1.18.3.3 for additional information. 1.18.3 Previous Related Safety Recommendations 1.18.3.1 Safety of EMS Flights On February 7, 2006, as a result of an NTSB special investigation of a number of accidents between January 2002 and January 2005 involving aircraft performing EMS operations, the NTSB issued four safety recommendations to the FAA addressing EMS operations.64 On October 28, 2008, these recommendations were added to the NTSB's Most Wanted List of Safety Improvements. Following are the recommendations and the FAA‘s responses:

63 FICEMS is an advisory committee whose function is to provide guidance and coordination on EMS. No federal agency is currently responsible for EMS oversight at the national level. 64 For more information, see Emergency Medical Services (EMS) Operations, Special Investigation Report NTSB/SIR-06-01 (Washington, DC: National Transportation Safety Board, 2006).

NTSB Aircraft Accident Report 42 A-06-12 Require all emergency medical services operators to comply with 14 Code of Federal Regulations Part 135 operations specifications during the conduct of all flights with medical personnel on board. On January 23, 2009, the FAA published revised Operations Specification A021, which requires that all civil EMS flights with medical personnel on board, regardless of the presence of patients, be subject to the weather minimums limitation in 14 CFR Part 135.65 Also on January 23, 2009, the NTSB responded that, although the revised operations specification is responsive to the recommendation, the FAA still needed to require the Part 135 flight and duty time limitations for EMS flights in order to fully meet the intent of the recommendation, and the NTSB classified Safety Recommendation A-06-12 ―Open—Unacceptable Response.‖ A-06-13 Require all emergency medical system (EMS) operators to develop and implement flight risk evaluation programs that include training all employees involved in the operation, procedures that support the systematic evaluation of flight risks, and consultation with others trained in EMS flight operations if the risks reach a predefined level. In August 2005, the FAA issued Notice N 8000.301, ―Operational Risk Assessment Programs for Helicopter Emergency Medical Services,‖ which provided detailed guidance on the development and use of flight risk evaluation plans by EMS operators. This notice expired in August 2006 without further FAA action for almost 2 years. In May 2008, the guidance within the expired notice was incorporated into FAA Order 8900.1, ―Flight Standards Information Management Systems.‖ On January 23, 2009, the NTSB informed the FAA that although guidance is valuable, Safety Recommendation A-06-13 asked for a requirement, such as an operations specification, that all EMS operators develop and use flight risk evaluation programs. Pending incorporation of a specific requirement to develop and use a flight risk assessment program, Safety Recommendation A-06-13 was classified ―Open—Unacceptable Response.‖ A-06-14 Require emergency medical services operators to use formalized dispatch and flight-following procedures that include up-to-date weather information and assistance in flight risk assessment decisions. In May 2008, the FAA published AC 120-96, which provides detailed guidance about the creation and operation of operations control centers for helicopter EMS operations. On January 23, 2009, the NTSB indicated that, although the AC was responsive to the recommendation, it was only guidance, and that the FAA needed to require that all EMS operators incorporate the guidance contained in the AC into their operations. Pending that action, Safety Recommendation A-06-14 was classified ―Open—Acceptable Response.‖

65 Title 14 CFR Part 135.203(b) requires helicopters operating under VFR to maintain a minimum altitude of 300 feet agl over congested areas. Part 135.205(b) and Part 135.207 require a minimum visibility of 1 mile and visual surface light reference, respectively, to operate a helicopter at night.

NTSB Aircraft Accident Report 43 A-06-15 Require emergency medical services (EMS) operators to install terrain awareness and warning systems [TAWS] on their aircraft and to provide adequate training to ensure that flight crews are capable of using the systems to safely conduct EMS operations. In June 2006, at the FAA‘s request, RTCA, Inc.66 established a committee tasked with developing helicopter TAWS (H-TAWS) standards. In March 2008, the commission completed the development of minimum operational performance standards for H-TAWS. On December 17, 2008, the FAA published Technical Standards Order C194, ―Helicopter Terrain Awareness and Warning System‖ based on the commission standards. The FAA must now initiate rulemaking. On January 23, 2009, the NTSB indicated that the continuing delays in development of a final rule to require H-TAWS were not acceptable. Pending issuance of a final rule to mandate the installation and use of TAWS on all EMS flights, Safety Recommendation A-06-15 was classified ―Open—Unacceptable Response.‖ 1.18.3.2 Safety of Public HEMS Flights On September 24, 2009, as a result of testimony given at the NTSB‘s public hearing on HEMS safety in February 2009 and the investigative findings of several 2008 HEMS accidents, the NTSB issued safety recommendations to the FAA, public HEMS operators, and other federal agencies. Following are the five recommendations made to public HEMS operators: A-09-97 Conduct scenario-based training, including the use of simulators and flight training devices, for helicopter emergency medical service (HEMS) pilots, to include inadvertent flight into instrument meteorological conditions and hazards unique to HEMS operations, and conduct this training frequently enough to ensure proficiency. A-09-98 Implement a safety management system program that includes sound risk management practices. A-09-99 Install flight data recording devices and establish a structured flight data monitoring program that incorporates routine reviews of all available sources of information to identify deviations from established norms and procedures and other potential safety issues.

66 RTCA, Inc. is a private, not-for-profit corporation that develops consensus-based recommendations regarding communications, navigation, surveillance, and air traffic management system issues.

NTSB Aircraft Accident Report 44 A-09-100 Install night vision imaging systems in helicopters used for emergency medical services (HEMS) and require HEMS pilots be trained in their use during night operations. A-09-101 Equip helicopters that are used in emergency medical services transportation with autopilots, and train pilots to use the autopilot if a second pilot is not available. These recommendations are currently classified ―Open—Await Response.‖ 1.18.3.3 National Guidelines for Selection of Emergency Transportation Modes In its September 24, 2009, letter to FICEMS, the NTSB stated that public hearing testimony indicated that a variety of standards are used by providers and organizations to determine when an EMS helicopter should be used to transport patients. No nationwide standards or recommended guidelines exist. Absent such criteria, the decision to undertake a HEMS flight may be made whether the medical situation merits the HEMS flight and its associated risks (compared to ground transportation) or not. Therefore, the NTSB issued Safety Recommendation A-09-103, which asked FICEMS to do the following: Develop national guidelines for the selection of appropriate emergency transportation modes for urgent care. This recommendation is currently classified ―Open—Await Response.‖ 1.18.3.4 Flight Recorder Systems The NTSB‘s first participation in a helicopter accident investigation in which an FDR was on board involved the August 10, 2005, accident of a Sikorsky S-76C+ helicopter that experienced an upset and crashed into the Baltic Sea, killing all 12 passengers and 2 pilots.67 Importantly, without the FDR data, investigators would not have been able to identify the airworthiness issue that resulted in the issuance of three urgent safety recommendations by the NTSB on November 17, 2005 (Safety Recommendations A-05-33 through -35).68 The NTSB

67 The Aircraft Accident Investigation Commission of Estonia investigated the accident with the assistance of accredited representatives from the NTSB and the Finland Accident Investigation Board under the provisions of Annex 13 to the International Convention on Civil Aviation. 68 Safety Recommendation A-05-33 asked the FAA to require Sikorsky S-76 helicopter operators to 1) conduct an immediate internal leakage test of all main rotor actuators with more than 500 hours since new and/or overhaul; 2) conduct subsequent recurrent tests at a period not to exceed 500 hours; 3) report the test results to the FAA and/or Sikorsky; and 4) correct any problems as necessary. This recommendation is classified ―Open—Acceptable Action.‖ Safety Recommendation A-05-34 asked the FAA to require Sikorsky S-76 helicopter operators to 1) conduct immediate visual and laboratory examination of hydraulic fluid and filter elements in hydraulic systems with

NTSB Aircraft Accident Report 45 issued an additional recommendation, Safety Recommendation A-06-017, on March 7, 2006, asking 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,[69] 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. On May 22, 2006, the FAA informed the NTSB that it would review and identify changes in FDR technology since 1988 to ensure that current technology used in airplanes is appropriate for helicopter operations. The FAA stated that it would consider changes to its regulations based on this review. On November 29, 2006, the NTSB indicated that it did not believe the FAA‘s study was necessary and that it should begin the process to mandate that all rotorcraft operating under Parts 91 and 135 with a transport-category certification be equipped with a CVR and an FDR. Pending the FAA initiating such a requirement, Safety Recommendation A-06-17 was classified ―Open – Unacceptable Response.‖ Following its investigation of a July 27, 2007, accident involving two electronic news- gathering helicopters that collided in midair while maneuvering in Phoenix, Arizona,70 neither of which was equipped with an FDR, the NTSB issued Safety Recommendation A-09-11 on February 9, 2009, which asked the FAA to do the following: Require all existing turbine-powered, nonexperimental, nonrestricted-category aircraft that are not equipped with a flight data recorder and are operating under 14 Code of Federal Regulations Parts 91, 121, or 135 to be retrofitted with a crash-resistant flight recorder system. The crash-resistant flight recorder system should record cockpit audio (if a cockpit voice recorder is not installed), a view of the cockpit environment to include as much of the outside view as possible, and parametric data per aircraft and system installation, all to be specified in European Organization for Civil Aviation Equipment document ED-155, Minimum Operational Performance Specification for Lightweight Flight Recorder Systems, when the document is finalized and issued.

actuators with more than 500 hours since new and/or overhaul for plasma flakes or other contamination that exceeds the manufacturers‘ allowable limits of concentration and size; 2) conduct subsequent recurring tests at a period not to exceed 500 hours; 3) report findings of contamination and flakes to the FAA and/or Sikorsky and 4) correct any problems as necessary. This recommendation is classified ―Open—Acceptable Action.‖ Safety Recommendation A-05-35 asked the FAA to direct principal operations inspectors of all Sikorsky S-76 helicopter operators to reemphasize the importance of and requirement for a preflight check of control movement smoothness and flight control ―stick-jump‖ at every engine start. This recommendation is classified ―Closed— Acceptable Action.‖ 69 Several sections of the regulations were changed on October 11, 1991, to upgrade the flight recorder requirements to require that multiengine, turbine-engine powered airplanes or rotorcraft having a passenger seating configuration, excluding any required crewmember seat, of 10 to 19 seats be equipped with a digital flight recorder. 70 For more information, see Midair Collision of Electronic News Gathering Helicopters KTVK-TV, Eurocopter AS350B2, N613TV, and U.S. Helicopters, Inc., Eurocopter AS350B2, N215TV Phoenix, Arizona, July 27, 2007, Aviation Accident Report NTSB/AAR-09-02 (Washington, DC: National Transportation Safety Board, 2009).

NTSB Aircraft Accident Report 46

In August 2009, European Organization for Civil Aviation Equipment document ED-155 was approved and published. On August 27, 2009, pending the FAA‘s issuance of a technical standards order that includes the specifications of ED-155, Safety Recommendation A-09-11 was classified ―Open—Acceptable Response.‖ 1.18.3.5 Obstructive Sleep Apnea On August 7, 2009, the NTSB issued three recommendations to the FAA about the need to educate, screen, and treat pilots for obstructive sleep apnea, a medically treatable sleep disorder in which an individual‘s airway is repeatedly blocked during sleep, resulting in daytime decrements in alertness and cognitive functioning. Specifically, the NTSB recommended that the FAA do the following: Modify the Application for Airman Medical Certificate to elicit specific information about any previous diagnosis of obstructive sleep apnea and about the presence of specific risk factors for that disorder. (A-09-61) Implement a program to identify pilots at high risk for obstructive sleep apnea and require that those pilots provide evidence through the medical certification process of having been appropriately evaluated and, if treatment is needed, effectively treated for that disorder before being granted unrestricted medical certification. (A-09-62) Develop and disseminate guidance for pilots, employers, and physicians regarding the identification and treatment of individuals at high risk of obstructive sleep apnea, emphasizing that pilots who have obstructive sleep apnea that is effectively treated are routinely approved for continued medical certification. (A-09-63) These recommendations are currently classified ―Open—Await Response.‖ 1.18.4 Minimum Safe Altitude Warning FAA radar systems are capable of providing minimum safe altitude warning (MSAW) service to aircraft under ATC control. The service is normally provided only to aircraft operating on an IFR transponder code. Trooper 2 was operating on a transponder code that was pre-assigned to the MSP helicopter at ADW. This code was classified by the PCT radar processing system as a VFR code, which was ineligible for MSAW processing. However, before Trooper 2 received clearance for an IFR approach, a new code that would make the aircraft eligible for MSAW service should have been issued by the PCT controller but was not. The FAA was asked by NTSB investigators to determine whether Trooper 2‘s flightpath would have caused an MSAW alert had the helicopter been on an MSAW-eligible code. The

NTSB Aircraft Accident Report 47 FAA‘s MSAW performance analysis determined that no MSAW alerts would have been issued for Trooper 2.

NTSB Aircraft Accident Report 48

1. Analysis
2. 1

General The pilot was properly certificated and qualified in accordance with MSP standards. Additionally, although the FAA classified the flight as a public operation, the pilot was qualified under 14 CFR Part 91 to conduct the flight under VFR or IFR as a civil operation. The helicopter was properly certificated, equipped, and maintained in accordance with the requirements in 14 CFR Parts 43 and 91 applicable to civil aircraft operating under VFR or IFR. The recovered components showed no evidence of any preimpact structural, engine, or system failures. IMC prevailed in the accident area with scattered clouds near 200 feet agl and cloud ceilings near 500 feet agl. Although ADW was reporting visibility of 4 miles in mist, lower visibilities in fog occurred locally in the accident area. This analysis will address the following issues: risk assessments, pilot performance and training, TAWS, ATC deficiencies, SYSCOM duty officer performance, and emergency response. Patient transport decisions, flight recorder requirements, and oversight are also discussed. 2.2 Pilot’s Decision to Accept the Flight At the beginning of his shift, the pilot obtained a computerized weather briefing from the FAA‘s DUAT service. Although the briefing the pilot obtained included observations, forecasts, and other information, it did not include weather hazards, a topic the pilot chose not to include in the briefing. If the pilot had included weather hazards, the briefing would have contained an AIRMET for IFR conditions issued at 1645 and valid until 2300 for an area that began immediately north and east of ADW, covered eastern Maryland and Delaware, and extended through New England. PGH was located within the boundaries of the AIRMET; ADW and the landing zone at Waldorf were not. At the time of the briefing, the current weather at ADW indicated VFR conditions with a temperature/dew point spread of 1° C. The ADW forecast weather until 0100 on September 28 indicated VFR conditions, and between 0100 and 0200, the weather at ADW was expected to deteriorate to IFR conditions with the ceiling broken at 500 feet and overcast at 1,000 feet. The DCA forecast indicated that by 2200, the weather conditions were expected to deteriorate to IFR conditions with scattered clouds at 400 feet and ceiling overcast at 800 feet. These conditions were above the MSP Aviation Command minimums for acceptance of a night medevac flight (800 foot ceiling, 3 miles visibility). However, the ADW and DCA forecasts of deteriorating

NTSB Aircraft Accident Report 49 weather and the small temperature/dew point spread at ADW should have alerted the pilot to the possibility of local fog or low cloud formation as the evening progressed. According to FAA AC 00-6A, ―Aviation Weather,‖ pilots should anticipate fog when the temperature-dew point spread is 5° F (3.6° C) or less and decreasing. Since the weather conditions were close to MSP minimums and the forecast called for conditions to deteriorate, the section was accepting flights on a ―call by call‖ basis, and MSP procedures required the pilot to conduct a check of the weather every 2 hours. The procedures did not specify what weather sources were considered acceptable for use in obtaining the required weather updates. There is no record of the pilot receiving another weather briefing during his shift either on the computer from DUAT or by calling a weather briefer. However, there is evidence that the pilot used the HEMS weather tool to check the weather before accepting the flight. Another pilot observed the HEMS weather tool displayed on the hangar computer after the accident, and the accident pilot‘s remarks suggest he was viewing the weather observations available through the tool during his conversation with the SYSCOM DO when he received the call for the flight. Normally, the surface weather observations for ADW, DCA, Fort Belvoir, and College Park are available through the HEMS weather tool. However, the weather reports for ADW and Fort Belvoir were not available on the night of the accident because of a technical failure of a DoD communications system (described in section 1.7.2). Therefore, the pilot was unaware that Fort Belvoir was reporting IFR conditions with a visibility of 1 1/4 miles in mist and a 0° temperature/dew point spread. It is unknown whether the pilot obtained the ADW weather (which was VFR conditions with a temperature/dew point spread of 0°) from another source, such as the airport‘s automatic terminal information service.71 During his conversation with the DO, the pilot specifically mentioned only the weather conditions at College Park and DCA. The weather reports for both of these locations met the MSP criteria for acceptance of a night medevac flight. However, College Park was at the 800-foot minimum ceiling for acceptance of a flight and was reporting a 0° temperature/dew point spread. The pilot‘s conversation with the DO indicated that the pilot was hesitant to accept the flight, as he was unsure he could make it to PGH due to deteriorating weather conditions. During the conversation, he stated that ―maybe [the first responders] would change their mind‖ about the flight request, indicating his reluctance to accept the flight. However, despite his misgivings, the pilot decided to accept the flight. The pilot‘s comments, ―if they can do it we can do it,‖ followed by, ―yeah we ought to be able to do it…we‘re going to try it,‖ show that his decision-making was influenced by the report that another medevac helicopter had just successfully completed a flight. This could have led the pilot to conclude the weather was better than reported. Regardless of the unavailability of the DoD surface weather observations, the pilot did have access to information that indicated the weather conditions were continuing to deteriorate throughout the evening. In addition to surface observations, the pilot could also have viewed terminal area forecasts and AIRMETs via the HEMS weather tool. He could have obtained the amended terminal forecast for DCA, issued at 1933, which indicated that weather conditions

71 Local (on airport) dissemination of the ADW observations was not affected by the DoD data communications failure.

NTSB Aircraft Accident Report 50 were expected to deteriorate temporarily from VFR to IFR between 2000 and 2300 with the ceiling broken at 800 feet, overcast at 1,500 feet. Additionally, he could have obtained an AIRMET for IFR conditions issued at 2245 for an area that encompassed the entire route of Trooper 2. The forecast ceilings and visibilities in the DCA terminal forecast and in the AIRMET were above the MSP Aviation Command minimums for acceptance of a night medevac flight. However, the amendment to the DCA forecast and the issuance of the AIRMET indicated that weather conditions were continuing to deteriorate. Since HEMS weather tool data is not archived, it is not possible to determine what information was viewed by the pilot. It appears that the pilot based his decision to launch solely on the weather observations at College Park and DCA and the suitable conditions implied by the other medevac helicopter‘s completed flight. Other pertinent weather data—the low temperature/dew point spreads at ADW and College Park, the AIRMET for IFR conditions encompassing the route of flight, and the continuing deterioration of the weather conditions as the evening progressed—were either discounted by the pilot or not obtained. If the pilot had thoroughly obtained and reviewed all of the available weather information, it is likely he would have realized that there was a high probability of encountering weather conditions less than MSP minimums on the flight and this would have prompted him to decline the flight. Therefore, the NTSB concludes that the pilot‘s decision to accept the flight, after his inadequate assessment of the weather, contributed to the accident. According to the safety officer, at the time of the accident, MSP did not have a formal risk management program in place. He explained that there was optional guidance available to pilots in the form of a ―Risk Assessment Matrix.‖ However, review of the MSP Operations Manual revealed that it stated the flight crew ―will apply‖ the matrix and based on the risk assessment, increase visibility and ceiling minimums ―to the crew‘s comfort level prior to accepting the mission.‖ The matrix indicated that a temperature/dew point spread of less than 2° C raised the flight risk from low to medium risk. Although the matrix indicated that no flights were to be made if the risk level was high, it provided no instructions concerning medium-risk flights. There is no evidence indicating that the accident pilot consulted the matrix before the flight. Even if he had referred to it, the pilot might not have changed his decision to accept the flight, since the matrix did not provide clear guidance on medium-risk flights. The NTSB notes that following the accident, MSP designed a new mission-specific flight risk assessment tool, and pilots are now required to use this tool before all flights. In addition to classifying the risk level as green (low), yellow (medium), or high (red), the new tool calculates a percentage associated with the operational risk. High-risk flights now require approval from the director of flight operations or a designee before a flight can be accepted. When medium-risk flights fall near the high end of the yellow range, the flight crew informs SYSCOM that any change in flight, such as deteriorating weather, could put them into the red and approval would be required to continue the flight or that the flight could be cancelled. Moreover, SYSCOM notifies the requesting agency that the estimated arrival time could be increased or the flight cancelled if there is an increase in operational risk. If this program had been in place at the time of the accident, then, when the pilot completed the risk assessment, he would likely have determined that the risk level was near the high end of the medium-risk range, which would have triggered the procedures described above, and the ensuing discussion may have resulted in

NTSB Aircraft Accident Report 51 cancellation of the flight. Therefore, the NTSB concludes that had a formal flight risk evaluation program been in place at MSP before the accident, it may have resulted in the cancellation of the flight. Safety Recommendation A-06-13 asked the FAA to require all EMS operators to develop and implement flight risk evaluation programs. The FAA has provided guidance on the development and use of flight risk evaluation programs by EMS operators but has not required that all EMS operators implement flight risk evaluation programs. As a result, Safety Recommendation A-06-13 was classified ―Open—Unacceptable Response.‖ The NTSB believes that this accident demonstrates the need for all EMS operators, both public and civil, to develop and implement flight risk evaluation programs. Since the FAA does not have the authority to regulate public operators, even if the FAA were to require flight risk evaluation programs for HEMS operators, public operators would not be required to comply. Therefore, the NTSB recommends that all public HEMS operators develop and implement flight risk evaluation programs that include training for all employees involved in the operation, procedures that support the systematic evaluation of flight risks, and consultation with others trained in HEMS flight operations if the risks reach a predefined level. Additionally, the NTSB continues to believe that the FAA should require all EMS operators to develop and implement flight risk evaluation programs that include training for all employees involved in the operation, procedures that support the systematic evaluation of flight risks, and consultation with others trained in EMS flight operations if the risks reach a predefined level. Therefore, the NTSB reiterates Safety Recommendation A-06-13. Following the accident, MSP developed new procedures that involve the DO in flight risk assessment decisions. Before the accident, when a flight request was received, the DO passed the request directly to the flight crew. Under the new procedures, the DO evaluates the local and regional weather conditions displayed on the HEMS weather tool and can make a no-go decision based on this evaluation before the flight crew is notified. Also, as discussed previously, the DO is notified by the flight crew if the crew determines that the flight risk is near the high end of the yellow range, and the DO is then responsible for notifying the requesting agency that the helicopter‘s arrival could be delayed or the flight cancelled if the operational risk increases. Safety Recommendation A-06-14 asked the FAA to require all EMS operators to use formalized dispatch and flight-following procedures (through ADS-B tracking) that include up-to-date weather information and assistance in flight risk assessment decisions. The FAA has published detailed guidance about the creation and operation of operations control centers for helicopter EMS operations, and, pending FAA action to require that all civil EMS operators follow the guidance, the NTSB classified Safety Recommendation A-06-14 as ―Open— Acceptable Response.‖ The NTSB notes that MSP does have formalized dispatch and flight- following procedures, which are functions of SYSCOM, and that the SYSCOM DO has access to the HEMS weather tool, which provides up-to-date weather information. The NTSB further notes that the postaccident changes made by the MSP which involve the DO in flight risk assessment decisions are in accord with Safety Recommendation A-06-14. However, the NTSB is concerned that other public HEMS operators may not have operations control centers like

NTSB Aircraft Accident Report 52 SYSCOM that provide dispatch and flight-following service, weather information, and assistance in flight risk assessment decisions. Therefore, the NTSB recommends that that all public HEMS operators use formalized dispatch and flight-following procedures that include up-to-date weather information and assistance in flight risk assessment decisions. 2.3 Accident Sequence The NTSB concludes that when the pilot was unable to reach PGH due to deteriorating weather conditions, he appropriately made the decision to divert to ADW and request ground transport for the patients. When the pilot contacted ADW tower, he reported to the controller that he was ―on the localizer for runway 19R.‖ At this time, the helicopter was about 6 nautical miles from the runway and tracking the localizer course at an altitude of 1,900 feet msl. Review of radar and ADS-B data showed that the helicopter‘s heading, turns, and intercept of the localizer course were smooth, uniform, and precise, consistent with autopilot use. Approximately 1 minute and 20 seconds after his initial call to ADW tower, the pilot reported that he was ―not picking up the glideslope.‖ The controller responded that her ILS equipment status display was indicating no anomalies with the equipment. Radar and ADS-B data indicated that at the time of the pilot's transmission, the helicopter was maintaining a descent consistent with following the glideslope. (See figure 7 below.) Additionally, a postaccident flight test conducted by the FAA revealed no anomalies with the Figure 7. Comparison of Trooper 2’s flightpath to the runway 19R glideslope. (Not to scale.) Blue line indicates runway 19R glideslope centerline; red line indicates Trooper 2’s flightpath.

NTSB Aircraft Accident Report 53 instrument approach equipment, and NTSB testing of the helicopter‘s navigation equipment found no deficiencies that would have precluded the pilot from capturing the glideslope. The NTSB was unable to determine which navigational frequencies the pilot had selected or what the pilot was seeing on his instruments. Thus, the NTSB concludes that no evidence was found that suggests that the glideslope was not functioning properly. Further, the lack of information regarding the accident airplane‘s navigation frequency settings and flight instrument indications precluded NTSB investigators from determining why the pilot believed he was not receiving a valid glideslope signal. Even if the glideslope had failed, the accident pilot could have continued the approach, following the localizer-only guidance and assuring terrain clearance by remaining at or above the localizer-only MDA of 680 feet msl. However, the pilot requested an ASR approach, which the controller stated that she was unable to provide because of her lack of currency on the procedure. NTSB investigators considered two possible reasons for the pilot‘s request for a surveillance approach. One possibility was that the pilot did not have the ILS/LOC runway 19R approach chart visible as he was executing the approach to ADW. Therefore, he would not have been able to reference it to determine the MDA, the missed approach point, and other details of the localizer approach. Under this circumstance, the pilot‘s request for an ASR approach would be plausible because, if a surveillance radar approach had been provided, the controller would have advised the pilot that the MDA for the surveillance radar approach was 780 feet msl and instructed the pilot when to begin descent to the MDA. Additionally, at each mile of the final approach, the controller would have provided the pilot with the helicopter‘s distance from the missed approach point. According to MSP Aviation Command personnel, the instrument approach charts were kept in a pouch on the right side of the pilot‘s seat and would have been readily accessible to the pilot. At the accident site, the charts were found scattered throughout the debris near the nose of the helicopter, precluding a determination of whether the pilot was looking at a particular chart while on approach to ADW. Another possible reason for the pilot‘s request for an ASR approach was that he did not have the DME transceiver set to the frequency of the ADW VORTAC. The localizer approach to runway 19R requires DME readings off the ADW VORTAC to determine the final approach fix (where descent to the MDA begins) and the missed approach point (where the pilot has to decide whether to continue to land or to abort the approach). As described in section 1.16.2, the DME transceiver and the navigational receiver are usually set to the same frequency. Thus, in order to switch to the localizer frequency for runway 19R and retain DME information from the ADW VORTAC, the pilot would have had to select the ―HOLD‖ function on the navigation control head before switching frequencies. If the pilot did not select ―HOLD‖ before switching frequencies, the DME transceiver would have also been switched. The pilot would not have had any DME information and, therefore, would have had no means of determining the final approach fix or the missed approach point. Under this circumstance, the pilot‘s request for an ASR would again be plausible.

NTSB Aircraft Accident Report 54 There was insufficient information available to determine whether either of these two scenarios was the reason that the pilot requested an ASR approach. Regardless of the reason for his request, once the controller denied it, the pilot still had many options available to conduct a safe landing in instrument conditions. He could have declared an emergency, which would have prompted the ADW controller to provide assistance, possibly including the ASR approach. Also, he could have executed a missed approach and attempted the ILS approach a second time to determine if the glideslope failure was a perceived failure or a legitimate one. Additionally, there were 11 other instrument approaches at ADW, any of which he could have requested. About 27 seconds after the controller stated that she was unable to provide an ASR approach, upon reaching an altitude of about 1,450 feet msl on the glideslope and at a distance of about 4.0 miles north of the runway threshold, the helicopter‘s rate of descent increased rapidly from about 500 feet per minute (fpm) to greater than 2,000 fpm. The helicopter continued the descent, passing through the MDA for the localizer approach (407 feet agl), the alert height set on the radar altimeter (300 feet agl), and the decision height for the ILS approach (200 feet agl), before impacting trees and terrain about 3.2 miles north of the runway threshold. Data recovered from the PAR computer indicate that the helicopter impacted with the engines near idle power, the main rotor system at 100 percent rpm, and an indicated airspeed of about 92 knots. No evidence was found to indicate that the pilot made any attempt to arrest the helicopter‘s descent before impact. The sudden increase in the helicopter‘s rate of descent may indicate that the pilot deliberately deviated from the approach procedure by attempting to ―duck under‖ the cloud layer to regain visual conditions. Several factors might have encouraged the pilot to attempt to ―duck under‖ the cloud ceiling. First, the outdated ADW weather report provided by the PCT controller indicated a ceiling of 1,800 feet and 7 miles visibility. Given these conditions, the pilot would have had a reasonable expectation that he could have descended below the cloud ceiling at an altitude well above the MDA for the approach. Second, the pilot was based at ADW and familiar with its visual environment. This likely would have given him confidence that he would be able to identify landmarks and quickly determine his position once he descended below the cloud ceiling. Third, a return to visual conditions would have relieved the pilot of the additional workload generated by instrument flight. All medical flights involve significant workload and time pressure to provide patients with timely service to medical aid. However, this flight involved unusually high workload once the pilot encountered instrument conditions. These conditions greatly increased the demands on the pilot since he had little recent experience in actual instrument flying. Additionally, the weather prevented him from reaching the planned medical center, forcing him to divert with the new responsibility of considering alternate transport arrangements for the patients along with his diversion considerations. Workload was further increased by the limited support he received from ATC, which included unresponsiveness, inefficient clearances to ADW, and an inability to provide a requested ASR approach. The NTSB therefore concludes that the pilot‘s workload increased substantially and unexpectedly as a result of encountering instrument weather conditions.

NTSB Aircraft Accident Report 55 Further, the NTSB concludes that the pilot‘s expectation that he could descend below the cloud ceiling at an altitude above the MDA for the approach, his familiarity with ADW, and the reduction in workload a return to visual conditions would have provided are all factors that may have encouraged the pilot to deviate below the glideslope and attempt to ―duck under‖ the cloud ceiling. Regardless of the pilot‘s expectations for reaching VMC, once he deviated below the glideslope, he should have been prepared to level off at the MDA prescribed by the instrument approach procedure until he was able to confirm the airport environment as required by federal regulations. The pilot‘s failure to stop or slow the descent indicates that he was not aware of the helicopter‘s excessive descent rate or its height above the terrain, likely because he was looking outside the cockpit for the ground. At night, with low cloud ceilings, reduced visibility, and no surface light references, there were insufficient visual cues available for the pilot to establish ground reference. The helicopter was equipped with a radar altimeter, which should have alerted the pilot when he descended below 300 feet agl, about 6 seconds before impact with the trees.72 However, there was no decrease in the helicopter‘s descent rate after it passed through 300 feet agl. Testing of the radar altimeter revealed no discrepancies that would have prevented it from functioning normally during the accident flight. The NTSB concludes that the pilot failed to adhere to instrument approach procedures when he did not arrest the helicopter‘s descent at the MDA. The NTSB further concludes that although descent rate and altitude information were readily available through cockpit instruments, the pilot failed to monitor the instruments likely because he was preoccupied with looking for the ground, which he could not identify before impact due to the lack of external visual cues. Additionally, NTSB investigators asked a manufacturer of TAWS to determine what pilot alerts would be expected if the helicopter had been equipped with TAWS. The manufacturer ascertained that three aural terrain alerts would have been generated at 7, 4, and 2 seconds prior to tree impact, and an aural glideslope alert would have been generated 24 seconds prior to tree impact if a valid glideslope signal was being received. It is unlikely the glideslope warning would have caused the pilot to arrest his descent since it appears that he intentionally deviated from the glideslope. However, if the helicopter had been equipped with a TAWS, the aural terrain alerts of ―Caution Terrain,‖ ―Warning Terrain,‖ and ―Pull-up,‖ would have been provided. These would have been more salient than the alert provided by the radar altimeter and likely would have caused the pilot to attempt to arrest his descent. Although it is unknown whether the pilot could have recovered in time to avoid hitting the trees, this scenario does illustrate the potential benefit of TAWS. Safety Recommendation A-06-15 asked the FAA to require EMS operators to install TAWS on their aircraft. The FAA has not yet issued a rule to mandate the installation and use of TAWS on EMS flights, and as a result, on January 23, 2009, Safety Recommendation A-06-15

72 The 6-second duration was determined by converting the radar altimeter alert height of 300 feet agl to msl by adding the accident site elevation of about 200 feet, resulting in 500 feet msl and noting that the ADS-B target data indicate the helicopter descended through 500 feet msl about 6 seconds before the end of the data.

NTSB Aircraft Accident Report 56 was classified ―Open—Unacceptable Response.‖ The NTSB believes that this accident demonstrates the need for all EMS operators, both public and civil, to equip their aircraft with TAWS. Therefore, the NTSB reiterates Safety Recommendation A-06-15. However, since the FAA does not have the authority to regulate public operators, even if the FAA were to require TAWS for EMS operators, public operators would not be required to comply. Therefore, the NTSB recommends that all public HEMS operators install TAWS on their aircraft and provide adequate training to ensure that flight crews are capable of using the systems to safely conduct HEMS operations. 2.4 Air Traffic Control On Trooper 2's initial contact with PCT, the pilot stated that he was climbing to 2,000 feet and requested an approach to ADW. Although the PCT controller acknowledged Trooper 2‘s initial contact, after the pilot stated his request, the controller did not respond for over a minute. The pilot called again, and the controller responded with an instruction to contact DCA tower, completely disregarding the pilot's request for an approach to ADW. The pilot had to restate his request before the controller began to handle the flight as an ADW arrival. While Trooper 2 was being vectored for the approach, the controller stated that the current ADW weather was 1,800 broken, visibility 7 miles, temperature 21 °C, and dew point 19 °C. Review of ADW weather data showed that the weather given to the pilot had been issued at 1855 local time, almost 5 hours earlier. Weather information available to controllers is time-stamped, and the controller should have noticed that the report was outdated. The controller did not appear to have noticed the time discrepancy and did not advise the pilot of the age of the report or take any action to contact ADW for current weather information. During the time that the aircraft was being vectored for the approach, ADW was reporting wind from 110° at 3 knots, visibility 7 miles, cloud ceiling 1,300 broken, temperature 20° C, dew point 20 °C. Although these weather conditions were well above the localizer-only and ILS landing minimums for the runway 19R approaches, the cloud ceiling was 500 feet lower than that reported to Trooper 2. If the pilot had been given the current weather information, he would have expected to be unable to see the ground until he had reached a significantly lower altitude. Knowing that the ceiling was 500 feet lower may have discouraged the pilot from attempting to duck under the cloud ceiling and resulted in his continuing the approach to the airport at a 500 fpm rate of descent. Therefore, the NTSB concludes that the failure of the PCT controller to provide the current ADW weather information likely led the pilot to expect that he could descend below the cloud ceiling and establish visual contact with the ground at an altitude well above the MDA for the approach. The controller did not explicitly issue Trooper 2 an instrument clearance or an IFR transponder code. An IFR transponder code is necessary for aircraft to receive MSAW service. When interviewed, he stated that the pilot never requested an instrument clearance, and the controller believed that the pilot wanted a VFR practice approach to ADW. As the pilot had requested IFR from DCA and there was no further discussion of VFR operations by either the pilot or the PCT controller after he was handed off, the pilot could have reasonably expected that he was operating under IFR despite not having received an explicit IFR clearance from PCT. The

NTSB Aircraft Accident Report 57 controller's statement that he believed Trooper 2 was VFR all the way to touchdown is contravened by the controller's failure to restrict the aircraft to VFR operations as required by FAA directives. Between the time Trooper 2 contacted PCT and issuance of the IFR approach clearance, Trooper 2‘s status as an IFR or VFR flight was ambiguous. Once the helicopter was cleared for an approach without a VFR restriction, Trooper 2 was an IFR flight and should have been given an IFR transponder code. Although the controller‘s failure to issue an IFR code resulted in Trooper 2 not being covered by MSAW service, postaccident MSAW analysis performed by the FAA and reviewed by NTSB determined that no MSAW alerts would have been issued for Trooper 2 even if the helicopter had been on an MSAW-eligible code. The PCT controller's handling of Trooper 2 as the aircraft approached the ILS localizer course was also deficient. The aircraft was turned to intercept the localizer late, resulting in an overshoot that was corrected by the pilot rather than the controller. The controller issued a heading of 170°, which would have allowed Trooper 2 to intercept the final approach course at an angle of about 20°, except that the instruction was issued too late. Trooper 2 crossed the localizer and had to turn to intercept the final approach course from the east side, requiring a heading of about 210°. The pilot corrected the poor intercept on his own, with no comment or assistance from the controller. After Trooper 2 was transferred to ADW tower, the pilot reported that he was on the localizer and was cleared to land on the runway. Shortly afterward, Trooper 2 reported that he could not pick up the glideslope and requested an ASR approach. The ADW tower controller responded that she was not current to provide that service. As the pilot made no indication that he was in any difficulty, the controller‘s expectation was that Trooper 2 would complete a localizer approach. When interviewed, the controller stated that, if there had been any emergency need for the ASR approach, she would have provided it. However, this event raises the question of why she was not current. NTSB investigators found that lack of currency was widespread among ADW controllers and appears to have been the result of a lack of diligence on the part of ADW tower management in monitoring currency and ensuring that controllers remained qualified on all positions. Following the accident, about 75 percent of the controllers at ADW achieved currency on ASR approaches. Subsequently, the FAA suspended ASR approaches at ADW because of an internal dispute about whether the service would be provided by ADW or PCT. At the time of this writing, ADW ASR procedures remain suspended. The NTSB concludes that air traffic services provided by the DCA and PCT controllers to the accident flight exhibited numerous procedural deficiencies, including unresponsiveness, inattention, and poor radar vectoring. These deficiencies were a distraction to the pilot and increased his workload by requiring him to compensate for the poor services provided. 2.5 Instrument Training and Experience Prior to this accident, MSP had flown helicopters for 22 years without a fatal accident. The previous fatal accident, in 1986, involved an encounter with instrument conditions and subsequent collision with terrain. Following the 1986 accident, MSP emphasized the importance

NTSB Aircraft Accident Report 58 of instrument experience and proficiency among its pilots. The instrument training program remained the same until 10 months before the accident, when according to some pilots and instructors, the instrument training requirements were effectively downgraded. Before the instrument training change in November 2007, MSP pilots performed six approaches every 6 months to maintain currency. The program was changed to require that pilots receive an IPC every 6 months. According to the chief pilot, he decided to change the training program because pilots were not conducting ―quality training‖ when practicing with other pilots. However, another instructor reported that the rationale behind the change was not just to have pilots fly with instructors but also to ―save flight time by reducing the total flying time it took to remain qualified for the job.‖ Although pilots were still allowed to practice approaches in addition to the required IPCs, interviews revealed this was not happening. Interviews with pilots also revealed a concern that, although they were maintaining currency with the new training program, they were not maintaining proficiency. One instructor stated that he did not think two IPCs a year was enough training for pilots to maintain proficiency and that pilots needed to practice more than that. Another pilot stated that ―getting half the previous number of practice approaches and going 6 months between training opportunities provides neither the frequency nor the quantity of instrument practice needed for this demanding and hazardous flying environment.‖ By definition, proficiency is a thorough competence derived from training and practice. Regarding instrument proficiency, an article by AOPA‘s Air Safety Foundation73 states that instrument flying is a "use it or lose it" skill. The article suggests that in addition to FAA currency requirements, pilots have: a) at least 1 hour of simulated or actual instrument time in the previous month; b) at least one instrument approach in the same period; and c) an IPC in the previous 6 months. By following these suggestions for 1 year, a pilot should accumulate a minimum of 12 hours of instrument time, 12 instrument approaches, and 2 IPCs. In the year prior to the MSP‘s change in its instrument training program, the pilot logged instrument time on 7 flights, accumulating 6.2 hours of instrument time, and completing 20 approaches. After the change and in the year prior to the accident, the pilot logged instrument time on only 2 flights, which included 2.1 hours of instrument time and 4 instrument approaches. This is a substantial reduction in training and well below that suggested by AOPA. In addition to his limited instrument experience in the 12 months prior to the accident, the pilot had not flown at night under instrument conditions since October 29, 2006, 23 months before the accident. Also, although the pilot had conducted the majority (20 out of 24) of his instrument approaches in the past 2 years at ADW, only 4 of those were nonprecision approaches, and they did not include the localizer approach to runway 19R.

73 AOPA Air Safety Foundation is a nonprofit organization promoting safety and pilot proficiency in general aviation through training, education, research, analysis, and information dissemination. The referenced article, ―Safety Hot Spot: Pilot Proficiency and the Flight Review,‖ can be found online at http://www.aopa.org/asf/hotspot/proficiency_check.html.

NTSB Aircraft Accident Report 59 The NTSB concludes that although the pilot met the recent-experience requirements to act as PIC under IFR, he was not proficient in instrument flight. This lack of proficiency likely contributed to the pilot‘s failure to properly conduct what effectively became a nonprecision approach at night in instrument conditions. Furthermore, the NTSB concludes that changes made by the MSP Aviation Command to its instrument training program about 10 months before the accident did not promote instrument proficiency. The NTSB notes that MSP Aviation Command has made postaccident changes in its training program including adding requirements for pilots to conduct ―one instrument approach in VMC per month on the return leg of a mission‖ and ―one instrument approach flight per month with another check pilot.‖ However, the NTSB is concerned that no requirements have been added for the performance of nonprecision approaches or for the performance of instrument approaches at night. If the accident pilot had received more recent and targeted instrument training and had more opportunities to practice his instrument skills, he would have been better prepared to cope with the situation he encountered during the accident flight. This accident highlights the need for scenario-based training tailored to address the hazards unique to HEMS operations. The NTSB recently issued Safety Recommendation A-09-97 to all public HEMS operators, including MSP, recommending they conduct scenario-based training, including the use of simulators and flight training devices, for HEMS pilots, to include inadvertent flight into IMC and hazards unique to HEMS operations, and conduct this training frequently enough to ensure proficiency. 2.6 Fatigue The pilot was off duty for 2 days before the accident, and evidence indicates that his activities, behavior, and sleep schedule were routine. On the day of the accident, he awoke about 0800, conducted routine activities, and began the accident shift at 1900. There was no evidence available to determine if the pilot napped or drank coffee before he was notified about the accident mission at 2302, although both rest facilities and coffee were available and either would have benefited the pilot as a fatigue countermeasure.74 The accident occurred around the pilot‘s normal bedtime of midnight, about 16 hours after he had awakened from his nighttime sleep. Both the late hour and length of time awake are factors that could have produced fatigue. The accident pilot displayed two significant risk factors for obstructive sleep apnea: obesity and loud snoring.75 The NTSB has recently issued recommendations to the FAA about a need to educate, screen, and treat pilots for obstructive sleep apnea, a medically treatable sleep disorder in which an individual‘s airway is repeatedly blocked during sleep resulting in daytime decrements in alertness and cognitive functioning. Such education, screening, and treatment may have benefitted the pilot, if he did suffer from a sleep disorder such as apnea. Untreated sleep

74 According to his wife, the pilot was normally able to nap during the day and regularly drank coffee. 75 Medical literature suggests that loud snoring and obesity are significant risk factors for the presence of obstructive sleep apnea. See O. Resta, et. al. (2001). Sleep-related breathing disorders, loud snoring and excessive daytime sleepiness in obese subjects. International Journal of Obesity, 25, 669-675.

NTSB Aircraft Accident Report 60 disorders such as obstructive sleep apnea could have been an additional potential cause of fatigue for the accident pilot. Police and air traffic recordings from the accident period revealed no gross deficiencies in alertness or pilot responsiveness (and in fact, as noted above, the pilot was sufficiently responsive to correct an air traffic controller‘s deficiencies in his handling). However, the pilot made an improper decision to deviate from the published instrument approach procedure. Fatigue, in combination with the high workload the pilot was experiencing, could explain this uncharacteristically deficient decision. Therefore, based on the late hour, the length of time awake, the risk factors for sleep apnea exhibited by the pilot, and the decision to deviate from the published procedures, the NTSB concludes that the pilot was likely less than fully alert, and fatigue may have contributed to his deficient decision-making. The NTSB recognizes that the implementation of a comprehensive program to educate, screen, and treat pilots of obstructive sleep apnea will take time. In the meantime, the NTSB recommends that the MSP implement a program to screen and—if necessary—treat its pilots for obstructive sleep apnea. 2.7 Survival Factors As the helicopter descended into the trees, the forward right part of the airframe experienced a significant tree strike that immediately killed the pilot and tore away the right side of the fuselage, ejecting the secondary litter and patient, who survived. The helicopter then fell on its left side. The crash forces and reduction in volume of occupiable space within the cabin (resulting from both tree strikes and the secondary impact with the ground) precluded survival for the cabin occupants; and therefore, this accident is considered nonsurvivable.76 Had the survivor remained inside the helicopter, she would likely have been fatally injured. Examination of the medic‘s restraints indicated they were not in use at the time of the accident. Given the loss of occupiable space within the cabin, it is unlikely that the medic‘s failure to restrain himself played a role in his death. 2.7.1 SYSCOM The SYSCOM DO made numerous errors on the night of the accident. In particular, he did not accomplish what MSP procedures specify as his primary duty: to ensure that all MSP Aviation Command helicopters were positively identified and tracked throughout each flight.

76 For an accident to be deemed survivable, the forces transmitted to occupants through their seat and restraint system cannot exceed the limits of human tolerance to abrupt accelerations, and the structure in the occupants‘ immediate environment must remain substantially intact to the extent that a liveable volume is provided for the occupants throughout the crash.

NTSB Aircraft Accident Report 61 It is apparent that the DO lost situational awareness of the accident helicopter during the final minutes of the flight. The ADS-B trip history report indicated that the DO logged Trooper 2 as landed at ADW at 0002:02. At this time, he most likely also silenced the audible alarm associated with the loss of ADS-B tracking. When he received a call 16 minutes after the crash asking where Trooper 2 was, the DO immediately responded, ―they landed at Andrews.‖ When informed that ADW tower had lost Trooper 2 off radar, he was surprised. He then attempted to contact Trooper 2 by radio and got no response. During the investigation, NTSB investigators learned that, against MSP operational policy, DOs routinely disregarded ADS-B loss of signal alerts and only attempted to contact flight crews when a signal was lost during cruise flight. This lack of adherence to policy created an institutional mindset that assumed that a helicopter had landed safely when its ADS-B signal was lost during the landing phase of flight. This problem was compounded because there was no requirement for flight crews to call back into SYSCOM within a specific timeframe after landing. The routine lack of positive feedback communication from helicopters allowed DOs to assume that aircraft had landed safely and, over time, safe landings were taken for granted. The NTSB concludes that the MSP SYSCOM DO lost situational awareness of the helicopter while it was in flight. Further, the NTSB concludes that the lack of adherence to effective flight-tracking policies by MSP SYSCOM personnel created an institutional mindset that allowed DOs to assume that aircraft had landed safely when the ADS-B signal was lost; over time, safe landings were taken for granted. In the memorandum detailing postaccident changes, the MSP indicated that it has resumed conducting unannounced, missing aircraft exercises. Additionally, flight crews are now required to call in to SYSCOM within 5 minutes of landing. 2.7.2 Emergency Response The wreckage was located by the pilot and medic of Trooper 8, who organized their own impromptu search effort. The two men took it upon themselves to travel by car to the search area after their air search had to be aborted due to weather conditions. After meeting with another MSP officer, they contacted ADW tower and, using the information obtained and their knowledge of aviation, correctly identified the most probable location of the accident and responded to Walker Mill Regional Park. The two men had been at Walker Mill Regional Park previously (after initially plotting the last known position coordinates they received from SYSCOM) but left the area after receiving information about a ―ping‖ from one of the troopers‘ cell phones. At the time the two men located Trooper 2, both PG County and MSP search efforts were primarily focused on a construction area about 1.25 miles east of the accident site. This area was very expansive and dark and the process of obtaining sufficient four-wheel drive vehicles for a search would have taken considerable time. Additionally, visibility in the area was reported to be approximately 50 feet, which would have further slowed the search process. Given the darkness,

NTSB Aircraft Accident Report 62 fog, and delay in obtaining four-wheel drive vehicles, it would likely have taken several hours to thoroughly search the construction area. Until this area was searched, it is unlikely that Walker Mill Regional Park would have been searched. Therefore, the NTSB concludes that had two MSP aviation employees not pursued their own search effort, locating the accident site would likely have taken several more hours than it did. 2.7.2.1 Maryland State Police Search and Rescue According to MSP operational policy at the time of the accident, the troopers at each barrack were to manage any incident that happened within their area of responsibility. Thus, the shift supervisor on duty at the Forestville barrack became the incident commander for the search until the barrack commander arrived about 0100 and took over. Both of these individuals were unfamiliar with aviation. The shift supervisor was not familiar with the flightpath inbound to ADW and was unable to tailor the search to the area directly along the flightpath. The barrack commander called MSP Forestville at 0154:39, almost 2 hours after the accident occurred, asking for Aviation Command units to respond to the command post at Forestville because, as she said, ―we‘ve got questions that we need them to answer about how things work.‖ If these Forestville troopers had been more knowledgeable about aviation, it is likely that MSP resources could have been used more effectively in searching for the missing helicopter. The NTSB concludes that the incident commander‘s lack of aviation knowledge diminished the effectiveness of search and rescue activities. The NTSB recognizes that it is not feasible to provide aviation-specific training to every trooper in a barrack who might conceivably serve as an incident commander. Therefore, the NTSB recommends that the MSP revise its policy regarding incident commanders to specify that, in any event involving a missing or overdue aircraft, an Aviation Command trooper will serve as the incident commander. About 0022:31, once he realized the helicopter was missing, the DO provided PG County dispatchers with Trooper 2‘s last ADS-B coordinates. He provided the coordinates by reading a string of numbers but did not mention the numbers were in the format of degrees, minutes, seconds. The PG County dispatchers assumed the coordinates were in the format of degrees, decimal degrees, which they were accustomed to using, and entered them in that format. The location returned by the software program was near Calvert Cliffs, Maryland, located about 30 miles southeast of the accident site. This location raised confusion among PG County personnel and, within 10 minutes, they called SYSCOM to verify the location. The PG County dispatcher reported the discrepancy to an operator at SYSCOM who responded, ―okay I don‘t know where the duty officer got those [coordinates]….‖ The operator did not communicate with the DO and verify the coordinates that were given to PG County dispatchers. Had the SYSCOM operator done so, the misunderstanding about the format of the coordinates might have been discovered, and the ongoing confusion about the helicopter being near Calvert Cliffs might not have persisted. NTSB investigators found evidence indicating that MSP personnel outside SYSCOM were not familiar with latitude and longitude coordinates. Interviews with MSP personnel at the Forestville barrack clearly indicated a complete lack of knowledge, at the time of the accident,

NTSB Aircraft Accident Report 63 regarding latitude and longitude coordinates and how they could be used. MSP road troopers performed their daily duties by referencing ADC grid maps and were not aware that those maps contained latitude and longitude coordinates. Some MSP patrol cars were equipped with laptop computers and software that allowed users to enter latitude and longitude coordinates, but none of the troopers interviewed had received any training on how to use this function. Therefore, the NTSB concludes that MSP troopers and SYSCOM personnel were insufficiently equipped and trained to conduct a search involving GPS coordinates, and that this hindered their ability to locate the site of the wreckage. In the memorandum detailing postaccident changes, the MSP indicated that it has provided instruction to all Aviation Command personnel and all MSP field personnel on the use and interpretation of latitude and longitude. At the time of the accident, the software on the SYSCOM DO‘s console provided a view of the ADS-B data overlaid on an aviation sectional chart. There was no ability to overlay the data on other types of maps, such as a topographic map or a road map, which would have provided the DO with more information about Trooper 2‘s last known position. For example, had the DO known that Trooper 2‘s last known position was in Walker Mill Regional Park, he would have provided this information to the incident commander at Forestville barrack, who would have undoubtedly sent more units to that location immediately. This would have obviated the need for MSP road troopers to know anything about GPS coordinates and given them a firm location with which to begin the search. It also would have ended the confusion about the helicopter being near Calvert Cliffs. MSP informed the NTSB that the software for ADS-B monitoring has been upgraded and is now capable of overlaying the data on ADC street maps, terrain maps, and satellite photos, as well as on aviation sectional charts. 2.7.2.2 Prince George’s County Search and Rescue During the search, PG County personnel offered to ―ping‖ the troopers‘ cell phones and possibly provide a better location to search. MSP accepted the offer and PG County personnel contacted the cellular service provider, who ―pinged‖ the cell phones and provided the street address of the closest cell phone tower. The cellular provider did not initially provide a distance or bearing from the tower to the cell phone, just the street address of the tower. Unfortunately, the street address location was immediately provided to PG County officers and MSP Forestville barrack troopers, and numerous officers responded to that location. Releasing the street address of the cell phone tower to all units without a distance and bearing only served to distract and confuse units that were already searching a more accurate location. (The SYSCOM DO had provided ADS-B coordinates of the helicopter‘s last known position.) The NTSB concludes that neither PG County nor MSP dispatchers fully understood the importance of obtaining distance and bearing information, as well as the cell tower location, before releasing a location obtained from cell phone ―pinging;‖ this lack of understanding led dispatchers to provide a simple street address of the cell phone tower without context to all units involved in the search. This distracted and confused units already searching a more likely

NTSB Aircraft Accident Report 64 location. Therefore, the NTSB recommends that the MSP and PG County provide additional training to their dispatchers on the use of cell phone ―pinging‖ and include instruction about how to integrate the data obtained from cell phone pinging into an overall search and rescue plan. 2.7.2.3 FAA Search and Rescue Support The ADW controller noticed that Trooper 2 was missing almost immediately after radar contact was lost, and she began attempting to contact the pilot. She also advised the ADW fire department chief, who was expecting to meet the helicopter, that Trooper 2 was out of contact. Although the controller's efforts did not follow the ADW tower emergency notification procedures precisely, all the emergency responders in the area were alerted within a few minutes of the accident either by the controller or by the ADW fire chief. When asked, neither the ADW controller nor the PCT operations manager-on-duty was able to provide the coordinates of the helicopter‘s last known position. NTSB investigators determined that there were at least two ways that ADW or PCT could have provided the latitude and longitude of the location using ATC radar data. Postaccident discussions at PCT showed that a traffic management system known as "CountOps," which is available at both PCT and ADW, would have been able to provide a position of the last radar target within a few seconds. However, the ADW controller and the PCT operations manager were both insufficiently familiar with the system to use it for that purpose. Alternatively, recorded ATC radar data could have been used to establish the direction and distance from the ADW radar site of the last target for Trooper 2. Plotted on a map, the last radar target would have placed the helicopter in Walker Mill Regional Park. The NTSB concludes that the FAA ATC‘s inability to produce timely location data also hampered search and rescue efforts. The NTSB concludes that knowledge of the disjointed search and rescue efforts and the techniques eventually employed to locate the accident site could provide valuable lessons to agencies, such as HEMS dispatch centers, 911 dispatch centers, and fire, police, and sheriff‘s departments, involved in search and rescue efforts. Therefore, the NTSB recommends that the National Association of Air Medical Communications Specialists, the Association of Public-Safety Communications Officials International, the National Emergency Number Association, the International Association of Police Chiefs, the National Sheriffs‘ Association, and the International Association of Fire Chiefs inform their members through their websites, newsletters, and conferences of the lessons learned from the emergency response to this accident, particularly emphasizing that search and rescue personnel need to understand how to interpret and use both GPS coordinates and the results of cell phone ―pinging.‖

NTSB Aircraft Accident Report 65 2.8 Other Related Issues 2.8.1 Patient Transport Decisions First responders to the automobile accident determined, using guidelines provided by MIEMSS, that the victims of the automobile accident required treatment at a trauma center. Per the guidelines, they requested helicopter transport, since the nearest trauma center, located at PGH, was more than a 30-minute drive from the accident site on wet and slippery roads. Following the accident, MIEMSS reviewed the first responders‘ decision and determined that the ambulance drive time would have been about 48 minutes. Therefore, MIEMSS concluded that first responders appropriately followed established guidelines on the scene of the auto accident when making the decision to request helicopter transport. Although the NTSB does not dispute MIEMSS‘s conclusion that the guidelines in effect at the time were followed, the NTSB notes that, in this case and based on the radar data, if Trooper 2 had not been forced to divert to ADW by deteriorating weather conditions, it would have landed at PGH about 45 minutes after it was requested by the first responders. Compared to the ambulance drive time of about 48 minutes (the ambulance was already at the scene when Trooper 2 was requested), the use of a helicopter would have resulted in the patients arriving at the trauma center about 3 minutes faster. Additionally, the NTSB notes that as a result of the helicopter accident, MIEMSS updated the guidelines to require that first responders caring for patients classified as Category C or D consult with a physician before HEMS transport is summoned. In this particular case, the victims were classified as Category C of the four level classification scheme, from ―A‖ (the most serious injury) to ―D‖ (the least serious injury), and under the revised guidelines, a consultation would have been required before Trooper 2 was requested. The report of the expert panel convened by MIEMSS to review Maryland‘s HEMS program stated that the new consultation rule ―appears to be a prudent and reasonable approach to curtail air transport of more minor trauma patients‖—those rated as category C or D. MIEMSS usage data show a notable decrease of 42.7 percent in the number of patients transported on MSP medevac flights from FY2008 (July 1, 2007, to June 30, 2008) to FY2009, which can be attributed to the implementation of the consultation rule. Testimony given at the NTSB public hearing on the safety of the HEMS industry indicated that providers and organizations use a variety of standards (of varying quality) to decide when to request helicopter transport. There are no nationwide standards or recommended guidelines. During the course of this investigation, the executive director of MIEMSS suggested that a forum should be held to develop national standards on the use of aeromedical services in the transport of trauma victims. The NTSB recently issued Safety Recommendation A-09-103 to FICEMS recommending that they develop national guidelines for the selection of appropriate emergency transportation modes for urgent care.

NTSB Aircraft Accident Report 66 2.8.2 Flight Recorder Systems If a recorder system that captured cockpit audio, images, and parametric data had been installed on the accident helicopter, NTSB investigators would have been able to use the recorded data to determine additional information about the accident scenario, including navigation frequency settings and flight instrument indications. It is also possible that recorded images could have shown whether the pilot had the approach chart available to him. The NTSB concludes that having aboard the aircraft a recorder system that captured cockpit audio, images, and parametric data would have aided the NTSB in determining the circumstances that led to this accident. The NTSB notes that the accident helicopter was not required to have a CVR or FDR installed. However, it would have been required to have either these devices or a cockpit image recorder if the FAA had implemented NTSB Safety Recommendation A-06-17. Safety Recommendation A-06-17 asked the FAA to require, among other things that transport-category rotorcraft manufactured before October 11, 1991, operating under 14 CFR Parts 91 and 135 be equipped with either a CVR and an FDR or a cockpit image recorder. The accident helicopter was a transport-category rotorcraft manufactured in 1988. When the NTSB issued this recommendation, it stated that transport-category helicopters should be equipped with flight recorders77 in order to gather data critical to diagnosing shortcomings in the passenger-carrying helicopter fleet. Further, the NTSB stated that, although the FAA had increased the stringency of flight recorder requirements on passenger-carrying airplanes over a period of years, it had not universally applied these more stringent requirements to helicopters. On May 22, 2006, the FAA stated that it would review changes in FDR technology since 1988 and consider changes to its regulations based on this review. On November 29, 2006, the NTSB indicated that it did not believe the FAA‘s study was necessary and that it should begin the rulemaking process. As a result, Safety Recommendation A-06-17 was classified ―Open—Unacceptable Response.‖ The NTSB continues to believe that the FAA should require all rotorcraft operating under 14 CFR Parts 91 and 135 with a transport-category certification to be equipped with a CVR and a FDR. For those transport-category rotorcraft manufactured before October 11, 1991, the FAA should 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. Therefore, the NTSB reiterates Safety Recommendation A-06-17. On February 9, 2009, the NTSB issued Safety Recommendation A-09-11 to the FAA, asking the FAA to require that all existing turbine-powered, nonexperimental, nonrestricted-category aircraft that are not equipped with an FDR and are operating under Parts 91, 121, or 135 be retrofitted with a crash-resistant flight recorder system. (See section 1.18.3.4 for more information about this recommendation.) This recommendation is currently classified ―Open—Acceptable Response.‖ As a turbine-powered transport-category aircraft, the accident helicopter is covered by this recommendation. The NTSB notes that the accident that prompted issuance of Safety Recommendation A-09-11 involved a midair collision between two

77 The term ―flight recorders‖ refers to all crash-protected devices installed on aircraft, including but not limited to, FDRs, CVRs, and onboard image recorders.

NTSB Aircraft Accident Report 67 helicopters. This accident, which provides additional support for the recommendation, also involved a helicopter. These and other accidents demonstrate the need for flight recorders on helicopters as well as on airplanes. 2.8.3 Oversight During the course of this investigation, the NTSB learned that the MSP has minimal oversight and surveillance by any outside organization. The Maryland state legislature oversees the MSP‘s budget but has no direct responsibility for the day-to-day operations of the MSP Aviation Command, nor do they have an aviation surveillance function similar to the FAA.78 The FAA provides oversight of MSP‘s aviation maintenance practices through its surveillance of MSP‘s 14 CFR Part 145 maintenance repair station but has not conducted any recent surveillance of MSP aviation operations. FAA Order 8900.1 requires a nominal level of surveillance for public aircraft operators. The order states that government-owned aircraft operators conducting public aircraft operations should be included in the FSDO‘s annual planned surveillance activities to ensure that the operator‘s public status remains unchanged. Additionally, the order states that government-owned aircraft operators holding any type of FAA certification will be included in the normal surveillance activities, such as spot inspections (ramp checks) of the aircraft and aircraft records. Since MSP aircraft have airworthiness certificates, MSP should be included in normal surveillance activities. However, despite its own order requiring surveillance, the FAA had not conducted any recent operational surveillance of MSP. Even if the FAA had performed the minimal amount of surveillance currently required by Order 8900.1, it is unlikely this would have prevented the accident. However, if MSP had been operating under a 14 CFR Part 135 certificate, the FAA would have reviewed the changes MSP made to its instrument training program in November 2007 and may have required modification of the program to include conducting nonprecision approaches, night approaches, and more frequent instrument practice. Additionally, the FAA would have reviewed MSP‘s operations manual and required the correction of any inconsistencies found between the manual and the procedures being followed. If the FAA had noted that the manual required the flight crew to apply the Risk Assessment Matrix before accepting each flight but that flight crews were not doing so, this may have resulted in the earlier implementation of a formalized flight risk management program at MSP. These types of changes may have prevented the accident. The NTSB recently learned that MSP had informed the FAA‘s Baltimore FSDO that it wanted to seek 14 CFR Part 135 certification, and, although the initial verbal response the MSP received from the FSDO manager was not supportive, later written guidance from the FAA associate administrator for aviation safety encouraged MSP to proceed with the application process for Part 135 certification. Additionally, the associate administrator informed MSP that it could ―immediately adopt, and comply with, the more stringent 14 CFR part 135 regulations

78 The legislature did conduct an audit of certain aspects of MSP‘s helicopter program in 2008; however, the scope of this audit did not include a review of aviation operational practices.

NTSB Aircraft Accident Report 68 required by the FAA for 14 CFR part 135 air carriers without having such a certificate.‖ The NTSB is reassured by the position the FAA has taken in this manner, which supports a voluntary request from a public operator for a higher level of oversight. At the time of the accident, MSP considered its medevac flights ―civil‖ aircraft operations operating under Part 91. A March 2008 memorandum from the commander to all personnel on the subject ―Public Aircraft (Use) vs. Civil Aircraft (Part 91) Operations‖ explained MSP‘s determination of which operations were ―civil‖ and which were ―public.‖ Review of the memorandum indicated that MSP made its determination by following the guidance provided in FAA AC 00-1.1, ―Government Aircraft Operations.‖ Per the guidance in the AC, the memorandum identified ―medevac operations, VIP transports, training flights, mechanic transports, photo flights, etc.‖ as ―civil‖ operations to be conducted in accordance with Part 91 and MSP policies and procedures. It identified ―search and rescue missions and law enforcement support/homeland security operations, etc.‖ as ―public‖ operations to be conducted in accordance with MSP policies and procedures. Further, the memorandum also followed the AC‘s guidance in stating that since MSP conducted both ―civil‖ and ―public‖ operations with the same aircraft, it was required to maintain its aircraft in accordance with the regulations applicable to civil aircraft in Parts 43 and 91. Prior to this accident, it appeared that the FAA also considered MSP‘s medevac flights to be civil, based on the FAA‘s published positions in AC 00-1.1 and Order 8900.1 and on a letter sent in 2000 from the FAA to a Part 135 HEMS operator, who requested an operational classification of MSP‘s interhospital patient transfers. In this letter, the FAA stated that assuming MSP‘s aircraft and pilots meet the requirements for civil aircraft operations, ―so long as the MSP does not receive compensation from the hospital or patients for the air transportation portion of the interhospital transfers, these flights may be conducted as civil aircraft operations under Part 91.‖ This statement is consistent with the guidance in Order 8900.1 regarding medevac flights that excludes the ―routine medical evacuation of persons due to traffic accidents and other similar incidents or hospital-to-hospital transfers‖ from the government function of search and rescue. Despite the FAA‘s earlier opinion, during this accident investigation, the FAA provided to the NTSB a memorandum with a conflicting opinion on the operating status of MSP medevac flights. In this memorandum, dated March 13, 2009, the FAA stated that it believed the accident flight was a ―public‖ aircraft operation. The FAA supported its determination by referring to the definition of public aircraft in 49 U.S.C. section 40102(a)(41)(C) and the exception provided in 49 U.S.C. section 40125(b), which states that a government-owned aircraft does not qualify as a public aircraft ―when it is used for commercial purposes or to carry an individual other than a crewmember or a qualified non-crewmember.‖ The FAA indicated that since MSP does not operate its helicopters ―for compensation or hire,‖ Trooper 2 was not being used for commercial purposes. Further, the FAA indicated that the accident victims are considered to be ―qualified non-crewmembers‖ as they are individuals who are ―associated with the performance of a governmental function.‖

NTSB Aircraft Accident Report 69 The FAA did acknowledge in its memorandum that medevac flights are not specifically called out as an example of a governmental function in the statute. However, the FAA stated that it considered ―helicopter emergency medical services as akin to the ‗search and rescue‘ function used as an example in the statute and as falling within the statutory intent of governmental function.‖ This new opinion is in direct contradiction with the guidance provided in FAA Order 8900.1 regarding medevac flights, which states that, ―the term ‗search and rescue‘ does not include routine medical evacuation of persons due to traffic accidents and other similar incidents or hospital-to-hospital patient transfers.‖ It is also in conflict with the guidance provided in AC 00-1.1, which states that the term ―medical evacuation‖ is not considered synonymous with ―search and rescue.‖ The FAA noted that it was aware of these contradictions and that ―internal agency materials‖ were being updated. As of the date of this writing, the guidance in FAA Order 8900.1 and AC 00-1.1 regarding medevac flights has not been revised. The NTSB sees no basis for the FAA‘s determination that all medevac flights fall within the statutory intent of governmental function. Given that medevac flights are routinely conducted each day by numerous civilian operators, medevac cannot, as a general matter, be considered a governmental function. The NTSB finds persuasive the FAA‘s earlier guidance that routine medevac of persons due to traffic accidents or other similar incidents and hospital-to-hospital patient transfers are not governmental functions but that specific nonroutine medevacs could be considered a governmental function if they meet specific criteria. Further, the NTSB notes that the earlier guidance provided in AC 00-1.1 and Order 8900.1 was comprehensive and consistent, whereas, to date, the FAA has provided no guidance beyond the March 13, 2009, memorandum regarding its new position. The NTSB is especially concerned that the FAA‘s current position means that it does not consider patients carried by a public operator, such as MSP, to be passengers, but rather ―qualified non-crewmembers.‖ Many of the patients carried by EMS aircraft have sustained life-threatening traumatic injuries and are in no condition to make a decision about whether or not to be transported by air. If these patients are transported on a public aircraft, the FAA medical rules, aircraft certification requirements, pilot certifications, aircraft maintenance requirements and aircraft operator requirements do not apply, and the FAA provides no oversight and minimal surveillance of the operator. If the same patients are carried by a civilian aircraft, they would be considered passengers, the operator would be required to comply with the rules and requirements noted above, including the standards of 14 CFR Part 135, and the FAA would provide extensive oversight and surveillance of the operator. The patients carried by public EMS aircraft deserve the same level of safety as those carried on civil EMS aircraft. Public Law 103-411 was enacted, in part, because Congress determined that government-owned aircraft that engage in transport of passengers should be subject to the regulations applicable to civil aircraft. Since the FAA has the statutory authority to regulate the operation and maintenance of civil aircraft but not public aircraft, the law redefined ―public aircraft‖ to exclude government-owned aircraft used for commercial purposes or engaged in the transport of passengers from operating as public aircraft. The purpose of this redefinition, as reflected in legislative history, was to mandate that FAA safety regulations, directives, and orders issued for civil aircraft be made applicable to all government-owned, nonmilitary aircraft engaged in passenger transport. The FAA‘s blanket classification of all medevac flights by

NTSB Aircraft Accident Report 70 government-owned aircraft operators as public operations does not appear to accord with the intent of Congress. The NTSB concludes that the FAA‘s classification of all medevac flights by government-owned aircraft as public operations conflicts with its own earlier guidance, creates a discrepancy in the level of FAA safety oversight of HEMS aircraft operations carrying passengers, and is contrary to the intent of Public Law 103-411, which states that aircraft carrying passengers are excluded from operating as public aircraft. The NTSB recommends that the FAA seek specific legislative authority to regulate HEMS operations conducted using government-owned aircraft to achieve safety oversight commensurate with that provided to civil HEMS operations.

NTSB Aircraft Accident Report 71

1. Conclusions
2. 1

Findings

1. The pilot was properly certificated and qualified in accordance with Maryland State Police

standards. Additionally, although the Federal Aviation Administration classified the flight as a public operation, the pilot was qualified under 14 Code of Federal Regulations Part 91 to conduct the flight under visual flight rules or instrument flight rules as a civil operation.

1. The helicopter was properly certificated, equipped, and maintained in accordance with the

requirements in 14 Code of Federal Regulations Parts 43 and 91 applicable to civil aircraft operating under visual flight rules or instrument flight rules. The recovered components showed no evidence of any preimpact structural, engine, or system failures.

1. Instrument meteorological conditions prevailed in the accident area with scattered clouds

near 200 feet above ground level (agl) and cloud ceilings near 500 feet agl. Although Andrews Air Force Base was reporting visibility of 4 miles in mist, lower visibilities in fog occurred locally in the accident area.

1. The pilot‘s decision to accept the flight, after his inadequate assessment of the weather,

contributed to the accident.

1. Had a formal flight risk evaluation program been in place at Maryland State Police before the

accident, it may have resulted in the cancellation of the flight.

1. When the pilot was unable to reach Prince George‘s Hospital Center due to deteriorating

weather conditions, he appropriately made the decision to divert to Andrews Air Force Base and request ground transport for the patients.

1. No evidence was found that suggests that the glideslope was not functioning properly. The

lack of information regarding the accident airplane‘s navigation frequency settings and flight instrument indications precluded National Transportation Safety Board investigators from determining why the pilot believed he was not receiving a valid glideslope signal.

1. The pilot‘s workload increased substantially and unexpectedly as a result of encountering

instrument weather conditions.

1. The pilot‘s expectation that he could descend below the cloud ceiling at an altitude above the

minimum descent altitude for the approach, his familiarity with Andrews Air Force Base, and the reduction in workload a return to visual conditions would have provided are all factors that may have encouraged the pilot to deviate below the glideslope and attempt to ―duck under‖ the cloud ceiling.

NTSB Aircraft Accident Report 72

1. The pilot failed to adhere to instrument approach procedures when he did not arrest the

helicopter‘s descent at the minimum descent altitude.

1. Although descent rate and altitude information were readily available through cockpit

instruments, the pilot failed to monitor the instruments likely because he was preoccupied with looking for the ground, which he could not identify before impact due to the lack of external visual cues.

1. If the helicopter had been equipped with a terrain awareness and warning system, aural

terrain alerts of ―Caution Terrain,‖ ―Warning Terrain,‖ and ―Pull-up,‖ would have been provided. These would have been more salient than the alert provided by the radar altimeter and likely would have caused the pilot to attempt to arrest his descent.

1. The failure of the Potomac Consolidated Terminal Radar Approach Control controller to

provide the current Andrews Air Force Base weather information likely led the pilot to expect that he could descend below the cloud ceiling and establish visual contact with the ground at an altitude well above the minimum descent altitude for the approach.

1. Air traffic services provided by the Ronald Reagan Washington Airport Tower and Potomac

Consolidated Terminal Radar Approach Control controllers to the accident flight exhibited numerous procedural deficiencies, including unresponsiveness, inattention, and poor radar vectoring. These deficiencies were a distraction to the pilot and increased his workload by requiring him to compensate for the poor services provided.

1. Although the pilot met the recent-experience requirements to act as pilot-in-command under

instrument flight rules, he was not proficient in instrument flight. This lack of proficiency likely contributed to the pilot‘s failure to properly conduct what effectively became a nonprecision approach at night in instrument conditions.

1. Changes made by the Maryland State Police Aviation Command to its instrument training

program about 10 months before the accident did not promote instrument proficiency.

1. Based on the late hour, the length of time awake, the risk factors for sleep apnea exhibited by

the pilot, and the decision to deviate from the published procedures, the pilot was likely less than fully alert, and fatigue may have contributed to his deficient decision-making.

1. The Maryland State Police System Communications Center duty officer lost situational

awareness of the helicopter while it was in flight.

1. The lack of adherence to effective flight-tracking policies by Maryland State Police System

Communications Center personnel created an institutional mindset that allowed duty officers to assume that aircraft had landed safely when the Automatic Dependent Surveillance- Broadcast signal was lost; over time, safe landings were taken for granted.

1. Had two Maryland State Police aviation employees not pursued their own search effort,

locating the accident site would likely have taken several more hours than it did.

NTSB Aircraft Accident Report 73

1. The incident commander‘s lack of aviation knowledge diminished the effectiveness of search

and rescue activities.

1. Maryland State Police troopers and System Communications Center personnel were

insufficiently equipped and trained to conduct a search involving global positioning system coordinates, and this hindered their ability to locate the site of the wreckage.

1. Neither Prince George‘s County nor Maryland State Police dispatchers fully understood the

importance of obtaining distance and bearing information, as well as the cell tower location, before releasing a location obtained from cell phone ‗pinging;‘ this lack of understanding led dispatchers to provide the cell phone tower‘s simple street address without context to all units involved in the search. This distracted and confused units already searching a more likely location.

1. The Federal Aviation Administration air traffic control's inability to produce timely location

data also hampered search and rescue efforts.

1. Knowledge of the disjointed search and rescue efforts and the techniques eventually

employed to locate the accident site could provide valuable lessons to agencies, such as helicopter emergency medical services dispatch centers, 911 dispatch centers, and fire, police, and sheriff‘s departments, involved in search and rescue efforts.

1. Having aboard the aircraft a recorder system that captured cockpit audio, images, and

parametric data would have aided the National Transportation Safety Board in determining the circumstances that led to this accident.

1. The Federal Aviation Administration‘s (FAA‘s) classification of all medical evacuation

flights by government-owned aircraft as public operations conflicts with its own earlier guidance, creates a discrepancy in the level of FAA safety oversight of helicopter emergency medical services aircraft operations carrying passengers, and is contrary to the intent of Public Law 103-411, which states that aircraft carrying passengers are excluded from operating as public aircraft. 3.2 Probable Cause The National Transportation Safety Board determines that the probable cause of this accident was the pilot's attempt to regain visual conditions by performing a rapid descent and his failure to arrest the descent at the minimum descent altitude during a nonprecision approach. Contributing to the accident were (1) the pilot‘s limited recent instrument flight experience, (2) the lack of adherence to effective risk management procedures by the Maryland State Police, (3) the pilot‘s inadequate assessment of the weather, which led to his decision to accept the flight, (4) the failure of the Potomac Consolidated Terminal Radar Approach Control (PCT) controller to provide the current Andrews Air Force Base weather observation to the pilot, and (5) the increased workload on the pilot due to inadequate Federal Aviation Administration air traffic control handling by the Ronald Reagan National Airport Tower and PCT controllers.

NTSB Aircraft Accident Report 74

1. Recommendations
2. 1

New Recommendations As a result of this investigation, the National Transportation Safety Board makes the following safety recommendations: To the Federal Aviation Administration: Seek specific legislative authority to regulate helicopter emergency medical services (HEMS) operations conducted using government-owned aircraft to achieve safety oversight commensurate with that provided to civil HEMS operations. (A-09-130) To All Public Helicopter Emergency Medical Services Operators: Develop and implement flight risk evaluation programs that include training for all employees involved in the operation, procedures that support the systematic evaluation of flight risks, and consultation with others trained in helicopter emergency medical services flight operations if the risks reach a predefined level. (A-09-131) Use formalized dispatch and flight-following procedures that include up-to-date weather information and assistance in flight risk assessment decisions. (A-09-132) Install terrain awareness and warning systems on your aircraft and provide adequate training to ensure that flight crews are capable of using the systems to safely conduct helicopter emergency medical services operations. (A-09-133) To the Maryland State Police: Implement a program to screen and—if necessary—treat your pilots for obstructive sleep apnea. (A-09-134) Revise your policy regarding incident commanders to specify that, in any event involving a missing or overdue aircraft, an Aviation Command trooper will serve as the incident commander. (A-09-135)

NTSB Aircraft Accident Report 75 Provide additional training to your dispatchers on the use of cell phone ―pinging‖ and include instruction about how to integrate the data obtained from cell phone pinging into an overall search and rescue plan. (A-09-136) To Prince George’s County, Maryland: Provide additional training to your dispatchers on the use of cell phone ―pinging‖ and include instruction about how to integrate the data obtained from cell phone ―pinging‖ into an overall search and rescue plan. (A-09-137) To the National Association of Air Medical Communications Specialists, the Association of Public-Safety Communications Officials International, the National Emergency Number Association, the International Association of Police Chiefs, the National Sheriffs’ Association, and the International Association of Fire Chiefs: Inform your members through your websites, newsletters, and conferences of the lessons learned from the emergency response to this accident, particularly emphasizing that search and rescue personnel need to understand how to interpret and use both global positioning system coordinates and the results of cell phone ―pinging.‖ (A-09-138) 4.2 Previously Issued Recommendations Reiterated in this Report The National Transportation Safety Board reiterates the following safety recommendations to the Federal Aviation Administration: Require all emergency medical services (EMS) operators to develop and implement flight risk evaluation programs that include training all employees involved in the operation, procedures that support the systematic evaluation of flight risks, and consultation with others trained in EMS flight operations if the risks reach a predefined level. (A-06-13) 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) Require all 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 systems to safety conduct EMS operations. (A-06-15)

NTSB Aircraft Accident Report 76

BY THE NATIONAL TRANSPORTATION SAFETY BOARD DEBORAH A.P. HERSMAN ROBERT L. SUMWALT Chairman Member

CHRISTOPHER A. HART

Vice Chairman

Adopted: October 27, 2009

NTSB Aircraft Accident Report 77

1. Appendix

Investigation and Public Hearing Investigation The National Transportation Safety Board (NTSB) was notified of the accident on the morning of September 28, 2008. NTSB investigators arrived on-scene later that day. Chairman Deborah A.P. Hersman was the Board member on-scene. Parties to the investigation were the Federal Aviation Administration, Maryland State Police, American Eurocopter, and Turbomeca USA. In accordance with Annex 13 to the International Convention on Civil Aviation, an accredited representative from the Bureau d‘Enquetes et d‘Analyses was appointed to participate in this investigation. Public Hearing No public hearing was held for this accident.

FD07362 ｜ 2009_美国_HAR0901.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2009 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

Motorcoach Run‐Off‐the‐Road and Rollover  U.S. Route 163  Mexican Hat, Utah  January 6, 2008            Accident Report NTSB/HAR-09/01 PB2009-916201

National Transportation Safety Board

(This page intentionally left blank.)

NTSB/HAR-09/01 PB2009-916201 Notation 8024A Adopted April 21, 2009

Highway Accident Report Motorcoach Run-Off-the-Road and Rollover U.S. Route 163 Mexican Hat, Utah January 6, 2008

National Transportation Safety Board

490 L’Enfant Plaza, S.W. Washington, D.C. 20594

National Transportation Safety Board. 2009. Motorcoach Run-Off-the-Road and Rollover, U.S. Route 163, Mexican Hat, Utah, January 6, 2008. Highway Accident Report NTSB/HAR-09/01. Washington, DC.

Abstract: About 8:02 p.m., mountain standard time, a 2007 Motor Coach Industries 56-passenger motorcoach with a driver and 52 passengers on board was traveling southbound, descending a 5.6-percent grade leading to a curve to the left, 1,800 feet north of milepost 29 on U.S. Route 163. After entering the curve, the motorcoach departed the right side of the roadway at a shallow angle, striking the guardrail with the right-rear wheel and lower coach body. The motorcoach traveled approximately 350 feet along the foreslope, with the right tires off the roadway. The back tires lost traction as the foreslope transitioned into the drainage ditch. The motorcoach rotated in a counterclockwise direction as it descended an embankment. The motorcoach overturned, struck several rocks in a drainage ditch bed at the bottom of the embankment, and came to rest on its wheels. During the 360-degree rollover sequence, the roof of the motorcoach separated from the body, and 50 of the 53 occupants were ejected. Nine passengers were fatally injured, and 43 passengers and the driver received injuries ranging from minor to serious. Major safety issues identified by this accident investigation include driver fatigue, excessive vehicle speed, hours-of-service violations, motor carrier trip planning, motorcoach occupant protection, and emergency medical notification and response with regard to large motorcoaches traveling on rural roads. As a result of its investigation, the Safety Board makes recommendations to the Federal Interagency Committee on Emergency Medical Services, the Utah Bureau of Emergency Medical Services, the Federal Highway Administration, the American Association of State Highway and Transportation Officials, the National Association of State Emergency Medical Services Officials, the American Bus Association, the United Motorcoach Association, and Arrow Stage Lines. The Safety Board also reiterates one previously issued recommendation to the Federal Motor Carrier 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 Internet at http://www.ntsb.gov. Other information about available publications also may be obtained from the website or by contacting:

National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, SW Washington, DC 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 PB2009-916201 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.

NTSB Highway Accident Report

iii Contents Figures.............................................................................................................................................v Acronyms and Abbreviations .................................................................................................... vii Executive Summary..................................................................................................................... xi Factual Information.......................................................................................................................1 Events Preceding the Accident ........................................................................................................1 Accident Narrative...........................................................................................................................2 Injuries .............................................................................................................................................6 Emergency Response.......................................................................................................................9 Resources..................................................................................................................................9 Emergency Preparedness........................................................................................................12 Weather..........................................................................................................................................13 Driver Information.........................................................................................................................14 Driver Fitness..........................................................................................................................14 Driver Performance ................................................................................................................16 Motor Carrier Operation ................................................................................................................17 Oversight and Compliance Reviews.......................................................................................17 Hours of Service .....................................................................................................................18 Trip Communications.............................................................................................................19 Vehicle Information.......................................................................................................................19 Roof Design............................................................................................................................21 Data Recording Equipment.....................................................................................................22 Road Design...................................................................................................................................23 Accident Location History.............................................................................................................28 Rural Versus Urban EMS Response..............................................................................................28 AASHTO Strategic Highway Safety Plan..............................................................................29 SAFETEA-LU and High-Risk Rural Roads...........................................................................29 Utah Highway Safety Improvement Program ........................................................................30 Tests and Research.........................................................................................................................31 Vehicle Speed Analysis..........................................................................................................31 Vehicle Acceleration Analysis ...............................................................................................33 Engine Performance Data.......................................................................................................34 Analysis.........................................................................................................................................35 Exclusions......................................................................................................................................35 Accident Discussion.......................................................................................................................36 Fatigue Countermeasures...............................................................................................................38 Driver Medical Conditions ............................................................................................................39 Hours of Service ............................................................................................................................40 Arrow Trip Scheduling ..................................................................................................................41

NTSB Highway Accident Report

iv Occupant Protection Systems ........................................................................................................42 Emergency Medical Services.........................................................................................................44 Emergency Notification..........................................................................................................45 Emergency Response..............................................................................................................47 Risk Assessment of Charter and Tour Bus Travel on Rural Roads........................................49 Conclusions...................................................................................................................................53 Findings..........................................................................................................................................53 Probable Cause...............................................................................................................................54 Recommendations........................................................................................................................55 New Recommendations .................................................................................................................55 Reiterated Recommendation..........................................................................................................56 Previously Issued Recommendations Classified in This Report ...................................................57 Board Member Statement...........................................................................................................58 Appendix A...................................................................................................................................61 Investigation...................................................................................................................................61 Appendix B ...................................................................................................................................62 Large Bus Accidents and Injuries in Rural and Urban Areas, 2000–2007....................................62 Appendix C...................................................................................................................................78 Video Study ...................................................................................................................................78 Appendix D...................................................................................................................................83 Safety Board Motorcoach Accident Investigations .......................................................................83

NTSB Highway Accident Report

v Figures Figure 1. Accident motorcoach’s route....................................................................................3 Figure 2. Scene diagram showing tire marks...........................................................................4 Figure 3. Tire marks on roadway.............................................................................................4 Figure 4. Position of accident motorcoach at end of rollover sequence..................................5 Figure 5. Accident motorcoach’s final location, as viewed looking back toward the route traveled. .........................................................................................................6 Figure 6. Seating diagram........................................................................................................8 Figure 7. Accident driver’s sleep and activity log.................................................................15 Figure 8. Motorcoach roof design..........................................................................................21 Figure 9. Motorcoach side supports for roof. ........................................................................22 Figure 10. View of descending road grade, 4 miles before the accident site. .......................24 Figure 11. View of descending road grade in the direction of travel, immediately preceding the accident curve. ............................................................................25 Figure 12. View of accident curve.........................................................................................26 Figure 13. View of guardrail..................................................................................................27 Figure 14. Vehicle speed estimate versus number of frame intervals (video analysis).........33 Figure C-1. Vehicle at time –7 seconds.................................................................................80 Figure C-2. Vehicle at time –6 seconds.................................................................................80 Figure C-3. Vehicle at time –5 seconds.................................................................................81 Figure C-4. Vehicle speed estimate versus number of frame intervals.................................82

(This page intentionally left blank.)

NTSB Highway Accident Report

vii Acronyms and Abbreviations ABA American Bus Association ADT average daily traffic AASHTO American Association of State Highway and Transportation Officials ALS advanced life support BLS basic life support BMI body mass index CDL commercial driver’s license CPAP continuous positive airway pressure CFR Code of Federal Regulations CSRS continuous shoulder rumble strips E-911 Enhanced 911 ECE Economic Commission for Europe ECM electronic control module EMS emergency medical service EMT emergency medical technician EOBR electronic on-board recorder FARS Fatality Analysis Reporting System FEMA Federal Emergency Management Agency

NTSB Highway Accident Report

viii FHWA Federal Highway Administration FICEMS Federal Interagency Committee on Emergency Medical Services FMCSA Federal Motor Carrier Safety Administration FMCSRs Federal Motor Carrier Safety Regulations FMVSS Federal Motor Vehicle Safety Standard GAO U.S. Government Accountability Office GPS global positioning system GUI graphical user interface GVWR gross vehicle weight rating HSIP Highway Safety Improvement Program IFR instrument flight rules IP Internet protocol ISS inspection selection system MCI Motor Coach Industries MCMIS Motor Carrier Management Information System MRB Medical Review Board MUTCD Manual on Uniform Traffic Control Devices NHTSA National Highway Traffic Safety Administration NIMS National Incident Management System

NTSB Highway Accident Report

ix NPRM notice of proposed rulemaking NTIA National Telecommunications and Information Administration PIEV perception-identification-emotion-volition PRT perception-reaction time PSAP public safety answering points SafeStat Motor Carrier Safety Status Measurement System SAFETEA-LU Safe, Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for Users SCT specialty care transport UDOT Utah Department of Transportation UMA United Motorcoach Association U.S.C. United States Code U.S. 163/191 U.S. Route 163/191 VEDR video event data recorder VMT vehicle miles traveled

(This page intentionally left blank.)

NTSB Highway Accident Report

xi Executive Summary On January 6, 2008, about 3:15 p.m. mountain standard time, a 2007 Motor Coach Industries 56-passenger motorcoach with a driver and 52 passengers on board departed Telluride, Colorado, en route to Phoenix, Arizona, as part of a 17-motorcoach charter. The motorcoach passengers were returning from a 3-day ski trip. The normal route from Telluride to Phoenix along Colorado State Route 145 was closed due to snow, and the lead driver planned an alternate route that included U.S. Route 163/191 through Utah. About 8:02 p.m., the motorcoach was traveling southbound, descending a 5.6-percent grade leading to a curve to the left, 1,800 feet north of milepost 29 on U.S. Route 163. The weather was cloudy, and the roadway was dry at the time of the accident. After entering the curve, the motorcoach departed the right side of the roadway at a shallow angle, striking the guardrail with the right-rear wheel and lower coach body about 61 feet before the end of the guardrail. The motorcoach traveled approximately 350 feet along the foreslope (portion of roadside sloping away from the roadway), with the right tires off the roadway. The back tires lost traction as the foreslope transitioned into the drainage ditch. The motorcoach rotated in a counterclockwise direction as it descended an embankment. The motorcoach overturned, struck several rocks in a drainage ditch bed at the bottom of the embankment, and came to rest on its wheels. During the 360-degree rollover sequence, the roof of the motorcoach separated from the body, and 50 of the 53 occupants were ejected. As a result of this accident, 9 passengers were fatally injured, and 43 passengers and the driver received injuries ranging from minor to serious. The National Transportation Safety Board determines that the probable cause of this accident was the driver’s diminished alertness due to inadequate sleep resulting from a combination of head congestion, problems acclimating to high altitude, and his sporadic use of his continuous positive airway pressure sleeping device during the accident trip. The driver’s state of fatigue affected his awareness of his vehicle’s excessive speed and lane position on a downhill mountain grade of a rural secondary road. Contributing to the accident’s severity was the lack of an adequate motorcoach occupant protection system, primarily due to the National Highway Traffic Safety Administration’s delay in developing and promulgating standards to enhance the protection of motorcoach passengers. Major safety issues identified by this accident investigation include driver fatigue, excessive vehicle speed, hours-of-service violations, motor carrier trip planning, motorcoach occupant protection, and emergency medical notification and response with regard to large motorcoaches traveling on rural roads. As a result of its investigation, the Safety Board makes recommendations to the Federal Interagency Committee on Emergency Medical Services, the Utah Bureau of Emergency Medical Services, the Federal Highway Administration, the American Association of State Highway and Transportation Officials, the National Association of State Emergency Medical Services Officials, the American Bus Association, the United

NTSB Highway Accident Report

xii Motorcoach Association, and Arrow Stage Lines. The Safety Board also reiterates one previously issued recommendation to the Federal Motor Carrier Safety Administration.

NTSB Highway Accident Report

1 Factual Information On January 6, 2008, about 3:15 p.m. mountain standard time,1 a 2007 Motor Coach Industries (MCI) 56-passenger motorcoach with a driver and 52 passengers on board departed Telluride, Colorado, en route to Phoenix, Arizona, as part of a 17-motorcoach charter.2 The motorcoach passengers were returning from a 3-day ski trip. The normal route from Telluride to Phoenix along Colorado State Route 145 was closed due to snow,3 and the lead driver planned an alternate route that included U.S. Route 163/191 (U.S. 163/191) through Utah. About 8:02 p.m., the motorcoach was traveling southbound, descending a 5.6-percent grade leading to a curve to the left, 1,800 feet north of milepost 29 on U.S. 163. The weather was cloudy and the roadway was dry at the time of the accident. After entering the curve, the motorcoach departed the right side of the roadway at a shallow angle, striking the guardrail with the right-rear wheel and lower coach body about 61 feet before the end of the guardrail. The motorcoach traveled approximately 350 feet along the foreslope (portion of roadside sloping away from roadway), with the right tires off the roadway. The back tires lost traction as the foreslope transitioned into the drainage ditch. The motorcoach rotated in a counterclockwise direction as it descended an embankment. The motorcoach overturned, struck several rocks in a drainage ditch bed at the bottom of the embankment, and came to rest on its wheels. During the 360-degree rollover sequence, the roof of the motorcoach separated from the body, and 50 of the 53 occupants were ejected. As a result of this accident, 9 passengers were fatally injured, and 43 passengers and the driver received injuries ranging from minor to serious. Events Preceding the Accident Arrow Stage Lines provided 17 motorcoaches for the charter trip from Phoenix, Arizona, to Telluride, Colorado, returning to Phoenix. According to the accident driver’s trip log, he arrived at the designated pickup location at a Phoenix shopping center about 7:35 a.m. on Thursday, January 3, 2008, for the weekend ski trip. After loading passengers, he departed about 9:15 a.m. and completed the 486-mile trip to Telluride, arriving about 5:30 p.m. During Friday and Saturday of the Telluride layover, the driver was off duty, though records show he purchased fuel for the motorcoach midday on Friday, January 4. The driver had obstructive sleep apnea, which was being treated with a continuous positive airway pressure (CPAP) device. While in Telluride, the driver had symptoms of a head

1 Unless otherwise indicated, all times given in this report are mountain standard time. 2 Although the 17 motorcoaches were en route to the same destination, they did not travel as a group. 3 The closure occurred at Lizard Head Pass.

NTSB Highway Accident Report

2 cold and self-medicated using an over-the-counter, nondrowsy cold medicine. His head congestion prevented effective use of the CPAP device. The driver told another driver that he slept poorly and had symptoms of a head cold. He told Safety Board investigators that he was not able to use the device effectively during his stay in Telluride due to his congestion and that he slept poorly. On Sunday, January 6, 2008, the driver awoke at 6:45 a.m. and attended a driver’s meeting at 10:00 a.m., at which he was informed by the lead driver that a portion of the return route was closed due to snow. A different return route to Phoenix was established. The alternate route was 70 miles longer than the originally planned route. He installed tire chains on the motorcoach, loaded passengers at 2:00 p.m., and departed Telluride at 3:15 p.m. The return trip, as planned, was 556 miles in snowy weather. Accident Narrative The motorcoach’s travel route was affected by snow and ice during the Colorado segment of the trip. After crossing into Utah, the accident motorcoach turned south on U.S. 163/191 for approximately 80 miles, at which point U.S. 191 separates with a left turn to the south before crossing into Arizona. The accident driver missed the turn to remain on U.S. 191; instead he stayed on U.S. 163 going further west. Both U.S. 163 and U.S. 191 eventually join U.S. 160 heading southwest through Arizona. Most of the caravan of motorcoaches took the U.S. 191 route; the accident driver and one other driver remained on U.S. 163. Figure 1 shows the route of the motorcoach in the vicinity of the accident. In a postaccident interview, the driver stated that he was unsure of which route he was traveling but knew that the route he was on would take him toward Phoenix. After several miles of downhill road and just before milepost 29, U.S. 163 begins a gradual, long curve to the left. Shortly after entering that curve, the bus departed the right side of the roadway at a shallow angle. There were no skid marks on the highway, and no other vehicles were involved in the run-off-the-road event. Evidence of tire marks was found along the guardrail for 61 feet before the guardrail came to an end.4 Two sets of tire marks on the side slope showed the front tires were tracking nearer the top of the embankment, and furrows from the rear tires were found further down the embankment. Tire marks are shown in figures 2 and 3.

4 The motorcoach’s force against the guardrail did not deform the W-beam rail nor did it break any weak-beam support posts.

NTSB Highway Accident Report

3

Figure 1. Accident motorcoach’s route.

NTSB Highway Accident Report

4

Figure 2. Scene diagram showing tire marks (dashed plow marks show the tire tracks gradually departing the road).

Figure 3. Tire marks on roadway (row of traffic cones to left of roadway follow the tire marks onto the foreslope).

NTSB Highway Accident Report

5 After departing the roadway, the motorcoach traveled approximately 350 feet before the rear wheels went off the embankment.5 The rear of the motorcoach rotated counterclockwise, with the front of the motorcoach facing perpendicular to the roadway.6 The motorcoach overturned, rolling to the right, and struck a rocky drainage ditch at the bottom of the embankment approximately 10 feet lower than the roadway. During the rollover sequence, the roof separated from the bus body at the point where the vertical posts attached to the base of the window sash along the right side and, subsequently, the roof separated from the motorcoach. During the accident sequence, the motorcoach impacted the ground and completed a full rotation (360 degrees) before coming to rest on its wheels. Figures 4 and 5 show the accident motorcoach in its final location after the accident.

Figure 4. Position of accident motorcoach at end of rollover sequence (topographical contour lines indicate steepness of the embankment or slope; the closer the lines, the steeper the slope).

5 Survey information in figure 2 shows the plow marks of the tires departing the pavement at station number 154,200 and ending at approximately station number 153,850, a difference of 350 feet. 6 One ground scar near the roadside showed that the front of the vehicle impacted the ground at 37 degrees relative to the roadside.

NTSB Highway Accident Report

6

Figure 5. Accident motorcoach’s final location, as viewed looking back toward the route traveled. (U.S. 163 is behind the motorcoach, with the curve coming around the bluff in the center of the horizon.) Injuries In this accident, 50 of 53 motorcoach occupants were ejected from the vehicle. The driver, who was wearing a three-point restraint, and one passenger, who was entrapped between damaged seats in rows 12 and 13,7 remained in the motorcoach. Another passenger told investigators that he was able to remain in his seat and exited after the motorcoach came to rest. The 9 fatally injured passengers died of blunt-force trauma to their heads and torsos; 13 of the 35 seriously injured occupants sustained a combination of fractures to the spine, torso, and extremities; and 12 of the remaining 22 seriously injured occupants sustained head and internal chest injuries. (See table 1 for a summary of injuries.) Passengers sustaining minor injuries had lacerations that required sutures, along with multiple abrasions and contusions to their faces, torsos, or extremities.

7 The passenger trapped between rows 12 and 13 had been seated in row 9.

NTSB Highway Accident Report

7 Table 1. Injuries. Injury type Drivers Passengers Total Fatal 0 9 9 Serious 1 34 35 Minor 0 9 9 None 0 0 0 Total 1 52 53 Title 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.

During the accident sequence, the majority of passengers were ejected from the top of the motorcoach as the roof became separated from the right side at the base of the windows. Investigator interviews of surviving passengers revealed that at least two, and possibly as many as four, passengers were found on the right (east) side of the motorcoach at final rest. The majority of ejected passengers were found on the left (west) side of the motorcoach. According to first responders and passenger interviews, at least one person was found under the right (east) side of the motorcoach body and at least three people were fully or partially trapped underneath the roof of the motorcoach, which was detached to the left of the vehicle. Of those passengers, two survived. Motorcoach passengers ranged in age from 5 to 67; the average age was 30. Fifteen passengers were 18 or younger; five fatalities were from this younger group. Seven passengers were pronounced dead at the scene of the accident and transported to two mortuaries. The average transport time between the accident scene and the initial critical care treatment facility was 2 hours 15 minutes. For ambulatory patients who were treated at the medical clinic in Blanding, Utah, the average transport time was 3 hours. Two passengers died en route to critical care; both 16-year-old victims had sustained head and torso injuries from blunt-force trauma. After being transported to San Juan Hospital, Monticello, Utah, for stabilization, they were again transported to another medical hospital for a higher level of critical care. The time of death for one of the two en route victims was 3:36 a.m., 7 hours after the accident. That victim was in ground transport to Moab, Utah, to be airlifted to University Hospital in Salt Lake City. Due to the victim’s deteriorating condition, the ambulance diverted to Allen Memorial Hospital in Moab, where the victim died. The second en route fatality occurred at 9:05 a.m., about 12.5 hours after the accident, as the accident victim arrived at St. Mary’s Hospital in Grand Junction, Colorado.8

8 Grand Junction is approximately 230 miles from the accident site by road and 115 miles by air.

NTSB Highway Accident Report

8 As a result of the accident, 9 passengers sustained fatal injuries, 34 passengers and the driver sustained serious injuries, and 9 passengers received minor injuries. Figure 6 shows the seating locations and injury patterns of motorcoach occupants. F - 16 : Fatal F - 20 : Serious M - 22 : Serious M - 27 : Minor M - 35 : Serious M - 52 : Serious F - 48 : Serious M - 24 : Minor M - 42 : Serious F - 13 : Minor F - 41 : Serious M - 18 : Fatal M - 47 : Serious M - 38 : Serious M - 30 : Serious M - 23 : Serious F - 56 : Serious M - 71 : Serious F - 17 : Serious F - 26- : Serious M - 39 : Serious F - 36 : Serious M - 26 : Serious M - 30 : Serious M - 25 : Serious M - 31 : Serious F - 42 : Serious SAMPLE F = FEMALE M = MALE # = AGE +International Civil Aviation Organization +INJURY LEVEL AGE GENDER F - 14 : Minor Source: NTSB M - 23 : Serious F - 51 : Serious M - 17 : Minor M - 18 : Minor F - 33 : Serious F - 27 : Serious M - 21 : Serious M - 32 : Fatal F - 29 : Serious M - 45 : Serious M - 13 : Serious M - 18 : Fatal F - 16 : Fatal M - 5 : Minor M - 10 : Serious M - 27 : Minor F - 45 : Fatal M - 13 : Serious M - 12 : Fatal M - 31 : Minor M - 44 : Serious M - 41 : Fatal M - 35 : Serious M - 17 : Minor HWY-08-MH-012 Mexican Hat, Utah F - 39 : Serious F - 67 : Fatal 3 1 2 4 5 6 7 8 9 10 11 12 13 14 15

Figure 6. Seating diagram.

NTSB Highway Accident Report

9 Of the 24 passengers who were seated on the right side of the motorcoach, 5 sustained fatal injuries (4 of 5 of these occupants were seated next to windows), 17 sustained serious injuries, and 2 sustained minor injuries. Of the 28 passengers who were seated on the left side of the motorcoach, 4 sustained fatal injuries (3 of 4 of these occupants were seated in the last three rows), 17 sustained serious injuries, and 7 sustained minor injuries. Emergency Response The San Juan County, Utah, Communication Center, located in the San Juan County Sheriff’s Office, was notified of the accident through the 911 system at 8:38 p.m. The San Juan County 911 dispatcher received a call at 8:04 p.m. reporting a bus accident, but when the dispatcher asked for a location, the call was lost.9 Following the accident, passengers alerted another motorist who passed the scene. That driver then drove to the next town, approximately 8 miles south, and called 911 from a service station. The first call from dispatch went to the Utah Highway Patrol at 8:38 p.m. The Chief of the Bluff Volunteer Fire Department, who was the incident commander for this accident, said that after hearing radio traffic on his scanner, he departed for the scene at 8:33 p.m.10 and arrived on scene at 8:56 p.m. The San Juan County Emergency Medical Service (EMS) Coordinator, who arrived at 9:56 p.m., was dispatched to the accident scene with the mass casualty incident trailer.11 The Bluff Volunteer Fire Department rescue unit was en route at 8:45 p.m. and arrived on scene at 9:00 p.m., followed by its ambulance unit at 9:01 p.m. The first deputy with the San Juan County Sheriff’s Office was dispatched at 8:48 p.m. and arrived on scene at 9:19 p.m. The Utah Highway Patrol sent four officers and the San Juan County Sheriff’s Office sent four deputies to the scene. Resources San Juan County has eight ambulances, none of which are staffed for advanced life support (ALS) due to the county having no licensed paramedics, only certified intermediate or

9 San Juan County does not have an Enhanced 911 system capable of automatically providing the public service answering point with identification and location information. The dispatcher had assumed that the dropped call was reporting a minor accident north of Blanding, Utah, which involved another of the other 16 motorcoaches on the ski trip. That accident occurred after the motorcoach became disabled on an ice-covered roadway 5 miles east of Blanding and another Arrow bus stopped to assist and was subsequently involved in a property damage accident when an automobile lost traction and slid into the stopped motorcoach. 10 Times reported by the different response organizations—the San Juan County 911 dispatch, the Utah Highway Patrol, the Bluff Fire Department, and the San Juan County Sheriff’s Office—were not synchronized and are therefore approximate. 11 The mass casualty incident trailer is a mobile unit that can be towed to the accident site. It is supplied with backboards, neck braces, and other supplies needed to assist with emergency response during mass casualty events.

NTSB Highway Accident Report

10 basic emergency medical technicians (EMTs).12 All San Juan County EMTs are volunteers.13 The following agencies responded to transport injured passengers: • San Juan County EMS—eight ambulances, one transport ambulance, and three 15-passenger vans to transport the “walking wounded” to the Blanding medical clinic. • Kayenta Navajo Nation—four basic life-support (BLS) ambulances. • Moab–Grand County EMS—three ALS mutual aid ambulances. • Mesa County, Colorado—two mutual aid ambulances. • Southwest Memorial Hospital in Cortez, Colorado—two mutual aid ambulances from Durango, Colorado. All of the on-scene ambulances traveled north from the accident site, except for the Navajo Nation ambulances, which traveled south. The less seriously injured were transported to the clinic in Blanding, 43 miles away; the more seriously injured were transported to San Juan Hospital, approximately 75 miles away, even though it had no trauma response capabilities. The injured were treated and released or triaged and transported to other medical facilities that had trauma units and could provide a higher level of care. According to the San Juan County EMS Coordinator on scene, the last ambulance transporting injured passengers left the accident site at approximately 12:20 a.m., more than 4 hours after the accident. That ambulance was from the Navajo Nation.14 The injured were treated at 12 hospitals/medical centers and 1 clinic, as shown in table 2. The nearest Level I trauma center15 was in Flagstaff, Arizona, approximately 190 miles away.

12 There are three categories of emergency service: basic life support (BLS), provided by personnel trained to be emergency medical technicians; ALS, provided by paramedics; and specialty care transport (SCT), provided by personnel trained to conduct critical care service beyond the scope of paramedics. 13 Volunteer EMTs receive the same training as full-time EMT personnel. 14 This was the only responding agency that would not comply with a subpoena for its transport records needed to reconstruct travel times. 15 Level I trauma centers provide the highest level of surgical care for trauma patients and are staffed with surgeons and anesthesiologists 24 hours a day.

NTSB Highway Accident Report

11 Table 2. Distribution of emergency medical facilities. Facility Trauma levelA Distance from site Number of injured treatedB Blanding Family Practice Blanding, Utah No trauma unit 43 miles 9 Kayenta Medical Clinic Kayenta, Arizona No trauma unit 45 miles 2 San Juan Hospital Monticello, Utah No trauma unit 75 miles 26 Chinle Comprehensive Healthcare Facility Chinle, Arizona No trauma unit 115 miles 2 Allen Memorial Hospital Moab, Utah Level IV 117 miles 5 Sage Memorial Hospital Navajo Nation, Tuba City, Arizona No trauma unit 120 miles 2 San Juan Regional Medical Center Farmington, New Mexico Level III 130 3 Flagstaff Medical Center Flagstaff, Arizona Level I 190 miles 2 St. Mary’s Hospital Grand Junction, Colorado Level II 230 miles 10 Banner Good Samaritan Hospital Phoenix, Arizona Level I 340 miles 2 Primary Children’s Hospital Salt Lake City, Utah Level I 360 miles 1 University Hospital Salt Lake City, Utah Level I 360 miles 1 Intermountain Healthcare LDS Hospital Salt Lake City, Utah Level I 360 miles 1 ATrauma centers are designated levels I–V, with level I providing the highest level of care based on American College of Surgeons criteria.

BThe total number of injured treated is greater than the number of motorcoach occupants because several of the injured were moved between facilities.

A life-flight crew from St. Mary’s Hospital was requested but was grounded due to weather conditions. A Classic Lifeguard helicopter from Page, Arizona, was also requested but could not fly due to the weather conditions in northern Arizona. At 11:24 p.m., San Juan Hospital in Monticello, Utah, requested that St. Mary’s Hospital send an ALS ground ambulance. St. Mary’s Hospital responded by having its life-flight crew, which consisted of a flight nurse, a paramedic, and a physician, travel approximately 169 miles by ambulance to San Juan Hospital. The ambulance then picked up two seriously injured passengers; one died en route to St. Mary’s Hospital. The other fatality that did not occur at the accident scene involved a victim who died at Allen Memorial Hospital. That victim had been transported in a Grand County ALS ambulance that, while en route to Moab Airport to meet an airplane, was diverted to Allen Memorial Hospital in Moab due to the patient’s deteriorating medical condition.

NTSB Highway Accident Report

12 Southwest Memorial Hospital in Cortez, Colorado, sent two ALS ambulances with one paramedic in each to San Juan Hospital in Monticello, Utah, which is approximately 60 miles away. In addition, a physician from Southwest Memorial Hospital accompanied one of the ambulances to Monticello to assist that hospital’s emergency room. Several seriously injured passengers were transported from San Juan Hospital by ambulance to Allen Memorial Hospital in Moab, Utah, and then taken to Canyonlands Field Airport in Moab for air medical transport to trauma hospitals in Salt Lake City.16 The weather conditions in the area were poor, necessitating air transport into an airport equipped with a published instrument approach using aircraft capable of operating in instrument flight rules (IFR) conditions. Monticello Airport was not equipped with an instrument approach. Canyonlands Field Airport has an instrument approach, as does Blanding Municipal Airport in Blanding, Utah. Shortly after the accident, on January 8, approximately 50 first responders, hospital staff, and local government officials met for an EMS debriefing in Bluff, Utah. On January 17, regional officials participated in a second postaccident review meeting in Monticello, Utah. Emergency Preparedness San Juan County, located in the southeast corner of the State, is the largest county in Utah in land mass with a total area of 7,933 square miles.17 As of the 2000 census, 14,413 people resided in the county, or roughly 2 residents per square mile, making it one of the least densely populated counties in the United States. San Juan County’s emergency operations plan18 did not contain a formal mass casualty incident plan but did have annexes that cover rescue and emergency medical services, mass fatalities, and shelter/mass care. Within those annexes are sections entitled “Situations and Assumptions” and “Concept of Operation,” which outline recommended actions and contacts in the case of a disaster. The “Assumption” section in the “Rescue and Emergency Service” annex notes that any large-scale emergency would increase the demands of the volunteer EMS to the extent that any mass casualty event would overwhelm the limited response capabilities of San Juan County. The Utah Department of Health, Bureau of Emergency Medical Service’s Emergency Operations Plan includes a section entitled “Request for State and Federal Assistance,” which states that State and Federal healthcare assets must be formally requested through the Utah Department of Health. The State Bureau of EMS participates in the Emergency Medical Assistance Compact, which is a signed State-to-State mutual aid agreement. In addition, Utah has established regional EMS support teams located around the State. On the day after the

16 A flight of approximately 160 miles. 17 Larger than the State of Connecticut. 18 The county prepares the plan for Utah Department of Health approval.

NTSB Highway Accident Report

13 accident, a regional support team from Price, Utah, arrived to relieve first responders who had been working through the night of January 6.19 Utah and San Juan County use the National Incident Management System (NIMS).20 According to the San Juan County EMS Coordinator, both State and County personnel receive most of their NIMS training from the Federal Emergency Management Agency (FEMA). Beginning in 2007, all first responders receive NIMS IS 700 training, an introductory on-line course that explains the purpose, principles, and components of incident command systems and takes about 3 hours to complete. According to the San Juan County EMS Coordinator, the majority of its personnel have already received basic NIMS and NIMS IS 700 training.21 Weather After starting the trip in Telluride with snowy and icy roads, driving conditions improved as the accident motorcoach drove west, then south. The Utah investigative officer who responded to the accident stated that road conditions at 9:20 p.m. at the accident scene were dry. At 8:50 p.m., the San Juan County Sheriff’s Office had contacted the Bluff Station road supervisor, who dispatched two plows/sanders to the accident scene for debris removal. The plow operators arriving on scene at 10:30 p.m. reported foggy conditions and the road at the crash site to be damp from rain. Temperature instruments mounted in one of the trucks reported a road surface temperature of 37° F and air temperature of 41° F. Astronomical data obtained from the U.S. Naval Observatory for Blanding indicated that sunset was 5:14 p.m., end of twilight was 5:43 p.m., and, at the time of the accident, the sun was more than 15 degrees below the horizon. The phase of the moon was a waning crescent with only 3 percent of the moon’s disk visible.

19 Price is 240 miles from Mexican Hat. The EMS support team arrived in Monticello at 9:00 a.m. on January 7. 20 NIMS provides a consistent nationwide template to enable all Government, private-sector, and nongovernmental organizations to work together during domestic incidents, as required by Homeland Security Presidential Directive 5 (February 28, 2003). 21 NIMS is a national standard and a curriculum. Currently, six courses managed by FEMA are required for an individual or organization to be considered NIMS-compliant through FY 2007. Basic incident command system training consists of the four classroom courses (ICS 100, ICS 200, ICS 300, and ICS 400) and two independent study courses (IS 700, an introductory course for NIMS, and IS 800, an introductory course for the National Response Plan).

NTSB Highway Accident Report

14 Driver Information Driver Fitness The 71-year-old driver resided in Michigan and had worked part-time for Arrow since March 2007. He possessed a valid Michigan commercial driver’s license (CDL) with a passenger endorsement and a restriction limiting CDL use to class B/C vehicles only.22 Michigan motor vehicle records indicated that the driver had no record of violations or accidents during the previous 5 years of motorcoach driving. Prior to driving motorcoaches, the driver had 7 years of CDL experience as a truck driver. The driver’s most recent medical examination report for commercial driver fitness determination, dated February 21, 2007, reported his visual acuity as 20/30 in both eyes evaluated together, without corrective lenses. The driver was 67 inches tall and weighed 235 pounds, and his medical report referred to a history of heart disease, heart surgery, and high blood pressure, indicating “heart bypass 1996” and “leg bypass 1998.” The report noted “no” for “sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring.” The report also noted, “due to hypertension, the driver qualified for only 1 year.” The driver’s personal medical records23 documented a history of atherosclerotic disease24 with coronary artery bypass surgery in 1996 and angioplasty in 2005 as well as surgery to clear blockages in major arteries in both legs in 1998. A pharmacological stress test in 2006 showed no evidence of blocked coronary arteries at that time. The driver’s personal medical records also indicated a history of sleep disorders. He underwent a polysomnogram in January 2007 and was diagnosed with moderate obstructive sleep apnea. He was being treated with a CPAP device to assist with sleeping. Prior to treatment, he had complained of snoring, periods during which he stopped breathing at night, disturbed sleep, and sleepiness during the day. He had been on CPAP treatment for approximately 1 month at the time of his February 2007 commercial driver fitness examination,25 but he marked “no” to the question asking if he had any history of “sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring” on the form documenting that examination.

22 The expiration date on the license was December 8, 2011. A Michigan class B license applies to single vehicles with a gross vehicle weight rating (GVWR) of 26,001 pounds or more or a gross combination weight rating of 26,001 pounds or more, towing trailers/vehicles rated at 10,000 pounds GVWR or less. A class C license applies to vehicles under 26,001 pounds GVWR; vehicles that are designed to transport 16 or more persons including the driver; vehicles that carry 15 or fewer people (including the driver) transporting children to or from school and home regularly for compensation; or vehicles that carry hazardous materials in amounts requiring placarding. 23 Dated May 22, 2006, January 5, 2007, and February 8, 2007. 24 Often referred to as “hardening of the arteries.” 25 At the time of the accident, the driver had been using the CPAP device for 11 months.

NTSB Highway Accident Report

15 The driver told the tour group leader, who was one of his passengers, that he had been sick for the 3 days in Telluride preceding the return portion of the accident trip.26 The driver stated to investigators that, due to his head congestion, use of the CPAP device was difficult. The driver could not use the CPAP device the first night in Telluride and used it only sporadically the other 2 nights, adversely affecting his sleep for the 3 nights preceding the accident. The driver’s activities in the 72 hours before the accident are shown in figure 7.

Figure 7. Accident driver’s sleep and activity log. (Note: Black bars indicate time available for sleep, not necessarily sleep obtained. Driving time occurs within, but is not synonymous with, on-duty time.) The driver reported to investigators that during the trip, he experienced what he described as a head cold, including a constant “runny nose.” While he was in Telluride, the driver purchased the “non-drowsy” form of a cold medicine on two occasions and self-medicated throughout his stay. The driver stated that he did not use the medication on the day of the accident. Postaccident blood specimens were collected from the driver while he was hospitalized in Flagstaff, Arizona, for toxicological testing by the Civil Aerospace Medical Institute. These specimens tested negative for drugs and alcohol. The specimen samples were taken at 7:40 a.m. on January 7, nearly 12 hours after the accident. The police, lacking probable cause, did not administer any tests or require specimens from the driver. Telluride, Colorado, is located at 8,750 feet altitude. On January 3, as the driver traveled from Phoenix to Telluride, he would have gained more than 7,000 feet in altitude. Resorts in Telluride caution visitors about the town’s high altitude.27 Headache, nausea, trouble sleeping, nasal congestion, and dizziness are symptoms of acute mountain sickness. One of the other drivers observed that the accident driver experienced some shortness of breath while installing tire chains on the morning of the accident.

26 Another passenger reported that he overheard the driver’s statement. 27 See http://www.telluride.com/the-mountain/high-altitude-information.html.

NTSB Highway Accident Report

16 Driver Performance On the day of the accident, the driver awoke at 6:45 a.m., and after being awake for 8.5 hours, began the accident trip at 3:15 p.m. According to a passenger, the driver stopped to remove tire chains about 20–30 minutes after leaving Telluride; he was unable to complete that task without the assistance of several passengers and another Arrow driver. Given the rerouting and weather conditions, the trip would have taken at least 11 hours.28 According to passenger interviews, the driver said that the trip to Phoenix would take about 12 hours, with an anticipated arrival time between 3:00–4:00 a.m. Interviewed passengers mentioned that earlier in the accident trip, the driver drifted onto the shoulder, running over the rumble strips.29 Several expressed concern to each other about the motorcoach’s speed. They also reported that earlier in the trip, when the motorcoach was south of Blanding, the driver swerved and objects inside the bus shifted and that one of the passengers yelled “slow down” to the driver. The DriveCam II video event data recorder30 from the motorcoach recorded another passenger saying “slow down” 2.75 seconds before the accident. The Safety Board received a transcript of a tape-recorded interview of the driver by the Utah Highway Patrol Officer on scene following the accident. In that interview, he stated that he had the cruise control set at 65 or 66 mph. Safety Board investigators interviewed the driver 6 days after the accident, following his release from the hospital. The driver said that he thought he may have been going too fast for the curve, but he was not speeding and was driving at a speed of 65 mph or less. Investigators reviewed the DriveCam II video recording of the passengers and motorcoach’s interior. The driver can be seen in the video; however, the video recording rate of 4 images per second was insufficient to determine the driver’s gaze location, duration, or the length of eye closures. The view of the driver is from about mid-chest level upward. His upper- right arm and shoulder are visible but not his hands or the steering wheel. The video shows the driver making a steering input in the beginning of the accident curve. His shoulders and right upper arm rotate slightly to his left, and his head turns toward the left. Accelerometer data indicate the vehicle turns toward the left. The driver’s head remains in this leftward position from this time until the accident. After this initial input, little or no movement of the driver’s arms or shoulders occurs for the next 3 seconds. The driver then makes a larger shoulder and arm rotation to the left, which is held relatively constant until the collision occurs, about 4.75 seconds later. As the motorcoach departs the roadway, passengers exhibit looks of alarm and brace themselves. The driver reacts more slowly than the passengers.

28 The outbound trip from Phoenix to Telluride was slightly longer than 9 hours, based on the driver’s log. The driver left Telluride at 3:15 p.m.; the accident occurred about 5 hours later. The remainder of the trip to Phoenix is 340 miles and would have taken 6 hours. 29 The section of the road where the accident occurred did not have rumble strips. This comment applied to an earlier portion of the route. 30 For more information on the DriveCam II video recorder, see “Data Recording Equipment” in the “Vehicle Information” section of the Factual portion of this report.

NTSB Highway Accident Report

17 Motor Carrier Operation Busco, Inc., doing business as Arrow Stage Lines, is an interstate, authorized for-hire carrier of passengers headquartered in Norfolk, Nebraska, with business locations in seven western States. The family-owned business, which was established in 1928, has 48-State and Canadian authority.31 Arrow also provides military transportation between bases in Kansas and Missouri. Arrow purchased a charter company in Phoenix called “Corporate Transportation ‘N Tours,”32 which was the terminal from which the accident motorcoach operated. Arrow operates 179 motorcoaches in both scheduled and charter service using a mixed fleet of Setra, MCI, Prevost, and VanHool motorcoaches and smaller buses and vans. The average age of Arrow’s motorcoach fleet is 5 years. The company employs 337 drivers. The average age of Arrow drivers is 60. Single-day drivers are paid by the hour, and overnight charter drivers are paid a flat daily rate plus expenses. Oversight and Compliance Reviews The Federal Motor Carrier Safety Administration’s (FMCSA’s) January 19, 2006, compliance review of Arrow, conducted before the accident, resulted in an overall “satisfactory” rating. That review included ”conditional” ratings for Driver and Vehicle factors. At that time, Arrow had an accident rate of 0.37 accidents per million miles traveled.33 The FMCSA’s Motor Carrier Management Information System (MCMIS) database indicated that Arrow had also received compliance reviews in 1991, 1996, and 2000, all resulting in satisfactory ratings. The FMCSA conducted a postaccident safety fitness compliance review of Arrow on February 2, 2008. That on-site review resulted in an overall conditional rating, meaning that the carrier did not have adequate safety management controls in place to ensure compliance with the safety fitness standards.34 The conditional rating was the result of Arrow being rated less than satisfactory in three areas: Factor 2—Driver (conditional), Factor 4—Vehicle (conditional), and Factor 3—Operational (unsatisfactory). The review found that Arrow failed to conduct postaccident alcohol and drug testing on the accident driver, all 16 drivers completing the accident-related trip had hours-of-service violations, and Arrow was using a commercial motor vehicle not periodically inspected. These are all critical elements in determining a carrier’s safety rating. Records from that review show that Arrow traveled 10,333,556 miles in 2007; during that time, the company had 6 reportable accidents, resulting in 0.58 accidents per million miles traveled. The FMCSA has determined that motor carriers with an accident rate of 1.50 or greater are deficient. A followup to the postaccident review was conducted on August 18, 2008, resulting in a satisfactory rating.

31 U.S. Department of Transportation identification number 433377 and motor carrier number 232723. 32 Arrow purchased the charter company on February 1, 2005. 33 Title 49 CFR Part 385 B(c) defines deficient motor carriers as those with an accident rate above 1.50 accidents per million miles traveled. 34Title 49 CFR Parts 40, 325, 350, and 355–399.

NTSB Highway Accident Report

18 In addition to the MCMIS, the FMCSA uses the Motor Carrier Safety Status Measurement System (referred to as SafeStat) to evaluate the safety posture of a motor carrier and to determine which motor carriers should be scheduled for compliance reviews. Of the eight SafeStat performance levels, only three would trigger compliance reviews. According to FMCSA, Arrow’s most recent SafeStat scores showed the carrier not to be deficient.35 Roadside inspection data for the 12 months before the accident showed that Arrow had 180 vehicle inspections with 7 vehicles placed out of service (4 percent) and 80 driver inspections with 2 drivers placed out of service (2.5 percent). The national averages are 23 percent for vehicle inspections and 7 percent for driver inspections. The FMCSA uses an inspection selection system (ISS) program to aid roadside inspectors in selecting vehicles for inspection. The ISS rating system has been combined with the SafeStat system, resulting in a more uniform system, called ISS-D, which categorizes operators as follows: pass (no inspection recommended), optional, or inspect.36 Before the accident, Arrow received a “pass” rating in the system; as a result of the postaccident compliance review, Arrow was rated as “inspect” for roadside inspections. As of September 26, 2008, Arrow’s score was 73 (optional). The Military Surface Deployment and Distribution Command of the U.S. Department of Defense contracts with a private company, Consolidated Safety Services Incorporated, to conduct facility, terminal, and vehicle inspections of motor carriers that transport military personnel. Consolidated Safety Services conducted a comprehensive audit of Arrow on October 9, 2007, in which Arrow received a rating of 1, the highest rating on a scale of 1–5. Hours of Service Hours-of-service regulations generally require carriers and drivers of passenger-carrying commercial motor vehicles not to exceed 10 hours of driving time following 8 consecutive hours off duty, except under adverse driving conditions. The hours-of-service regulations define adverse driving conditions as snow, sleet, fog, or other adverse weather conditions; a highway covered with snow or ice; or unusual road and traffic conditions, none of which were apparent on the basis of information known at the beginning of the accident trip. Under adverse conditions, a passenger-carrying driver en route to a destination is permitted to drive a commercial motor vehicle up to 2 additional hours to complete that run or to reach a place offering safety for the occupants of the commercial motor vehicle and security for the commercial motor vehicle and its cargo. However, drivers of passenger-carrying commercial motor vehicles may not drive or be permitted to drive for more than 12 hours total following 8 consecutive hours off duty.37 If a motor carrier or a driver is aware of adverse weather before departing on a trip, as would have been the case for the accident trip because of the lead driver’s knowledge of the road closure, the

35 As of December 19, 2007, Arrow scored as follows in these areas: 13.01—Accident, 33.97—Driver, and 6.43—Vehicle. A carrier scoring 75 or above in two or more areas warrants a compliance review. After the postaccident compliance review, Arrow scored higher than 75 in two areas (Driver—93.13 and Safety Management—89.53), prompting the followup review conducted in August 2008. 36 ISS-D score ranges are 1–49 (pass), 50–74 (optional), and 75–100 (inspect). 37 49 CFR 395.1(b)(iii), adverse driving conditions.

NTSB Highway Accident Report

19 adverse weather rule allowing 12 hours does not apply.38 The FMCSA’s postaccident compliance review found that 14 drivers exceeded the 10-hour driving rule and the 2 other drivers had false reports of duty status for the trip from Telluride, Colorado, to Phoenix. Arizona. Trip Communications Arrow normally provides Nextel wireless telephones to its drivers on trips involving multiple motorcoaches.39 Nextel units were not provided to the drivers for the accident trip because Nextel service coverage is very limited in the geographic area covered by the charter trip. Instead, drivers were encouraged to use personal wireless telephones to communicate with other drivers during the trip when coverage was available. A review of the motorcoach’s internal video recorder, DriveCam II, conclusively established that the driver was not using a wireless telephone at the time of the accident. An interview with the Arrow Safety Director confirmed that the lead driver had discussed plans for the return trip with the company on the day of the accident. Despite the fact that road closures due to heavy snowfall and avalanche risk are a common occurrence during winter months in the mountains, Arrow did not present the drivers with a contingency plan. The drivers did not request relief drivers, and Arrow did not arrange for them. Vehicle Information The accident motorcoach was a 2007 Motor Coach Industries, model J-4500, 56-passenger, three-axle, intercity motorcoach, delivered into service June 30, 2007, and registered in Nebraska. The total vehicle mileage was 23,941, and the gross vehicle weight was 54,000 pounds. The vehicle was equipped with a DriveCam II video event data recorder (VEDR) and a video entertainment system. The motorcoach was powered by a six-cylinder Caterpillar diesel engine equipped with a Jacobs Engine Brake40 and cruise control. In a postaccident interview with investigators, the driver stated that the “jake brake” was not engaged and it was not his practice to use it in changing road conditions (wet to dry). The vehicle had a conventional air brake system with disc brakes on all three axles. A postaccident visual inspection of the braking system was conducted,

38 The FMCSA’s interpretation of the hours-of-service regulations, guidance no. 5, states: “An absolute prerequisite for such claim must be that the trip involved is one of which could normally and reasonably have been completed without a violation and that the unforeseen event occurred after the driver began the trip. Drivers who are dispatched after the motor carrier has been notified or should have known of adverse driving conditions are not eligible for the two hours additional driving time provided under 396.1(b), adverse driving conditions.” 39 The Arrow employee manual states that cellular telephones should be used only when absolutely necessary and only for work-related communication. 40 An engine brake, often referred to as a jake brake, is a device that uses air compression to change the timing of the engine exhaust valves. The retarding power is proportional to the engine speed (rpm) and results in lower control speed in downhill descents with reduced use of the foundation braking system.

NTSB Highway Accident Report

20 and no audible leaks were detected from the pressurized system.41 The front wheels/tires were removed from the motorcoach, and an operational check of the brakes was performed by applying the service brake (regular brake pedal) in the driver’s compartment. When rotated, the hubs stopped when the brakes were applied. Because the automatic adjusting mechanism is integrated in the body of the disc brake system, there were no pushrods to be measured. No appreciable wear was found on the rotors,42 and the measured brake pads were well within wear limits.43 The vehicle was equipped with a Meritor-WABCO six-channel automatic braking system but did not have electronic stability control. The motorcoach was equipped with manufacturer-recommended-size tires,44 with more than adequate tread depths.45 The front tires remained inflated after the accident sequence, measuring 105 psi each; of the remaining six tires, four were deflated as a result of being off the bead or off the rim. Two tires on the middle dual-wheel drive axle measured 101 psi and 105 psi. The steering system was found to have adequate fluid; there were no indications of power steering fluid leaks. A portion of the steering assembly was damaged, consistent with accident damage.46 In a postaccident interview, the driver stated that he experienced no handling problems with the motorcoach.47 The DriveCam II video recording confirmed that the vehicle headlights were on. Testing of the headlight bulbs for filament distortion to determine whether the lights were on high or low beam was inconclusive. The setting of the high-beam steering wheel spring switch before the accident could not be confirmed, and no vehicle record of the setting was available.

41 The brake air system retained air pressure at 70 psi after the accident. 42 The front rotors were without cracks, and the rotor thickness was measured at 1.75 inches for the right-front brake and 1.77 inches for the left. Both measurements were similar to the approximately 1.75 inches found on a new rotor. 43 The brake pads were pulled and measured and none of the front brake pads exhibited heat damage. The right-inside pad measured 0.64 inch and the right-outside pad measured 0.62 inch; the left-inside pad measured 0.62 inch and the right-inside pad measured 0.64 inch, all well within the legal wear limit of 0.125 inch (1/8 inch) as required by the Federal Motor Carrier Safety Regulations (FMCSRs), Section 393.47. 44 Firestone model FS-400 radial tires that had an “L” speed rating (75 mph) and a “J” load rating (8,270 pounds at 120 psi). 45 The tires, when new, have tread depths of 0.562 (18/32) inch. The postaccident tread depths measured between 0.312 (10/32) and 0.562 (18/32) inch. FMCSR 393.75 states that any tire on the front wheel of a bus shall have a tread groove pattern depth of at least 4/32 inch, and all other tires shall have a tread groove pattern depth of 2/32 inch. 46 The steering shaft was disconnected from the U-joint on top of the miter box. The upper-front spare tire truss supporting the miter box was bent upward. One of the inner flanges of the U-joint had metal chipped away, and the end of the cross pin had pin indentations. The fresh markings on the cross pin showed that it had been fully engaged in the U-joint. 47 In a statement to the Utah Highway Patrol, the driver stated, “excellent equipment…new bus…handled like a dream.”

NTSB Highway Accident Report

21 Roof Design According to an MCI representative, the accident motorcoach, as well as others that MCI manufactures, was constructed using a monocoque-type frame. Monocoque construction offers a weight advantage and is commonly utilized in motorcoaches and van-type semitrailers, in which the sides of the vehicle bear a substantial part of the load in shear. The roof panel was made of aluminum and secured to the stainless steel roof bows using structural adhesive; the edges of the panel and the periphery of the roof hatches were riveted. The roof had five longitudinal supports running from the front-upper structure to the rear-upper structure. The roof was supported by eight stainless steel posts on each side, which extended vertically from the belt rail to the roof rail and were welded at the belt rail and again at the roof rail. Although not a single continuous tube, the eight vertical posts continued across the roof, becoming roof bows. Figures 8 and 9 illustrate segments of the motorcoach’s roof and side construction. The roof of the motorcoach became detached from the body during the rollover. The motorcoach rotated about its longitudinal axis, rolling over 360 degrees to its right, and approximately 180 degrees about its vertical axis, stopping on its wheels facing east. During the rollover, the right side of the motorcoach’s roof, at the lower edge of the window sill (sash rail) and vertical support posts for the window, became separated from the body. At final rest, the motorcoach was right side up, with the roof lying on the ground near the motorcoach, top side down. The windshield glazing and all windows along both sides of the motorcoach were displaced during the rollover.

Figure 8. Motorcoach roof design. (Source: MCI.)

NTSB Highway Accident Report

22

Figure 9. Motorcoach side supports for roof. (Source: MCI.) Data Recording Equipment The accident vehicle was not equipped with an advanced event data recorder capable of detailed accident reconstruction, nor was it required to be. The electronically controlled engine did have an advanced electronic control module (ECM)48 capable of recording selected vehicle movement and performance information. The engine, as delivered by Caterpillar, had the ECM data recording function turned off and did not capture vehicle speed, rpm, or braking information at the time of the accident. Although not configured to record “quick stop” data, the ECM was capable of logging data associated with critical diagnostic events. Logged diagnostic data include information on when the event started, how long it was active, the extreme value, and the average values. ECM data extraction determined that the accident vehicle’s maximum speed had been recorded at

48 An ECM is a semiconductor unit for controlling ignition timing, fuel delivery, speed control, and other parameters related to the engine management system. It is capable of logging data associated with critical diagnostic events. This capability is not intended to capture crash data, but to assist technicians in trouble-shooting system fault conditions.

NTSB Highway Accident Report

23 88 mph. It could not be determined from ECM data when, over the life of the vehicle, that maximum speed occurred.49 ECM calibration and configuration data revealed that the cruise control feature of the ECM was enabled, with a maximum potential cruise speed of 72 mph. It could not be determined whether the electronic controls integrated in the steering wheel for the cruise control and the Jacobs engine brake were engaged at the time of the accident. The motorcoach was also equipped with a Saucon on-board global positioning system (GPS) and telemetry system capable of transmitting time-tagged location information. During recovery of the motorcoach on the day after the accident, the wrecker operator disconnected the vehicle battery, resulting in permanent and total loss of quick-stop data.50 The DriveCam II system incorporated digital recording capability that successfully captured interior and exterior video, audio, and dual-axis accelerometer (longitudinal and lateral)51 parametric data at the time of the crash. A detection of lateral acceleration of 0.45 g would have started a 20-second video and data recording. There was only one DriveCam II recording between Telluride and Mexican Hat, the one from the accident event, meaning that the camera did not sense any events that exceeded the thresholds prior to the accident. The DriveCam II video recorder utilized an internally housed 64-megabyte compact flash memory card to store video, audio, and accelerometer data. A review of the external video footage showed the motorcoach gradually departing the pavement to the right as the roadway curved to the left. No other vehicle or obstacle was involved.52 Road Design In southeastern Utah, U.S. 163 is a two-lane, asphalt-paved, secondary rural road with an average daily traffic count of 650 vehicles per day. The roadway forms part of the Trail of the Ancients National Scenic Byway and cuts through the heart of Monument Valley. Although the roadway is mainly straight, there are numerous curves and steep grades. The road is marked with a centerline and white edge lines and route delineator posts with reflectors. The surrounding terrain is rough with varying elevation. Shortly after the driver missed the U.S. 191 turn, and 10 miles before the accident site, U.S. 163 becomes a long downhill stretch (5-percent downgrade) beginning at approximately milepost 39.53 At the beginning of the downgrade, the driver would have experienced a sharp

49 The recording of a maximum speed in the ECM could occur during loss of traction and may not reflect a valid road speed. 50 Data storage in the unit was accomplished through volatile (internal random access) memory, requiring an uninterrupted power supply to maintain memory storage. 51 An accelerometer is an electromechanical device that measures the magnitude and direction of acceleration and gravity-induced reaction forces. 52 A discussion of the motorcoach’s internal video recording appears in “Driver Performance” in the “Driver Information” section of the Factual portion of this report. 53 Milepost numbers decrease on approach to the accident site.

NTSB Highway Accident Report

24 horizontal curve that was well marked with chevron curve signs54 and a 35-mph speed advisory warning. Beginning 4 miles before the accident site, about milepost 33, the highway begins a gradual descent,55 as shown in figure 10. The immediate approach to the curve where the accident occurred is a long, straight downgrade (1,200 feet long with a 5.6-percent downgrade), as shown in figure 11.

Figure 10. View of descending road grade, 4 miles before the accident site.

54 Chevrons are geometric shapes (<< >>) that indicate direction. 55 For more than a mile (6,400 feet) preceding the curve where the accident occurred, the highway averages a 4- percent downgrade.

NTSB Highway Accident Report

25

Figure 11. View of descending road grade in the direction of travel, immediately preceding the accident curve. The accident occurred on a long left-hand curve that extends for nearly one-third of a mile (1,641 feet) at milepost 29. The curve, shown in figure 12, has a spiral transition and a 1,400-foot radius resulting in a 4-degree curve. The curve had a 6-percent superelevation or bank. A curve warning sign is posted on the right-hand roadside approximately 750 feet in advance of the curve.56 The curve warning sign does not have a posted advisory speed warning sign. The posted speed for the area is 65 mph.

56 The curve sign is 12 feet from the roadside and 7 feet above the pavement.

NTSB Highway Accident Report

26

Figure 12. View of accident curve. The highway design plan indicates that this section of the roadway has a 60-mph design speed. In December 1996, ball-bank indicator tests57 were performed on this curve at the 65-mph speed limit, and a reading of less than 10-degree angle was observed,58 indicating that the reduced advisory speed did not need to be posted on this curve.59 The accident curve had a W-rail, weak-post guardrail60 erected 220 feet after the beginning of the curve. The guardrail, shown in figure 13, continued for approximately 550 feet along the right side of the road in the first half of the curve and was marked with reflectors. The guardrail provided vehicle protection from a drainage culvert at the toe of the slope, and the foreslope had a 1V:2H drop.61 This slope would be classified as critical, meaning that an errant

57 The term ball-bank indicator refers to an inclinometer used for the specific purpose of determining safe curve speeds for horizontal curves. It measures the overturning force (side friction), measured in degrees, on a vehicle negotiating a horizontal curve. 58 The minimum radius for a curve under these conditions is 1,348 feet. The road’s actual curvature is 1,432 feet. 59 A Policy on Geometric Design of Highways and Streets, American Association of State Highway and Transportation Officials (Washington, DC: AASHTO, 1994) page 144. 60 Weak-post guardrails provide larger dynamic deflections in a collision and are considered more forgiving than stiffer barriers. 61 The slope dropped 1 foot vertically for every 2 feet of horizontal distance.

NTSB Highway Accident Report

27 vehicle running off the road onto the slope would likely overturn. The existing guardrail had no end treatment.62

Figure 13. View of guardrail. On the left side of the road, approximately halfway through the curve, a bluff that is 20– 30 feet high extends across the landscape and up to the road’s edge. That terrain blocked the driver’s view of the route delineator posts marking the last 500 feet of the curve. Likewise, as the road curved to the left behind the bluff, the motorcoach headlights would not have illuminated reflectors on the route delineator posts. For approximately 200 feet after the guardrail, the terrain on the right side of the road rose into a 3-foot-high mound that was traversable and would serve to help an errant motorist regain control. A little over halfway through the curve, the foreslope again fell away from the side of the road bed at a rate of 1V:3H, a flatter slope. Guidance in the American Association of State Highway and Transportation Officials (AASHTO) Roadside Design Guide indicates that this slope is considered traversable but not recoverable.63 The Roadside Design Guide also indicates that a slope of this magnitude would not have been required to have a longitudinal barrier or guardrail unless some other hazard was located on the slope or in the clear zone.

62 The American Association of State Highway and Transportation Officials Roadside Design Guide, Section 9.2.2, identifies standard guardrail end treatments. For further information, see American Association of State Highway and Transportation Officials, Roadside Design Guide (Washington, DC: AASHTO, 2006). 63 In other words, an errant motorist would likely follow the slope down.

NTSB Highway Accident Report

28 Accident Location History Records for the 5-year period from 2002–2006 showed that 10 other accidents had occurred along the 4-mile-long stretch from mileposts 28–32. Four of these accidents were property damage only and six involved injuries but no fatalities. One accident occurred on the accident curve. One accident involved a truck; no motorcoaches were involved in that 5-year period. Further Utah Department of Transportation (UDOT) research found a record of a fatal accident involving a passenger car that had occurred on the accident curve in February 1997; in that accident, the driver had a blood alcohol concentration of 0.17 and, according to accident reconstruction, was traveling approximately 93 mph when he lost control of the vehicle. Rural Versus Urban EMS Response Most U.S. residents (approximately 85 percent) can reach either a level I or level II trauma center within an hour, but that proportion drops to 24 percent if only residents living in rural areas are considered. According to the National Highway Traffic Safety Administration (NHTSA), nearly 60 percent of all trauma deaths occur in rural areas,64 where 20 percent of the nation’s population lives. According to the National Academy of Sciences, the relative risk of a rural resident dying in a motor vehicle accident is 15 times greater than in urban areas, after adjusting for accident statistics, age, and gender. 65 NHTSA’s technical report on rural and urban crashes,66 based on Fatality Analysis Reporting System (FARS) data from 1994–2003, reported that 218,539 fatal rural road accidents occurred during this 10-year period, resulting in 249,986 fatalities. The report states that proportionally more accidents occur in rural areas than in urban areas despite the fact that fewer miles are driven in rural areas, and rural accidents are more severe and cause greater injuries. The Safety Board’s recent data report, which was particular to the type of vehicle involved in the Mexican Hat accident, also found greater risk to charter/tour bus occupants involved in rural road accidents. That report, Large Bus Accidents and Injuries in Rural and Urban Areas, 2000-2007, is discussed in the Analysis section and presented in appendix B.

64 U.S. Department of Transportation, National Highway Traffic Safety Administration, Contrasting Attributes Between Rural and Urban Fatal Crashes, 1994–2003, Technical Report DOT HS 809 896 (Washington, DC: NHTSA, 2005). 65 Emergency Medical Services: At the Crossroads, Institute of Medicine of the National Academies (Washington, DC: National Academies Press, 2007). 66 DOT HS 809 896.

NTSB Highway Accident Report

29 AASHTO Strategic Highway Safety Plan The AASHTO Strategic Highway Safety Plan67 identifies 22 key emphasis areas (goals) that affect highway safety and focus attention on selected strategies to reduce highway fatalities.68 One of the 22 goals, Enhancing Emergency Medical Capabilities to Increase Survivability (#20), consists of five areas to be researched and evaluated. If an area is found to be effective, funding for it would be expanded nationally. The five areas to be researched are as follows: Strategy 20A: Develop and implement a model comprehensive approach that will ensure appropriate and timely response to the emergency needs of crash victims. Strategy 20B: Develop and implement a plan to increase education and involvement of EMS personnel in the principles of traffic safety. Strategy 20C: Develop and implement an emergency preparedness model in three high-incident interstate highway settings (urban, rural, and wilderness). Strategy 20D: Implement and/or enhance trauma systems. Strategy 20E: Develop and support integrated EMS/public health/public safety information and program activities. SAFETEA-LU and High-Risk Rural Roads The U.S. Department of Transportation’s Federal Highway Administration (FHWA) targets rural road safety through the High Risk Rural Road Program funded by the 2005 Safe, Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for Users (SAFETEA-LU). SAFETEA-LU establishes, in law, the requirements and funding for highway safety programs at the Federal and State levels from fiscal years 2006–2009. Each State must develop and implement a “Strategic Highway Safety Plan” that specifically identifies its Highway Safety Improvement Program (HSIP). Rural road safety improvements that are funded by SAFETEA-LU are treated as candidate HSIPs, which States can address in their annual Strategic Highway Safety Plans.69 Proposed HSIPs identify highway safety improvements and can help guide a State’s investment decisions to achieve a significant reduction in fatalities and serious injuries on rural roads. HSIPs generally target highway infrastructure and span a wide range of improvements,

67 See http://safety.transportation.org/elements.aspx. 68 State and Federal safety and transportation officials aim to reduce the fatality rate from 1.5 to no more than 1.0 fatality per 100 million vehicle miles traveled. 69 23 CFR 148.(a)(3)(B)(xxi).

NTSB Highway Accident Report

30 including lane and shoulder widening, rumble strips, skid-resistant road surfaces, traffic calming, or the removal of a roadside obstacle. Not all projects must be related to infrastructure improvement or highway construction; for example, one type of HSIP would be to improve the collection and analysis of crash data. In developing HSIPs, States must adhere to SAFETEA-LU’s requirement to incorporate a data-driven, analytical approach to highway safety based on traditional approaches to risk assessment that define risk in terms of accident frequency and accident severity. SAFETEA-LU requires each State to include in its Strategic Highway Safety Plan a crash data system, an analysis of hazardous locations and roadway elements, criteria for establishing the severity of locations, priorities for corrective action based on data analysis, and a data-driven means for evaluating the effectiveness of HSIPs. In its published guidance, the FHWA outlines a two-step process for identifying high-risk rural roads and selecting projects.70 The first step requires a State to identify eligible roadways with accident rates for fatalities and incapacitating injuries that exceed statewide averages for their respective roadway functional classifications. Accident rates must be based on crash data and on exposure data; typically, vehicle miles traveled (VMT), average daily traffic (ADT), and lane miles are considered exposure data, although States working toward a comprehensive statewide data system may use other sources for exposure data. States may also consider roads with a potential for increased traffic volumes and subsequent increase in accidents and fatalities. The second step in the identification and selection process requires a State to use the eligible set of roadways identified in the first step to determine appropriate safety improvements and select projects. These projects form the basis for the HSIPs that appear in a State’s Strategic Highway Safety Plan. Utah Highway Safety Improvement Program UDOT’s 2007 annual report summarizes the Utah Comprehensive Safety Plan,71 which includes four emphasis areas, including roadway departure crashes.72 Emphasis areas were identified based on Utah accident data, and locations selected for highway improvements were identified based on the high-proportion testing method73 rather than on accident rates. For

70 For FHWA guidance on the High Risk Rural Roads Program, see http://safety.fhwa.dot.gov/safetealu/hrrrpattachment.htm. 71 Utah’s version of the federally required Strategic Highway Safety Plan. 72 These emphasis areas form the basis of the “Utah 2007 Five Percent Report.” Other emphasis areas are the use of safety restraints, impaired driving, and aggressive driving. 73 Generally, for each highway segment, the probability that a specific crash type was proportionally higher than the average for roads belonging to the same functional class (that is, two-lane highways) was computed based on the binomial test. If this probability was greater than would be expected by chance, the site was flagged and the number of crashes of a specific type out of the total number of crashes at that site was reported. For example, a value of 8/10 would mean that there were 8 crashes of that crash type out of a total of 10 crashes at that site, meaning that the proportion is substantially greater than expected to occur strictly by chance. This screening method identifies highway segments that have a high proportion of a target collision (that is, emphasis area) in relation to all collisions

NTSB Highway Accident Report

31 roadway departure crashes, Utah has identified the 5 percent of roadway locations exhibiting the most severe safety needs and prioritized these locations for improvements such as rumble strips, signing, and education. All four improvement projects74 target 155 miles of roadway along interstate road segments: three along Interstate 70 and one along Interstate 15. Tests and Research Vehicle Speed Analysis The vehicle did not have an event data recorder, and vehicle performance data, as captured by the ECM, was limited. Consequently, the video record of the motorcoach departing the highway provided the best evidence of the event, and the Safety Board was able to develop a method for using those data to derive a speed estimate. Because the Safety Board does not have a history of using this analytical approach to calculate speed, several confirmatory analyses were also conducted. The three methods discussed in the following sections all corroborate the extreme speed of the motorcoach. To estimate the speed of the motorcoach just before departing the roadway, the Safety Board’s vehicle performance staff conducted an analysis of the video data taken from the motorcoach’s DriveCam II video recorder. The analysis matches video image data with fixed survey points from the accident scene to establish the motorcoach’s location in relation to time. A full discussion of the video study for this accident is presented in appendix C. That analysis determined that, 4 seconds before it departed the roadway, the accident motorcoach was traveling approximately 88 mph. The DriveCam II video recorder continuously records color images in 640x360 format, at as high a rate as possible, which can vary between 10 and 30 frames per second. At any time, there is an image in the image sensor buffer’s memory; these images are updated continually as new ones become available commensurate with the recording rate. The camera uses a 0.25-second timer to retrieve images from the buffer for storage into flash memory. Consequently, the actual timing difference between two adjacent stored images may vary from 0.15 second to 0.35 second;75 that is, there is a potential timing error of up to 0.1 second relative to the nominal timing period of 0.25 second. When a continuous sequence of images is

within a functional class for serious and fatal injury crashes. The high proportion testing method is an effective way to evaluate crash history when traffic volume data are insufficient to facilitate the use of crash rates. 74 The projected cost for the improvements to the four interstate segments was $650,000. 75 The worst-case variance occurs at the slowest image acquisition rate of 10 times per second. If the timer selects an image from the buffer that is “old” by 0.09999 second and then 0.25 second later, selects a just-refreshed buffer image (age 0.00001 second), the actual recording time between the two images can be as long as 0.34999 second. Conversely, if the timer selects a just-refreshed image recorded at 0.00001 second and 0.25 second later, it selects an “old” image, the difference in recording times between such images can be as short as 0.15001 second.

NTSB Highway Accident Report

32 considered, the timing error remains ±0.1 second relative to the total duration of the continuous sequence of images. The DriveCam II video recording starts 10 seconds before the triggering event and lasts 10 seconds after the event, generating a total of 81 frames.76 A triggering event is an acceleration that exceeds threshold.77 The DriveCam II system includes one forward- and one rearward- facing camera. Only the video from the forward-facing camera viewing the roadway was used in the speed analysis. Safety Board staff calibrated the camera and mathematically corrected for distortion associated with its wide-angle lens. On January 14–15, 2008, the Safety Board, UDOT, and Utah Highway Patrol staff used survey equipment consisting of a Trimble Robotic Total Station and Trimble 5800 receivers to take precise measurements of the accident scene. (This information is depicted in the scene diagram in figure 4.) Those survey data provided 183 fixed points (points on solid white lines, solid and broken yellow lines, and reflector locations) for use in the video study. Particularly useful reference points were the 12 reflectors that were mounted on a guardrail. The analysis determined the location of the moving vehicle by comparing locations of landmarks in the camera image with their locations in a mathematically synthesized image based on surveyed data. If, at an assumed vehicle location, the camera image landmarks and synthesized image landmarks coincide, then the vehicle location is assumed to be where the vehicle was when the camera image was acquired. Vehicle speed was then estimated by “driving the distance” between locations within a timeframe corresponding to camera image frames. Motorcoach locations were estimated at 19 known vehicle positions (18 intervals) corresponding to the time period -8.75 to -4.25 second relative to the triggering event. A speed estimate based on exact 0.25-second timing of the camera frame intervals was calculated, as well as upper and lower speed estimates that take into account the potential ±0.1 second timing error. The lower bound of the estimated speed at the end of the considered time period was 88 mph. (See figure 14.)

76 10 seconds x 4 frames per second + 1 frame of the triggering event + 10 seconds x 4 frames/per second = 81 frames. 77 The threshold settings were 0.5 g for forward acceleration, 0.45 g for lateral acceleration, and 1.5 g for shock in either direction.

NTSB Highway Accident Report

33

Figure 14. Vehicle speed estimate versus number of frame intervals (video analysis). Vehicle Acceleration Analysis Safety Board staff also conducted analytical work to determine whether the accident motorcoach could have reached the estimated speeds shown in figure 14 with the engine governed at 72 mph.78 That analysis was based on the physical parameters of the vehicle (including mass, aerodynamic drag coefficient, and tire rolling resistance coefficient) and the forces acting on the vehicle.79 The acceleration was estimated using a simulation model of the

78 The accident motorcoach’s engine had a governor that shut off fuel at 72 mph. 79 Vehicle mass, frontal area of the vehicle, air density, downgrade slope, and acceleration of gravity were known with some degree of precision. The nominal value of the aerodynamic drag coefficient was estimated to be 0.6 and the values of 0.5, 0.6, and 0.7 were considered in the analysis. The nominal value of the tire rolling resistance coefficient is usually assumed to be 0.01, and the values of 0.01 and 0.02 were considered in the analysis.

NTSB Highway Accident Report

34 vehicle dynamics starting with the motorcoach entering a 4.5-percent downgrade at 70 mph. That analysis showed the vehicle reaching a speed of 90 mph in 54 seconds.80 Over the 1,000-foot-long segment of roadway approaching the curve, the road downgrade decreases from about 5 percent to about 3 percent. An analysis was performed to estimate the effect of the downgrade reduction on the motorcoach’s speed. That simulation started at 88 mph and showed the motorcoach to slow by less than 0.2 mph. The Safety Board also calculated a terminal velocity of the vehicle, which is a steady state speed at which gravitational forces on the roadway downgrade are balanced by aerodynamic drag and tire rolling resistance forces. The nominal terminal velocity on a 5-percent downgrade using conservative values81 was estimated to be 96.7 mph. Although these vehicle performance analyses are only estimates based on acceptable engineering practices, they serve as additional confirmation that the motorcoach could attain the 88-mph speed estimated from the video analysis. Engine Performance Data The motorcoach’s engine ECM provided two data parameter fields within the Fleet and Driver Trip Reports that were used for evaluating the validity of the speed analyses. The subject ECM data indicated that the maximum vehicle speed ever obtained during the vehicle’s life was 88 mph.82 Staff also conducted a vehicle speed-by-gear ratio analysis based on the accident motorcoach’s known mechanical properties. Although the motorcoach’s engine was governed at 72 mph, it was capable of achieving much higher road speeds while in 10th gear when going downhill. Calculations indicated that, while in 10th gear, the motorcoach could obtain a road speed of approximately 88 mph with the engine being driven at 2,000 rpm.

80 Over a distance of approximately 6,500 feet. 81 The analysis used an aerodynamic drag coefficient of 0.7 and a rolling resistance coefficient of 0.02. 82 ECM values are not heavily filtered and can be subject to “noise” that generates “spikes” in the data received and interpreted by the ECM. Data spikes in vehicle speed can be the result of noise caused by excessive vibration, the improper installation of a speed sensor, or intermittent connections within the wiring.

NTSB Highway Accident Report

35 Analysis This analysis first discusses the factors and conditions that the Safety Board has excluded as neither causing nor contributing to the accident. It then provides a brief overview of accident events and discusses some of the safety issues relevant to the accident: driver fatigue, excessive vehicle speed, hours-of-service violations, and motor carrier trip planning. It then discusses the Safety Board’s concern about the motorcoach crashworthiness and the lack of adequate occupant protection systems for passengers in commercial motorcoaches. The analysis concludes with a discussion of emergency medical services notification and response with regard to large motorcoaches traveling on rural roads. Exclusions Single-vehicle, run-off-the-road crashes are primarily associated with driver fatigue or distraction. Based on interviews and video records, the Safety Board was able to rule out several of the most common driver distractions. Video evidence also confirmed that the driver was not using his cellular telephone and was not incapacitated at the time of the accident. Toxicological testing found no evidence of illicit drugs. The Safety Board therefore concludes that the driver was neither distracted by his cellular telephone nor impaired by illicit drugs at the time of the accident. Although the Safety Board can conclude from toxicological testing that the driver was not impaired by illicit drugs, toxicological testing was performed too late for the Safety Board to conclusively rule out alcohol as a factor in this accident. However, there was no evidence that the driver drank during the 5 hours that he drove the bus; nor was there evidence for the police to have probable cause to test the accident driver for alcohol or drugs. The Safety Board therefore concludes that, although it was unlikely that the driver was under the influence of alcohol, the delay in collecting a toxicological specimen prevents the Safety Board from conclusively ruling out alcohol as a factor in this accident. Although the weather affected the accident trip overall, road conditions at the time of the accident were reported to be dry. The Safety Board therefore concludes that the weather at the time of the accident was not a factor in the motorcoach’s departure from the roadway. Based on physical evidence, investigators were also able to confirm that a tire blowout, brake failure, or steering failure did not affect the driver or vehicle. There were no precrash mechanical defects found during postaccident inspection of the motorcoach. The Safety Board concludes that the mechanical condition of the motorcoach was not a factor in this accident. Investigators also considered the role of highway design in the accident. The accident curve’s signage complied with the Manual on Uniform Traffic Control Devices (MUTCD).83 The bank-ball indicator test conducted by UDOT confirmed that the curve did not need an additional

83 U.S. Department of Transportation, Federal Highway Administration, Manual on Uniform Traffic Control Devices (Washington, DC: FHWA, 2003).

NTSB Highway Accident Report

36 advisory speed warning sign84 for less than the 65-mph posted speed. Evaluation of the curve showed it had good frictional properties and the proper bank and radius for the posted speed. Additionally, no tire yaw marks were found on the roadway.85 The guardrail erected at the beginning of the curve provided a barrier for a drainage culvert at the bottom of a steep slope (1V:2H).86 Although the absence of end treatment for the existing guardrail was substandard, it was not a factor in the accident. Following the guardrail in the center portion of the curve, the terrain rose into a 3-foot-high berm that would be traversable and might aid an errant motorist in regaining control after departing the roadway. The last section of the curve had a foreslope of 1V:3H that, according to the AASHTO Roadside Design Guide, is traversable but not recoverable. A longitudinal barrier or guardrail would not be warranted for a slope of this magnitude unless some other hazard was located on the slope in the clear zone. In summary, the posted speed was appropriate for the curve, the signage was correct, and, based on Roadway Design Guide guidelines, additional roadside barriers were not warranted. The Safety Board concludes that the design and condition of the highway were not factors in this accident. Accident Discussion The part-time driver had been ill during his stay in Telluride, Colorado, and suffered from a self-reported difficulty sleeping that resulted in a lack of adequate rest during each of the 3 nights before the accident. He was experiencing head congestion that he attributed to a head cold, but the symptoms could also have been associated with altitude sickness.87 Sleep disturbances are common in individuals sleeping at higher altitudes than normal and, on the first day of the trip, the driver gained 7,000 feet in altitude.88 The driver had previously been diagnosed with obstructive sleep apnea and was prescribed a CPAP device to assist with sleeping. The driver’s head congestion would have resulted in restricted air capacity of his nasal passages, which, in turn, would have inhibited the effectiveness of the CPAP device, which operates by supplying forced air to assist in breathing. The driver did not use his CPAP device the first night in Telluride and used it only sporadically

84 MUTCD, Sign W1-2. 85 Tire yaw marks occur when a vehicle slides sideways while still moving forward. 86 The slope dropped 1 foot vertically for every 2 feet of horizontal distance. 87 Altitude sickness can occur when people rapidly ascend to a high altitude as a result of the combination of reduced air pressure and a lower concentration of oxygen at high altitude. Symptoms are commonly mild and can include difficulty sleeping, dizziness, fatigue, headache, nasal congestion, loss of appetite, nausea, rapid heart rate, or shortness of breath with exertion. 88 T.A. Kinsman, A.G. Hahn, C.J. Gore, B.R. Wilsmore, D.T. Martin, and C.M. Chow, “Respiratory Events and Periodic Breathing in Cyclists Sleeping at 2,650-m Simulated Altitude,” Journal of Applied Physiology, Volume 92, No. 5 (2002): 2114-8, determined that 15 of 17 subjects experienced significant increase in sleep-disturbing events at simulated altitudes of 2,000 to 8,700 feet.

NTSB Highway Accident Report

37 the other 2 nights. Based on the driver’s statements, he was aware that he had not been sleeping adequately during his time in Telluride. On the day of the accident, the driver had been awake for 8.5 hours, and, at 3:15 p.m., he began the anticipated 10–12 hour trip. Physical evidence of the vehicle’s gradual departure from the road is consistent with run-off-the-road crashes associated with fatigue. The Safety Board therefore concludes that the driver was experiencing diminished alertness and fatigue-related impairment due to inadequate sleep resulting from the following factors: head congestion, possible problems acclimating to high altitude, and his sporadic use of his CPAP sleeping device during the accident trip. Nine miles before the accident, at milepost 38, the driver would have experienced a sharp, well-marked curve where the posted speed decreased to 35 mph. Several interviewed passengers stated that before the accident, the driver drove off the road and when he swerved back, passengers’ personal belongings slid out from under the seats.89 At that point, a passenger shouted “slow down.” Another passenger estimated this occurred about 10 minutes before the accident. That time estimate correlates with the sharp curve at milepost 38. Video evidence taken seconds before the accident also records a raised voice saying “slow down.” Interviews indicate that passengers had voiced concern during the trip that the driver was going too fast. The Safety Board’s video analysis, summarized in the factual portion of this report and presented in detail in appendix C, determined that the vehicle was traveling at approximately 88 mph. The Safety Board conducted several other confirmatory estimates of speed. The ECM’s recorded maximum speed for the accident motorcoach was 88 mph. Vehicle speed based on the DriveCam II video recorder’s lateral accelerometer was estimated at 89 mph. Further, vehicle performance modeling of the vehicle’s acceleration on the downgrade of the road and of its terminal velocity showed that the vehicle had the capacity to exceed 90 mph. Vehicle performance analysis using engine speed, gear ratios, and tire geometry also confirmed that the motorcoach could reach a speed of 88 mph. The Safety Board concludes that the motorcoach was traveling approximately 88 mph in a 65-mph speed zone when the driver departed the road and lost control of his vehicle. Due to the driver’s diminished state of alertness, he may have neglected to monitor the motorcoach’s excessive speed as the vehicle traversed a long, straight descent. In a dark, rural area with few outside lights for reference and with some level of inside light reflection from the motorcoach’s entertainment video, the driver may have focused exclusively on lane following on the narrow two-lane rural road.90 The driver’s lack of awareness of driving tasks was also evident in the route-following mistake that occurred shortly before the accident. The fact that a passenger had, within minutes of the accident, shouted for the driver to “slow down” makes a compelling case that the vehicle speed had been called to the driver’s attention. At that time, several miles before the accident curve, the driver may have slowed down. But with the progressive downgrade, the motorcoach would have again picked up speed. A fatigued, inattentive driver may have been unaware of the increasing speed of the vehicle on the long downgrade just before

89 A detection of lateral acceleration of 0.45 g would have started a 20-second video and data recording. The DriveCam II accelerometer did not record the reported event. 90 C.D. Wickens, Attentional Tunneling and Task Management, NASA Ames Research Center Technical Report AHFD-05-23/NASA-05-10 (Moffett Field, CA: NASA, December 2005).

NTSB Highway Accident Report

38 the accident curve. The Safety Board concludes that the driver’s fatigue affected his monitoring of the motorcoach’s speed. The driver’s excessive speed contributed to his inability to regain control of the vehicle once it departed the roadway. Reaction time for steering inputs to correct for the road departure would have been in the range of 2.5–4.0 seconds.91 Evidence at the accident scene indicated that the vehicle traveled 350 feet from the point of road departure to where it lost traction on the embankment.92 At a speed of approximately 88 mph, the vehicle would have traveled that distance in approximately 2.7 seconds.93 The DriveCam II video recording shows that the driver traveled this portion of the accident sequence without reacting until the very end. Video evidence shows that the driver reacted more slowly than the passengers in realizing that the motorcoach had departed the roadway. The driver’s abrupt final steering input to the left probably contributed to a vehicle trajectory that involved a full 360-degree rollover. The Safety Board concludes that the driver’s reaction to the motorcoach’s departure from the roadway was delayed and, by the time he executed corrective steering action, he had lost control of the vehicle. The driver made a series of errors just before the accident that were associated with inattention: he was not monitoring his speed; he made some, but not enough, steering input to accomplish lane following; he did not respond to the increased lateral acceleration of the motorcoach;94 and he was slower than the passengers in realizing that his right wheels were off the roadway. The accident sequence can therefore be summarized as follows: (1) the driver was fatigued and in a diminished state of alertness at the time of the accident; (2) the driver was speeding and neglected to establish an appropriate speed for the upcoming curve; (3) the driver’s response to the road departure was delayed; and (4) given that delayed response, the driver had almost no opportunity to regain control of the vehicle. Fatigue Countermeasures The FHWA recommends that continuous shoulder rumble strips (CSRS) be installed on rural freeways and expressways as an effective means of reducing single-vehicle, run-off-road crashes caused primarily by motorist inattention. Utah is now installing these devices along its interstate highways as part of its HSIP. But, citing increased maintenance costs and safety concerns for bicyclists, the FHWA does not recommend CSRS for all roadway types. For rural

91 National Cooperative Highway Research Program, Human Factors Guidelines for Road Systems, NCHRP Report 600A (Washington, DC: Transportation Research Board, 2008) uses 3 seconds in Perception-Identification-Emotion-Volition (PIEV) calculations and 2.5–4.0 seconds PIEV for brake reaction time. AASHTO uses 2.5 seconds for perception-reaction time (PRT) criteria. PRT should not be viewed as a fixed human attribute; therefore, a general range is most appropriate for this discussion. 92 At 88 mph, the motorcoach could have traveled 323–516 feet in 2.5–4.0 seconds. 93 Because the vehicle was decelerating based on the changing surface conditions, the time could be slightly longer. 94 Research cited by AASHTO indicates that a lateral acceleration of 0.2 g or greater makes drivers uncomfortable, prompting them to slow down in response. The driver’s lateral acceleration prior to departing the roadway, at 2.75 seconds before impact, reached 2.5 g, causing papers to slide off the front passenger seat.

NTSB Highway Accident Report

39 multilane and two-lane roadways, the FHWA recommends that an engineering study or crash analysis be conducted to determine whether crashes would likely be reduced by the presence of rumble strips. The low traffic count and the low accident rate make it unlikely that the Utah DOT would embark on a CSRS infrastructure improvement along U.S. 163. Moreover, CSRS treatment to the roadside would not have prevented this accident because of the driver’s excessive speed. The high-speed departure from a rural two-lane roadway with narrow shoulders offered too short a timeframe for detection, processing, and corrective action. The Safety Board’s recent investigation of a truck-tractor semitrailer rollover accident that resulted in the subsequent collision of a motorcoach with the overturned truck in Osseo, Wisconsin,95 examined the issue of fatigue countermeasure technologies in detail. As a result of that investigation, the Safety Board asked that the FMCSA develop and implement a plan to deploy technologies in commercial vehicles to reduce the occurrence of fatigue-related accidents (Safety Recommendation H-08-13). The Safety Board is currently awaiting the FHWA’s response to that recommendation.96 Driver Medical Conditions In February 2007, the CDL medical examiner set the accident driver’s fitness examination timeframe for renewal at 1 year instead of the usual 2 years due to the driver’s hypertension.97 During that examination, the driver did not acknowledge a history of sleep disorders. The driver’s sleep disorder had been medically evaluated and was being treated with a CPAP device that the driver had used for approximately 1 month before the CDL medical examination. Because the driver’s sleep disorder was being treated, it is unclear whether the medical examiner would have modified his certification decision even had that information been conveyed. In addition to obstructive sleep apnea, the driver had a history of several other health conditions. His coronary artery disease had been treated, and a recent stress test was normal. His high blood pressure was controlled by medication. The driver was also obese; he had a body mass index (BMI) of 36.8 kg/m2.98,99 The FMCSA’s Medical Review Board (MRB) has identified a set of medical conditions that, occurring in combination, would factor into the duration of medical certification. The investigation revealed that the driver had multiple medical conditions that are the subject of a recent MRB recommendation. However, no evidence exists,

95 National Transportation Safety Board, Truck-Tractor Semitrailer Rollover and Motorcoach Collision With Overturned Truck, Interstate Highway 94 Near Osseo, Wisconsin, October 16, 2005, Highway Accident Report NTSB/HAR-08/02 (Washington, DC: NTSB, 2008). 96 Safety Recommendation letter to the FMCSA dated February 2, 2009. 97 Arrow also has an operating policy that states that drivers 65 years and older must be medically certified every year; Arrow pays for that medical certification. 98 The Centers for Disease Control and Prevention defines obesity as a BMI of 30 kg/m2 or greater. 99 On January 28, 2008, the MRB presented recommendations to the FMCSA that included screening drivers for obstructive sleep apnea if they had a BMI of greater than 35 kg/m2 and warning drivers of the consequences of CPAP device non-use.

NTSB Highway Accident Report

40 either from the witnessed actions of the driver before the accident or from the driver’s medical history, that these conditions played a role in the accident. The Safety Board therefore concludes that none of the driver’s preexisting medical conditions, except for sleep apnea, played a role in this accident. The Safety Board is closely following the MRB’s work and the FMCSA’s disposition of its recommendations. The Safety Board’s Most Wanted List of Transportation Safety Improvements includes the prevention of medically unqualified drivers from operating commercial vehicles. Safety Recommendations H-01-17 through -24,100 issued as a result of the Safety Board’s investigation of a 1999 motorcoach accident in New Orleans, Louisiana,101 address all aspects of an appropriate, comprehensive program for Federal medical oversight of commercial drivers.102 In October 2008, the Safety Board considered this issue at its meeting to update the Federal Most Wanted List of Transportation Safety Improvements and classified the FMCSA’s response on this issue as “Unacceptable.” In February 2009, the Safety Board commented on the FMCSA’s notice of proposed rulemaking (NPRM),103 addressing the certification, training, and testing of medical examiners. Hours of Service Arrow received a conditional rating during a postaccident compliance review conducted in February 2008.104 One component of that less-than-satisfactory rating was based on violations of the hours-of-service regulations (49 CFR Part 395). In addition to the accident driver, 16 other drivers associated with the Telluride trip had such violations: 14 had exceeded the 10-hour driving rule, 2 had falsified records, and 10 had exceeded the 15-hour work rule. The lead driver communicated with Arrow management on the morning of the accident trip and, following that telephone call, made the decision to return to Phoenix along the alternate route. Hours-of-service regulations allow drivers to complete 10 hours of driving time under normal conditions. The regulations also provide consideration for adverse driving conditions, allowing for up to 12 hours of driving time, but only when those conditions are encountered en route, not if they are known prior to departure. The driving time exception would not have applied to the accident trip, which started on an alternate route because adverse weather had closed the preferred route, prompting drivers to begin the trip equipped with tire chains. The accident route was 556 miles, so travel time would have had to average better than 55 mph to not

100 Only two of these eight recommendations (H-01-19 and -20, on updating medical certification regulations) are currently in “Acceptable” status. 101 National Transportation Safety Board, Motorcoach Run-Off-The-Road Accident, New Orleans, Louisiana, May 9, 1999, Highway Accident Report NTSB/HAR-01/01 (Washington, DC: NTSB, 2001). 102 For more information, see http://www.ntsb.gov/recs/mostwanted/medical_certification.htm. 103 Notice of Proposed Rulemaking, “National Registry of Certified Medical Examiners,” Federal Register, vol. 73, no. 231, pp. 73129–73147. 104 Arrow received two compliance reviews in the 2 years preceding the accident; in January 2006, Arrow received a satisfactory rating from the FMCSA; in October 2007, Arrow received a rating of 1 (highest) from the U.S. Department of Defense contractor Consolidated Safety Services.

NTSB Highway Accident Report

41 exceed the 10-hour hours-of-service rule. Considering the mountainous secondary roads, adverse weather conditions, and time required to remove tire chains, the average rate of travel should have been expected to be less than 55 mph, resulting in a trip time that would have exceeded 10 hours. The Safety Board concludes that both Arrow and its drivers knew of the adverse weather conditions before starting the accident trip and thus intentionally engaged in a trip that would likely exceed hours-of-service regulations. Until systemic monitoring capabilities are put in place, hours-of-service violations can be expected to continue. It has been the Safety Board’s position that the only way the FMCSA can effectively enforce carrier hours-of-service compliance is to mandate the use of electronic on-board recorders (EOBRs) by all operators.105 Over 2 years ago, the FMCSA issued an NPRM106 requiring EOBRs for the most egregious hours-of-service violators; that NPRM has not yet been issued as a final rule. The Mexican Hat accident involves a carrier that would not likely be affected by the proposed EOBR rule; this accident again illustrates why the Safety Board’s past recommendation called for EOBRs for all commercial operators, not just problem carriers. The Safety Board therefore reiterates its EOBR recommendation to the FMCSA: Require all interstate commercial vehicle carriers to use electronic on-board recorders that collect and maintain data concerning driver hours of service in a valid, accurate, and secure manner under all circumstances, including accident conditions, to enable the carriers and their regulators to monitor and assess hours-of-service compliance. (H-07-41) Arrow Trip Scheduling At the time of the accident, the driver had been driving for approximately 5 hours and was within the operational time constraints of the hours-of-service regulations. However, both Arrow and the drivers should have been aware that the scheduling of the longer return trip would be problematic. The trip route from Phoenix to Telluride was 486 miles, but the rerouted return trip was 556 miles, presenting the likelihood that contingency planning would be needed to avoid hours-of-service violations.107 Arrow’s options to avoid exceeding hours-of-service requirements included overnight accommodations for the more than 800 passengers and drivers, either in Telluride or along the

105As a result of its investigation of a 2004 accident involving a fatigued tractor-trailer driver, the Safety Board recommended that EOBRs be required for all interstate commercial carriers (Safety Recommendation H-07-41). For further information, read National Transportation Safety Board, Rear-End Chain Reaction Collision, Interstate 94 East, Near Chelsea, Michigan, July 16, 2004, Highway Accident Brief NTSB/HAB-07/01 (Washington, DC: NTSB, 2007). 106 Notice of Proposed Rulemaking, “Electronic On-Board Recorders for Hours-of-Service Compliance,” Federal Register, vol. 72, no. 11, pp. 2340–2394, January 18, 2007. 107 FMCSA Regulation 392.6, Schedules to Conform With Speed Limits, provides the following guidance about trip length: Total trip distances of 550–600 miles on highways with a speed limit of 65 mph or of 450–500 miles on highways with a speed limit of 55 mph are considered “questionable,” and motor carriers may be asked to document that such trips were made in compliance with the speed limit and hours-of-service limitations.

NTSB Highway Accident Report

42 return route to Phoenix108 or the provision of relief drivers along the route for the 17 motorcoaches. Either option would have required substantial coordination, both in terms of the logistics to arrange either hotel accommodations or additional drivers and with the charter passengers, who expected to return to regular activities on Monday following the weekend trip. Arrow could not reasonably expect the drivers to handle contingency plan arrangements for rescheduling the charter trip to avoid exceeding hours-of-service regulations. The Safety Board therefore concludes that Arrow should have developed contingency plans to avoid hours-of-service violations associated with the return trip. For contingency plans to be effective, they must be considered before the start of the trip, documented, and coordinated with the charter group. The Safety Board believes that Arrow should develop written contingency plans for each charter to ensure that trip planning is in place in the event of driver fatigue, incapacitation, or illness or in the event of trip delays necessitating replacement drivers to avoid hours-of-service violations and inform drivers of their trip’s contingency plans. Such plans could include but not be limited to: identifying alternate drivers and equipment and checking on their availability, identifying suitable relief positions to swap drivers or equipment, planning rerouting options around road closures or weather, and identifying overnight accommodations that could be contacted in the event that a trip needs to be delayed. Moreover, the Safety Board believes the American Bus Association (ABA) and the United Motorcoach Association (UMA) should inform their members through Web sites, newsletters, and conferences of the circumstances of the Mexican Hat, Utah, accident. The prepared information should encourage charter operators to develop written contingency plans for each charter to ensure that trip planning is in place in the event of driver fatigue, incapacitation, or illness or in the event of trip delays necessitating replacement drivers to avoid hours-of-service violations and inform drivers of their trip’s contingency plans. Occupant Protection Systems A comprehensive occupant protection system considers many aspects of the vehicle, including roof strength, window glazing, seat strength, and restraints and their anchorage strength—all working together to protect occupants in the event of a crash. Further, the vehicle needs to remain intact and protect the survivable space of the occupants, and the occupants need to remain within their seating compartments. The most direct method of retaining passengers in motorcoach seating compartments is lap/shoulder belts, but because no Federal regulations require motorcoaches in the United States to have occupant protection systems, few motorcoaches are so equipped. The Safety Board’s 1999 bus crashworthiness special investigation109 called for NHTSA to develop standards for motorcoach occupant protection systems and require their use. As a result of that special

108 Arrow could have delayed the trip departure until the shorter route through Lizard Head Pass was reopened, though it is unlikely that room accommodations in the resort town would have been available. For such a large group, accommodations all along the return route would have been necessary. 109 National Transportation Safety Board, Bus Crashworthiness Issues, Highway Special Investigation Report NTSB/SIR-99/04 (Washington, DC: NTSB, 1999).

NTSB Highway Accident Report

43 investigation, the Safety Board issued recommendations concerning occupant protection and roof strength, two of which (H-99-47 and -50) are on the Safety Board’s Most Wanted List of Transportation Safety Improvements:110 In 2 years, develop performance standards for motorcoach occupant protection systems that account for frontal impact collisions, side impact collisions, rear impact collisions, and rollovers. (H-99-47) Once pertinent standards have been developed for motorcoach occupant protection systems, require newly manufactured motorcoaches to have an occupant crash protection system that meets the newly developed performance standards and retains passengers, including those in child safety restraint systems, within the seating compartment throughout the accident sequence for all accident scenarios. (H-99-48) In 2 years, develop performance standards for motorcoach roof strength that provide maximum survival space for all seating positions and that take into account current typical motorcoach window dimensions. (H-99-50) Once performance standards have been developed for motorcoach roof strength, require newly manufactured motorcoaches to meet those standards. (H-99-51) The Safety Board’s 1999 special investigation concluded that the overall injury risk to occupants in motorcoach accidents involving rollover and ejection would be reduced significantly by retaining the occupant in the seating compartment throughout the collision. Ten years later, no Federal regulations or standards require motorcoaches operated in the United States to be equipped with occupant protection systems except for the driver. This accident, with 50 ejections, represents an extreme case, but motorcoach passenger ejections during accidents are not rare. From 1998 to 2008, the Safety Board investigated 33 motorcoach accidents involving 255 passenger ejections (see appendix D).111 Complete separation of a motorcoach roof during rollover is a rare accident event that increases the likelihood of passenger ejections from the motorcoach. However, because energy increases exponentially with speed, the failure mechanisms affecting a vehicle traveling approximately 88 mph indicate little about the roof’s ability to withstand controlled crash forces at significantly slower test speeds. Furthermore, because motorcoaches in the United States are not required to meet any roof strength standards, or even passenger crash protection standards, assessing the vehicle’s ability to protect passengers during a crash at any speed is difficult.

110 The Safety Board’s Most Wanted List of Transportation Safety Improvements 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. 111 The Safety Board is currently investigating six additional motorcoach accidents involving ejections: Westport, New York (HWY-06-MH-026); Clearfield, Pennsylvania (HWY-07-IH-020); Bowling Green, Kentucky (HWY-07-IH-022); Sherman, Texas (HWY-08-MH-022); Victoria, Texas (HWY-08-MH-011); and Dolan Springs, Arizona (HWY-09-MH-009). The total number of passenger ejections has not yet been determined.

NTSB Highway Accident Report

44 Subsequent to issuance of the Board’s safety recommendations, NHTSA developed a plan entitled “NHTSA’s Approach to Motorcoach Safety.”112 NHTSA subsequently conducted frontal crash tests in December 2007 and rollover tests with instrumented dummies, both belted and unbelted, in February 2008, with the results of both sets of tests published in August 2008.113 Vehicle and occupant instrumentation data, photographs, videos, and reports are currently being analyzed. The Safety Board recognizes the extreme catastrophic nature of this particular rollover accident; however, what is at issue is not whether the crash forces exceeded the design standards, because no design standards currently exist for motorcoach roofs, seats, seat belts, or seat anchorages.114 Although the Safety Board is encouraged that NHTSA is working toward developing standards by conducting tests, no changes can be anticipated until rulemaking occurs in this area. The Safety Board concludes that because of NHTSA’s delay in defining motorcoach occupant protection performance standards, U.S. motorcoaches have not been equipped with such systems, leaving the traveling public inadequately protected during motorcoach crashes, particularly during rollovers. Because of NHTSA’s unacceptably slow progress in defining and developing motorcoach occupant protection standards, the Safety Board is reclassifying Safety Recommendations H-99-47, -48, -50, and -51115 from “Open—Acceptable Response” to “Open—Unacceptable Response.” Emergency Medical Services Although the Safety Board recognizes that tour and charter bus accidents are relatively infrequent events,116 it is their potential severity, not frequency, that is of concern. A tour or charter bus accident can be a mass casualty event that presents a challenge to any rural EMS operation. This section discusses (1) the delay in accident notification and potential improvements that could be made in that area; (2) the coordinated effort to handle 53 people, transported in 20 ambulances, to and through 13 different medical facilities spread across four

112 Docket No. NHTSA-2007-28793. 113 These tests used the following protocols for rollover protection strength and structural integrity: Federal Motor Vehicle Safety Standard (FMVSS) 220, School Bus Rollover Protection, and Economic Commission for Europe (ECE) Regulation 66, Uniform Provisions Concerning the Approval of Large Passenger Vehicles With Regard to the Strength of Their Superstructure. 114 Motorcoaches must comply with FMVSS 217, which establishes standards for window retention and release. Motorcoaches do not have to comply with most FMVSS occupant protection standards applying to school buses and passenger cars. 115 In the past decade, the Safety Board has reiterated these occupant protection recommendations in association with other accidents. Most recently, Safety Recommendations H-99-47 and -48 were reiterated in Motorcoach Override of Elevated Exit Ramp, Interstate 75, Atlanta, Georgia, March 2, 2007, Highway Accident Report NTSB/HAR-08/01 (Washington, DC: NTSB, 2008). 116 To more accurately consider the safety risks of motorcoach operations, the Safety Board analyzed motorcoach accidents occurring from 2000 to 2007, affording the opportunity to include bus-use criteria. The analysis included all fatalities resulting from large bus accidents to capture the risk to all motorists and nonmotorists in crashes involving large buses (see appendix B). For the 8-year period, fatal accidents involving large buses totaled 1,093, for an average of 137 fatal accidents per year. Total fatalities for that timeframe totaled 1,315, for an average of 164 fatalities annually.

NTSB Highway Accident Report

45 States and two sovereign Indian nations; and (3) the difficulty in understanding travel risk on rural roads used by tour and charter buses. Emergency Notification Effective management of traumatic injury is critically dependent on the time in which definitive care can be delivered.117 It took 36 minutes to report the Mexican Hat accident, a delay that was directly attributable to a lack of wireless telephone coverage at the accident scene. According to the National Emergency Number Association and reported by the U.S. Government Accountability Office (GAO),118 approximately 40 percent of all calls to 911 call centers, generically referred to as public safety answering points (PSAPs), are made on wireless telephones, and in some jurisdictions, that figure is higher.119 According to the National Academy of Sciences, approximately 255 million wireless telephones are in use in the United States.120 About 80 percent of Americans now subscribe to wireless telephone service; further, 14 percent of adults live in households with only wireless telephones (that is, no landline telephones). Yet, many rural areas, such as parts of San Juan County, do not have wireless telephone coverage,121 and, in those areas, it is still not possible to make 911 calls from wireless devices. Enhanced 911. A nationwide upgrade of 911 call systems, referred to as Enhanced 911 (E-911), is underway.122 NHTSA issued an NPRM in October 2008 proposing that Federal grant funding be made available to enhance existing PSAP communication capabilities.123 However, those monies cannot be used to establish wireless communication systems or to expand the coverage of existing systems, only to upgrade an existing system’s infrastructure to handle digital Internet protocol (IP) service.124 The E-911 initiative is an interagency program involving NHTSA and the National Telecommunications and Information Administration (NTIA) of the U.S. Department of Commerce. The initiative, managed by NHTSA’s Office of Emergency Medical Services, will enable PSAPs to automatically receive location and call-back information

117 It is widely accepted that a victim’s chances of survival are greatest if definitive care is received in the operating room within the first hour after a severe injury. 118 U.S. Government Accountability Office, Telecommunication: States’ Collection and Use of Funds for Wireless Enhanced 911 Services, GAO-06-338 (Washington, DC: GAO, 2006). 119 PSAPs receive 200 million calls annually; 82 million are wireless. 120 Emergency Medical Services: At the Crossroads. 121 Since the accident, three cellular antenna/repeaters have been installed near the accident site. 122 Ensuring Needed Help Arrives Near Callers Employing 911 (ENHANCE 911) Act of 2004 (Public Law 108-494, codified as 47 United States Code [U.S.C.] 942). The Act authorizes grants for the implementation and operation of Phase II E-911 services and for migration to a voice-over Internet protocol, Internet protocol-enabled emergency network that provides caller identification and location information. 123 Notice of Proposed Rulemaking, “E-911 Grant Program,” Federal Register, vol. 73, no. 193, pp. 57567-57580. 124 According to Section 3011 of the Deficit Reduction Act of 2005 (Public Law 109-171), Congress has authorized $43.5 million to NTIA for implementation of E-911.

NTSB Highway Accident Report

46 associated with emergency calls. E-911 systems serve as the foundation for public emergency services in a wireless environment and are the basis for automatic crash notification systems. In 2003, the GAO examined how States use revenue collected from fees on wireless customers’ bills,125 which wireless carriers pass on to States and localities to support 911 services.126 During its investigations, the GAO found that States have often used these funds for other purposes. Concerns over misappropriation have influenced the restrictive nature of the E-911 grant process in which grants are to be used exclusively for IP infrastructure upgrades.127 But, by focusing exclusively on 911 IP infrastructure upgrades, the Federal government is systematically ignoring rural areas of the United States that do not have even basic wireless service. The Safety Board concludes that basic wireless service capability is needed along high-risk rural roads and along rural roads frequently traveled by large buses to enable wireless telephone notification of accidents and emergencies. EMS Federal Oversight. According to the National Academy of Sciences, “government leadership in emergency care is fragmented and inconsistent” with “a regulatory vacuum at the Federal level.”128 A host of departments, divisions, and agencies play a role in the various aspects of EMS: the Federal Communications Commission regulates carriers, State and local jurisdictions control PSAPs,129 NTIA funds some infrastructure development, the U.S. Department of Homeland Security provides equipment grants,130 and a Federal committee coordinates policy. In addition, many other agencies have a vested interest in emergency notification systems, including the U.S. Department of Health and Human Services, the Centers for Disease Control, the U.S. Department of Commerce, and FEMA. The congressionally mandated Federal Interagency Committee on Emergency Medical Services (FICEMS) was established by the 2005 SAFETEA-LU legislation. The law required the Secretaries of Transportation, Health and Human Services, and Homeland Security to establish FICEMS and required NHTSA to provide administrative support. As a result, FICEMS was established to identify EMS services and 911 needs; ensure coordination among Federal, State, and local entities; and recommend new or expanded programs, such as E-911.131 A pervasive wireless capability throughout our nation’s highway system will undoubtedly improve highway accident notification for EMS response and coordination of prehospital

125 Since 2003, the GAO has investigated other aspects of E-911. See U.S. Government Accountability Office, Survey on State Wireless E911 Funds, GAO-06-400SP (Washington, DC: GAO, 2006) and Telecommunication: States’ Collection and Use of Funds for Wireless Enhanced 911 Services (GAO-06-338). 126 GAO reported that these charges range from $0.20-3.00 per month per subscriber. 127 As explained in the “Background” section of the E-911 NPRM. 128 Emergency Medical Services: At the Crossroads, pp. 3 and 153, respectively. 129 Organizationally, the approximately 6,000 PSAPs reside in fire, police, city, county, or other public health entities. 130 Although EMS personnel represent a third of the nation’s first responders, EMS providers receive only 4 percent of the funds distributed by the Department of Homeland Security for emergency preparedness. 131 The first meeting of FICEMS was held on December 8, 2006, and the committee meets twice a year.

NTSB Highway Accident Report

47 transport and offer substantial collateral benefit to rural citizens. Local public officials will be able to better monitor and respond in cases of fire, medical emergencies, hazardous material spills, and law enforcement activities. Further, cellular towers are often used to house autonomous weather stations that could assist with the dispatch of air medical assets and improve local sensor information of severe weather events. The Safety Board concludes that until wireless service capability is extended along highly traveled rural roads, motor carriers servicing rural areas without wireless telephone coverage remain at risk of being unable to report an accident or emergency in those locations. The Safety Board believes that FICEMS should develop a plan that can be used by the States and PSAPs to pursue funding for enhancements of wireless communications coverage that can facilitate prompt accident notification and emergency response along high-risk rural roads, as identified under SAFETEA-LU criteria, and along rural roads having substantial large bus traffic (as defined by the criteria established in Safety Recommendation H-09-07). These plans could include State HSIP projects to develop cellular communication for transportation accident notification. The Safety Board recognizes the amount of time that will be required to develop the infrastructure necessary for wireless communication along rural roads. In the interim, the Safety Board believes that the ABA and the UMA should inform its members through Web sites, newsletters, and conferences about the risks of operating in rural areas without wireless telephone coverage and advise members to carry mobile cellular amplifiers132 or satellite-based devices133 to communicate emergency events. Emergency Response The EMS community understands well the challenges faced by rural EMS. According to the National Academy of Sciences, the issues facing rural EMS include potentially lengthy response times; long travel distances to medical facilities; increased regionalization134 of medical services, resulting in a loss of medical care facilities and emergency departments in rural areas; and a major shift to air ambulance services to overcome the long patient transport distances.135 The Mexican Hat accident dramatically illustrates each of these issues. Due to travel distances, the first emergency response unit arrived on scene almost an hour after the accident occurred, and the injured were transported from the scene for more than 4 hours following the accident. The limited local EMS resources and critical care facilities available in the Mexican Hat accident area dictated that assistance be drawn from around the region,136 ultimately involving 13 medical facilities in four States (Utah, Arizona, New Mexico,

132 Electronics designed specifically for mobile applications can be used to amplify weak cellular signals in rural areas. For example, Wilson Electronics in St. George, Utah, sells a mini-mobile amplifier kit that is comparable in cost to a GPS unit. 133 Transport companies often make use of satellite-based mobile resource management systems. In addition to satellite phones, satellite personal trackers are available (for example SPOT Portable ELT) that provide real-time location tracking using Google Earth with one-way text messaging. 134 Regionalization refers to the organization of a health care delivery system within a region to avoid the costly duplication of services. 135 Emergency Medical Services: At the Crossroads. 136 Utah has statutory requirements for intrastate and interstate mutual aid (Utah Code, Title 53, chapter 2, sections 201 and 501).

NTSB Highway Accident Report

48 and Colorado). To transport the injured to these facilities, 20 ambulances and 3 general-purpose transport vehicles were used. A local mass casualty response trailer, one of nine positioned around the State, was driven to the accident site by the EMS Coordinator.137 The morning after the accident, an EMS support team from Price, Utah, arrived to support EMS operations and relieve the local first responders who had worked through the night; that team traveled more than 4 hours to arrive at Monticello, Utah. Only BLS ambulances with EMTs were available locally.138 None of these ambulances were staffed with paramedics, causing ALS capability to be delayed because of travel distances. Seven ALS ambulances staffed with paramedics responded to transport patients between medical facilities, some in inclement weather, with two ambulances traveling 230 miles from Grand Junction, Colorado; three traveling 117 miles from Moab, Utah; and two traveling more than 60 miles from Cortez, Colorado. Triage operations were conducted at the closest hospital to the accident site, San Juan Hospital, in Monticello, Utah, 75 miles away,139 and at a family clinic in Blanding, Utah, 40 miles away.140 The nearest trauma center, St. Mary’s Hospital, was approximately 230 miles from the accident site, in Grand Junction, Colorado. Several seriously injured passengers were driven from the accident scene a distance of 117 miles to Allen Memorial Hospital in Moab and then transferred to an EMS airplane and flown to a trauma center in Salt Lake City, Utah. Two 16-year-old victims died after being transported from the accident scene. They received stabilization medical care at San Juan Hospital and from there were en route to hospitals with trauma treatment capabilities. One victim, en route to the Moab Airport to be airlifted to Salt Lake City, was diverted to Allen Memorial Hospital in Moab due to that victim’s deteriorating medical condition. That victim died at 3:36 a.m., 7 hours after the accident. Another victim died just after reaching St. Mary’s Hospital at 9:05 a.m. the next morning, 12.5 hours after the accident. Both had serious injuries, including head trauma. One EMS solution to travel distances in rural areas is air medical response, because it can reduce transport time to emergency care and can provide a higher skill mix of medical flight crews. The growth of air medical response parallels hospital regionalization; further, the air medical industry is increasingly using EMS helicopters to bring more of the assets of a trauma center—including physician-level skills, hospital-type equipment, and advanced drugs—directly to the accident scene. Unfortunately, this accident highlights the obvious limitation of an emergency response system that relies on air transport. Weather grounded the two helicopters requested from Grand Junction and Phoenix, Arizona, thereby precluding rapid air EMS transport for the most severely injured.141 Transfers to a fixed-wing air ambulance were made in

137 The trailer contains BLS supplies, such as backboards and medical supplies, for 100 people. 138 Although ALS-equipped ambulances were on scene, they lacked paramedics who could provide more than basic life support care. 139 Twenty-six accident victims were transferred to San Juan Hospital by ground ambulances, rescue units, and county vans. Most were in serious condition, requiring stabilization and transfer to higher levels of care. 140 Thirteen accident victims were transported to this clinic; several were then transferred to other facilities. 141 By the afternoon after the accident, two helicopter crews were able to land in Blanding, Utah, to provide patient transport to higher-level care facilities.

NTSB Highway Accident Report

49 Moab, Utah, because that airport had an instrument approach for IFR flight; these transfers required a 117-mile trip by ground ambulance from the accident scene. The Safety Board concludes that the regionalization of medical care relies on air medical support to accomplish timely long-distance patient transport without adequate contingency plans when air medical services are not available because of weather or equipment limitations. The Safety Board acknowledges the efforts of the on-scene emergency response and the challenges that had to be overcome by the EMS responders. Many aspects of the Mexican Hat EMS response are to be commended. Although its timeliness was affected by travel distances, mutual aid response by surrounding jurisdictions appeared to be well coordinated. A mass casualty incident trailer was locally available and used by the EMS Coordinator on scene. Many volunteers supported the EMS first responders.142 An EMS regional support team arrived from Price, Utah, the morning after the accident to relieve first responders who had worked through the night. Postaccident review meetings were conducted at the local hospital. While the available regional resources were well utilized, emergency response would still have benefited from the availability of local paramedics with ALS ambulances and trauma centers closer to the accident site. The Safety Board recognizes that although these are desirable assets for any community, funding issues must be considered, particularly for a large, rural jurisdiction such as San Juan County. In most States, as with Utah, the State handles EMS licensing, training, and regulatory policy, while EMS operations, including grant writing and funding, are performed locally.143 The Safety Board concludes that although the EMS mutual aid drawn from around the region was well coordinated, long-distance ground travel delayed the availability of ALS care. The Safety Board believes the Utah Bureau of Emergency Medical Services and its State Emergency Medical Services Committee should establish written contingency plans for response to large-scale transportation-related emergencies along rural roads traveled by tour and charter buses, such as occurred in Mexican Hat, Utah, that cannot be handled by air medical services due to inclement weather. Additionally, the Safety Board believes that FICEMS should evaluate the system of emergency care response to large-scale transportation-related rural accidents and, once that evaluation is completed, develop guidelines for EMS response and provide those guidelines to the States. The Safety Board realizes that the varied nature of State EMS organizations, as well as their characteristic differences, may dictate that several sets of recommended practices or guidelines be developed or that the information be developed in modules that can be customized by States. Risk Assessment of Charter and Tour Bus Travel on Rural Roads The Mexican Hat accident route, U.S. 163, highlights one of the difficulties in defining rural roads. Mexican Hat, Utah, is located in San Juan County, the largest county in the State,

142 A passing motorist drove to the nearest town to report the accident. A second Arrow motorcoach driver stopped at the accident scene before first responders arrived. A passing truck provided temporary emergency lighting, and other motorists assisted the victims. 143 Emergency Medical Services: At the Crossroads concluded that the States are often left to their own devices to develop EMS arrangements.

NTSB Highway Accident Report

50 covering 7,933 square miles, making it larger than several eastern States. It is also sparsely populated, with fewer than two people per square mile. Although the ADT count along the accident route is quite low at 650 vehicles per day, the route connects several major tourist locations144 that experience elevated levels of seasonal traffic, particularly commercial tours. ADT counts do not distinguish vehicle type and, because they represent an average, can disguise peaks in seasonal traffic. The Safety Board’s analysis of fatal accidents involving buses indicates that rural road travel risk extends to tour and charter buses (see appendix B).145,146 The analysis determined that the risk of a fatal accident and subsequent injury to charter and tour bus occupants is greater in rural areas than in urban areas and that this pattern is consistent with the overall pattern in rural fatal accidents. 147 The importance of rural road travel risk was underscored in the 2005 SAFETEA-LU legislation, which involves a set-aside allocation for high-risk rural roads, which States can use to fund HSIPs.148 Underlying a State’s development of a HSIP is the SAFETEA-LU requirement to incorporate a risk-based, data-driven, analytical approach to highway safety. This requirement is based on traditional approaches to risk assessment using accident frequency and accident severity. The analysis must include, at a minimum, use of crash data to identify hazardous locations and roadway elements, criteria for establishing the severity of locations, priorities for corrective action based on data analysis, and a data-driven means for evaluating the effectiveness of HSIPs. Analysis based solely on fatal accidents and fatalities results in a focus on infrequent, worst-case scenarios. Fatal accidents typically account for less than 1 percent of the total number of accidents in any one year. In addition, an analysis that considers only fatalities cannot adequately account for accidents that produce a large number of nonfatally injured, such as motorcoach accidents, and the subsequent demands placed on emergency response systems.

144 In the vicinity are the Valley of the Gods, Four Corners Monument, Arches National Park, Lake Powell, Mesa Verde National Park, Bryce Canyon National Park, Zion National Park, and Grand Canyon-Parashant National Monument. 145 The data in appendix B are based on two data reports prepared in support of the Mexican Hat, Utah, accident investigation: Large Bus Accidents and Injuries in Rural and Urban Areas, 2000–2006, May 29, 2008, and Addendum 1—Large Bus Accidents and Injuries in Rural and Urban Areas, 2000–2007, December 31, 2008. Both the data report and data report addendum are available in the accident docket (HWY-08-MH-012). 146 In addition to the FARS analysis presented in appendix B, the Safety Board conducted a study entitled Study of Rural Travel Risk Factors for Large Buses: Fatal Accidents, Emergency Response, and Highway Safety Improvements. The Safety Board’s work is summarized in this section and included in its entirety in the Mexican Hat accident docket (HWY-08-MH-012). 147 In fatal accidents involving charter/tour buses, the proportion of fatally injured occupants (24 percent) represented a substantially larger proportion of total fatalities in rural accidents than in urban accidents (3 percent). (See appendix B for more details.) 148 Title 23 U.S.C. Section 148 was established by Section 1401 of SAFETEA-LU, which implemented HSIPs effective October 2005.Title 23 U.S.C. Section 148 establishes suballocations (set-asides) for two specific purposes: highway-rail grade crossings and high-risk rural roads.

NTSB Highway Accident Report

51 VMT and ADT provide the standard measures of highway activity in the assessment of accident risk and, when used to calculate accident rates, are the basis for identifying road segments and locations that meet high-risk criteria. States collect VMT data and are required to use such data to assess risk in the development of an HSIP, but the detail is typically insufficient to determine the routes and travel characteristics of charter and tour buses. This is especially true in States such as Utah, where travel between population centers and recreation areas may include long distances through remote areas.149 Finally, the “ruralness” of a road differs substantially from one area of the country to another. The FHWA functionally classifies roads using a population census definition. In that classification, an “urban road” is defined as any road or street within the boundaries of an urban area with a population of 5,000 or more, and a “rural road” is any road not classified as urban. This classification based on population reasonably assumes that traffic volume in urban areas will be greater than in rural areas. However, it does not consider factors such as use or travel patterns or traffic corridors, nor does it adequately characterize the extent of long-distance travel in remote areas. While the Safety Board supports data-driven decision-making for HSIP projects, programmatic measures that rely primarily on fatal accidents and aggregated activity data (such as VMT and ADT) cannot adequately characterize the accident risk of rural travel, especially in rural areas that may experience relatively high volumes of charter or tour bus traffic. The Safety Board concludes that the lack of adequate data on large bus travel in rural areas—especially data related to charter and tour bus activity, travel patterns, and routes—severely limits a State’s ability to assess rural road travel and hazardous locations, especially in remote areas where a tour or charter bus accident can result in large numbers of injured. HSIPs have historically focused on highway design features and infrastructure characteristics. This accident and the analysis of rural fatal accidents involving charter and tour buses indicate that the risks of rural road travel are not limited to highway design features but may also be associated with the consequences of a mass casualty event. A recent GAO report150 found that the FHWA’s emphasis on infrastructure projects in HSIPs may not allow States to allocate Federal safety dollars to their highest-priority safety improvements and specifically referred to EMS projects. The report concluded that Congressional action should be taken to modify the HSIP’s flexible funding provisions so that States can more freely direct funds to EMS and other such projects. Accident risk assessment in rural areas that experience high volumes of charter or tour bus travel can be used to target roads and road segments for special consideration. Moreover, an accurate assessment of all nonfatal injury accidents is necessary to evaluate emergency response

149 Industry estimates are available, but they, too, contain aggregate data and insufficient detail to support detailed analyses of charter and tour bus routes and travel patterns. Furthermore, the source of the industry estimates and the validity of the methods used to obtain the data cannot be adequately verified. 150 U.S. Government Accountability Office, Highway Safety Improvement Program: Further Efforts Needed to Address Data Limitations and Better Align Funding with States’ Top Safety Priorities, GAO-09-35 (Washington, DC: GAO, 2008), pp. 5, 7, 14, and 31–33.

NTSB Highway Accident Report

52 capabilities in rural areas. The accident data for rural accidents involving charter or tour buses, where almost all of the transported injured are bus occupants, show that these types of accidents can place substantial demands on rural EMS (see appendix B). The Safety Board believes that the FHWA should develop and implement, in conjunction with AASHTO and the National Association of State EMS Officials, criteria based on traffic patterns, passenger volume, and bus types that can be used to assess the risks of rural travel by large buses. The Safety Board further believes that the FHWA should use this criteria as part of the SAFETEA-LU requirement to identify and select HSIP projects. The criteria should allow assessment of both fatal and nonfatal accidents involving large buses in all types of service and use, travel routes, travel activity and travel characteristics of these buses, and the potential problems for EMS in rural communities.

NTSB Highway Accident Report

53 Conclusions Findings

1. The driver was neither distracted by his cellular telephone nor impaired by illicit drugs at the

time of the accident.

1. Although it was unlikely that the driver was under the influence of alcohol, the delay in

collecting a toxicological specimen prevents the National Transportation Safety Board from conclusively ruling out alcohol as a factor in this accident.

1. The weather at the time of the accident was not a factor in the motorcoach’s departure from

the roadway.

1. Neither the mechanical condition of the motorcoach nor the design and condition of the

highway were factors in this accident.

1. The driver was experiencing diminished alertness and fatigue-related impairment due to

inadequate sleep resulting from the following factors: head congestion, possible problems acclimating to high altitude, and his sporadic use of his continuous positive airway pressure sleeping device during the accident trip.

1. The motorcoach was traveling approximately 88 mph in a 65-mph speed zone when the

driver departed the road and lost control of his vehicle.

1. The driver’s fatigue affected his monitoring of the motorcoach’s speed.
2. The driver’s reaction to the motorcoach’s departure from the roadway was delayed and, by

the time he executed corrective steering action, he had lost control of the vehicle.

1. None of the driver’s preexisting medical conditions, except for sleep apnea, played a role in

this accident.

1. Both Arrow Stage Lines and its drivers knew of the adverse weather conditions before

starting the accident trip and thus intentionally engaged in a trip that would likely exceed hours-of-service regulations.

1. Arrow Stage Lines should have developed contingency plans to avoid hours-of-service

violations associated with the return trip.

1. Because of the National Highway Traffic Safety Administration’s delay in defining

motorcoach occupant protection performance standards, U.S. motorcoaches have not been equipped with such systems, leaving the traveling public inadequately protected during motorcoach crashes, particularly during rollovers.

NTSB Highway Accident Report

54

1. Basic wireless service capability is needed along high-risk rural roads and along rural roads

frequently traveled by large buses to enable wireless telephone notification of accidents and emergencies.

1. Until wireless capability is extended along highly traveled rural roads, motor carriers

servicing rural areas without wireless telephone coverage remain at risk of being unable to report an accident or emergency in those locations.

1. The regionalization of medical care relies on air medical support to accomplish timely long-

distance patient transport without adequate contingency plans when air medical services are not available because of weather or equipment limitations.

1. Although the emergency medical service mutual aid drawn from around the region was well

coordinated, long-distance ground travel delayed the availability of advanced life support care.

1. The lack of adequate data on large bus travel in rural areas—especially data related to charter

and tour bus activity, travel patterns, and routes—severely limits a State’s ability to assess rural road travel and hazardous locations, especially in remote areas where a tour or charter bus accident can result in large numbers of injured. Probable Cause The National Transportation Safety Board determines that the probable cause of this accident was the driver’s diminished alertness due to inadequate sleep resulting from a combination of head congestion, problems acclimating to high altitude, and his sporadic use of his continuous positive airway pressure sleeping device during the accident trip. The driver’s state of fatigue affected his awareness of his vehicle’s excessive speed and lane position on a downhill mountain grade of a rural secondary road. Contributing to the accident’s severity was the lack of an adequate motorcoach occupant protection system, primarily due to the National Highway Traffic Safety Administration’s delay in developing and promulgating standards to enhance the protection of motorcoach passengers.

NTSB Highway Accident Report

55 Recommendations New Recommendations As a result of its investigation of this accident, the National Transportation Safety Board makes the following safety recommendations: To the Federal Interagency Committee on Emergency Medical Services: Develop a plan that can be used by the States and public safety answering points to pursue funding for enhancements of wireless communications coverage that can facilitate prompt accident notification and emergency response along high-risk rural roads, as identified under SAFETEA-LU criteria, and along rural roads having substantial large bus traffic (as defined by the criteria established in Safety Recommendation H-09-7). (H-09-4) Evaluate the system of emergency care response to large-scale transportation-related rural accidents and, once that evaluation is completed, develop guidelines for emergency medical service response and provide those guidelines to the States. (H-09-5) To the Utah Bureau of Emergency Medical Services: Establish written contingency plans for response to large-scale transportation-related emergencies along rural roads traveled by tour and charter buses, such as occurred in Mexican Hat, Utah, that cannot be handled by air medical services due to inclement weather. (H-09-6) To the Federal Highway Administration: Develop and implement, in conjunction with the American Association of State Highway and Transportation Officials and the National Association of State Emergency Medical Services Officials, criteria based on traffic patterns, passenger volume, and bus types that can be used to assess the risks of rural travel by large buses. Use this criteria as part of the SAFETEA-LU requirement to identify and select Highway Safety Improvement Program projects. (H-09-7)

NTSB Highway Accident Report

56 To the American Association of State Highway and Transportation Officials and the National Association of State Emergency Medical Services Officials: Work with the Federal Highway Administration to develop and implement criteria based on traffic patterns, passenger volume, and bus types that can be used to assess the risks of rural travel by large buses. (H-09-8) To the American Bus Association and the United Motorcoach Association: Inform your members through Web sites, newsletters, and conferences of the circumstances of the Mexican Hat, Utah, accident. The prepared information should encourage charter operators to develop written contingency plans for each charter to ensure that trip planning is in place in the event of driver fatigue, incapacitation, or illness or in the event of trip delays necessitating replacement drivers to avoid hours-of-service violations and inform drivers of their trip’s contingency plans. The prepared information should also provide information about the risks of operating in rural areas without wireless telephone coverage and advise members to carry mobile cellular amplifiers or satellite-based devices to communicate emergency events. (H-09-9) To Arrow Stage Lines: Develop written contingency plans for each charter to ensure that trip planning is in place in the event of driver fatigue, incapacitation, or illness or in the event of trip delays necessitating replacement drivers to avoid hours-of-service violations and inform drivers of their trip’s contingency plans. (H-09-10) Reiterated Recommendation The National Transportation Safety Board reiterates the following recommendation: To the Federal Motor Carrier Safety Administration: Require all interstate commercial vehicle carriers to use electronic on-board recorders that collect and maintain data concerning driver hours of service in a valid, accurate, and secure manner under all circumstances, including accident conditions, to enable the carriers and their regulators to monitor and assess hours-of-service compliance. (H-07-41)

NTSB Highway Accident Report

57 Previously Issued Recommendations Classified in This Report The following recommendations to the National Highway Traffic Safety Administration are classified “Open—Unacceptable Response”: In 2 years, develop performance standards for motorcoach occupant protection systems that account for frontal impact collisions, side impact collisions, rear impact collisions, and rollovers. (H-99-47) Once pertinent standards have been developed for motorcoach occupant protection systems, require newly manufactured motorcoaches to have an occupant crash protection system that meets the newly developed performance standards and retains passengers, including those in child safety restraint systems, within the seating compartment throughout the accident sequence for all accident scenarios. (H-99-48) In 2 years, develop performance standards for motorcoach roof strength that provide maximum survival space for all seating positions and that take into account current typical motorcoach window dimensions. (H-99-50) Once performance standards have been developed for motorcoach roof strength, require newly manufactured motorcoaches to meet those standards. (H-99-51)

Member Higgins filed the following concurring statement on April 28, 2009. BY THE NATIONAL TRANSPORTATION SAFETY BOARD MARK V. ROSENKER KATHRYN O’LEARY HIGGINS Acting Chairman Member DEBORAH A. P. HERSMAN ROBERT L. SUMWALT Member Member

Adopted: April 21, 2009

NTSB Highway Accident Report

58 Board Member Statement Member Higgins, concurring I voted for and support the report on this accident. Important safety improvements were recommended and reiterated that, if implemented, will provide added protections for those who travel by motorcoach. I am pleased that we cited NHTSA in the probable cause as contributing to the severity of the accident, for their failure to formulate standards to protect motorcoach occupants. I am very disappointed, however, that the Board did not go further. This accident should never have happened. The driver was fatigued before he got behind the wheel. While we cite his fatigue as the cause of the accident we did not place any responsibility on the company who planned the trip and employed the driver. I believe that we should have cited Busco Inc./dba Arrow Stage Lines in the probable cause of this accident. Busco/Arrow has been in business for 81 years, with business locations in 7 western states and the authority to operate in 48 states and Canada. Busco/Arrow operates 179 motorcoaches in scheduled and charter service with 337 drivers, including the 17 motorcoaches and drivers for the charter ski trip central to this accident. While this was the driver’s first trip to Telluride, the company provided buses for this ski trip annually. This was the fifth such charter they arranged. They should have been familiar with the route, the weather, the change in altitude, the isolation of the region and the lack of cell phone service, and they should have planned accordingly. Busco/Arrow has a clear responsibility to plan for the unexpected—illness, bad weather, unforeseen emergencies, and anything else that could endanger the safety of their passengers. There was no contingency plan. Management of this company knowingly approved a longer than normal return trip to Phoenix that would violate the hours-of-service limits for all the drivers. They made no provision to relieve drivers en route, apparently made no provision for drivers to be relieved for illness or fatigue—the driver complained that he’d been sick for three days—and made no provision for emergencies that did occur while their buses were transporting more than 800 passengers in a remote and isolated region in inclement weather. This company has the responsibility to recognize, anticipate, and prevent the consequences of driver behavior and environmental circumstances that put their passengers at risk. The driver bears primary responsibility for this accident, but I also believe the company is at fault. Second, in our discussion during the Board Meeting, staff and I repeatedly agreed that this is a fatigue accident, not an hours-of-service accident. We did not agree, however, to include any recommendations related to fatigue in this report. I believe we should have asked Busco/Arrow to implement a fatigue management program for their employees. While they may provide information to their drivers on fatigue, they clearly have not done enough to make sure their drivers recognize the signs of fatigue and take the appropriate action. I appreciate the work FMCSA and others are doing in the area of fatigue management. However, I do not think we should have to wait for FMCSA to act before we ask Busco/Arrow to implement a fatigue

NTSB Highway Accident Report

59 management program. This accident clearly shows that motorcoach operators with good FMCSA ratings can still have fatigue accidents. We should have done more to address that issue by requiring this operator to establish a comprehensive fatigue management program to assist their drivers in recognizing the symptoms of fatigue and understanding the consequences of driving while fatigued. Third, I understand the “rural” focus of the data recommendation for this report but I continue to be concerned that it will limit the development of exposure data and the evaluation of risk to rural areas. The special report prepared for this report (Appendix B) is very helpful in putting this accident in perspective. As staff emphasized during the Board meeting, data on motorcoach accidents is collected, but apparently very little is done with it. Given the increasing number of fatal motorcoach accidents, I believe we need an annual, comprehensive report that provides information on these accidents. Hopefully our recommendations will begin to generate information on accidents in rural areas, but I do not understand why we stop there. I believe one of the reasons there has been so little priority given to motorcoach safety is the lack of good, actionable information. The press, public, regulators and policymakers do not have the data in a form that would help them understand the dimensions of the problem. Motorcoach safety has been on our Most Wanted List for over a decade but we have seen very little movement on our recommendations. I believe we should recommend that DOT issue an annual report on motorcoach accidents that includes exposure data as well as data on injuries and fatalities, regardless of accident or travel location. Such information should be known and accessible to legislators, policymakers, regulators, investigators, and, most importantly, the traveling public. Finally I urged that our long-standing recommendations on motorcoach occupant protection systems and electronic on-board recorders not only be reiterated to NHTSA and FMCSA but also be sent directly to the Secretary of Transportation. I believe it is important for the entire Board to be on the record in asking the new Secretary to make motorcoach safety a high priority. The agencies have not acted in 10 years. It will take the Secretary’s leadership to change that track record. The Secretary is the only one who can hold his Administrators accountable. While I appreciate and welcome the acting Chairman’s willingness to meet with the Secretary, I would have preferred a written request for action signed by all Board Members.

(This page intentionally left blank.)

NTSB Highway Accident Report

61 Appendix A Investigation The National Transportation Safety Board was notified of the Mexican Hat accident on January 6, 2008. An investigative team was dispatched with members from the Washington, D.C.; Arlington, Texas; and Denver, Colorado, offices. Groups were established to investigate human performance; motor carrier operations; and highway, vehicle, and survival factors. No Board Member participated in the on-scene investigation. Participating in the investigation were representatives of the Federal Motor Carrier Safety Administration, the Utah Highway Patrol, the Utah Department of Transportation, Arrow Stage Lines, and Motor Coach Industries. No public hearing was held, and no dispositions were taken.

NTSB Highway Accident Report

62 Appendix B Large Bus Accidents and Injuries in Rural and Urban Areas, 2000–20071 Travel on rural roads has been recognized as especially hazardous. According to a recent National Highway Traffic Safety Administration (NHTSA) report that compared rural and urban accidents from 1994–2003, rural roads accounted for almost 60 percent of the fatal crashes and 60 percent of the fatalities, but only 39 percent of the total vehicle miles traveled (VMT).2 During that period, 218,539 fatal rural road accidents occurred, resulting in 249,986 fatalities. In support of the Mexican Hat accident, which occurred in a rural area, the Safety Board prepared a data report focusing on charter/tour bus travel on rural roads using fatal accident data from NHTSA’s Fatality Analysis Reporting System (FARS) to determine the scope of charter/tour bus accidents in rural areas. The report examined fatal accidents involving large buses engaged in charter and tour operations, scheduled service, commuter service, and shuttle bus service from 2000–2007, using these data to show: • Differences between rural and urban charter/tour bus accidents, • Extent of fatal accidents involving charter/tour buses in rural areas, • Fatalities and injuries for both bus occupants and occupants of other vehicles, and • Number of injured transported to hospitals. Data Limitations and Constraints Accidents in FARS Accident data drawn from the FARS database3 provide a census of all fatal crashes within the United States, including the District of Columbia and Puerto Rico. A fatal crash is included in FARS if it involves “a motor vehicle traveling on a traffic way customarily open to the public, and must result in the death of a person (occupant of a vehicle or a nonmotorist) within 30 days of the

1 The data in this appendix are based on two data reports prepared in support of the Mexican Hat, Utah, accident investigation: Large Bus Accidents and Injuries in Rural and Urban Areas, 2000–2006, May 29, 2008, and Addendum 1—Large Bus Accidents and Injuries in Rural and Urban Areas, 2000–2007, December 31, 2008. Both the data report and data report addendum are available in the accident docket (HWY-08-MH-012). 2 U.S. Department of Transportation, National Highway Traffic Safety Administration, Contrasting Rural and Urban Fatal Crashes, 1994–2003, DOT HS 809 896 (Washington, DC: NHTSA, 2005). 3 For the latest data, from calendar year 2007, see http://www-fars.nhtsa.dot.gov/Main/index.aspx.

NTSB Highway Accident Report

63 crash.”4 FARS has documented fatal highway crashes since 1975 and provides data for each crash in terms of accident event characteristics, the people and vehicles involved, and the extent and type of injuries suffered by vehicle occupants and nonmotorists. Data in FARS are based on State police accident reports and verified by FARS analysts. Although FARS provides a census of all fatal highway accidents for any given year back to 1975, it represents only a very small subset of all accidents. For example, in 2007, 37,248 fatal accidents were represented in FARs, less than 1 percent of all accidents that occurred in that year.5 As a result, large bus accidents involving injuries, but no fatalities, are not included in FARS or in the Safety Board’s analysis. Although fatal accidents can be viewed as the worst-case scenario, where the severity of the crash is sufficient to produce fatal injuries, they may not adequately characterize the kinds of accidents where nonfatal, but severe, injuries can occur. An accurate estimate of these types of accidents would be needed to adequately assess many of the risks of rural road travel (for example, the demands placed on emergency medical response). The extent of the risk of injury during rural travel cannot be fully determined using only FARS data. In addition, fatal rural accidents involving large buses represent a small proportion of all fatal rural accidents. Given that almost 60 percent of all fatal accidents occur on rural roads, the magnitude of rural road travel risk may be substantially higher than is shown in this report. Charter/Tour Bus Activity in Rural Areas The calculation of accident rates to characterize accident risk is dependent upon accurate measures of activity, such as VMT or passenger populations, which are used as the basis for exposure measures to risk. These measures of exposure are used by Federal and State highway agencies in safety programs to calculate accident rates, evaluate accident risk, and help pinpoint areas of high risk on highways. Accident rates are missing from this data report because accurate estimates of large bus activity are not readily available or reported. This is especially true for charter/tour bus operations in rural areas where travel patterns, travel characteristics, driver and passenger demographics, and seasonal variations are unknown. For example, the charter/tour bus involved in this accident was 1 of 17 buses traveling between a population center to a recreational area. Whether this was a rare, single trip or a regularly occurring trip is unknown, and the frequency with which the route is taken by such buses cannot be easily determined.

4 U.S. Department of Transportation, National Highway Traffic Safety Administration, National Center for Statistics and Analysis, FARS Analytic Reference Guide 1975–2006 (Washington, DC: DOT, 2006), p. F-i. 5 For fatal crash data, see U.S. Department of Transportation, Bureau of Transportation Statistics, Table 2-27: Motor Vehicle Safety Data and U.S. Department of Transportation, National Highway Traffic Safety Administration, Traffic Safety Facts: 2007 Data, DOT-HS-810-993 (Washington, DC: NHTSA, 2008).

NTSB Highway Accident Report

64 Industry estimates of the number of passengers carried by buses exist, but these estimates are typically aggregated and contain insufficient detail to support the kinds of analyses found in this report. Furthermore, the source estimates and the validity of the methods used to obtain the underlying data cannot be adequately determined. This is especially problematic for assessing the risks of rural road travel because there do not appear to be any data collected on large bus travel in rural areas, especially in those areas where accident notification and emergency response might be an issue. Accident Selection As noted earlier, fatal accidents involving large buses were selected from FARS for the period 2000–2007. This timeframe was chosen because, prior to 2000, bus use was not universally recorded, and any analysis of bus activity relied on existing FARS criteria. As a result, before 2000, finding accidents involving buses of any type being used in a tour or charter would have been difficult. The data report’s analysis specifically uses FARS criteria related to bus use, bus body type, gross vehicle weight rating (GVWR), and vehicle configuration.6 The analysis also characterizes buses as motorcoaches, transit/city buses, and large buses with a GVWR between 10,000 and 26,000 pounds. These distinctions allowed comparisons among buses of different types that may be used in a similar way. For example, both motorcoaches and smaller truck chassis-based tour buses may be used for tours and charters, which is also the case for buses used in shuttle service. In addition, transit/city buses are specifically designed for use in urban areas requiring slow speeds and frequent stops, and accommodating both seated and standing passengers. Further, because the Safety Board’s analysis focused on accidents involving large buses being used in scheduled service, commuter service, or as a charter/tour or shuttle, vehicles in selected accidents had to meet the following criteria: • Possess a “bus” body type, • Be used in scheduled service, commuter service, or as a charter/tour or shuttle, • Have a GVWR greater than 10,000 pounds, and • Be configured to hold more than 15 passengers. These criteria excluded school buses, other buses being used as school buses, and 15- passenger vans. (For more specific details about motorcoach selection criteria, see the reference section at the end of this appendix.)

6 See the 2007 FARS Coding and Validation Manual for more details.

NTSB Highway Accident Report

65 Finally, injury data were compiled for all of the fatal accidents cited in this report to show the extent of injuries in fatal accidents involving large buses so as to illustrate the need for accident notification and emergency medical services. Consequently, fatal and nonfatal injury data, and data indicating transport to a hospital, are shown for both bus occupants and occupants of the other vehicles involved in the accidents included in the data report. Results Overview Fatal accidents involving large buses in 2000–2007 numbered 1,093, resulting in 1,315 fatalities and 3,471 nonfatal injuries. Fatal accidents involving charter/tour buses accounted for 234 of the accidents (representing 21 percent of the total), resulting in 349 fatalities and 1,771 nonfatal injuries. The discussion that follows examines these accidents and injuries in more detail, specifically focusing on comparisons between rural and urban accidents. Fatal accidents involving large buses (table B-1) occurred primarily in urban areas (table B-2). The 839 urban fatal accidents (table B-2) resulted in 950 fatalities and 1,808 nonfatal injuries (table B-3), accounting for 77 percent of the fatal accidents, 72 percent of the fatalities, and 52 percent of the nonfatal injuries. Table B-1. Fatal accidents involving large buses, 2000–2007. Bus use 2000 2001 2002 2003 2004 2005 2006 2007 Total Charter/tour 27 33 30 20 37 36 19 32 234 Scheduled service 110 80 73 82 65 57 80 78 625 Commuter 21 28 21 22 14 22 30 20 178 Shuttle 6 5 9 7 8 10 2 9 56 Total 164 146 133 131 124 125 131 139 1,093

NTSB Highway Accident Report

66 Table B-2. Fatal bus accidents by rural or urban location and type of bus, 2000-2007. Bus type Rural Urban Charter/tour Motorcoach 104 96 Transit/city bus 5 13 GVWR 10,000–26,000 pounds 5 3 Scheduled service Motorcoach 18 57 Transit/city bus 40 486 GVWR 10,000–26,000 pounds 1 5 Commuter service Motorcoach 4 11 Transit/city bus 18 132 GVWR 10,000–26,000 pounds 3 5 Shuttle service Motorcoach 10 14 Transit/city bus 3 6 GVWR 10,000–26,000 pounds 8 11 Total 219 839

NTSB Highway Accident Report

67 Table B-3. Fatal and nonfatal injuries in fatal accidents involving large buses, 2000–2007. All accident victims TotalA Rural Urban Fatalities Charter/tour 349 195 148 Scheduled service 661 69 581 Commuter 206 45 160 Shuttle 99 37 61 Total 1,315 346 950 Nonfatal Injuries Charter/tour 1,771 1,172 586 Scheduled service 1,187 248 908 Commuter 246 100 145 Shuttle 267 97 169 Total 3,471 1,617 1,808 Total fatalities and injuries 4,786 1,963 2,758 Uninjured Charter/tour 343 177 161 Scheduled service 592 47 534 Commuter 173 23 146 Shuttle 51 20 31

Total uninjured 1,159 267 872 A Total includes accidents excluded from the Safety Board’s analysis because they had unknown variables preventing them from being classified as either urban or rural. For more information, see table B-7 and its discussion.

Accidents involving buses in scheduled service accounted for the majority (65 percent) of the urban accidents, followed by buses in commuter service (18 percent), charter/tour buses (13 percent), and shuttle buses (4 percent). Almost all of the scheduled service bus accidents (88 percent) occurred in urban areas, and almost all of these types of urban accidents (89 percent) involved transit buses. The large number of urban accidents involving buses in scheduled and in commuter service reflects the high level of public transport provided by buses in populated areas.

NTSB Highway Accident Report

68 In rural areas, charter/tour buses, rather than scheduled service buses, accounted for the greatest proportion of accidents. Charter/tour buses were involved in more than half (52 percent) of fatal rural accidents, with the remaining accidents divided among scheduled service (27 percent), commuter service (11 percent), and shuttle bus service (10 percent). Motorcoaches were involved in more than 60 percent of rural accidents; almost all of these motorcoaches were part of charters or tours. These data show that rural fatal accidents involving large buses primarily involve motorcoaches being used in a tour or as a charter. This result is in contrast to urban accidents, which are dominated by transit/city buses in scheduled service. Fatalities and Injuries All Fatalities and Injuries Fatalities and injuries resulting from the fatal accidents involving large buses are shown in table B-3. As might be expected, the large number of urban accidents produced the greatest number of fatalities and nonfatal injuries. However, nonfatal injuries were more evenly distributed between urban and rural accidents. In urban areas, 950 fatalities and 1,808 nonfatal injuries occurred in fatal accidents involving large buses. Accidents involving buses in scheduled service accounted for 61 percent of the urban fatalities and 50 percent of the nonfatal injuries. In rural areas, 346 fatalities and 1,617 nonfatal injuries occurred. Rural fatal accidents involving charter/tour buses accounted for 56 percent of the rural fatalities and 72 percent of the nonfatal injuries. Rural charter/tour bus fatal accidents resulted in more fatalities and nonfatal injuries than urban charter/tour bus accidents, a pattern that is exactly the reverse for accidents involving buses in any other type of service or use. In fact, rural accidents involving charter/tour buses resulted in almost twice the number of nonfatal injuries as urban accidents for the same bus type. Bus Occupants Overall, bus occupants accounted for a small percentage (15 percent) of the total number of fatalities in fatal accidents involving large buses (table B-4). However, a greater number of bus occupants were fatally injured in rural accidents than in urban accidents, with these fatalities accounting for more than a third of the total number of people killed in rural accidents. In contrast, bus occupants accounted for only 8 percent of the fatalities in urban accidents. The proportion of charter/tour bus occupants fatally injured in rural accidents (24 percent)

NTSB Highway Accident Report

69 represented a substantially larger proportion of the total number of rural fatalities than did the urban charter/tour bus occupants fatally injured in urban accidents (3 percent). Table B-4. Bus occupant fatalities and nonfatal injuries in fatal accidents involving large buses, 2000–2007. Bus occupant TotalA Rural Urban Fatalities Charter/tour 111 82 29 Scheduled service 18 8 10 Commuter 10 8 2 Shuttle 58 22 36 Total 197 120 77 Nonfatal Injuries Charter/tour 1,572 1,061 502 Scheduled service 868 201 645 Commuter 195 89 106 Shuttle 234 84 149 Total 2,869 1,435 1,402 Total fatalities and injuries 3,066 1,555 1,479 Uninjured Charter/tour 172 61 108 Scheduled service 470 34 427 Commuter 144 18 125 Shuttle 37 12 25 Total uninjured 823 125 685 A Total includes accidents excluded from the Safety Board’s analysis because they had unknown variables preventing them from being classified as either urban or rural. For more information, see table B-7 and its discussion.

Furthermore, bus occupants were more likely to be nonfatally than fatally injured in these accidents involving large buses. Bus occupants accounted for 89 percent of the nonfatal injuries in rural accidents and 78 percent of the nonfatal injuries in urban accidents.

NTSB Highway Accident Report

70 Rural accidents involving charter/tour buses accounted for the largest proportion of all rural nonfatal injuries (72 percent). In fact, almost all (91 percent) of the nonfatal injuries in these rural charter/tour bus accidents occurred on the bus. Furthermore, rural fatal accidents involving charter/tour buses accounted for only 10 percent of the total number of fatal accidents involving large buses, but they resulted in 15 percent of the total fatalities and 34 percent of the total nonfatal injuries. In addition, passengers of buses involved in rural fatal accidents were less likely to escape injury than their urban counterparts; only 7 percent of bus occupants in rural accidents were reported uninjured, whereas 29 percent of bus occupants in urban areas were uninjured. Injured Transported to Hospitals The demands placed on emergency medical response and services can be estimated by the number injured in an accident who were transported to a hospital. FARS provides hospital transport data for all injured and indicates whether the injured person was an occupant of the bus. Almost 75 percent of all the people injured in fatal accidents involving large buses were transported to a hospital (table B-5). This was the case for both rural and urban areas.

NTSB Highway Accident Report

71 Table B-5. Total injured transported to hospitals, 2000–2007. Total injured transported to hospitals TotalA Rural Urban Fatalities Charter/tour 114 50 63 Scheduled service 409 22 378 Commuter 107 11 95 Shuttle 27 7 19 Total 657 90 555 Nonfatal injuries Charter/tour 1,492 986 499 Scheduled service 892 175 705 Commuter 201 83 117 Shuttle 209 89 119 Total 2,794 1,333 1,440 Total transported 3,451 1,423 1,995 A Total includes accidents excluded from the Safety Board’s analysis because they had unknown variables preventing them from being classified as either urban or rural. For more information, see table B-7 and its discussion.

As might be expected, a greater proportion of the nonfatally injured were transported to hospitals (81 percent) than the fatally injured (50 percent). In rural areas, a much smaller proportion of the fatally injured (26 percent) were transported, perhaps reflecting the greater severity of rural accidents and the greater emergency medical response times in rural areas. For all accidents, a large proportion of the injured who were transported to hospitals (67 percent) were bus occupants (table B-6). In rural fatal accidents involving large buses, most of the transported injured were bus occupants (84 percent). In urban accidents, a much smaller proportion of the transported injured were bus occupants (55 percent). When only rural accidents involving charter/tour buses were considered, bus occupants accounted for almost all (88 percent) of the accident victims transported to a hospital. Almost all (98 percent) of these bus occupant transports had suffered nonfatal injuries.

NTSB Highway Accident Report

72 Table B-6. Injured bus occupants transported to hospitals, 2000–2007. Bus occupants transported to hospitals TotalA Rural Urban Fatalities Charter/tour 19 14 5 Scheduled service 9 2 7 Commuter 3 1 2 Shuttle 8 4 4 Total 39 21 18 Nonfatal injuries Charter/tour 1,328 895 430 Scheduled service 605 132 470 Commuter 152 72 80 Shuttle 178 78 99 Total 2,263 1,177 1,079 Total transported 2,302 1,198 1,097 A Total includes accidents excluded from the Safety Board’s analysis because they had unknown variables preventing them from being classified as either urban or rural. For more information, see table B-7 and its discussion. Summary Motorcoaches being used as a charter or in a tour account for most rural fatal accidents involving large buses. Overall, rural fatal accidents involving charter/tour buses accounted for only 10 percent of the total number of fatal accidents involving large buses, but they resulted in 15 percent of the total fatalities and 34 percent of the total nonfatal injuries. Charter/tour buses were involved in more than half (52 percent) of the fatal rural accidents, with the remaining bus accidents divided among scheduled service (27 percent), commuter service (11 percent), and shuttle bus service (10 percent). This result is in contrast to urban accidents, which are dominated by transit/city buses in scheduled service. Rural fatal accidents involving charter/tour buses accounted for more than half of the rural fatalities and almost three-quarters of the rural nonfatal injuries, with almost all of the nonfatal injuries suffered by the occupants of the bus. The proportion of charter/tour bus

NTSB Highway Accident Report

73 occupants fatally injured in rural accidents was also substantially higher (24 percent) than the charter/tour bus occupants fatally injured in urban accidents (3 percent). Furthermore, passengers of buses involved in rural fatal accidents were less likely to escape injury than their urban counterparts. The number of persons transported to hospitals was used as an estimate of the demands placed on rural emergency response. The data showed that, in rural accidents involving large buses, most of the people transported to hospitals were bus occupants. When only those accidents involving charter/tour buses were considered, almost all of the transported accident victims were bus occupants. Reference FARS Codes and Definitions The FARS database is organized into three principal files: accident, vehicle, and person. Each of these files contains variables that code the characteristics of a fatal crash (called a case). In this analysis, all three files were used. Variables from each of these files were used in the Safety Board’s data report; their respective codes and definitions are shown in table B-7.

NTSB Highway Accident Report

74 Table B-7. FARS variables, codes, and code definitions. Variable FARS variable name FARS codes used in analysis and definitions Accident file

Year YEAR 2000–2007 Fatalities FATAL Count of total fatalities in an accident Roadway function class (using Federal Highway Administration [FHWA] classification guidelines) ROAD_FNC 01–Rural Principal Arterial—Interstate 02–Rural Principal Arterial—Other 03–Rural Minor Arterial 04–Rural Major Collector 05–Rural Minor Collector 06–Rural Local Road or Street 09–Rural Unknown 11–Urban Principal Arterial–Interstate 12–Urban Principal Arterial–Other Freeways or Expressways 13–Urban Principal Arterial 14–Urban Minor Arterial 15–Urban Collector 16–Urban Local Road or Street 19–Urban Unknown Vehicle file

How bus used in transport BUS_USE 4–Used as Scheduled Service Bus 5–Used as Tour Bus 6–Used as Commuter Bus 7–Used as Shuttle Bus Bus body type BODY_TYP 51–Cross-Country/Intercity Bus (i.e.,Greyhound) 52–Transit Bus (city bus) 58–Other Bus Type 59–Unknown Bus Type GVWR (maximum allowable total weight of bus, including weight of vehicle plus fuel, passengers, and cargo) GVWR 2–10,000–26,000 pounds 3–26,000 pounds or more Vehicle configuration V_CONFIG 21–Bus (seats for more than 15 people, including driver) Person file

Vehicle body type occupied by injured and uninjured persons

51–Cross-Country/Intercity Bus (i.e., Greyhound) 52–Transit Bus (City Bus) 58–Other Bus Type 59–Unknown Bus Type Severity of injuries INJ_SEV 0–No Injury (O) 1–Possible Injury (C) 2–Nonincapacitating Evident Injury (B) 3–Incapacity Injury (A) 4–Fatal Injury (K) 5–Injured, Severity Unknown Person type in accident PER_TYP 01–Driver 02–Passenger of Motor Vehicle in Transport 03–Occupant of Motor Vehicle Not in Transport

NTSB Highway Accident Report

75 Variable FARS variable name FARS codes used in analysis and definitions 04–Occupant of Non-Motor-Vehicle Transport Device 05–Pedestrian 06–Bicyclist 07–Other Cyclist 08–Other Pedestrian (includes persons on personal conveyances) 09–Unknown Occupant Type in Motor Vehicle in Transport 19–Unknown Type of Nonmotorist Transported to hospital HOSPITAL For year 2007: 0–No 1–Yes, EMS 2–Yes, Law Enforcement 3–Yes, Other 4–Yes, Transported by Unknown Source 9–Unknown

For years 2001–2006: 0–No 1–Yes For year 2000: 0–No 1–Yes 7–Died at the Scene 8–Died En Route

Note that only those accidents meeting the specific criteria shown in table B–7 were included in the data study. Almost all the variables in the table have an “unknown” code; consequently, in any analysis where an unknown was possible in a critical variable, the case was excluded from the analysis. For example, in 16 of the 1,093 fatal accidents involving large buses, the variable roadway function class was coded “Unknown.” As a result, these 16 accident cases were excluded from any analysis that compared rural and urban accidents. Motorcoach Selection Criteria for Data Study The basic steps used to select specific accidents, types of buses, and bus occupants are described below. Step 1: Select the time period for the accidents. As previously discussed, calendar years 2000–2007 were chosen for this analysis because one of the important variables, bus use, was not universally coded before 2000. Step 2: Select fatal accidents involving large buses. Because accidents involving large buses being used in scheduled service, commuter service, or as a charter/tour or shuttle bus were being analyzed, vehicles in selected accidents had to meet the following criteria:

NTSB Highway Accident Report

76 a. Possess a bus body type (FARS Body Type code of 51, 52, 58, or 59). b. Be used in scheduled or commuter service, or as a charter/tour or shuttle bus. The set of accidents involving buses was further limited to those that met FARS BUS_USE codes equal to 4, 5, 6, or 7. These codes excluded any type of bus being used as a school bus. c. Have a GVWR greater than 10,000 pounds. The set of accidents involving large buses being used in scheduled or commuter service or as a charter/tour or shuttle bus was further restricted to vehicles with a FARS GVWR code of 2 or 3. d. Be configured to hold more than 15 passengers. This criterion required that all the fatal accidents in the final set equal FARS V_CONFIG code 21. These criteria excluded school buses, any type of bus being used as a school bus, and small passenger vans configured to carry 15 or fewer passengers. Step 3: Identify different types of buses. In the analysis, buses were characterized as motorcoaches, transit/city buses, and large buses with a GVWR between 10,000 and 26,000 pounds to allow comparisons among buses of different types that may be used in a similar way. Therefore, vehicles in selected accidents had to meet the following criteria: a. Transit/city buses that were in the final set of fatal accidents derived from steps 1 and 2 were identified by the FARS BODY_TYP code 52 (Transit/City Bus). b. Large buses with a GVWR between 10,000 and 26,000 pounds were identified by the FARS GVWR code 2. Identifying motorcoaches required multiple criteria. As previously discussed, no FARS or NHTSA regulation definition of a motorcoach exists. In previous analyses of motorcoach7 accidents, motorcoaches were treated as cross-country/intercity buses because such buses typically operate in a manner similar to motorcoaches. In practice, a number of definitions have been used. In the Safety Board’s data report, a motorcoach is defined as any large bus with a GVWR greater than 26,000 pounds that is configured to carry more than 15 passengers and is being used as a charter/tour bus, in scheduled service, in commuter service, or as a shuttle bus. This definition would include the cross/country intercity bus type used in previous NHTSA and industry analyses and other types of buses that function as motorcoaches. Given that all large buses in the set of fatal accidents met the FARS V_CONFIG code equal to 21 (seats for more than 15 people, including driver), the following criteria were used to characterize motorcoaches: a. All buses that met FARS BODY_TYP code 51 (Cross-Country/Intercity Bus).

7 NHTSA’s Approach to Motorcoach Safety (Washington, DC: DOT, 2007).

NTSB Highway Accident Report

77 b. All buses with a FARS BODY_TYP code of 58 or 59 that met FARS BUS_USE code 4, 5, 6, or 7, and FARS GVWR code 3. Step 4: Identify bus occupants. The analysis required evaluating bus occupant injuries and transport to hospital of bus occupants. Injured transported to a hospital were identified by using FARS INJ_SEV codes 1, 2, 3, 4, or 5 and FARS HOSPITAL code 1 (1, 7, or 8 for year 2000). Bus occupants can be identified by using the FARS BODY_TYP variable in the Person File to determine the type of vehicle in which the person was an occupant. Bus occupants were identified by using the Person File FARS Body_TYP codes of 51, 52, 58, or 59. Step 5: Identify whether rural or urban accident. Many of the analyses in this report compared rural and urban accidents. Selecting rural and urban accidents involving large buses was based on the FHWA’s Roadway Function Classification system, a method typically used in the analysis of highway accident data to characterize rural or urban accidents. In this report, rural and urban accidents involving large buses were identified using FARS ROAD_FNC codes 1 through 9 for rural accidents and codes 11 through 19 for urban accidents.

NTSB Highway Accident Report

78 Appendix C Video Study7 The purpose of this study was to estimate the speed of the accident motorcoach just prior to roadway departure. To do so, Safety Board staff developed a computer program to analyze video recorded by the DriveCam II video recorder installed on the accident motorcoach. DriveCam II Video Recorder Details The MCI J4500 motorcoach in the Mexican Hat, Utah, accident was equipped with a DriveCam II video recorder that recorded video and accelerations. The DriveCam II system records color video frames at the rate of 4 per second (that is, at 0.25-second frame spacing) in 640×360 (H×V) format. The recording starts 10 seconds before a triggering event and lasts 10 seconds after it, for a total of 81 frames. The triggering event is an acceleration level that exceeds threshold 0.5 g for forward acceleration, 0.45 g for lateral acceleration, and 1.5 g for shock. The specific triggering event in this accident was shock acceleration above the threshold. The DriveCam II video recorder successfully captured the events before and during the accident. The camera was mounted on the right-front windshield of the motorcoach, close to the center post. The DriveCam II system includes two camera sensors, one forward-looking and one rearward-looking. Only the video from the forward-looking camera sensor was used in this study. The DriveCam II system uses a wide-angle lens that exhibits barrel distortion near the edges of the images it captures. Safety Board staff calibrated the camera and mathematically corrected the distortion. The corrected images closely matched the images that an ideal pinhole camera would capture and that the analysis program is designed to handle. Site Survey Data The site of the Mexican Hat accident was accurately surveyed by Utah authorities. The survey included numerous fixed points on and off the roadway, including vehicle debris. From this survey, the video study used 183 surveyed points as landmarks for vehicle speed estimation, to include points representing the following: • Solid white lines, solid yellow lines, and broken yellow lines on the roadway; • Reflector locations, including 12 reflectors that were mounted on a guardrail;

7 The material in this appendix is based on a video study prepared in support of the Mexican Hat, Utah, accident investigation; the study is available in the accident docket (HWY-08-MH-012).

NTSB Highway Accident Report

79 • A post painted with reflective paint just past the last reflector and higher than it; and • A large rectangular reflective “Valley of the Gods” road sign some distance past the last reflector. Vehicle Speed Estimation The Safety Board’s video analysis program can be used to determine the location of a moving vehicle by comparing the locations of landmarks in a camera image with their locations in a mathematically synthesized image generated by the program. If, at an assumed vehicle location, the camera image landmarks and synthesized image landmarks coincide, then the vehicle location is assumed to be where the vehicle was when the camera image was acquired. Speed estimation is performed interactively. The user moves the vehicle that is displayed in the program’s graphical user interface (GUI) until the landmarks coincide. Vehicle speed can be estimated by dividing the distance between two vehicle locations by the time difference between the corresponding camera image frames. Figures C-1, C-2, and C-3 show the program GUI at times –7 seconds, –6 seconds, and –5 seconds, respectively. The vehicle is positioned at its estimated locations at those times. The lower plot in figures C-1 through C-3 shows the surveyed landmarks and the vehicle, with plot points corresponding to survey points representing the white solid lines on the pavement, the solid yellow lane-dividing line, the ends of broken yellow line segments, and the locations of reflectors. The upper plot is the camera image (shown as negative of the original), which shows the locations of the survey points as computed by the camera model that is built into the analysis program. Each reflector is marked at the elevation of the reflective surface and at ground level beneath it.

NTSB Highway Accident Report

80

Figure C-1. Vehicle at time –7 seconds.

Figure C-2. Vehicle at time –6 seconds.

NTSB Highway Accident Report

81

Figure C-3. Vehicle at time –5 seconds. The motorcoach’s location was estimated at 19 positions, corresponding to 19 camera frames spanning the time period from –8.75 to –4.25 seconds. The vehicle’s speed was estimated using the formula Vn=Δx/Δt, where Δx is the total travel of the vehicle during n contiguous time intervals, and Δt is 0.25×n. The middle line in the graph shown in figure C-4 represents this nominal speed estimate. The estimate becomes more accurate as more contiguous intervals are considered.

NTSB Highway Accident Report

82

Figure C-4. Vehicle speed estimate versus number of frame intervals. The nominal speed estimate is based on exact 0.25-second timing of the camera frame intervals. If camera timing is not exact, this nominal speed estimate could be too high (if the actual Δt was longer than 0.25×n) or too low (if Δt was shorter than 0.25×n). The possible speed estimation error due to such video frame timing was analyzed in detail and taken into account. The bottom line in the figure C-4 graph represents the lower bound of the speed estimate and the uppermost line represents the upper bound. The lower bound is higher than 85 mph if 10 or more camera frame intervals are considered. After 18 frame intervals, the lower bound of the motorcoach’s speed is estimated to be 88 mph and the upper bound, 92 mph. Summary of Results Based on the Safety Board’s analysis of video from the accident vehicle’s DriveCam II video recorder, the motorcoach’s speed was estimated to have been between 88 and 92 mph shortly before roadway departure.

NTSB Highway Accident Report

83 Appendix D Safety Board Motorcoach Accident Investigations The National Transportation Safety Board’s 1999 special investigation on bus crashworthiness1 included statistics on 36 motorcoach accidents investigated by the Safety Board from 1968 through 1997. This appendix summarizes 33 motorcoach frontal crash and rollover accidents investigated by the Board (major accidents, field investigations, and incidents) since

1. Table D-1 accounts for motorcoach passengers, not drivers, because drivers’ use of seat

belts decreases the likelihood of ejection. Table D-1. Motorcoach accidents investigated by the Safety Board since 1998.

Year Accident Fatalities Injuries Ejections Crash type 1 1998 Burnt Cabins, PA (HWY-98-MH-033) 6 16 0 Frontal impact 2 1998 Old Bridge, NJ (HWY-99-MH-007) 8 14 7 Rollover 3 1999 Santa Fe, NM (HWY-99-FH-012) 2 35A 1 Rollover 4 1999 New Orleans, LA (HWY-99-MH-017) 22 21 10 Frontal impactB 5 1999 Braidwood, IL (HWY-99-FH-017) 1 23 2 Rollover 6 1999 Canon City, CO (HWY-00-FH-011) 2 57 53 Rollover 7 2000 Eureka, MO (HWY-00-IH-051) 0 25 0 Frontal impact 8 2001 Allamuchy, NJ (HWY-01-FH-011) 0 39 0 Rollover 9 2001 Bay St. Louis, MO (HWY-01-IH-024) 0 16 0 Frontal impactB 10 2001 Fairplay, CO (HWY-01-IH-028) 0 45 12 Rollover 11 2001 Pleasant View, TN (HWY-01-FH-03) 1 43 1 Rollover 12 2002 Manchester, TN (HWY-02-IH-002) 6 UnknownC 6 Rollover 13 2002 Loraine, TX (HWY-02-MH-021) 3 29 0 Frontal impact 14 2002 Victor, NY (HWY-02-MH-025) 5 41 6 Rollover 15 2002 Nephi, UT (HWY-03-IH-001) 6 20 13 Rollover 16 2003 Hewitt, TX (HWY-03-MH-022) 5 29 15 Rollover

1 National Transportation Safety Board, Bus Crashworthiness Issues, Highway Special Investigation Report NTSB/SIR-99/04 (Washington, DC: NTSB, 1999).

NTSB Highway Accident Report

84

Year Accident Fatalities Injuries Ejections Crash type 17 2003 Tallulah, LA (HWY-04-MH-002) 8 6 1 Frontal impact 18 2003 Apache Co., AZ (HWY-04-IH-007) 0 44 0 Rollover 19 2004 North Hudson, NY (HWY-04-FH-015) 0 47 0 Frontal impact 20 2003 Anahuac, TX (HWY-04-FH-026) 1 35 0 Frontal impact 21 2004 Phoenix, AZ (HWY-04-IH-029) 1 38 0 Frontal impact 22 2004 Jackson, TN (HWY-04-IH-035) 2 18 0 Frontal impact 23 2004 Turrell, AR (HWY-05-MH-006) 14 15 30 Rollover 24 2005 Geneseo, NY (HWY-05-FH-017) 3 20 0 Frontal impact 25 2005 Baltimore, MD (HWY-05-FH-031) 0 33 0 Rollover 26 2005 Osseo, WI (HWY-06-MH-003) 4 35 1 Frontal impact 27 2006 Westport, NY (HWY-06-MH-026) 4 48 22 Rollover 28 2006 Auburn, MA (HWY-06-IH-028) 0 34 0 Rollover 29 2007 Atlanta, GA (HWY-07-MH-015) 6 28 12 Frontal/rollover 30 2007 Clearfield, PA (HWY-07-IH-020) 2 25 2 Rollover 31 2007 Bowling Green, KY (HWY-07-IH-022) 1 64 10 Rollover 32 2008 Victoria, TX D (HWY-08-MH-001) 1 46 1 Rollover 33 2008 Mexican Hat, UT (HWY-08-MH-012) 9 44 50 Rollover Total 123 1,033 255

ADriver injuries unknown. BRun-off-road, then frontal impact into terrain. CDriver attacked by passenger; subsequent injuries unknown. DLap belts available; none reportedly were used.

FD07363 ｜ 2009_美国_HAR0902.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2009 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

Motorcoach Run-Off-the-Bridge and Rollover Sherman, Texas August 8, 2008

Accident Report NTSB/HAR-09/02 PB2009-916202

National Transportation Safety Board

(This page intentionally left blank.)

NTSB/HAR-09/02 PB2009-916202 Notation 8078A Adopted October 27, 2009

Highway Accident Report Motorcoach Run-Off-the-Bridge and Rollover Sherman, Texas August 8, 2008

National Transportation Safety Board

490 L’Enfant Plaza, S.W. Washington, D.C. 20594

National Transportation Safety Board. 2009. Motorcoach Run-Off-the-Bridge and Rollover, Sherman, Texas, August 8, 2008. Highway Accident Report NTSB/HAR-09/02. Washington, DC.

Abstract: About 12:45 a.m. on August 8, 2008, a 56-passenger motorcoach was northbound on U.S. Highway 75 when it was involved in a single-vehicle accident in Sherman, Texas. The motorcoach had left Houston, Texas, about 8:30 p.m. on August 7, 2008, with a driver and 55 passengers onboard, en route to Carthage, Missouri. Before the crash, the motorcoach was traveling in the right lane of the four-lane divided highway. As the motorcoach approached the Post Oak Creek near Sherman, its right steer axle tire failed. The motorcoach departed the roadway, overrode a 7-inch-high, 18-inch-wide concrete curb, and struck the metal bridge railing. After riding against the bridge railing for about 120 feet, the motorcoach went through the railing and off the bridge. It fell about 8 feet and slid on its right side before coming to rest on the inclined earthen bridge abutment adjacent to the creek. As a result of the accident, 17 motorcoach passengers died, the motorcoach driver received serious injuries, and 38 passengers received minor-to-serious injuries.

The major safety issues identified in the accident investigation included the need for tire pressure monitoring systems on commercial vehicles; the need for criteria for the selection of bridge railing designs; the lack of oversight of the Federal commercial vehicle inspections delegated to the states; the lack of motorcoach occupant protection systems; and the deficiencies in Federal safety oversight of new entrant motor carriers. As a result of its investigation, the NTSB makes recommendations to the Federal Highway Administration, the Federal Motor Carrier Safety Administration (FMCSA), the National Highway Traffic Safety Administration (NHTSA), the American Association of State Highway and Transportation Officials, the American Association of Motor Vehicle Administrators, and Motor Coach Industries, Inc. The NTSB also reiterates previous recommendations to the FMCSA and NHTSA.

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 NTSB 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 Internet at http://www.ntsb.gov. Other information about available publications also may be obtained from the website or by contacting:

National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, SW Washington, DC 20594 (800) 877-6799 or (202) 314-6551

NTSB publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2009-916202 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 NTSB reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

NTSB Highway Accident Report iii Contents Figures .............................................................................................................................................v Acronyms and Abbreviations .................................................................................................... vii Executive Summary ..................................................................................................................... ix Factual Information .......................................................................................................................1 Accident Narrative ...........................................................................................................................1 Injuries .............................................................................................................................................3 Emergency Response .......................................................................................................................6 Motorcoach Driver ...........................................................................................................................6 Driver Interview ........................................................................................................................8 Driver’s Medical Certification ..................................................................................................9 Toxicology Results .................................................................................................................10 Survival Factors .............................................................................................................................10 Accident Reconstruction ................................................................................................................12 Vehicle ...........................................................................................................................................15 Vehicle Systems ......................................................................................................................15 Tires ........................................................................................................................................17 Vehicle Maintenance ..............................................................................................................22 Commercial Motor Vehicle Inspections .................................................................................23 Highway .........................................................................................................................................24 Physical Evidence ...................................................................................................................26 Traffic Metrics ........................................................................................................................28 Environmental Conditions ......................................................................................................28 Motor Carrier .................................................................................................................................29 Angel Tours ............................................................................................................................29 Iguala BusMex ........................................................................................................................31 Liberty Charters and Tours .....................................................................................................32 Other Information ..........................................................................................................................33 Bridge Railing Design Guidance ............................................................................................33 Means Used to Check Tire Pressure .......................................................................................38 Motorcoach Crash Testing ......................................................................................................40 New Entrant Program .............................................................................................................41 Analysis .........................................................................................................................................44 Exclusions ......................................................................................................................................44 The Accident ..................................................................................................................................45 Accident Sequence ..................................................................................................................45 Motorcoach Driver ..................................................................................................................46 Tire Failure.....................................................................................................................................49 Vehicle Load and Tire Capacity .............................................................................................50 Tire Pressure ...........................................................................................................................50

NTSB Highway Accident Report iv Tire Pressure Monitoring Systems ..........................................................................................52 Bridge Railings ..............................................................................................................................53 Design Guidelines ...................................................................................................................53 Warrants ..................................................................................................................................54 Commercial Vehicle Inspections ...................................................................................................56 Occupant Protection .......................................................................................................................57 Safety Standards .....................................................................................................................57 Luggage Rack Failure .............................................................................................................60 Motor Carrier Oversight ................................................................................................................61 New Entrant Program .............................................................................................................61 Revocation of Operating Authority ........................................................................................62 Conclusions ...................................................................................................................................64 Findings..........................................................................................................................................64 Probable Cause...............................................................................................................................66 Recommendations ........................................................................................................................67 New Recommendations .................................................................................................................67 Previously Issued Recommendations Reiterated in This Report ...................................................68 Appendix A ...................................................................................................................................70 Investigation ...................................................................................................................................70

NTSB Highway Accident Report v Figures Figure 1. Map of accident location. ............................................................................................... 2 Figure 2. View of approach to Post Oak Creek bridge. ................................................................. 3 Figure 3. Motorcoach seating chart................................................................................................ 5 Figure 4. Motorcoach driver’s 72-hour work/rest history.............................................................. 8 Figure 5. Postaccident view of the accident motorcoach. ............................................................ 11 Figure 6. Cross-sectional diagram of a tire similar to those on the accident motorcoach, labeled to show significant tire elements. .................................................................... 13 Figure 7. Accident reconstruction diagram. ................................................................................. 14 Figure 8. Right steer axle tire of the accident motorcoach. ......................................................... 19 Figure 9. Photographs of a Goodyear 315/80 R22.5 tire inflated to 115 psi (left) and 60 psi (right). ................................................................................................................ 22 Figure 10. Highway accident scene, looking at the motorcoach’s path off the bridge. ............... 24 Figure 11. Motorcoach on the bank of the Post Oak Creek. ........................................................ 25 Figure 12. Two views of the repaired bridge railing. ................................................................... 27

(This page intentionally left blank.)

NTSB Highway Accident Report vii Acronyms and Abbreviations AAMVA American Association of Motor Vehicle Administrators AASHO American Association of State Highway Officials AASHTO American Association of State Highway and Transportation Officials ADT average daily traffic ANPRM Advance Notice of Proposed Rulemaking Bridgestone Bridgestone Americas, Inc. CDL commercial driver’s license CFR Code of Federal Regulations CVSA Commercial Vehicle Safety Alliance DOT U.S. Department of Transportation DWI Driving While Intoxicated ECE R66 United Nations Economic Commission for Europe Regulation 66 ECM electronic control module EDA evasion detection algorithm EMS emergency medical services EU European Union FHWA Federal Highway Administration FMCSA Federal Motor Carrier Safety Administration FMCSRs Federal Motor Carrier Safety Regulations FMVSSs Federal Motor Vehicle Safety Standards GAO U.S. Government Accountability Office GAWR gross axle weight rating Goodyear Goodyear Tire & Rubber Company Greyhound Greyhound Lines, Inc. GVWR gross vehicle weight rating HbA1c hemoglobin A1c Liberty Liberty Charters and Tours LRFD Load and Resistance Factor Design MASH Manual for Assessing Safety Hardware MCI Motor Coach Industries, Inc.

NTSB Highway Accident Report viii MCMIS Motor Carrier Management Information System MCSAP Motor Carrier Safety Assistance Program Michelin Michelin North America, Inc. µg/mL micrograms per milliliter mg/dL milligrams per deciliter mm millimeter NCHRP National Cooperative Highway Research Program NHS National Highway System NHTSA National Highway Traffic Safety Administration PRISM Performance and Registration Information Systems Management SAFETEA-LU Safe, Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for Users SEE-80-5 1980 Safety Effectiveness Evaluation of Traffic Safety Barriers THC tetrahydrocannabinol TL-1 (through TL-6) Test Level One (through Test Level Six) TPMS tire pressure monitoring system TRB Transportation Research Board TREAD Act Transportation Recall Enhancement, Accountability, and Documentation Act TxDOT Texas Department of Transportation TxDPS Texas Department of Public Safety USDOT number U.S. Department of Transportation number US-75 U.S. Highway 75

NTSB Highway Accident Report ix Executive Summary About 12:45 a.m., central daylight time, on Friday, August 8, 2008, a 2002 56-passenger Motor Coach Industries, Inc., motorcoach, operated by Iguala BusMex, Inc., was northbound on U.S. Highway 75 when it was involved in a single-vehicle, multiple-fatality accident in Sherman, Texas. The chartered motorcoach had departed the Vietnamese Martyrs Catholic Church in Houston, Texas, at approximately 8:30 p.m. on August 7, 2008, with a driver and 55 passengers onboard, en route to the Marian Days Festival in Carthage, Missouri. When the accident occurred, the motorcoach had completed about 309 miles of the approximately 600-mile-long trip. Before the crash, the motorcoach was traveling in the right lane of the four-lane divided highway. As the motorcoach approached the Post Oak Creek bridge at a speed of about 68 mph, its right steer axle tire failed. The motorcoach departed the roadway on an angle of about 4 degrees to the right, overrode a 7-inch-high, 18-inch-wide concrete curb, and struck the metal bridge railing. After riding against the bridge railing for about 120 feet and displacing approximately 136 feet of railing, the motorcoach went through the bridge railing and off the bridge. It fell about 8 feet and slid approximately 24 feet on its right side before coming to rest on the inclined earthen bridge abutment adjacent to Post Oak Creek. As a result of the accident, 17 motorcoach passengers died; 12 passengers were found to be dead at the crash site, and 5 others later died at area hospitals. In addition, the 52-year-old driver received serious injuries, and 38 passengers received minor-to-serious injuries. The National Transportation Safety Board determines that the probable cause of this accident was the failure of the right steer axle tire, due to an extended period of low-pressure operation, which resulted in sidewall, belting, and body ply separation within the tire, leading to loss of vehicle control. Contributing to the severity of the accident was the failure of the bridge railing to redirect the motorcoach and prevent it from departing the bridge. The lack of an adequate occupant protection system contributed to the severity of the passenger injuries. The following safety issues are identified in this report: The tire failure and the need for tire pressure monitoring systems on commercial vehicles; The failure of the bridge railing and the need for criteria for the selection of appropriate bridge railing designs; The lack of oversight of the Federal commercial vehicle inspections that are delegated to the states; The lack of motorcoach occupant protection systems; and The deficiencies in Federal safety oversight of new entrant motor carriers.

NTSB Highway Accident Report x As a result of the investigation, the NTSB makes recommendations to the Federal Highway Administration, the Federal Motor Carrier Safety Administration (FMCSA), the National Highway Traffic Safety Administration (NHTSA), the American Association of State Highway and Transportation Officials, the American Association of Motor Vehicle Administrators, and Motor Coach Industries, Inc. The NTSB also reiterates previous recommendations to the FMCSA and NHTSA.

NTSB Highway Accident Report 1 Factual Information Accident Narrative About 8:30 p.m., central daylight time,1 on Thursday, August 7, 2008, a 2002 56-passenger Motor Coach Industries, Inc. (MCI), motorcoach, operated by Iguala BusMex, Inc., departed the Vietnamese Martyrs Catholic Church in Houston, Texas, with a driver and 55 passengers on board. The chartered motorcoach was en route to the Marian Days Festival in Carthage, Missouri, a trip of approximately 600 miles. About 4 hours later, the motorcoach had completed about 309 miles of the trip and was northbound on U.S. Highway 75 (US-75). About 12:45 a.m., the motorcoach was involved in a single-vehicle, multiple-fatality accident in Sherman, Texas. (See location map in figure 1.) Before the crash, the motorcoach had traversed a 1,389-foot-long, 2.3-degree right curve with a 3.75-percent downgrade and had begun traversing a 1.5-degree left curve on a 0.4-percent ascending grade as it approached the Post Oak Creek bridge. (See figure 2.) As the motorcoach approached the bridge at a speed (provided by electronic control module [ECM]) of about 68 mph, its right steer axle tire failed.2 The motorcoach departed the roadway on an angle of about 4 degrees to the right, overrode a 7-inch-high, 18-inch-wide concrete curb, and struck the 31-inch-high metal bridge railing.3 After riding against the bridge railing for about 120 feet and displacing approximately 136 feet of railing, the motorcoach went through the bridge railing and off the bridge.4 It fell about 8 feet and slid approximately 24 feet on its right side before coming to rest on the inclined earthen bridge abutment adjacent to the creek. Seventeen of the 55 passengers died as a result of this accident; 12 motorcoach passengers were found to be dead at the crash site, and 5 others later died at area hospitals. In addition, the 52-year-old driver received serious injuries, and 38 passengers received minor-to-serious injuries. Investigators found no indication that the driver had been engaged in nondriving tasks, such as text-messaging or talking on a citizens band radio, loudspeaker, or cellular telephone, when the accident occurred. Postaccident interviews were conducted with 17 passengers; they indicated that there had been no distractions caused by passengers. At the time of the accident, the weather was clear and the roadway was dry.

1 Unless otherwise indicated, all times in this report are central daylight time. 2 This motorcoach had three axles—a steer axle in the front, a drive axle connected to the power train, and a tag axle in the rear that provided support and stability. 3 A bridge railing is a longitudinal barrier intended to prevent a vehicle from running off the edge of a bridge. 4 The first bridge railing displaced by the motorcoach was struck midway along its length.

NTSB Highway Accident Report 2

Figure 1. Map of accident location.

NTSB Highway Accident Report 3

Figure 2. View of approach to Post Oak Creek bridge. (Photograph was taken after postaccident repairs were made to the bridge.) Injuries See table 1 for injury information. Table 1. Injury summary. Injury Severity Motorcoach Driver Passengers Total Fatal 0 17 17 Serious 1 26 27 Minor 0 12 12 None 0 0 0 Total 1 55 56 Title 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.”

NTSB Highway Accident Report 4 The motorcoach driver sustained serious traumatic injuries to the head and upper torso, as well as internal injuries. The majority of those killed and seriously injured incurred blunt force trauma to the head, neck, chest, and spine. Minor injuries were characterized by lacerations and contusions. Based on interviews with passengers, as well as information provided by Sherman police, fire, and emergency medical services (EMS) personnel, investigators established the seating positions of the motorcoach occupants. (See figure 3.) Thirteen of the 17 passengers who died as a result of the accident were on the right side of the motorcoach at the time of the accident, and 8 of those 13 were in the first five rows. The four fatalities who had been seated on the left side of the motorcoach at the time of the accident were in rows 3 through 7. One seat was unoccupied; it was the aisle seat in row 9 on the right side of the motorcoach. Nineteen passengers were male; 36 were female. The average age of passengers on the motorcoach was 46; nine passengers were younger than 16, and eight were older than 70. The average age of the 17 passengers who died was 62, and the average age of the 38 passengers who survived was 39. None of the passenger seating positions were equipped with occupant restraints. The driver’s seat was equipped with a 2-point lap seat belt, but the driver was not wearing it at the time of the accident. First responders and motorcoach occupants told investigators that some passengers had been ejected as a result of the accident. Investigators established that at least four passengers were fully or partially ejected; however, the exact number of fully and partially ejected passengers could not be determined. Partially ejected passengers were seated in seats 9B and 12D; fully ejected passengers were seated in seats 6D and 13C. First responders’ records regarding ejections were inconclusive because other passengers rendered immediate assistance, and the injured were moved quickly away from the wrecked motorcoach because of passenger fears of a postcrash fire. Also, some passengers who had been partially ejected were trapped under the vehicle, making it difficult for witnesses to determine how many had been ejected.

NTSB Highway Accident Report 5

Figure 3. Motorcoach seating chart. 1 2 3 4 5 6 7 8 9 10 11 12 13 LAV A B C D 14 1 2 3 4 5 6 7 8 9 10 11 12 13 14 A B C D M-52:Serious DRIVER M-81:Fatal M-76:Fatal F-19:Serious F-62:Fatal F-29:Fatal M-31:Serious M-67:Fatal F-59:Fatal F-33:Serious F-48:Serious F-50:Fatal M-21:Minor F-50:Minor M-54:Serious F-49:Fatal F-38:Serious F-57:Serious M-54:Serious M-38:Serious Empty Seat F-71:Fatal F-27:Fatal F-60:Serious M-60:Fatal M-84:Fatal F-44:Serious F-13:Minor M-12:Minor F-59:Fatal F-34:Minor F-71:Fatal M-67:Serious F-60:Fatal F-14:Serious M-7:Minor F-34:Minor F-36:Serious F-65:Serious F-12:Minor F-73:Serious M-47:Serious M-63:Serious F-89:Fatal F-45:Minor F-71:Minor F-45:Serious M-9:Serious M-15:Serious F-12:Minor F-11:Serious F-25:Minor M-54:Serious M-53:Serious In Rest Room F-65:Serious F-41:Serious F-59:Fatal Sherman, TX HWY-08-MH-022 Injury level as defined by Title 49 Code of Federal Regulations 830.2: Fatal: injury which results in death within 30 days of the accident. Serious: injury which requires hospitalization or results in fractures; hemorrhages; nerve, tendon, or internal organ damage; or serious burns. Minor:other injury that is not a serious injury. None: used for occupants who were not injured. Legend SAMPLE F = FEMALE M = MALE # = AGE INJURY LEVEL AGE GENDER F - 14 : Serious

NTSB Highway Accident Report 6 Emergency Response The City of Sherman Communications Center received initial notification of the accident at 12:45 a.m. from a motorist who saw the motorcoach depart the roadway. Police, fire, and EMS personnel were dispatched at 12:46 a.m. and arrived on the scene about 12:50 a.m. The City of Sherman and Grayson County Communications Centers worked to coordinate on-scene resources. The Sherman fire chief served as the incident commander, establishing a mobile command post near the accident site. Separate transfer points were established for ground ambulance and helicopter transport. Nineteen helicopter EMS response trips were executed by units from Sherman, McKinney, and Frisco, Texas.5 About 25–30 ground ambulances from nine different service departments responded.6 The injured were transported to nine regional medical facilities.7 Seven of the injured were transported to a local medical facility in Sherman; most were transported 30–40 miles to regional treatment facilities. Four were taken to two facilities in the Dallas, Texas, area, approximately 60 miles away; and one patient was transported to a facility in Fort Worth, Texas, about 90 miles away. The Dallas and Tarrant County Medical Examiner’s Offices also responded. By 1:08 a.m., within 23 minutes of the initial notification of the accident, the most critically injured patients had arrived at local medical facilities in Sherman and nearby McKinney, Texas.8 By 2:39 a.m., 1 hour 54 minutes after the accident, all the injured had been transported to medical facilities. Grayson County has an emergency response plan that includes all the county’s public safety agencies and area medical facilities. The response plan contains annexes with checklists and process descriptions for responding to mass casualty transportation accidents. During the emergency, the Sherman Fire Department activated the regional mutual aid plan to staff the ongoing work shift requirements for fire and rescue personnel called to the accident. Motorcoach Driver The 52-year-old male driver held a Texas class B commercial driver’s license (CDL) with a passenger endorsement, issued on December 15, 2005, and due to expire in 2010. There were no restrictions on the license. The driver said he began driving motorcoaches in 1983 while employed by the Houston Metropolitan Transit Authority. On the driver’s employment application at Angel Tours, Inc.,9 dated April 28, 2008, he indicated that he had been employed

5 Life Star in Sherman, Texas, responded. Sky Med (PHI) in McKinney, Texas, approximately 30 miles from the accident site, and Care Flight in Frisco, Texas, approximately 40 miles from the accident site, also responded. 6 Ambulances responded from the Sherman, Bells, Denison, Grayson, McKinney, and Van Alstyne Fire Departments and from the Preston, Texas Vital, and Bryan County EMS organizations. 7 These facilities were the Texoma Medical Center, Denison, Texas; Wilson N. Jones Medical Facility, Sherman, Texas; Parkland Health and Hospital System, Dallas, Texas; McKinney Medical Center, McKinney, Texas; Medical Center of Southwest Oklahoma, Durant, Oklahoma; Presbyterian Medical Center, Allen, Texas; North Central Medical Center, McKinney, Texas; Methodist Hospital, Dallas, Texas; and Harris Methodist Medical Center, Fort Worth, Texas. 8 Approximately one-third of those transported went to two facilities; the Wilson N. Jones Medical Facility in Sherman received seven patients, and the McKinney Medical Center in McKinney, about 40 miles away, received eight patients. 9 The ―Motor Carrier‖ section of this report discusses the business relationship between Iguala BusMex and Angel Tours, Inc.

NTSB Highway Accident Report 7 by Genesis Tours from March 2004 to March 2007,10 by Autobuses Adame Tours from December 2002 to February 2004, by Continental Tours from April 2000 to November 2002, and by Carrington Tours from March 1999 to March 2000. In a postaccident interview with investigators, the driver said that he had additional driving experience with Greyhound Lines, Inc. (Greyhound), from 1989–1995 and with Grayline from 1995–1999. Further, the driver said that he had completed ―numerous safety classes,‖ as well as a Greyhound training course in Oklahoma. Greyhound verified that it had employed the driver 13 years earlier. The driver told NTSB investigators that he had been terminated by Greyhound for failure to report for a medical examination. Information that the NTSB subpoenaed from Greyhound indicated that the driver had been terminated on March 21, 1995, because he tested positive for cocaine during a mandatory random drug test. NTSB investigators were unable to contact several of the other employers that the driver cited due to incomplete information and/or disconnected telephone numbers for the carriers.11 The NTSB attempted to obtain additional information about the driver’s history of controlled substance testing. The state of Texas maintains records on the results of controlled substance tests for commercial drivers. The NTSB asked Texas to check its database of drug and alcohol test results for information concerning the accident driver. The state required the NTSB to serve a subpoena upon the Texas Department of Public Safety (TxDPS) to obtain access to the information. The available database information showed no records for the driver. (The dates of the driver’s positive test results when he was employed by Greyhound preceded the establishment of the Texas database, which was initiated in January 2003, with mandatory reporting beginning in September 2005.) On his application for employment, the driver denied having had any accidents, traffic convictions, or forfeitures in the preceding 3 years. He also said that he had not been denied a license, permit, or privilege to operate a motor vehicle, and that he had not had a suspension or revocation of license, permit, or privilege to operate a motor vehicle. However, the driver’s history of motor vehicle violations obtained by the Sherman Police Department and the TxDPS showed that the driver had two speeding violations, one on March 20, 2007, and another on May 3, 2004.12 He was also convicted on August 16, 2001, of Driving While Intoxicated (DWI), following his refusal to submit to an alcohol screening test.13 The driver had undergone two roadside inspections in the 16 months preceding the accident. On May 2, 2007, and August 6, 2007, the driver was placed out of service for violation of 49 CFR 395.8(k)(2), because he did not have a record-of-duty status log covering the

10 Investigators found another application in the driver’s qualification file that indicated his dates of employment with Genesis Tours as February 2003 to April 2006. 11 Title 49 CFR 391.51 requires employers to maintain driver qualification files for 3 years after an employee leaves employment. 12 In a postaccident interview, the driver stated that he received a speeding ticket in a commercial vehicle while working for Autobuses Adame Tours. 13 The adjudicative docket NTSB investigators obtained from the Texas District Courts did not distinguish vehicle type. The driver stated that his DWI violation took place while driving his personal vehicle.

NTSB Highway Accident Report 8 preceding 7 days in his possession at the time of those inspections. Additionally, for the May 2007 inspection, the motor carrier was cited for the driver’s failure to possess a valid medical certificate.14 According to the driver’s record-of-duty status logbook, in the days preceding the Sherman accident, he was on duty Monday, August 4, 2008, from midnight to 12:30 p.m. The driver did not work on Tuesday, August 5. He returned to work on Wednesday, August 6, at 7:45 a.m., and worked until 10:00 a.m., when he went off duty. He resumed driving at 1:15 p.m., and he went off duty at 2:45 p.m. On Thursday, August 7, the driver went on duty at 5:00 p.m. He had a 1-hour break at 7:15 p.m. He resumed driving at 8:15 p.m. and continued driving until the accident occurred at 12:45 a.m. on August 8. The driver’s pattern of work is shown in figure 4.

Figure 4. Motorcoach driver’s 72-hour work/rest history. [Note: Due to his injuries, investigators were unable to interview the driver immediately following the accident; when he was interviewed—weeks later—he provided only limited information about his off-duty activities.] Driver Interview The driver was critically injured in the crash and gave only a brief statement to NTSB investigators on August 8, 2008, while he was in the hospital. When investigators attempted to interview the driver again on August 9, his medical condition had deteriorated such that he could not be interviewed then, or for the duration of the on-scene investigation. Two months later, in the presence of his legal counsel, the driver was interviewed. During the October 9, 2008, interview, the driver said that he had spent much of the day preceding the accident (August 7) in bed resting in preparation for the nighttime trip. He said that

14 In 2007, it was not an out-of-service violation for a driver not to have a current medical certificate. On April 1, 2009, the Federal Motor Carrier Safety Administration changed inspection procedures to make lack of a valid medical certificate an out-of-service violation.

NTSB Highway Accident Report 9 he also recalled going for a walk and washing clothes for the trip. He said that he had never been diagnosed with a sleeping disorder. He said that on the day of the trip, he arrived at the carrier about 4:45 p.m. and conducted a pretrip inspection of the motorcoach. He said that he examined the tires, looking for protrusions, wear and tear, and discoloration; he said he also kicked the tires. He said the bus appeared to be in good shape and that it drove smoothly, with no pulling to either side. He said that when he arrived at the first pick-up location, he met with the chaperone. He waited about 40 minutes for passengers to arrive, loaded the luggage, and then departed about 6:45–6:50 p.m. for a second pick-up location. He said that after he loaded luggage at the second pick-up site, he completed another walk-around inspection to ensure that the luggage bins were locked, and he also checked the motorcoach’s fluids. He indicated that most of the luggage had been stored in the first and second compartments from the bus’s front. He said that he began driving about 8:15 p.m. and stopped about 10 minutes later at a convenience store so he could purchase gum and an energy drink, because he knew he was going to be driving all night. The driver stated that he had previously made the trip to Carthage, Missouri, a year or two earlier. The driver said that the first 4 hours of the trip were uneventful. In describing the accident event, the driver said that he first felt a sway or vibration with the bus and let off the accelerator because he was unsure of what was causing it. Then, within seconds, he heard an explosion, and the right front of the bus dropped. He stated that he ―tried not to apply the brakes real hard.‖ He tried to hold onto the steering wheel, but it quickly became impossible, and the bus drifted to the right. The driver told investigators that, while driving for another company many years earlier, he had experienced a tire failure on the tag axle. He recalled that during that incident, he could feel the tire rubber breaking off and could smell it. He stated that he had had no difficulty controlling that vehicle and had been able to pull it over to the shoulder. The driver also stated that in training he recalled being told, with respect to tire blowouts, not to hit the brakes. Driver’s Medical Certification At the time of the accident, the driver had an expired medical certificate. It had been issued on May 24, 2007, and had expired on May 24, 2008. The driver’s May 24, 2007, Medical Examination Report for Commercial Driver Fitness Determinations indicated ―Yes‖ to ―High Blood Pressure‖ and ―Medications: Lisinopril.‖ The report indicated ―No‖ to all other items under ―Health History,‖ including ―Regular, frequent alcohol use,‖ and ―Narcotic or habit forming drug use.‖ The driver’s blood pressure was noted as 108/78. The medical examiner noted that the driver met standards, but because of his taking high blood pressure medication, which would require periodic evaluation, the driver was qualified for 1 year, rather than the typical 2-year period. Review of the driver’s personal medical records revealed that he had been treated for high blood pressure, diabetes, and high cholesterol, as well as gastritis due to alcohol use. On May 9, 2008, the driver’s blood sugar was 293 milligrams per deciliter (mg/dL) (reference range

NTSB Highway Accident Report 10 70–110), and his hemoglobin A1c (HbA1c) was 11.2 percent.15 The driver was advised at that time to begin using injectable insulin, and he received a prescription for insulin.16 The driver was also prescribed an oral antidiabetic medication at that time (metformin). Testing performed on a blood specimen obtained from the driver following the accident showed an HbA1c of 8.2 percent. Several bottles of prescription medications were among the driver’s personal effects recovered following the accident. According to the labels on the bottles, the medications and instructions for use were as follows: lisinopril, 20 mg, 1–2 daily;17 metformin HCL, 500 mg, once daily;18 and omeprazole, 20 mg, twice daily.19 In addition, a bottle of nonprescription Tylenol PM was found.20 Toxicology Results Blood and urine specimens were obtained from the motorcoach driver at 4:26 a.m. (approximately 3.75 hours after the accident) and analyzed by the Federal Aviation Administration Civil Aerospace Medical Institute. The results were positive for benzoylecgonine in the blood (0.242 micrograms per milliliter [µg/mL]) and urine (11.09 µg/mL), and for cocaine (0.171 µg/mL) and cocaethylene (0.293 µg/mL) in the urine.21 Ecgonine methyl ester22 was detected at unspecified levels in the blood and urine. Diphenhydramine23 was detected in the blood (0.0075 µg/mL) and at unspecified levels in the urine. No ethanol, cocaine, or cocaethylene was detected in the blood. Survival Factors A 2-point lap belt was available at the driver’s seat. Investigators examined the belt and found it inoperative. The right side hasp portion of the belt was jammed in its retaining reel, preventing belt extension. The motorcoach was not equipped with passenger seat belts.

15 HbA1c is used to monitor the blood sugar control of diabetics over time. HbA1c levels above 6 percent are considered abnormal. HbA1c provides an indication of the average glucose level in the blood over the previous few months. 16 No refills were documented in the records investigators reviewed. 17 Lisinopril is a prescription medication used for the treatment of high blood pressure and certain other cardiovascular disorders and to help prevent certain complications of diabetes. 18 Metformin is a prescription oral medication used for the treatment of diabetes. 19 Omeprazole is an antacid medication used to treat a variety of gastrointestinal disorders that is available over the counter in the United States. 20 Tylenol PM is a compound of acetaminophen and diphenhydramine, available over the counter. Acetaminophen is a widely used pain reliever and fever reducer, and diphenhydramine is a sedating antihistamine. Tylenol PM is marketed as a combined analgesic and sedative, intended to treat occasional headaches and minor aches and pains with accompanying sleeplessness. 21 Benzoylecgonine is an inactive metabolite of cocaine, which is a central nervous system stimulant. Cocaethylene is an active substance formed in the body when cocaine and alcohol have been consumed together. 22 Ecgonine methyl ester is a metabolite of cocaine. 23 Diphenhydramine, commonly known by the trade name Benadryl, is an ingredient of Tylenol PM.

NTSB Highway Accident Report 11 The bus sustained significant impact damage on the right front corner near the boarding door extending across the width of the front and approximately 53 inches aft from the right front corner to about the midpoint of the right steer axle wheel. (See figure 5.) The front windshield, passenger boarding door, and seven emergency window exits along the right side of the vehicle were destroyed. The roof was damaged along the front portion, especially on the right front corner. The emergency hatches were intact and functional.

Figure 5. Postaccident view of the accident motorcoach. The sidewalls and the emergency windows on both sides of the motorcoach were vertically deformed. The window frames of the seven emergency window exits on the right side were intact; however, the safety glass was broken. The emergency windows on the left side remained intact and were functional but had not been used. All the passenger seats were intact and secured to the floor, except the right side aisle seat in row 12, which had its seat pan detached,24 and the double-retractable passenger seat on the left side of the row, which was moved by first responders during the rescue operation. The 3/4-inch

24 ―Seat pan‖ refers to the structural support for the lower seat cushion.

NTSB Highway Accident Report 12 plywood floor decking on the right side near row 1 failed, as did the floor decking across the width of the motorcoach at row 12. Overhead luggage racks, affixed with cast aluminum brackets to the roof and sidewall above the passenger seats, sustained damage at their anchorage points.25 The left side overhead luggage rack was 36 feet long and affixed with 11 brackets attached to the ceiling with two 1/2-inch bolts per bracket and to the sidewall with two inline 1/2-inch bolts. The right side rack, which was 3 feet shorter than the left, was attached by nine aluminum brackets. The brackets on the right side were found broken at their connection points to the ceiling and sidewall. The rack on the right side became detached and came to rest along the tops of the passenger seats on the right side, extending diagonally across the aisle on top of the seats to the left of the aisle. According to interviews with first responders, the displaced luggage rack was blocking the aisle near rows 3 and 4 as well as the right side emergency window exits. The underside of the detached luggage rack showed evidence of passenger contact along its length. Accident Reconstruction Accident investigators used documented physical evidence in conjunction with electronic engine data to reconstruct the accident event sequence. This factual information included tire marks, scraping and gouging of the roadway and bridge surfaces, tire fragments and debris locations, engine load/rpm, vehicle speed/rpm, and brake and throttle status. Distances calculated based on engine time records are approximate. The tire failure was initiated by the separating of steel belting materials, which led to belt edge lifting and shoulder rubber tearing, and ultimately to the detachment of belting and tread materials. During the belting and tread detachment phase, the tire casing ruptured, and an immediate inflation pressure loss resulted. (See figure 6 for cross-sectional diagram of a tire similar to those on the accident motorcoach, labeled to show significant tire elements.)

25 The contents of the luggage racks were not documented at the scene of the accident, and some personal belongings had been removed before NTSB investigators arrived.

NTSB Highway Accident Report 13

Figure 6. Cross-sectional diagram of a tire similar to those on the accident motorcoach, labeled to show significant tire elements. As the motorcoach traveled north toward the bridge, at a point 685 feet prior to the impact with the bridge, the motorcoach’s right steer axle tire began marking and depositing tire fragments. At this time, the motorcoach was traveling about 68 mph (approximately 100 feet per second). From this point to the tire blowout, the motorcoach traveled for 4.3 seconds. Vehicle engine data indicated variation in the percent throttle in these seconds preceding the blowout.26 The tire casing rupture (blowout) occurred approximately 3.0 seconds before impact with the bridge. The driver activated the brakes 1.1 seconds after the tire blowout, and the motorcoach struck the bridge railing 1.9 seconds later. Brake application reached 90 psi 0.7 second after driver input and reached maximum force about 1.0 second following driver input, when the motorcoach was traveling about 54 mph. The motorcoach struck the bridge railing while traveling about 44 mph. The right steer wheel departed the roadway as the motorcoach rotated clockwise along its longitudinal axis, traveling approximately 35 mph. Once the motorcoach had gone through the bridge railing, traveling about 29 mph, it fell 8 feet to the earthen bridge abutment and slid 24 feet. From the point of impact with the bridge railing to final rest, the motorcoach traveled 186 feet. The sequence of events is shown in figure 7.

26 Percent throttle varied between 32 percent and 58 percent in the 6 seconds before the hard braking event that followed the blowout.

NTSB Highway Accident Report 14

Figure 7. Accident reconstruction diagram. 685' Beginning of tire mark (68 mph) 253' 143' 123' Brakes applied Tire blowout Sidewall and tread begin to separate Impact with bridge railing (44 mph) 4.3 sec. 1.1 sec. 1.9 sec. Final rest 186' N

NTSB Highway Accident Report 15 The motorcoach and its occupants experienced multiple impact events. The impact forces first resulted from contact with the curb, uprights, and bridge railing, then from the right front corner of the motorcoach striking the earthen abutment, and then from the side and rear of the motorcoach striking the abutment. Vehicle The 2002 MCI model J4500 56-passenger-capacity motorcoach was 45 feet 7 inches long, 8 feet 6 inches wide, and 11 feet 9 inches high. Its gross vehicle weight rating (GVWR) was 54,000 pounds, with a steer axle weight rating of 16,500 pounds, a drive axle weight rating of 23,000 pounds, and a tag axle weight rating of 16,500 pounds.27 Due to the vehicle’s extensive frontal deformation, postaccident axle weights were not obtained; however, the motorcoach weight as recovered, including the baggage, was determined to be approximately 44,000 pounds. The gross vehicle weight, including the estimated weight of occupants, was 51,707 pounds. The accident motorcoach had been previously owned by Schoolman Transportation System, Inc.,28 which traded it to MCI Sales and Service. It was received at MCI’s Blackwood, New Jersey, facility on November 30, 2007. The motorcoach remained at the Blackwood facility until January 9–10, 2008, when it was transferred to MCI’s Loudonville, Ohio, facility for refurbishing. Once the refurbishment was completed, the motorcoach was transferred to the MCI Sales and Service facility in Dallas, Texas, for resale, where it was purchased by Angel Tours, Inc.,29 on July 19, 2008. The vehicle was operating with a Texas temporary registration (P13705) that expired August 9, 2008, the day after the accident. Vehicle Systems The motorcoach had a Detroit Diesel, Series 60, 12.7-liter, 6-cylinder, engine-brake-equipped, electronically controlled diesel engine. The transmission was an Allison B500 automatic transmission. The Detroit Diesel engine was equipped with an ECM capable of recording limited operating data. Data from the ECM indicated a ―hard brake‖ event and a ―last stop‖ event in connection with the accident.30 Three diagnostic fault codes were identified but were determined not to be relevant to the accident.31

27 The GVWR is the manufacturer-recommended upper limit to the operational weight for a motor vehicle and any cargo or passengers to be carried. The GVWR may be less than but not more than the sum of the gross axle weight ratings. 28 Schoolman Transportation System, Inc., operates in Bohemia, New York. 29 Angel Tours, Inc., received interstate operating authority in 1994 but was placed out of service for interstate transportation on June 23, 2008. The owner then applied for operating authority under the name Iguala BusMex, Inc. Business transactions were comingled between the two companies. Further information on this business relationship appears in the ―Motor Carrier‖ section of this report. 30 An ECM ―hard brake‖ report contains 1 minute of data prior to the triggering event and 15 seconds following the event. In this case, a hard brake was triggered when the vehicle’s calculated speed decelerated faster than 7 mph per second. A ―last stop‖ event is triggered when the vehicle transitions from a driving state to a stopped state and remains stopped for at least 15 seconds or when the ignition is switched off. 31 Diagnostic codes or records can contain engine parameter data that are present when a fault code is generated. None of the diagnostic records were associated with the accident.

NTSB Highway Accident Report 16 The motorcoach was equipped with a power-assisted steering system that utilized a hydraulic pump mounted at the front of the engine. The hydraulic pump was examined and tested on November 26, 2008, at Ixetic USA Inc.32 No physical damage to the pump’s external or internal components was observed, and performance-based testing found the pump functioning within the production parameters of a newly manufactured pump. The motorcoach was equipped with pneumatically actuated S-cam drum brakes with a 6S/6M Meritor-Wabco antilock control system.33 Brake system components are shown in table 2. Postaccident inspection found all brakes to be within the Commercial Vehicle Safety Alliance (CVSA) North American Standard Out-of-Service Inspection Criteria. Examination of the steer axle brake components revealed that the right brake drum had fractured as a result of the crash. No defects were found with the brake components on the drive axle. Inspection of the tag axle revealed oil and grease/road debris contamination of the left brake drum and lining friction surfaces with considerable caking and buildup, which is a rejection defect within the Minimum Periodic Inspection Standards in appendix G to subchapter B of the Federal Motor Carrier Safety Regulations (FMCSRs).34 Table 2. Brake system components. Axle Type/Size Chamber Type/Size Adjuster (inches) Measured Applied Stroke (inches) Measured Lining Thickness (inches) Brake Drum Size (inches) Steer right Clamp 30 5.5 Auto 1 3/4 3/4 & 7/8 16.5 X 6 Steer left Clamp 30 5.6 Auto 1 5/8 7/8 & 5/8 16.5 X 6 Drive right Clamp 30L/30 6.0 Auto 2 1/8 7/8 & 7/8 16.5 X 8.625 Drive left Clamp 30L/30 6.0 Auto 2 3/8 3/4 & 3/4 16.5 X 8.625 Tag right Clamp 24L/24 5.5 Auto 1 5/8 5/8 & 1/2 16.5 X 6 Tag left Clamp 24L/24 5.5 Auto 2 1/4 3/4 & 3/4 16.5 X 6

32 NTSB investigators attended the testing. 33 The citation ―6S/6M‖ indicates that the system was equipped with six wheel-speed sensors and six modulator valves. 34 Appendix G criteria of the FMCSA annual inspection standards reject vehicles with any defective brakes, air leaks, etc. The brake contamination defect would have caused the motorcoach to be rejected during a required annual safety inspection. The CVSA North American Standard Out-of-Service Inspection Criteria allow 20-percent defective brakes on nonsteering axles before placing a vehicle out of service; therefore, a single contaminated brake out of six would not have placed the vehicle out of service.

NTSB Highway Accident Report 17 Tires General. The three-axle motorcoach was equipped with eight tires;35 two tires on the steer axle, four on the drive axle, and two on the tag axle. All tread depths were examined postaccident and found to be within the North American Standard Out-of-Service Inspection Criteria, as well as the FMCSRs.36 All the tires were mounted on 22.5-inch by 9-inch one-piece steel wheel assemblies, with the exception of the two tires on the tag axle, which were mounted on 8.25-inch wheel assemblies.37 (See table 3.) Table 3. Postaccident tire make, size, and pressure information. Axle Make Size Pressure Right steer Goodyear G409 MBA (retreaded)a 315/80 R22.5 Deflated - failed Left steer Firestone FS-400 315/80 R22.5 118 psi @ 79°F Right drive inner Ling Long LLF02 315/80 R22.5 94 psi @ 79°F Left drive inner Firestone FS-400 315/80 R22.5 96 psi @ 79°F Right drive outer Ling Long LLF02 315/80 R22.5 0 psi @ 79°F (debeaded)b Left drive outer Firestone FS-400 315/80 R22.5 93 psi @ 79°F Right tag Ling Long LLF02 315/80 R22.5 89 psi @ 79°F Left tag Goodyear G409 MBA 315/80 R22.5 88 psi @ 79°F a “Retreaded” tires have had a new layer of surface rubber with a tread pattern added (often called “recapped”) to extend the life of the tire. b “Debeading” is a separation of the tire from the rim at the tire bead, resulting in an immediate loss of tire pressure. The motorcoach’s vehicle specification plate indicated that the recommended tires for the coach were 315/80 R22.5-size tires. According to the specification plate, the recommended tire inflation pressures were as follows: steer axle, 120 psi; drive axle, 90 psi; and tag axle, 120 psi.38 The information in table 4 appeared in the 2001 MCI J4500 maintenance manual for the accident motorcoach regarding required tire inflation rates by make and model of tire; table 5 indicates the discrepancies between the measured tire pressures and those recommended on the vehicle’s specification plate. Table 6 provides tire pressure and load capacity data for 315/80 R22.5-size tires.

35 The postaccident vehicle inspection found four new tires, which had been purchased on July 29, 2008, two days before the motorcoach’s July 31, 2008, annual inspection. Two of the new tires were on the right drive axle (inner and outer positions), one was on the right tag axle, and one was used as a spare. 36 See 49 CFR 393.75. 37 The mounting and use of a size 315/80 R22.5 tire on a rim designed with a bead width less than 9 inches or more than 9.75 inches does not comply with the 2007 interchangeability of tires, rims, and allied parts standards established by the Tire and Rim Association, Inc. However, according to the Tire and Rim Association, Inc., Engineering Design Information (Rev. 5, October 2006), p. 3-41, the use of 8.25-inch wheels with 315/80 R22.5 tires is permissible, if the maximum allowable load is reduced to 8,000 pounds per tire in single usage and 7,610 pounds per tire in dual usage, when inflated to 120 psi. 38 Pressures vary by position because of differences in axle weight rating and number of tires.

NTSB Highway Accident Report 18 Table 4. Tire inflation information in the MCI J4500 maintenance manual (May 2001). Make and Type of Tire Size Steer Axle (psi) Drive Axle (psi) Tag Axle (psi) Goodyear G391 315/80 R22.5 120 85 105 Goodyear G124 (snow tires) 12 R22.5 Not approved 85 Not approved Michelin XM + S4 (snow tires) 12 R22.5 Not approved 95 Not approved Firestone HP3000 315/80 R22.5 120 85 105 Goodyear G291 315/80 R22.5 120 85 105 Michelin PXZA 1 315/80 R22.5 120 90 105 Table 5. Comparison of postaccident tire inflation pressures with recommended tire inflation pressures, as indicated by the motorcoach vehicle specification plate. Axle Measured Left Tire Pressure (psi) Measured Right Tire Pressure (psi) Specification Plate Recommended Pressure (psi) Steer 118 deflated 120 Drive inner 96 94 90 Drive outer 93 0, debeaded 90 Tag 88 89 120 Table 6. Tire pressure and load capacity data for tire size 315/80 R22.5. Pressure (psi)

80 85 90 95 100 105 110 115 120 Load capacity (lbs.) .

Single 6175 6415 6670 6940 7190 7440 7610 7920 8270 Dual 5675 5840 6070 6396 6545 6770 6940 7210 7610 (Load range)

(G)

(H)

(J) Source: Values per Tire and Rim Association standards publication, 2009 Year Book. The MCI Operator Manual for the accident motorcoach indicates that the tire pressures should be checked before each trip using an accurate gauge. The manual also indicates that a 5-psi underinflation of a steer axle tire can cause hard steering, create steering hazards, and cause an unsafe condition. It also states that underinflation of a tag tire can affect braking. Postaccident examination revealed that the right front tire on the steer axle was a retreaded tire. According to 49 CFR 393.75(d), ―No bus shall be operated with regrooved, recapped or retreaded tires on the front wheels.‖ In accordance with Federal regulations, the tire was identifiable as a retreaded tire.39 The original tire casing was a Goodyear model G409 MBA

39 The tire was marked ―[R]ANC-B23507.‖

NTSB Highway Accident Report 19 radial tire that had been retreaded with a Bandag model T4100 tread. The tire was retreaded by Henise Tire Service of Cleonea, Pennsylvania, which received the tire from MCI Sales and Service of Blackwood, New Jersey, on August 30, 2007. Henise Tire retreaded the tire and returned it to MCI Sales and Service on September 6, 2007. The accident tire is shown in figure 8.

Figure 8. Right steer axle tire of the accident motorcoach. Retreading a tire involves bonding a new tread to the tire casing through the application of heat and pressure over time.40 The Tire Retread and Repair Information Bureau and the Technology and Maintenance Council of the American Trucking Associations have stated that retread tires are as safe as originally manufactured tires. In addition, a recent National Highway Traffic Safety Administration (NHTSA) heavy vehicle tire study41 found that nearly half of heavy vehicle replacement tires are retreads, and evidence from road debris collected and

40 From Understanding Retreading (Louisville, Kentucky: International Tire and Rubber Association Foundation, Inc., 2001). See http://www.retread.org/PDF/UnderstandingRetreading.pdf, accessed March 13, 2009. 41 J.F. Woodrooffe, O. Page, D. Blower, and P.F. Green, Commercial Medium Tire Debris Study, prepared for DOT/NHTSA, DOT HS 811 060, contract number DTNH22-05-D-01019, task order 0012, December 2008.

NTSB Highway Accident Report 20 examined as part of the study indicated that retread tires do not fail at rates higher than new tires.42 It is not known when the retread tire was mounted on the accident motorcoach’s steer axle. MCI provided photographs of the accident motorcoach dated January 10, 2008 (before refurbishment), and June 23, 2008 (after refurbishment and approximately 6 weeks prior to the accident). Both photographs show the right steer axle tire to be a Firestone brand (the retread tire was a Goodyear brand). The vehicle was purchased by Angel Tours on July 19, 2008, from MCI. Vehicle maintenance and inspection records, as well as financial records, included no documentation that the tire was positioned on the steer axle before its annual safety inspection (July 31, 2008), which was conducted 8 days prior to the accident. Inspections of Failed Tire. NTSB investigators, in conjunction with representatives of the Goodyear Tire & Rubber Company (Goodyear), examined the right steer axle tire of the accident vehicle on November 24, 2008.43 They noted the following conditions: Multilayer tearing into the belts and multilayer tearing into the belt coat compound. Good coarse tear lines and good ply-belt wire cord impressions. Wheel flange impressions on the face of both beads. Circumferential impressions at the mid-base of both beads. Diagonal undulations to the face of both beads. Heat discoloration on the serial side bed and on the belt coat stock on the crown. Circumferential abrasion bands on the wheel taper/bead seat. A puncture/cut through the casing on the serial side tread shoulder rib. Tread rubber around the puncture/cut is abraded/bruised and torn. Goodyear attributed the tire failure to the following factors: Short term underinflation caused by the puncture/cut resulted in severe overdeflection[44] of the tire. The stress and heat generated from the overdeflection and the forces acting on the rotating tire caused loss of adhesion between tire components, and eventual separation and detachment of tread and belt pieces.

42 The NHTSA tire debris study also included interviews with industry operators. Sales estimates for medium-duty tires were 34–36 million per year. The proportion of retread tires was estimated at 50 percent or higher for drive tires. For trailer tires, the proportion was estimated at 70–100 percent. (See page 80, NHTSA Commercial Medium Tire Debris Study.) 43 Information was obtained from Goodyear’s January 15, 2009, written report to the NTSB, received January 24, 2009. 44 Tire ―deflection‖ is the tread and sidewall flexing where the tread comes into contact with the road. ―Overdeflection‖ is a deflection [of the tire] that is greater than that intended for the rated load and inflation pressure. Overdeflection occurs when the load is excessively high or the inflation pressure is too low, or when a combination of load and inflation pressure creates an excessively high deflection, resulting in a flattening of the tire. (Information obtained from the e-book The Pneumatic Tire, A.N. Gent and J.D. Walter, eds. [Akron, Ohio: University of Akron and National Highway Traffic Safety Administration, 2005].)

NTSB Highway Accident Report 21 With tread and belt detachment, the unsupported casing ruptured exhausting any remaining inflation pressure. Goodyear also concluded that there were ―No defects in materials, workmanship or manufacture‖ of the tire. It stated that The multi-layer and multi-level tearing through crown components and the coarse tear lines and ply-belt wire cord impressions indicate good initial component adhesion within the casing and between the casing and the retread. At NTSB’s request, Bridgestone Americas, Inc. (Bridgestone), in conjunction with NTSB investigators, conducted an additional independent inspection of the tire on November 25–28, 2008.45 Based on the examination, Bridgestone indicated that the tire failure ―Initiated and propagated within the original casing.‖ Bridgestone also indicated that the puncturing object gouged and tore the tread surface and the bulk of the rubber but did not pass through the tire casing. The tread rubber hole was abraded/bruised and torn, indicating that there had been some time between the puncture and the blowout. Further, the ―Belt edge lift and shoulder rubber tearing occurred along the serial side (outboard facing) shoulder as the tread/belt detachment initiated in this area due to the centrifugal force of highway speed tire rotation.‖ Bridgestone identified multiplane tear patterns, including fatigue and crack propagation, as well as evidence of adequate adhesion and tear resistance on the separated and detached tread, belt, and casing surfaces. It found numerous exposed rubber surfaces that had a ―blue-tint‖ appearance, indicating excessive heat generation during operation. Bridgestone found no indication of separation or detachment of retread material along the splice or along any surface of the casing buffed during the retread process. Bridgestone concluded that the failure of the right steer axle tire was a result of Damage caused by over-deflected operation. In this case, the most probable cause of over-deflection is underinflation due to an un-repaired puncture to the tire which lead [sp] to inflation pressure loss and damaging stress/strain and heat build-up... Bridgestone also found that the tire was retreaded properly, and the failure was not related to the retreading. The Bridgestone report further stated that the puncture that led to the failure occurred after the tire was retreaded and put back into service. Bridgestone also said the puncturing object Most likely ejected from the tire during the tread/belt detachment process. Although it is difficult to state with precision how long the subject tire operated in an over-deflected manner, the tread/belt tear patterns and a lack of polishing of the separated surfaces indicate relatively short-term operation in such a condition, most likely for less than 1000 miles.

45 Bridgestone provided the NTSB with a written report dated March 13, 2009.

NTSB Highway Accident Report 22 Visual Inspection of Tire Inflation. According to NHTSA, the fact that a tire is inflated to half its recommended inflation value may not be detected by visual inspection.46 Figure 9 shows a Goodyear 315/80 R22.5 tire inflated to 115 psi and 60 psi, respectively.

Figure 9. Photographs of a Goodyear 315/80 R22.5 tire inflated to 115 psi (left) and 60 psi (right). The photographs illustrate the difficulty in visually detecting proper tire inflation. Visual detection of proper tire inflation on such larger vehicles may be negatively affected by the nature of commercial vehicle tire construction, which employs stronger materials, including stiffer sidewalls and harder rubber compounds, than are typically used in tires for light trucks and passenger vehicles. Tire Pressure Information in MCI Model J4500 Maintenance Manual. Investigators found that the MCI Model J4500 Maintenance Manual contained inaccurate tire information and inflation pressure. Drive axle tire inflation for tire size 315/80 R22.5 was listed as 85 psi, rather than the correct inflation pressure of 90 psi. Tag axle tire inflation for tire size 315/80 R22.5 was listed as 105 psi, rather than 120 psi.47 Additionally, the manual’s GENERAL DESCRIPTION material, section 15A ―Wheels‖ and section 15C ―Tires,‖ incorrectly stated that the motorcoach’s steer axle gross axle weight rating (GAWR) was 16,000 pounds rather than 16,500 pounds. Vehicle Maintenance About 3 weeks before the accident, on July 19, 2008, Angel Tours purchased the motorcoach from MCI as a refurbished vehicle. The carrier did not identify any maintenance actions between the purchase date and the accident. MCI refurbishment records documented extensive inspection and corrective actions to bring the vehicle into proper operating specifications prior to the motorcoach’s sale.

46 Data and photographs on checking tire pressure may be viewed at NHTSA’s Safercar website , accessed August 4, 2009. 47 The manual listed the correct tire inflation pressure for the steer axle tires, which is 120 psi.

NTSB Highway Accident Report 23 Commercial Motor Vehicle Inspections Title 49 CFR 396.17 requires commercial vehicles to receive annual inspections utilizing criteria set forth in appendix G of subchapter B of the FMCSRs. Under 49 CFR 396.23(b)(1), a motor carrier may meet the regulatory inspection requirements if the vehicle is subject to a mandatory state inspection program. The Federal Motor Carrier Safety Administration (FMCSA) certified the state of Texas’s vehicle inspection program as meeting the Federal inspection requirements at 49 CFR 396.17. In Texas, motor vehicles, including motorcoaches, are inspected and approved by privately owned and operated garages and repair facilities. Official vehicle inspection stations in Texas are required to operate under the state’s Rules and Regulations Manual.48 The state sets and regulates the fees charged for the inspection of vehicles; currently, the fee for a commercial vehicle safety inspection of a motorcoach in Texas is $62. A TxDPS-approved facility inspected the motorcoach 8 days before the accident, on July 31, 2008. After the inspection, the motorcoach received a Texas Commercial Vehicle Inspection Certificate sticker, indicating that the motorcoach ―Complies with all Federal and state inspection requirements.‖ The inspection was conducted at the ―5 Minute Inspections‖ facility in Houston, Texas. The inspection report data obtained from the TxDPS concerning the garage’s inspection actions contained, in part, the following: the odometer reading was 0 miles; no Texas Department of Transportation (TxDOT) number was entered; and the insurance expiration date was given as October 12, 2009 (more than 1 year into the future for an annual policy). During a postaccident interview with the mechanic who conducted the inspection, he stated that he remembered the accident motorcoach, and he recalled that it took 30–45 minutes to complete the inspection. NTSB investigators visiting the facility noted that it did not have a service pit or a commercial vehicle lift capable of lifting a motorcoach. On August 7, 2008, another Angel Tours49 motorcoach was inspected at 5 Minute Inspections. That vehicle, like the accident motorcoach, received an ―all items passed‖ inspection report and a Texas Commercial Vehicle Inspection Certificate sticker. The following day, August 8, 2008, the vehicle underwent a Motor Carrier Safety Assistance Program (MCSAP)-sponsored roadside inspection conducted by the Missouri Highway Patrol. The vehicle was placed out of service with numerous equipment violations, including that the right steer axle, left steer axle, and right tag axle brakes were in violation. The automatic brake adjustor on the air brake system was also cited for a safety violation. NTSB staff contacted the TxDPS Houston Regional Office several times to request an audit of the 5 Minute Inspections station, as well as of the subject inspector. On March 10, 2009, a TxDPS representative visited the station, interviewed the inspector, and confirmed the inspector’s certificate. The TxDPS sent the NTSB a copy of its internal memorandum on this visit, dated March 11, 2009. The memorandum did not include any reference to audit processes (other than use of the emissions analyzer), knowledge testing, or practical exercises.

48 The Texas Rules and Regulations Manual is issued and maintained by the TxDPS in accordance with the Texas Transportation Code, ―Compulsory Inspection of Vehicles,‖ chapter 548. 49 See the ―Motor Carrier‖ section of this report for a discussion of Angel Tours’s relationship with Iguala BusMex.

NTSB Highway Accident Report 24 Highway The accident occurred on the Post Oak Creek bridge, along a portion of US-75 classified as urban principal arterial roadway.50 It is a four-lane highway with the two northbound lanes separated from the two southbound lanes by an earthen median and a 32-inch-high, Jersey-shape concrete median barrier. Lanes of same direction travel are separated by dashed white pavement striping. The right shoulder of the northbound lanes is delineated from the main travel lanes by a solid white pavement stripe, and the left shoulder is delineated from the travel lanes by a solid yellow pavement stripe. The right shoulder is 9 feet wide as it approaches the bridge and narrows to 30 inches on the bridge deck. Rumble strips are located on the right shoulder as it approaches the bridge. The left shoulder is 4 feet wide and narrows to 22 inches on the bridge deck. A speed limit sign posted about 1 mile south of the bridge indicated the daytime speed limit as 70 mph and the nighttime limit as 65 mph. Figure 10 shows the accident scene, and figure 11 shows the final position of the motorcoach near the creek.

Figure 10. Highway accident scene, looking at the motorcoach’s path off the bridge. (Photograph was taken after postaccident repairs were made to the bridge.)

50 ―Urban principal artery‖ is a functional classification of road. Urban principal arterial roadways serve major metropolitan centers and corridors with the highest traffic volumes and longest trip lengths. They carry most trips entering and leaving urban areas and provide continuity for all rural arterials that intercept urban boundaries.

NTSB Highway Accident Report 25

Figure 11. Motorcoach on the bank of the Post Oak Creek. [Courtesy Sherman Police Department] Beginning approximately 1/3 mile before the accident site, the design plan profile for the roadway indicates a 3.75-percent downgrade as the road makes a slight (2.3-degree) curve to the right, followed by a transition into a slight (1.5-degree) curve to the left for 768 feet. The approach to the bridge was equipped with a 279-foot-long, 27-inch-high metal beam guardrail fence. It comprised a 47-foot-long safety end treatment, followed by a 180-foot-long main section element, and then a 25-foot-long transition area into the bridge end, terminating with a 27-foot-long turned-down end piece that was anchored into the bridge railing curb.51 The safety end treatment area of the guardrail had double wooden blocks for support. The main element had 28 blocked metal posts spaced at 6-foot 6-inch intervals. The transition area into the bridge end had eight metal blocked posts at 3-foot 1 1/2-inch intervals to stiffen the barrier in case of impact close to the bridge.

51 TxDOT design records indicate that the bridge railing was a Type II rail designed in 1954 in accordance with the 1953 American Association of State Highway Officials Bridge Specifications Manual.

NTSB Highway Accident Report 26 The bridge had an 7-inch-high, 18-inch-wide concrete curb above the bridge deck, as shown in figure 10. The bridge also had a 210-foot-long metal bridge railing composed of seven 30-foot-long sections with 1-inch-long nominal separations for expansion. The railing was 12 inches wide and 1/4 inch thick and was positioned 23 3/4 to 24 inches above the curb, for a total height of approximately 31 inches. It was connected to the curb with 36-inch-long by 5-inch-wide steel I-beams (five I-beam supports per section of railing) that were bolted to the railing with four bolts. I-beams were attached to the concrete bridge deck by 18-inch-long bolts cast into place in the curb during the 1958 construction of the bridge. A June 10, 2007, bridge inspection report by TxDOT noted repairs to the bridge railing on two 30-foot-long sections of the east railing in the northern span of the bridge. It noted those repairs to be marginal because the original cast-in-place bolts, damaged as the result of a 2001 truck-semitractor accident that penetrated the bridge railing, were replaced with bolts into the side of the deck and reinforced with steel plates welded to the I-beam structure. Following the August 2008 accident, TxDOT repaired the bridge railing to its existing design. (See figure 12.) According to TxDOT, in September 2009 it completed a railing retrofit for the accident bridge and four others along the same road segment, upgrading the accident bridge railing to a T-501 railing, which complies with a Test Level Four standard.52 (Bridge railing designs are discussed in the ―Other Information‖ section of this report.) In addition to the bridge railing retrofit project, the TxDOT Bridge Division has identified a U.S. corridor improvement project for US-75 and is exploring funding options.53 Physical Evidence The physical evidence at the accident scene indicated a right steer axle tire mark beginning 685 feet before the motorcoach struck the curbing and bridge railing. Approximately 100 feet beyond that initial road mark, pieces of tire were found. Deflated right steer axle tire marks began 130 feet before the motorcoach struck the curbing and bridge railing. The motorcoach hit the curb at about a 4-degree angle about 29 feet north of the bridge. The motorcoach came into contact with the bridge railing midway along the second 30-foot-long section of railing (about 47 feet from the beginning of the northbound railing). The motorcoach bowed in the second section of railing to a depth of about 32 inches, breaking two of the five support posts. It then struck the leading edge of the third railing section at the expansion space. The bolts at the bottom of the I-beams sheared off, and the third section of railing came to rest about 25 feet below in Post Oak Creek. Four more sections of bridge railing, totaling 136 feet, were displaced from the bridge deck. The bridge railing showed evidence of past vehicle strikes. No corrosion was found on the metal of the bridge railing or its fixtures.

52 Test levels for bridge railing designs are in National Cooperative Highway Research Program Report 350, Recommended Procedures for the Safety Performance Evaluation of Highway Features. 53 TxDOT estimates that the US-75 corridor improvement project will cost $125 million.

NTSB Highway Accident Report 27

Figure 12. Two views of the repaired bridge railing. (Top) Looking down along the inside of the repaired railing from the roadway. (Bottom) Looking at the outside of the repaired railing from the bank of Post Oak Creek.

NTSB Highway Accident Report 28 Traffic Metrics In 2006, TxDOT performed an average daily traffic (ADT) count for US-75 in the vicinity of the bridge. The ADT was 46,961 vehicles. TxDOT indicated that the ADT of the northbound bridge lanes was about 21,000. Commercial vehicles composed approximately 16 percent of the total traffic. TxDOT conducted a speed survey on August 18 and 21, 2008, during daylight conditions. The 85th percentile speed was 72 mph.54 Accident data for a 6-year period indicated that 42 additional accidents occurred in the vicinity of this accident. (See table 7.) One fatal accident occurred along this road segment in 2003, but it did not involve the bridge. Some vehicle contact was indicated by the evidence of vehicle strikes on the bridge railing, but no reports of passenger cars leaving the roadway after contact with the bridge railing were found. In the bridge’s 50-year history, only two accidents, including this motorcoach event, resulted in a bridge railing failure, and both accidents involved large commercial motor vehicles. As has been noted, in 2001, an injury accident occurred when a truck tractor penetrated the bridge railing, destroying two 30-foot-long sections. No motorcoaches were involved in past accidents at this location. Table 7. Accident history. Year Number of Accidents Number of Fatalities 2003 6 1 2004 5 0 2005 5 0 2006 11 0 2007 9 0 2008a 6 0 6-year total 42 1 a Not including the August 8, 2008, accident. Environmental Conditions Surface weather observations were obtained from the National Oceanic and Atmospheric Administration, National Climatic Data Center for Sherman/Denison, Texas–Grayson County Airport, for August 8, 2008, at 12:26 a.m. The weather was clear, with visibility of at least 10 miles, temperature 77° F, relative humidity 79 percent, and winds calm. U.S. Naval Observatory records indicated that there was a first quarter moon on the night of August 7–8, 2008.55

54 The 85th percentile speed is the speed at which or below 85 percent of surveyed vehicles are traveling. 55 A first quarter moon has one-half of its surface illuminated.

NTSB Highway Accident Report 29 Motor Carrier The motor carrier Iguala BusMex, Inc., was operating the Sherman accident motorcoach. The owner of Iguala BusMex also owned Angel Tours, Inc., a motor carrier that operated from the same address. Angel Tours had received operating authority in 1994 but was placed out of service by the FMCSA on June 23, 2008. Just over a month later, on July 27, 2008, the owner of Angel Tours applied to the FMCSA for motor carrier operating authority under the name ―Iguala BusMex, Inc.‖ As of the accident date, the FMCSA had not granted operating authority to Iguala BusMex because its application was incomplete. The owner of Iguala BusMex had an unsigned lease arrangement with Liberty Charters and Tours (Liberty) to provide drivers and buses to Liberty. The FMCSA, in part C of its postaccident compliance review, indicated that Iguala BusMex used Liberty’s operating authority and U.S. Department of Transportation (DOT) number (USDOT number)56 to engage in interstate commerce. Information on these motor carriers and their relationships is provided below. Angel Tours According to state of Texas tax records, the owner of Iguala BusMex was also the owner of Angel Tours, Inc., which had been operating from the same location as Iguala BusMex. The owner of Angel Tours told FMCSA inspectors that he was the owner of Iguala BusMex. According to FMCSA records, Angel Tours received its authority to operate in 1994. It was an interstate, for-hire passenger carrier that had six buses and six drivers. On May 1, 2008, the FMCSA conducted a compliance review of Angel Tours, which resulted in an unsatisfactory rating. Three critical violations were found, as well as several other violations. (See table 8.) The compliance review records showed that in the previous year, Angel Tours had traveled 400,000 miles with no recordable accidents.57 The compliance review documented that the carrier had had five roadside inspections during the previous year, resulting in two vehicles being placed out of service (40 percent).58 According to roadside inspection data for the 24 months prior to the Sherman accident, Angel Tours had 31 vehicle inspections with 6 vehicles placed out of service (19.4 percent), and 27 driver inspections with 7 drivers placed out of service (25.9 percent).

56 The USDOT number is a registration number and is required for interstate operations. 57 According to 49 CFR 390.5, an ―accident‖ is defined as an occurrence involving a commercial motor vehicle operating on a highway in interstate or intrastate commerce which 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 vehicles to be transported away from the scene by a tow truck or other motor vehicle. 58 The FY 2008 national average bus out-of-service rate was 7.7 percent, and the average bus driver out-of-service rate was 4.8 percent.

NTSB Highway Accident Report 30 Table 8. Violations identified in May 2008 FMCSA compliance review of Angel Tours. Critical Violations:a

Using a driver before the motor carrier received a negative preemployment controlled substance test result.

Using a driver not medically examined and certified during the preceding 24 months.

Failing to require a driver to prepare a driver vehicle inspection report. Additional Violations:

Failing to conduct random alcohol testing at an annual rate of driver positions.

Failing to conduct random controlled substance testing at an annual rate of driver positions.

Failing to provide educational material explaining the drug and alcohol policy as required.

Failing to ensure that persons designated to drive undergo reasonable suspicion testing training for controlled substances.

Using a driver who has not completed an employment application.

Failing to maintain a driver’s driving record in driver qualification file.

Failing to investigate a driver’s background within 30 days of employment.

Failing to investigate previous DOT-regulated employers that employed the driver within the previous 3 years.

Failing to maintain a driver’s employment application in driver qualification file.

Failing to maintain a list or certificate relating to violations of motor vehicle laws and ordinances required by FMCSR 391.27.

Requiring or permitting a passenger-carrying commercial motor vehicle driver to drive more than 10 hours.

Failing to require a driver to prepare record-of-duty status in the form and manner prescribed.

Failing to keep maintenance records that identify vehicles, including make, serial number, year, and tire size.

Failing to have a means of indicating the nature and due dates of various inspection and maintenance operations to be performed.

Failing to keep a record of tests conducted on push-out windows, emergency doors, and emergency door marking lights.

Using a commercial motor vehicle not periodically inspected. a During a safety audit, the FMCSA gathers information by reviewing a motor carrier’s compliance with “acute” and “critical” regulations. Acute regulations are those in which noncompliance is so severe as to require immediate corrective actions by the motor carrier regardless of the overall basic safety management controls of the motor carrier. Critical regulations are those in which noncompliance relates to management and/or operational controls. Violations are indicative of breakdowns in a carrier’s management controls. (Per appendix A to 49 CFR Part 385 ”Explanation of Safety Audit Evaluation Criteria,” paragraphs III [b] and [c]). The motor carrier had 45 days to submit a corrective action plan to the FMCSA to change its unsatisfactory rating. On June 23, 2008, the FMCSA placed Angel Tours out of service because it had not submitted an action plan. Angel Tours submitted an action plan on June 24, but the FMCSA denied its request to change its rating due to the lateness of the submission and the inadequacy of the response. A review of the Angel Tours driver logbook records revealed several trips in interstate travel after the FMCSA had placed the motor carrier out of service.

NTSB Highway Accident Report 31 Iguala BusMex Iguala BusMex applied to the FMCSA for operating authority on July 27, 2008. It registered with the FMCSA as an interstate, for-hire passenger carrier. The FMCSA listed Iguala BusMex as having two buses and five drivers.59 As part of its application for authority to operate, Iguala BusMex was required to provide proof of the required $5 million insurance coverage (per 49 CFR 387.33). The FMCSA advised Iguala BusMex that its authority to operate would not be granted until proof of insurance could be verified. When the accident occurred, Iguala BusMex had not provided proof of the $5 million insurance coverage required to obtain operating authority; therefore, the FMCSA considered Iguala BusMex’s operating authority to be pending. According to the insurance company from which Iguala BusMex was seeking insurance, as of the date of the accident, the carrier had submitted paperwork to obtain insurance, but the insurance company had not reviewed the documentation; consequently, Iguala BusMex had no active insurance policy at the time of the accident. Review of the logbooks of Iguala BusMex bus drivers indicated that the company had conducted several trips in June 2008 without operating authority and in August 2008 with pending operating authority. On August 9, 2008, a day after the Sherman accident, the FMCSA issued an imminent hazard and out-of-service order for Iguala BusMex and Angel Tours and their officers and directors. The bases of the imminent hazard order were the operation of vehicles in a mechanically unsafe operating condition; the failure to ensure that the vehicles were properly and regularly inspected, repaired, and maintained; and the failure to ensure compliance with the Federal controlled substance and alcohol use and testing requirements, driver qualifications requirements, and driver hours-of-service requirements.60 Iguala BusMex and Angel Tours were required to cease all motor vehicle operations.61 The FMCSA also said that ―Angel Tours’ continuity of operation through Iguala BusMex demonstrated a blatant disregard for previous FMCSA Out-of-Service Orders, which were issued based upon the company’s substandard safety record.‖62 The FMCSA’s Motor Carrier Management Information System (MCMIS) report on the carrier did not indicate any roadside inspections for Iguala BusMex. The day after the Sherman accident, August 9, 2008, the FMCSA began a compliance review of Iguala BusMex, but FMCSA personnel were asked by the company owner to leave within 2 hours of starting the review. The FMCSA obtained a subpoena for the company records, and the compliance review was continued on September 19, 2008. The subpoena for company records and the imminent hazard shutdown order were obtained on August 9, 2008, and were served to an attorney

59 In a postaccident interview, the accident driver stated that the company operated six buses. 60 U.S. Department of Transportation, FMCSA, Operations Out-of-Service Order issued August 9, 2008, at http://www.fmcsa.dot.gov/about/news/news-releases/2008/IH-Order-Angel-Tours-Iguala-Busmex-8-9-08.pdf, accessed August 4, 2009. 61 The Missouri State Police placed a second Iguala BusMex motorcoach out of service after it arrived in Carthage, Missouri. 62 The FMCSA’s review of the motor carrier operations demonstrated that Angel Tours and Iguala BusMex were motor carriers that transported passengers on identical routes, had the same customer base, used the same equipment and drivers, operated from the same physical location, and were controlled by the same owner.

NTSB Highway Accident Report 32 representing the company. The delay in conducting the compliance review involved negotiations with the attorney to obtain copies of Iguala BusMex corporate records. No principals of the company were available to be subpoenaed or questioned during the conduct of the compliance review. The compliance review resulted in an unsatisfactory rating. Iguala BusMex received unsatisfactory ratings for the Driver, Operational, and Vehicle factors and a conditional rating for the General factor. The violations listed in table 9 were noted in the review. Table 9. Violations identified in September 2008 FMCSA compliance review of Iguala BusMex. Acute Violation:

Operating a motor carrier without having in effect the required minimum levels of financial responsibility. Critical Violations:

Using a driver before the motor carrier received a negative preemployment controlled substance test result.

Using a driver not medically examined and certified during the preceding 24 months.

Failing to maintain a medical examiner’s certificate in driver’s qualification file.

Failing to require a driver to forward, within 13 days of completion, the original of the record-of-duty status.

Failing to keep records of inspection and vehicle maintenance indicating their date and nature.

Failing to require a driver to prepare driver vehicle inspection reports. Other Violations:

Using a driver who had not completed and furnished an employment application.

Failing to maintain a road test certificate in a driver’s qualification file, or a copy of the license or certificate the motor carrier accepted as equivalent.

Operating without the required operating authority. [Sherman accident trip]

Making false reports of record-of-duty status.

Operating a motor vehicle in such a condition as likely to cause an accident or breakdown. Liberty Charters and Tours The FMCSA conducted a compliance review of Liberty on August 11, 2008. During its compliance review, the FMCSA found an unsigned vehicle lease agreement between Liberty and Angel Tours, covering the period from June 28 through September 28, 2008.63 Part C of the FMCSA’s postaccident compliance review also stated that the owner of Liberty had agreed to let the owner of Iguala BusMex/Angel Tours use Liberty’s operating authority to engage in interstate commerce. In its compliance review of Liberty, the FMCSA found 24 violations, including the following: using a driver known to have tested positive for a controlled substance, failing to adequately conduct random alcohol and controlled substance testing, failing to investigate

63 The lease agreement document called for Angel Tours to provide Liberty with three motorcoaches. The agreement identified the vehicles by year and make but did not include vehicle identification numbers.

NTSB Highway Accident Report 33 drivers’ backgrounds, failing to maintain drivers’ qualification files, and making false record-of-duty status reports. Liberty received an unsatisfactory rating. The FMCSA issued an out-of-service order to Liberty on August 12, 2008, citing Liberty’s affiliation with Angel Tours and Iguala BusMex as an imminent hazard and stating that continued motor carrier operations with Angel Tours, Iguala BusMex, or the owner of these companies was prohibited. Liberty had 45 days to submit a corrective action plan to have its unsatisfactory rating changed. The FMCSA conducted a second compliance review of Liberty on November 13, 2008. Six violations, none critical or acute, were found during that review. The carrier received a satisfactory rating. Restrictions associated with the imminent hazard order remain; Liberty cannot have any dealings with Angel Tours, Iguala BusMex, or the owner of these companies. Other Information Bridge Railing Design Guidance This section summarizes the NTSB’s past investigative and recommendation history concerning highway barriers—a general category of highway safety appurtenances—and bridge railings, an important subcategory of barriers. It includes a discussion of the design documents used by highway engineers and distinguishes between guidance documents, which bridge owners may follow, and requirement specifications, which must be followed. NTSB History. On May 21, 1976, a 29-fatality school bus crash occurred on Interstate 680 near Martinez, California.64 That accident and the NTSB’s investigation of it served as catalysts for the development of higher performance bridge railings. In that accident, a school bus climbed the bridge railing, fell to the ground below, and landed on its roof. As a result of that investigation, the NTSB issued Safety Recommendations H-77-12 through -14 to the Federal Highway Administration (FHWA) concerning bridge railings, as follows: Develop bridge railing designs that will meet performance standards to be established by the FHWA for various classes of vehicles and that will be sufficient in number to meet the various state requirements with regard to climatic and other physical conditions that affect the operation and maintenance of a roadway system. Such bridge barrier railing designs should be available to states that do not desire to develop their own designs in accordance with mandatory performance standards issued by the FHWA. (H-77-12) Investigate through dynamic crash testing and analytical procedures the effects of various geometric configurations and adjacent roadway surfaces on the performance of traffic barrier rail systems. The investigation should also consider how maintenance practices or the lack of maintenance affects the performance of the barrier rail systems. (H-77-13)

64 Student Transportation Lines, Inc., Charter Bus Climbing of Bridge Rail and Overturn Near Martinez, California, May 21, 1976, Highway Accident Report NTSB/HAR-77/02 (Washington, DC: National Transportation Safety Board, 1977).

NTSB Highway Accident Report 34 In cooperation with the states, establish priority guidelines for improving, through modification or retrofit, the performance of existing traffic barrier rail systems at bridges. Consideration should be given in the priority guidelines to the potential for multi-fatality accidents involving high occupancy vehicles such as buses. (H-77-14)65 In 1980, the NTSB completed a Safety Effectiveness Evaluation of Traffic Safety Barriers (SEE-80-5). That report reviewed the NTSB’s previous work on the issue66 and evaluated the FHWA effort to develop safer traffic barriers. SEE-80-5 contained Safety Recommendation H-80-64, to the FHWA, which reads as follows: Establish mandatory performance standards, and associated test procedures to be used in determining compliance, for all traffic barriers constructed on Federal-aid roads after January 1, 1982. The performance standards should first address automobiles and should be expanded for heavier passenger vehicles and trucks as research is completed to provide needed information. (H-80-64)67 In November 1983, a fatal bus crash in which the bus penetrated the bridge railing occurred in Livingston, Texas.68 This accident prompted the NTSB to make Safety Recommendation H-84-65 to the Texas State Department of Highways and Public Transportation, which reads as follows: As part of any major pavement improvement project, provide wherever feasible for the installation of advanced barrier systems on and approaching bridges in the state of Texas. (H-84-65)69 Following the issuance of SEE-80-5, the NTSB continued to investigate both barrier and bridge railing accidents. Accident investigations to date involving barriers have included Fairfield, Connecticut; Memphis, Tennessee; New Orleans, Louisiana; Slinger, Wisconsin; and St. Louis County, Missouri.70 Past investigations involving bridge railings have included Atlanta,

65 Safety Recommendation H-77-12 was ―Closed—Superseded,‖ Safety Recommendation H-77-13 was ―Closed—Acceptable Action,‖ and Safety Recommendation H-77-14 was ―Closed—Unacceptable Action.‖ 66 Five highway accident investigations were reviewed. They were as follows: (a) NTSB/HAR-77/02; (b) Transport Company of Texas, Tractor Semitrailer (Tank) Collision with Bridge Column and Sudden Dispersal of Anhydrous Ammonia Cargo, Houston, Texas, May 11, 1976, Highway Accident Report NTSB/HAR-77/01 (Washington, DC: National Transportation Safety Board, 1977); (c) Automobile Collision With and Collapse of the Yadkin River Bridge, Near Siloa, North Carolina, February 23, 1975, Highway Accident Report NTSB/HAR-76/03 (Washington, DC: National Transportation Safety Board, 1976); (d) Automobile Crash Off the Silliman Evans Bridge, I-24/65, Nashville, Tennessee, July 27, 1973, Highway Accident Report NTSB/HAR-74/02 (Washington, DC: National Transportation Safety Board, 1974); (e) Wilmeth Cattle Company Truck/Bridge Transportation Enterprises, Inc., Bus, U.S. 60-84, Fort Sumner, New Mexico, December 26, 1972, Highway Accident Report NTSB/HAR-74/01 (Washington, DC: National Transportation Safety Board, 1974). 67 Safety Recommendation H-80-64 was ―Closed—Acceptable Alternate Action.‖ 68 Trailways Lines, Inc., Bus/E.A. Holder, Inc., Truck, Rear End Collision and Bus Run-Off-Bridge, U.S. Route 59, Near Livingston, Texas, November 30, 1983, Highway Accident Report NTSB/HAR-84/04 (Washington, DC: National Transportation Safety Board, 1984). 69 Safety Recommendation H-84-65 was ―Closed—Unacceptable Action.‖ 70 (a) Multiple Vehicle Collision on Interstate 95, Fairfield, Connecticut, January 17, 2003, Highway Accident Report NTSB/HAR-05/03 (Washington, DC: National Transportation Safety Board, 2005); (b) 15-Passenger Child

NTSB Highway Accident Report 35 Georgia; Omaha, Nebraska; White Plains, New York; Middletown, New Jersey; Frederick, Maryland; and Hermanville, Mississippi.71 Design Documents. The Post Oak Creek bridge, built in 1958, was designed according to the 1953 American Association of State Highway Officials (AASHO)72 Bridge Specifications Manual. Since 1958, several new design standards and associated guides for their usage have been introduced. The following chronology summarizes the development of guidelines addressing the intent of the NTSB’s original bridge railing performance standard recommendations (Safety Recommendations H-77-12 through -14).73 FHWA memorandums show that bridges constructed prior to 1964 generally do not have crash-tested bridge railings. In the late 1960s and early 1970s, some states, such as California and Texas, began crash-testing programs to develop crashworthy bridge railings. By 1972, California had a standard design for bridge railings that would redirect passenger cars, but the design did not address heavier vehicles. The Transportation Research Board (TRB) National Cooperative Highway Research Program (NCHRP) Project 22-2(4) was initiated to recommend procedures for the safety performance evaluation of barrier systems. That project resulted in a 1980 report, NCHRP Report 230, Recommended Procedures for the Safety Performance Evaluation of Highway Safety Appurtenances, which served thereafter as the primary reference for full-scale crash testing in the United States.74 The crash-test procedures were based on three performance levels to evaluate the

Care Van Run-Off-Road Accident, Memphis, Tennessee, April 4, 2002, Highway Accident Report NTSB/HAR-04/02 (Washington, DC: National Transportation Safety Board, 2004); (c) Motorcoach Run-Off-The-Road, New Orleans, Louisiana, May 9, 1999, Highway Accident Report NTSB/HAR-01/01 (Washington, DC: National Transportation Safety Board, 2001); (d) Multiple Vehicle Crossover Accident, Slinger, Wisconsin, February 12, 1997, Highway Accident Report NTSB/HAR-98/01 (Washington, DC: National Transportation Safety Board, 1998); (e) School Bus-Loss of Control and Collision With Guard Rail and Sign Pillar, U.S. Highway 70 Near Lucas and Hunt Road, St. Louis County, Missouri, November 11, 1985, Highway Accident Report NTSB/HAR-87/02 (Washington, DC: National Transportation Safety Board, 1987). 71 (a) Motorcoach Override of Elevated Exit Ramp, Interstate 75, Atlanta, Georgia, March 2, 2007, Highway Accident Report NTSB/HAR-08/01 (Washington, DC: National Transportation Safety Board, 2008); (b) School Bus Run-Off-Bridge Accident, Omaha, Nebraska, October 13, 2001, Highway Accident Report NTSB/HAR-04/01 (Washington, DC: National Transportation Safety Board, 2004); (c) Propane Truck Collision with Bridge Column and Fire, White Plains, New York, July 27, 1994, Highway Accident Report NTSB/HAR-95/02 (Washington, DC: National Transportation Safety Board, 1995); (d) Academy Lines, Inc., Intercity Bus Run-Off-Roadway and Overturn, Middletown, New Jersey, September 6, 1987, Highway Accident Report NTSB/HAR-88/03 (Washington, DC: National Transportation Safety Board, 1988); (e) Intercity Bus Loss of Control and Collision With Bridge Rail on Interstate 70 Near Frederick, Maryland, August 25, 1985, Highway Accident Report NTSB/HAR-87/01 (Washington, DC: National Transportation Safety Board, 1987); (f) Pattison Head Start Center School Van Run Off Bridge and Fire, Near Hermanville, Mississippi, December 17, 1981, Highway Accident Report NTSB/HAR-82/05 (Washington, DC: National Transportation Safety Board, 1982). 72 AASHO was the predecessor agency to the American Association of State Highway and Transportation Officials. 73 It should be noted that bridge railings are a distinct category within a larger group of highway safety appurtenances, which includes longitudinal barriers, transitions, end terminals, crash cushions, breakaway supports, truck-mounted attenuators, and work zone traffic control devices. Design guidance is both general to safety appurtenances and specific to bridge railings. 74 Two earlier documents preceded NCHRP Report 230. The Highway Research Correlation Services Circular 481 (1962) was a 1-page document that introduced the concept of uniformity to traffic barrier research. NCHRP Project 22-2 resulted in NCHRP Report 153, Recommended Procedures for Vehicle Crash Testing of Highway Appurtenances, a 16-page report that expanded on Circular 481 but was still limited in scope.

NTSB Highway Accident Report 36 structural adequacy of a barrier system. NCHRP Report 230 did not include site-specific guidance as to which performance level would be appropriate for a given location. The American Association of State Highway and Transportation Officials (AASHTO) 1989 Guide Specifications for Bridge Railings categorized crash tests into three performance levels similar to those in NCHRP Report 23075 and provided guidance to highway engineers regarding the selection of a barrier with an adequate performance level based on a project site’s characteristics. The preface to this document contains the following statement: ―Bridge railing performance needs differ greatly from site to site over our highway network, and railing designs and costs should match site needs.‖ Use of the AASHTO 1989 Guide Specifications for Bridge Railings by state highway agencies is optional, and states are encouraged to develop their own selection criteria. As knowledge about roadside safety performance evaluations continued to evolve, NCHRP Project 22-7 was formed to update NCHRP Report 230. The result was NCHRP Report 350, Recommended Procedures for the Safety Performance Evaluation of Highway Features, issued in 1993. NCHRP Report 350 describes full-scale crash testing using six test levels to evaluate the structural adequacy of a barrier system as follows:

is taken to be generally acceptable for work zones with low posted speeds and very low volume, low-speed local streets; TL-2 (Test Level Two) is taken to be generally acceptable for work zones and most local and collector roads with favorable site conditions, as well as where a small number of heavy vehicles is expected and posted speeds are reduced; TL-3 (Test Level Three) is taken to be generally acceptable for a wide range of high-speed arterial highways with very low mixtures of heavy vehicles and with favorable site conditions; TL-4 (Test Level Four) is taken to be generally acceptable for the majority of applications on high-speed highways, freeways, expressways, and interstate highways with a mixture of trucks and heavy vehicles; TL-5 (Test Level Five) is taken to be generally acceptable for the same applications as TL-4 and where large trucks make up a significant portion of the average daily traffic or when unfavorable site conditions justify a higher level of railing resistance; TL-6 (Test Level Six) is taken to be generally acceptable for applications where tanker-type trucks or similar high center of gravity vehicles are anticipated, particularly with unfavorable site conditions. As with NCHRP Report 230, NCHRP Report 350 did not include specific guidance as to which test level (that is, which performance level) would be appropriate for a given site.

75 The crash test matrix included in the 1989 Guide Specifications for Bridge Railings differed in several areas from the NCHRP Report 230 test matrices.

NTSB Highway Accident Report 37 Work by AASHTO’s Highway Subcommittee on Bridges and Structures determined that the Standard Specifications for Highway Bridges76 had gaps and inconsistencies and did not use the latest design philosophy and knowledge.77 In response, in 1994, AASHTO adopted the Load and Resistance Factor Design (LRFD) Bridge Design Specifications, which were published as an alternative to the Standard Specifications for Highway Bridges. Section 13 of the LRFD Bridge Design Specifications contains recommendations on bridge railing designs and incorporates a crash-test matrix that differs from those used in NCHRP Report 350 and the AASHTO Guide Specifications for Bridge Railings. In May 1996, the FHWA held discussions with the AASHTO Highway Subcommittee on Bridges and Structures, Technical Committee for Guardrails and Bridge Rails. As a result of those discussions, the FHWA issued a memorandum containing its position regarding AASHTO guidance on bridge railings. That 1996 policy memorandum strongly suggested that AASHTO adopt the definitions and test criteria in NCHRP Report 350. But the FHWA memorandum stated that until AASHTO adopts a new railing level selection procedure, the FHWA will accept the procedures in the 1989 Guide Specifications for Bridge Railings78 or a rational, experience-based, consistently applied procedure proposed by the state. The 2007 LRFD Bridge Design Specifications replaced the 1994 specifications, but the document still incorporated six test levels similar to NCHRP Report 350. It provided some general guidance to be considered for site selection but made no provisions for analytically determining the barrier performance level appropriate for a given site. The document also specified that ―It shall be the responsibility of the user agency to determine which of the test levels is most appropriate for the bridge site.‖ It also stated the following: Agencies should develop objective guidelines for use of bridge railings. These guidelines should take into account factors such as traffic conditions, traffic volume and mix, cost and in-service performance, and life-cycle cost of existing railings. Most recently, AASHTO has issued the 2009 Manual for Assessing Safety Hardware (MASH),79 developed under NCHRP Project 22-14(02), ―Improvement of Procedures for the Safety-Performance Evaluation of Roadside Features.‖ MASH represents the latest evolution in barrier testing and will be used to evaluate the structural adequacy of a barrier system based on updated test vehicles and impact conditions. It contains revised criteria for evaluation of highway safety features based on changes in vehicle fleets. MASH will replace NCHRP Report 350 on

76 Standard Specifications for Highway Bridges, 17th edition (Washington, DC: American Association of State Highway and Transportation Officials, September 1, 2002). 77 AASHTO Highway Subcommittee on Bridges and Structures, Grand Challenges: A Strategic Plan for Bridge Engineering, http://bridges.transportation.org/Documents/2005strategicplan-websiteversion.pdf, accessed September 25, 2009. 78 These are based on the three performance levels developed in NCHRP Report 230, not the six levels in NCHRP Report 350. 79 MASH has been reviewed and approved by AASHTO’s Standing Committee on Highways as of June 1,

1. As it stands now, immediately upon publication, any new devices, including any modifications and/or

revisions to NCHRP Report 350-compliant devices, will have to be crash-tested under the new AASHTO MASH. However, if an NCHRP Report 350 test program has already begun, that program may continue, and results may be submitted to the FHWA prior to January 1, 2011.

NTSB Highway Accident Report 38 January 1, 2011. As with the previous NCHRP project documents, MASH will utilize full-scale crash testing and will not provide site-specific guidance regarding barrier performance. Guidance for bridge railing design also appears in AASHTO’s Roadside Design Guide. Guidance in the 2006 edition of the document is similar to what is found in the LRFD Bridge Design Specifications, in that the 2006 Roadside Design Guide states that ―For existing bridges, individual states should develop guidelines for retention, upgrading… of in-place railings,‖ and ―Owners should develop warrants for the bridge site.‖80 Texas has developed a Bridge Rail Manual; the manual does not contain selection criteria or warrants for the installation of high-performance barriers, including bridge railings. NTSB investigators asked other state departments of transportation what guidance they use when selecting a barrier system for a specific site; many replied that they use AASHTO’s LRFD Bridge Design Specifications.81 Since 1986, the FHWA has required that bridge railings used on Federal-aid projects meet full-scale crash-test criteria.82 An FHWA policy memorandum, dated 1997, stated, ―All new or replacement safety features on the National Highway System [NHS]… are to have been tested and evaluated and found acceptable in accordance with NCHRP Report 350.‖83 The minimum acceptable bridge railing will be a TL-3 unless supported by a rational selection procedure. That same memorandum stated that the FHWA does not intend for that requirement to result in the replacement or upgrading of existing installed features beyond the course of normal improvements. Means Used to Check Tire Pressure Pretrip Examinations. Title 49 CFR 392.7 requires commercial drivers to examine the tires of their motor vehicles at the beginning of each trip. The regulation does not require that the driver use a tire pressure gauge. If the tire is found to be improperly inflated, the driver must remedy the problem before driving the vehicle. The American Association of Motor Vehicle Administrators (AAMVA) model CDL manual84 recommends that drivers check for proper tire inflation by ―Using a tire gauge, or by

80 The LRFD Bridge Design Specifications define a ―warrant‖ as a document that provides guidance to the designer in evaluating the potential safety and operational benefits of traffic control devices or features. Warrants describe criteria for use of a higher level highway feature; for example, 30 percent truck traffic might indicate that a higher performance barrier is appropriate. The warrant serves to convey concern over a particular traffic hazard and is used to evaluate the potential safety and operational benefits of a highway feature. 81 All states require at least TL-3 barriers on new construction and rehabilitation projects on National Highway System highways. Based on an examination of the 28 state bridge rail policies that are available online, investigators confirmed that some states have requirements for high-performance barriers. Eleven states require TL-4 barriers on National Highway System projects, and seven states either have requirements for TL-5 barriers on interstate projects or have specific guidance on when to select TL-5 barriers (Arizona, Iowa, Maine, Massachusetts, New York, Oregon, and Pennsylvania). 82 Crash tests are conducted using vehicles of known weights operating at controlled speeds and impact angles. 83 See http://safety.fhwa.dot/roadway_dept/docs/accept.pdf, accessed July 20, 2009. 84 AAMVA 2005 model Commercial Driver’s License Manual. The AAMVA model manual is a template used by the states as a guide for preparing their state CDL manuals.

NTSB Highway Accident Report 39 striking tires with a mallet or other similar device.‖ The manual specifically notes that kicking the tires to check for proper inflation is not an effective way to examine them. The AAMVA model CDL manual lists the following problems to be aware of when conducting a pretrip tire inspection: Too much or too little air pressure. Bad wear. You need at least 4/32-inch tread depth in every major groove on front tires. You need 2/32 inch on other tires. No fabric should show through the tread or sidewall. Cuts or other damage. Tread separation. Dual tires that come in contact with each other or parts of the vehicle. Mismatched sizes. Radial and bias-ply tires used together. Cut or cracked valve stems. Regrooved, recapped, or retreaded tires on the front wheels of a bus. These are prohibited. According to the FMCSA, a sampling of commercial vehicle tires indicated that approximately 7.08 percent of all such tires were underinflated by as much as 20 psi. Only 44.15 percent of all tires were within ± 5 psi of their target pressure.85 Data also showed that only 34.55 percent of chartered motorcoach tires were within ± 5 psi of their target pressure and that 9.37 percent of chartered motorcoach tires were underinflated by 20 psi or more. Motorcoach fleets with fewer than 50 power units had 11.75 percent of their tires underinflated by 20 psi or more, while fleets with more than 500 power units had 2.09 percent of their tires underinflated by 20 psi or more. Tire Pressure Monitoring Systems. A tire pressure monitoring system (TPMS) automatically detects tire pressure information and can communicate it to the driver or fleet manager.86 Typically, tire inflation pressure is measured with sensors attached to the tire, wheel, or valve stem and is displayed at the valve or on the driver’s control panel. ―Indirect‖ TPMSs calculate a tire’s apparent state of inflation by monitoring its rotational speed. Indirect systems cannot detect multiple underinflated tire conditions unless equipped with additional sensors and software to capture wheel vibration and load shifts. ―Direct‖ TPMSs use pressure sensors to determine the tire’s inflation pressure, and some systems can transmit data from the tire to the driver. Direct systems are capable of identifying multiple underinflated tires simultaneously and

85 Commercial Motor Vehicle Tire Pressure Sensors, FMCSA-PSV-05-002 (Washington, DC: Federal Motor Carrier Safety Administration, July 2005). 86 Commercial Motor Vehicle Safety and Security Systems Technology Tire Pressure Monitoring Systems, available on the FMCSA website. See , accessed August 4, 2009.

NTSB Highway Accident Report 40 can account for changes in tire pressure due to environmental conditions. Some systems measure temperature in addition to pressure, alerting the driver to the risk of tire failures that can result from underinflation, overloading, or the presence of other dangerous mechanical conditions, such as dragging brakes or failing wheel bearings. On November 1, 2000, Congress enacted the Transportation Recall Enhancement, Accountability, and Documentation Act (TREAD Act),87 which directed the Secretary of Transportation to conduct rulemaking to require warning systems on all new motor vehicles that would indicate to the vehicle operator when a tire is underinflated. In 2007, NHTSA rulemaking at 49 CFR Part 57188 required TPMSs on new passenger cars, multipurpose passenger vehicles, and trucks and buses with GVWRs of 10,000 pounds or less (except for those vehicles with dual wheels on an axle). The rulemaking also established Federal Motor Vehicle Safety Standard (FMVSS) 138,89 which specifies the system performance requirements.90 According to FMVSS 138, the TPMS must activate not more than 20 minutes after inflation pressure in one or more tires is equal to or less than 25 percent below the vehicle manufacturer’s recommended cold inflation pressure.91 No requirement or standard currently exists for the application of TPMSs on commercial vehicles with GVWRs greater than 10,000 pounds. Motorcoach Crash Testing In December 2007, NHTSA conducted its first motorcoach crash test.92 That frontal crash test, and subsequent sled tests, looked at crash forces under different velocities, impact angles, and restraint conditions. In the frontal crash test, the luggage rack failed. In February 2008, NHTSA conducted roof strength tests on four motorcoaches, comparing U.S. school bus and European motorcoach roof strength requirements. An MCI motorcoach and a Prevost motorcoach were tested under both the FMVSS 220 school bus rollover protection standard and the United Nations Economic Commission for Europe Regulation 66 (ECE R66), ―Rollover Protection Strength and Structural Integrity,‖ requirements. The motorcoaches failed both the FMVSS 220 and the ECE R66 tests. An additional ECE R66 test of a 2000 MCI motorcoach was performed in July 2009. Of the two standards, the ECE R66 test is considered a more ―real-world‖ test because it is a dynamic fall onto a hard surface from an 800-millimeter (mm) (about 2.6-foot) step. In this test, the motorcoach is equipped with templates representing the residual space. No object outside of the residual space at the start of the test, including the luggage racks, may intrude upon this space during the test; however, those

87 Public Law 106-414. 88 Federal Register, vol. 72, no. 133 (July 12, 2007), p. 38017. 89 See 49 CFR 571.138. 90 The regulation is in effect for vehicles manufactured after September 1, 2007. 91 Title 49 CFR 571.138 also contains a ―Low Tire Pressure Warning Telltale Minimum Activation Pressure Table‖ by tire type load rating that can be used as an alternative reference to the 25-percent manufacturer-recommended pressure. 92 Based on NHTSA’s ―Approach to Motorcoach Safety,‖ NHTSA Docket 2007-28793.

NTSB Highway Accident Report 41 racks are unloaded.93 In the February 2008 ECE R66 test of the MCI motorcoach, the left side luggage rack inboard hangers (supports) rearward of the two front hangers broke, exposing sharp metal edges.94 In this test, contact was documented between the back of an unrestrained crash test dummy’s head and the bottom of the luggage rack. The lap/shoulder-belted dummies on the far side showed much lower risk for injury than the unrestrained dummies. In addition, during the 2007 frontal crash test, several unrestrained crash dummies experienced their highest resultant head accelerations during head contact with the luggage racks. New Entrant Program As a result of a 2002 truck tractor-semitrailer accident in Loraine, Texas,95 the NTSB issued Safety Recommendation H-03-2 to the FMCSA, recommending that it Require all new motor carriers seeking operating authority to demonstrate their safety fitness prior to obtaining new entrant operating authority by, at a minimum: (1) passing an examination demonstrating their knowledge of the Federal Motor Carrier Safety Regulations; (2) submitting a comprehensive plan documenting that the motor carrier has management systems in place to ensure compliance with the Federal Motor Carrier Safety Regulations; and (3) passing a Federal Motor Carrier Safety Administration safety audit, including vehicle inspections. (H-03-2) The recommendation is currently classified ―Open—Acceptable Response.‖ In response to Safety Recommendation H-03-2, the FMCSA developed the New Applicant Screening Program. All new motor carriers operating in interstate commerce are required to apply to the FMCSA for registration as a new entrant. A new entrant carrier is subject to an 18-month safety-monitoring period, and it receives a safety audit sometime after its first 3 months of operation but before it completes 18 months of operation. At a minimum, the safety audit will cover driver qualifications, driver duty status, vehicle maintenance, accident register, and controlled substance and alcohol use testing requirements. If the FMCSA identifies deficiencies, the carrier must provide evidence to the FMCSA that the faults found during the audit are being corrected. The FMCSA has stated that it will grant permanent motor carrier registration only if the new entrant successfully completes the 18-month monitoring period. On December 16, 2008, the FMCSA published a final rule addressing the New Entrant Safety Assurance Process.96 The stated intent of the rule is to improve the FMCSA’s

93 NHTSA Motorcoach Roof Crush/Rollover Testing presentation, February 2009 Government Industry Meeting , accessed September 21, 2009. 94 NHTSA ECE Regulation 66-Based Research Test of Motorcoach Roof Strength, Final Report, ECE66-MGA2007-001, May 2008. 95 Collision of Greyhound Lines, Inc., Motorcoach and DelCar Trucking Truck Tractor-Semitrailer, Loraine, Texas, June 9, 2002, Highway Accident Report NTSB/HAR-03/01(Washington, DC: National Transportation Safety Board, 2003). 96 Federal Register, vol. 73, no. 242 (December 16, 2008), pp. 76472–76497.

NTSB Highway Accident Report 42 Ability to identify at-risk new entrant motor carriers and ensure that deficiencies are corrected before granting them permanent registration. It also ensures that applicants will become knowledgeable about Federal Safety regulations before they commence interstate operations. The rule specifically addresses ―reincarnated carriers,‖ which are defined in the final rule as ―A carrier that attempts to register as a new entrant and operate as a different entity under a new USDOT Number in an effort to evade enforcement action and/or out-of-service orders issued against it by the [FMCSA].‖ The new regulations state that any carrier that provides false or misleading information or conceals information is subject to revocation of its new entrant registration and civil penalties.97 In the final rule, the FMCSA stated that it is also planning to address reincarnated carriers under a separate rulemaking in response to section 4113 of the Safe, Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for Users (often referred to as SAFETEA-LU) regarding patterns of safety violations by motor carrier management. According to the FMCSA, all new entrant applications are sent to its division offices for review. The FMCSA also contacts state agencies to obtain information on the new entrant.98 The FMCSA has developed an evasion detection algorithm (EDA) to identify those household goods carriers with histories of poor safety performance. In August 2008, the FMCSA began applying the EDA screening process to newly registered passenger carriers before granting them operating authority.99 The EDA searches selected data to identify new applicants that may be enforcement evaders by detecting matches between new registrants and information provided by previously registered motor carriers. Following publication of the December 2008 final rule on the New Entrant Safety Assurance Process, a petition for reconsideration challenged that the FMCSA had failed to address section 210(a) of the Motor Carrier Safety Improvement Act of 1999 (Public Law 106-159, 113 Stat. 1764, December 9, 1999) requiring new entrant carriers to demonstrate a minimum knowledge of the safety standards. On August 25, 2009, the FMCSA published an Advance Notice of Proposed Rulemaking (ANPRM)100 to address the knowledge requirements in 49 CFR Part 385. The ANPRM requested comments on proficiency examinations or alternative methods that the FMCSA should consider implementing to provide assurance that new applicant carriers are knowledgeable about applicable safety requirements. The ANPRM relates to Safety Recommendation H-03-2 (see above), which contains an element that calls for new entrant carriers to pass an examination demonstrating their knowledge of the FMCSRs. Issuance of the ANPRM suggests that work may be underway to fulfill the knowledge examination element of Safety Recommendation H-03-2. Due to the circumstances of the Sherman accident, the U.S. Government Accountability Office (GAO) was asked to determine the number of carriers registered with the FMCSA as new entrants that were substantially related to carriers previously ordered out of business. The results

97 Title 49 United States Code 521(b)(2)(A) sets civil penalties not to exceed $2,500. 98 December 10, 2008, presentation by the director of the FMCSA Office of Enforcement and Compliance to the Motor Carrier Safety Advisory Committee. 99 In July 2009, the new applicant screening methodology became available as a web-based tool. 100 Federal Register, vol. 74, no. 163 (August 25, 2009), pp. 42833–42836.

NTSB Highway Accident Report 43 of the GAO study were published in late July 2009.101 The GAO examined the records of carriers placed out of service in fiscal years 2007 and 2008. It identified 20 carriers out of 220 (9 percent) that it believed had most likely attempted to evade enforcement actions by reopening as new companies. The GAO acknowledged that its analysis probably underestimated the true number of reincarnated carriers because it did not look at the entire new entrant population; it considered only those new entrants for which an accident or an inspection had occurred. Also, the GAO analysis required exact matches of at least two data elements to avoid linking carrier records in case typographical errors or abbreviations affected the data match; the study could not identify carriers that had provided false information on their applications. The GAO study did not evaluate the effectiveness of the New Entrant Safety Assurance Process or of new entry safety audits, and it could not determine the extent to which reincarnated carriers are able to avoid detection when registering to operate with the FMCSA.

101 U.S. Government Accountability Office, Reincarnating Commercial Vehicle Companies Pose Safety Threat to Motoring Public; Federal Safety Agency Has Initiated Efforts to Prevent Future Occurrences, GAO-09-924, July 28, 2009.

NTSB Highway Accident Report 44 Analysis The analysis begins with a discussion of the factors and conditions the NTSB has excluded as neither causing nor contributing to the accident. It then proceeds to a discussion of the safety issues. The safety issues identified in this report are the tire failure and the need for tire pressure monitoring systems on commercial vehicles; the failure of the bridge railing and the need for criteria for the selection of appropriate bridge railing designs; the lack of oversight of the Federal commercial vehicle inspections that are delegated to the states; the lack of motorcoach occupant protection systems; and, the deficiencies in the Federal safety oversight of new entrant motor carriers. Exclusions At the time of the accident, skies were clear, the temperature was about 77° F, and no rain was reported. The pavement was dry. Therefore, the NTSB concludes that the weather did not cause or contribute to the accident. Police, fire, and EMS units were dispatched to the scene within 2 minutes of the initial notification of the accident and arrived on the scene within 6 minutes. All injured passengers were triaged at the scene and transported to nine medical facilities in the region using both air and ground EMS. Emergency response and medical care resources were provided by three Texas counties and one Oklahoma county. The most critically injured arrived at local medical facilities within 23 minutes following the event, and all of the injured were transported to medical facilities in less than 2 hours. Based on interviews with first responders and a review of records from the event, the NTSB concludes that the accident notification and emergency response by surface and air resources were timely and adequate. Postaccident mechanical inspection of the motorcoach’s brake and steering systems indicated that, other than the failed tire, no mechanical defects or deficiencies contributed to the uncontrollability of the motorcoach. Investigators did identify oil and grease contamination in the braking system of one of the six brakes, which presented a safety risk, but determined that braking performance would not have affected the outcome of the accident due to the limited time available for driver response. Similarly, investigators identified the use of wheel rims of improper size on the tag axle tires as a problem that would affect load capacity, but this was not a factor in the accident sequence. Therefore, the NTSB concludes that, with the exception of the right steer axle tire, the mechanical condition of the motorcoach did not contribute to the cause or severity of the accident. The driver’s medical certificate had expired on May 24, 2008. The driver was diagnosed with diabetes after his most recent fitness examination, with markedly elevated blood sugar and HbA1c102 detected 3 months prior to the accident. He was prescribed insulin but never refilled the prescription. His HbA1c was substantially lower at the time of the accident, consistent with some effective treatment of his diabetes. An oral prescription medication for the treatment of

102 The HbA1c provides a measure indicating the average blood sugar level over the previous few months.

NTSB Highway Accident Report 45 diabetes was found with his effects. The driver’s HbA1c at the time of the accident did not suggest a blood sugar level high enough to have been associated with impairment. The driver was also being treated for high blood pressure and high cholesterol levels but neither of these conditions, nor the medications used for their treatment, was likely to have had a measurable impact on his driving performance. The NTSB concludes that the driver’s diabetes, high blood pressure, and high cholesterol were not factors in the accident. The Accident Accident Sequence According to data gathered from the ECM, the motorcoach was traveling about 68 mph at the time the right steer axle tire began leaving tire marks on the highway, approximately 4.3 seconds prior to the blowout. The driver, in a postaccident interview, stated that he felt a sway or vibration of the motorcoach. However, the degree to which these perceptual cues are distinguishable from encountering rumble strips or other vehicle noise is uncertain and probably case-specific, depending on the sequence of tire failure. He said he let off the accelerator, unsure of what was causing the sensation. Within a few seconds, he heard ―an explosion‖ and the right front of the motorcoach ―dropped.‖ The vehicle ECM data indicated that percent throttle was varied in the seconds preceding the blowout. It seems likely that the driver experienced unexpected noise or vibration before he understood the impending tire failure. Tire marks on the roadway, indicating the beginning of the failure of the sidewalls and belt separation, began 685 feet before the motorcoach struck the bridge railing. The blowout occurred 253 feet before impact. The ECM indicated braking input at 1.1 seconds following the tire blowout. Calculations of the motorcoach’s braking efficiency indicated a brake lag time (delayed brake actuation) of 0.7 second. The roadway tire marks and travel distances indicate that the motorcoach struck the bridge railing before any appreciable braking occurred. Once the motorcoach mounted the curb and struck the bridge railing and the railing began separating from the bridge deck structure, braking would have been largely ineffective in slowing the vehicle or otherwise altering the vehicle dynamics. Vehicle handling characteristics have been shown to be drastically altered, and steering efficiency significantly reduced, following a tire failure, particularly on a steer axle wheel.103 When the right steer axle tire on the Sherman motorcoach failed, the vehicle pulled to the right. Because the right shoulder width on US-75 northbound narrowed to 30 inches on the Post Oak Creek bridge deck, it would most likely have required significant driver input to prevent the motorcoach from striking the bridge curb. The NTSB concludes that given the limited distance between the roadway and the bridge curb and the lack of recovery time, there is no evidence that the actions of the driver caused or contributed to the tire failure, and it is unlikely that the driver had sufficient time to respond to the tire failure and avoid the loss of control, the collision with the bridge railing, and the subsequent departure of the motorcoach from the bridge.

103 (a) M.W. Arndt, M. Rosenfield, and S.M. Arndt, Measurement of Changes in Vehicle Handling Due to Tread-Separation-Induced Axle Tramp, SAE Technical Paper No. 2006-01-1680 (Warrendale, PA: Society of Automotive Engineers, 2006); (b) C.P. Dickerson, M.W. Arndt, and S.M. Arndt, Vehicle Handling with Tire Tread Separation, SAE Technical Paper No. 1999-01-0450 (Warrendale, PA: Society of Automotive Engineers, 1999).

NTSB Highway Accident Report 46 Motorcoach Driver Driver Issues. Toxicological testing performed on samples gathered about 3.75 hours after the accident detected cocaine and its metabolites in the driver’s blood and/or urine.104 One metabolite, cocaethylene, detected in the urine, is formed only when cocaine and ethanol are simultaneously present. The finding of cocaine and cocaethylene (which both have half-lives less than 90 minutes) in the urine, and the levels of benzoylecgonine in the blood and urine, suggest that the driver had used cocaine and alcohol approximately 5 hours prior to the accident. At the time of the accident, the driver had been on duty for 6 hours 45 minutes (not including a 1-hour-long work break). He had come on duty at 5:00 p.m. He had driven briefly between 6:30 and 7:00 p.m. to pick up passengers and then had had a 1-hour work break between 7:15 and 8:15 p.m. before beginning to drive again. He drove nearly continuously105 for the 4 hours 30 minutes between 8:15 p.m. and 12:45 a.m., when the accident took place. Therefore, the driver probably used cocaine and alcohol after reporting for work at 5:00 p.m. The extended period of driving prior to the accident makes it unlikely that the driver was impaired by the effects of cocaine itself. But it is certainly possible that the driver was experiencing aftereffects from use of the drug (primarily resulting in depression and fatigue). Aftereffects from ethanol use have been shown to impair certain aspects of simulator performance in pilots for as long as 14 hours after intoxication.106 Therefore, the possibility that aftereffects from alcohol or cocaine use or both may have impaired the driver cannot be ruled out. The NTSB concludes that the driver used cocaine and alcohol either during or shortly before starting the trip, and he may have been impaired by aftereffects from either or both drugs. Postaccident interview statements by the driver describing the accident sequence events indicated that he was alert and responsive to developments. He was aware of his driving tasks— for example, he reported that he felt the vibration of the motorcoach when the tire failed, he said he let off the accelerator, and he said he heard an explosion. Tire marks on the roadway indicate that the driver had approximately 4.3 seconds before the blowout, as the internal structure of the tire continued to fail. The driver may have been aware of vibration or changes in handling characteristics and was trying to understand what was happening. Once the blowout occurred, the driver reacted quickly, braking in 1.1 seconds. But approximately 1.9 seconds after he applied the brakes, the motorcoach struck and mounted the curb and then the bridge railing. Therefore, the NTSB concludes that fatigue was not a factor in the accident and, based on event timing in the accident reconstruction analysis, even a well-rested, completely alert driver could not have reacted in time to affect the accident sequence.

104 Title 49 CFR 382.303 requires that postaccident testing be conducted as soon as practicable. 105 The driver said that he stopped at a convenience store about 10 minutes after beginning driving at 8:15 p.m., to buy gum and an energy drink. 106 J.A. Yesavage and V.O. Leirer, ―Hangover Effects on Aircraft Pilots 14 Hours After Alcohol Ingestion: A Preliminary Report,‖ American Journal of Psychiatry, vol. 143, no. 12 (1986), pp. 1546-1550.

NTSB Highway Accident Report 47 Preemployment Checks of Driver History by Motor Carrier. According to the driver, he had almost 25 years of experience driving commercial vehicles. Investigators were able to verify that the driver had been employed by two existing companies, Greyhound and Carrington Tours, during the 1990s, and NTSB subpoenaed records from those companies. Other motor carriers listed on the driver’s application for employment could not be contacted because of mergers, acquisitions, or changes in ownership. Cessation of operations by motor carriers is fairly common within the industry, making inquiry into the long-term driving experience of a prospective driver difficult. The driver told investigators that he had been terminated by Greyhound for failure to report for a medical examination. However, records subpoenaed from Greyhound revealed that the driver was terminated on March 21, 1995, after he tested positive for cocaine in Greyhound’s federally mandated random drug testing program. Title 49 CFR 382.401(b)(1) requires that a motor carrier maintain copies of positive drug test results for a minimum of 5 years. Prospective employers are required by 49 CFR 382.413 to contact each applicant’s previous employer to determine whether, in the preceding 2 years, the applicant had failed an alcohol or controlled substance test, had refused to be tested, or had successfully completed return-to-duty requirements after having tested positive for alcohol or a controlled substance. However, release of these records is limited. Title 49 CFR 382.405(f) states that ―Records shall be made available to a subsequent employer upon receipt of a written request from a driver. Disclosure by the subsequent employer is permitted only as expressly authorized by the terms of the driver’s request.‖ A driver is not obligated to report the positive drug test result to a prospective employer; however, a driver’s authorized release of his records as an application requirement provides prospective employers with a viable mechanism for obtaining access to drug test results. The NTSB previously addressed driver drug testing in its investigation of a May 9, 1999, motorcoach crash in New Orleans, Louisiana, which killed 22 passengers.107 The motorcoach driver tested positive for tetrahydrocannabinol (THC, the psychoactive substance in marijuana). The driver had been terminated by at least two previous employers on the basis of positive results in random drug testing. When the New Orleans driver applied for the position with the accident carrier, he omitted mention of these two past employers who had terminated him for drug use. He explained the gaps in employment by stating that he had been working as a musician during those periods. Although his employer at the time of the accident had made reference checks with two former employers listed on the driver’s application, neither responded. The NTSB concluded that the results of tests for controlled substances performed under the DOT testing guidelines, even when positive, are often not available to prospective employers, making it difficult for them to make well-informed hiring decisions. The NTSB issued Safety Recommendation H-01-25 as a result of the New Orleans investigation, recommending that the FMCSA take the following action: Develop a system that records all positive drug and alcohol test results and refusal determinations that are conducted under the U.S. Department of Transportation testing requirements, require prospective employers to query the system before making a hiring decision, and require certifying authorities to query the system before making a certification decision. (H-01-25)

107 NTSB/HAR-01/01.

NTSB Highway Accident Report 48 As a result of the NTSB’s recommendation, in 2004, the FMCSA completed a study of the feasibility and merits of requiring medical review officers and employers to report positive test results to state CDL licensing agencies. The study found that it was feasible to establish a national database of positive drug test results and that it should be operated by the Federal government to ensure consistency and uniformity. The FMCSA is developing rulemaking to establish a National Drug and Alcohol Test Results Database, which would allow Federal and state governments to identify drivers who have refused a DOT drug or alcohol test or have tested positive for drug(s) and/or alcohol under the established DOT drug and alcohol testing regulations. Areas of consideration for the rulemaking include the following: (1) requiring Medical Review Officers to submit confirmed positive controlled substances test results to the FMCSA, including follow-up tests stemming from an initial positive test; (2) having motor carriers submit information on refusals-to-test, positive alcohol test results, and annual summaries of their controlled substances and alcohol testing programs each year; and (3) requiring all laboratories to submit annual reports to the FMCSA.108 Safety Recommendation H-01-25 is currently classified ―Open—Unacceptable Response‖ because of the FMCSA’s slow response time. The recommendation to develop a database of positive drug and alcohol test results and to establish requirements for use of the system is now 8 years old. Although the FMCSA has increased its enforcement action against commercial motor vehicle drivers who have tested positive for controlled substances and failed to comply with the return-to-duty requirements before performing a DOT safety-sensitive function, and also against motor carriers that use or have used a driver to perform safety-sensitive functions if the motor carrier was aware or should have known that the driver did not comply with return-to-duty requirements, these actions will be the result of investigations and will, therefore, affect only a small percentage of the driver and carrier populations. The NTSB concludes that if motor carriers cannot check the controlled substance testing backgrounds of prospective employees, they cannot make well-informed decisions when attempting to hire safe drivers. Consequently, the NTSB is reiterating Safety Recommendation H-01-25 to the FMCSA, and the recommendation remains classified ―Open—Unacceptable Response.‖ The state of Texas maintains records on the positive results of controlled substance tests for commercial drivers. In seeking such information concerning the accident driver, the NTSB found it necessary to serve a subpoena upon the TxDPS. (The database contained no records for the driver.) Information concerning the toxicological and medical condition of vehicle operators is vital to successful accident investigation. The NTSB concludes that the difficulty in obtaining state records in connection with the controlled substance test results for the driver of the accident motorcoach in this case highlights the NTSB’s need for investigative access to a national database of positive drug test results. Therefore, in addition to the reiteration of Safety Recommendation H-01-25, the NTSB recommends that the FMCSA establish a regulatory requirement within 49 CFR 382.405 that provides the NTSB, in the exercise of its statutory

108 This information appears in a letter from the FMCSA, dated June 5, 2009.

NTSB Highway Accident Report 49 authority, access to all positive drug and alcohol test results and refusal determinations that are conducted under the DOT testing requirements. Tire Failure The right steer axle tire was a Goodyear G409 MBA radial tire retreaded with a Bandag model T4100 tread. NTSB investigators conducted two independent examinations of the failed tire: one with experts from Goodyear and another with experts from Bridgestone. Both examinations of the right steer axle tire resulted in similar conclusions, which were documented in reports provided by Goodyear and Bridgestone to the NTSB. The tire companies found no defects or dangerous conditions in the design or manufacture of the original tire or the retread. They believed that separation and detachment of the tread and belt pieces occurred as a result of damage caused by overdeflected operation. The overdeflected condition was most likely caused by a puncture or cut in the tire that caused it to lose air, leading to underinflation. Operation of an underinflated tire in an overdeflected condition generates excessive heat, which can cause tread belt separation, the internal separation of the sidewall, belting, and body plies. Numerous exposed rubber surfaces exhibited a blue-tint appearance, indicative of excessive heat generation during operation. Moreover, such heat damage is cumulative and may go undetected by visual inspection. Although it is difficult to state how long the punctured or cut tire may have operated in an underinflated/overdeflected condition, the tread/belt tear patterns and the lack of polishing of the separated surfaces indicate relatively short-term operation in such a condition, most likely for less than 1,000 miles. Thus, it appears that the tire on the right steer axle of the accident motorcoach was punctured and suffered a slow leak, as indicated by a tread rubber hole that was abraded/bruised and torn, which ultimately led to the tire’s failure. Based on the available physical evidence and expert review, therefore, the NTSB concludes that the tire on the accident motorcoach’s right steer axle experienced a puncture, and the resultant gradual pressure loss led to severe overdeflection, which resulted in sidewall, belting, and body ply separations within the tire. Federal regulations at 49 CFR 393.75(d) state that ―No bus shall be operated with regrooved, recapped or retreaded tires on the front wheels.‖ Retreading a tire involves bonding a new tread to the tire body through the application of heat and pressure. The NTSB found good adhesion within the casing and between the casing and the retread on the retreaded tire on the right steer axle, and investigators found no indication that the tire failure was related to the retread. The mechanics of failure in this accident resulted in short, thin strands of tire material separating from the tire, not delamination of the retread. The failure of the tire initiated and resulted from within the original tire casing. The NTSB concludes that although the use of a retreaded, recapped, or regrooved tire on the steer axle of a motorcoach is prohibited, the right steer axle tire’s failure was not associated with its being a retreaded tire. The failed tire was located on the steer axle on the right side of the motorcoach. Had the tire been mounted on the drive or tag axle and failed, there would have been less lateral and retarding force, so the motorcoach’s departure from the road would have been slower, and the driver might have been able to retain control over it. Therefore, the NTSB concludes that failure of the tire on the steer axle resulted in the loss of control of the motorcoach.

NTSB Highway Accident Report 50 Vehicle Load and Tire Capacity The GVWR of the accident motorcoach’s three axles was 16,500 pounds on the steer axle, 23,000 pounds on the drive axle, and 16,500 pounds on the tag axle. The motorcoach manufacturer’s recommended tires for the steer axle were Load Range J size 315/80 R22.5 tires inflated to 120 psi. Load Range J tires with inflation pressures of 120 psi have a maximum working load rating of 8,270 pounds each or 16,540 pounds for the axle. This configuration provides a reserve working limit of only 20 axle-weight pounds per tire. If the motorcoach were to be loaded in such a manner that the weight upon the steer axle was exceeded by as little as 40 pounds (less than 1/2 of 1 percent of the GVWR), the tires would begin to be overloaded. The tag axle possessed a GAWR of 16,500 pounds. According to the MCI maintenance manual,109 the tag axle was required to be equipped with Load Range J size 315/80 R22.5 tires mounted on 9.00-inch wheel assemblies, inflated to 105 psi. If such a tire were inflated to 105 psi, the recommended tire would be rated to only 7,440 pounds, providing the tag axle with only 14,880 pounds of load capacity, compared to the required 16,500 pounds. The vehicle specification plate recommended a tag axle tire inflation pressure of 120 psi; the accident motorcoach’s tag axle tires as measured after the accident were inflated to 88 psi and 89 psi. Additionally, the tag axle wheel assemblies on the accident coach were 8.25 inches wide, as opposed to the recommended 9.00-inch wheels. Although an 8.25-inch wheel can be used, the maximum load permitted upon the tire when inflated to 120 psi is reduced to 8,000 pounds. Because the tag axle had a GAWR of 16,500 pounds, the 8.25-inch wheels were not appropriate for use on the motorcoach’s tag axle. Underinflating a tire may dramatically reduce its load capacity. For example, lowering the inflation pressure of a Load Range J tire by only 10 psi reduces its load capacity from 8,270 pounds to 7,610 pounds, or by 8 percent. (See table 6.) In the case of the accident motorcoach, underinflation by less than 1 percent on the steer axle tires would have resulted in an overloading condition if the vehicle were loaded to its GVWR. Therefore, the NTSB concludes that underinflation of tires on commercial motor vehicles by even small margins can result in dangerous overloading of the tires. Tire Pressure Following the accident, the pressure of each intact tire was measured. Compared to the recommended tire pressures on the vehicle specification plate, the left steer axle tire pressure was 2 psi below the recommended 120 psi. The pressures of three of the tires on the drive axle were above the recommended 90 psi, by values of 6 psi, 4 psi, and 3 psi.110 The pressures of the two tires on the tag axle were 31 psi and 32 psi below the recommended 120 psi.

109 The recommended pressure listed in the MCI maintenance manual differed from the recommended pressure on the vehicle specification plate. This difference is discussed in the next section. 110 The drive axle had four tires, but the right outer tire on the drive axle was found debeaded as a result of the accident.

NTSB Highway Accident Report 51 Title 49 CFR 392.7 requires commercial drivers to examine the tires of their motor vehicles at the beginning of each trip. The driver of the accident motorcoach reported that he checked the tires, looking for protrusions, wear and tear, and discoloration, and that he kicked the tires prior to departing on the accident trip. According to the regulations, drivers are permitted to visually inspect the tires to determine if they are properly inflated; use of a tire gauge is not mandated. However, it is difficult, if not impossible, to visually determine whether a tire is inflated to the proper pressure.111 Tires designed to give a smooth ride may always look underinflated, while tires with stiff sidewalls can look properly inflated even at pressures substantially lower than those recommended. The AAMVA model CDL manual recommends that a driver use a tire gauge to check tire inflation; however, it also states that use of a mallet to check inflation is permissible. Postaccident inspection of the motorcoach indicated that several of the vehicle’s tires did not meet recommended inflation levels. The tires on the tag axle were more than 25-percent underinflated when examined. As demonstrated by this accident, underinflation of tires can lead to safety issues such as overloading and tire failures. It is possible that the right steer axle tire that failed, leading to the accident, was underinflated before the trip began. It is also possible that had the pressure in the motorcoach’s tires been checked with a tire gauge before the accident trip began, the underinflated tires would have been detected, because a gauge would have given a specific pressure number. The FMCSA regulations and AAMVA guidelines that permit drivers to measure tire pressure by either visually inspecting the tire or ―thumping‖ it with a mallet are not adequate to identify an underinflated tire. Therefore, the NTSB concludes that because underinflated tires can lead to tire failure and because the currently approved methods of visual inspection or ―thumping‖ tires with a mallet are inaccurate, a tire pressure gauge should be used to accurately assess tire pressure. Consequently, the NTSB recommends that the FMCSA require that tire pressure be checked with a tire pressure gauge during pretrip inspections, vehicle inspections, and roadside inspections of motor vehicles. The NTSB also recommends that the AAMVA revise the model CDL manual to stipulate that tire pressure be checked with a tire pressure gauge during pretrip inspections, vehicle inspections, and roadside inspections of motor vehicles. During the course of the investigation, the NTSB determined that the recommended tire pressure information in the MCI model J4500 motorcoach maintenance manual differed from information on the specification plate on the vehicle, and that the manual was incorrect. The tire inflation chart in the MCI J4500 manual lists the drive axle tire pressure as 85 psi and the tag axle tire pressure as 105 psi. The correct inflation pressures, as listed on the vehicle specification plate, are 90 psi for the drive axle tires and 120 psi for the tag axle tires. Additionally, a note in the manual about the wheels improperly identifies the model and gives the GAWR of the accident motorcoach’s steer axle as 16,000 pounds, rather than the correct figure of 16,500 pounds. MCI’s only guidance, whether written or electronic, for this motorcoach and others like it remains uncorrected. The most recent MCI manual with corrections does not apply to the earlier or legacy model 4500 motorcoaches, because the applicability of information is stipulated by vehicle identification number ranges. The NTSB concludes that until MCI informs

111 Goodyear tire photographs in figure 9; and S. Singh, K. Kingsley, and C. Chen, Tire Pressure Maintenance-A Statistical Investigation, DOT HS 811 086 (Washington, DC: National Highway Traffic Safety Administration, April 2009).

NTSB Highway Accident Report 52 operators of the inaccuracies in the J4500 motorcoach maintenance manual, operators may be confused as to the proper tire pressures for these motorcoaches. Therefore, the NTSB recommends that MCI correct any inaccurate tire pressure and GAWR information in the maintenance manuals of its J4500 motorcoaches and make electronic versions of the revised manuals readily available on its website; in addition, it should review the maintenance manuals of its other motorcoaches for similar errors and make appropriate corrections. Tire Pressure Monitoring Systems TPMSs are designed to monitor and inform the driver of tire pressures and are capable of detecting operating temperatures. Direct TPMSs have the advantage of providing actual tire pressures to the driver in real time while the vehicle is in operation.112 In this accident, a direct TPMS could have detected the decreasing pressure of the right steer axle tire and alerted the driver before the tire’s catastrophic failure. The TREAD Act, enacted by Congress on November 1, 2000, directed the Secretary of Transportation to conduct rulemaking to require warning systems in new motor vehicles to indicate to the operator when a tire is significantly underinflated. In 2007, NHTSA rulemaking at 49 CFR Part 571113 established FMVSS 138 for TPMSs to warn the driver when a tire is significantly underinflated. Application of that standard, however, was restricted to light vehicles—specifically to passenger cars, trucks, multipurpose passenger vehicles, and buses with GVWRs of 10,000 pounds or less, except for those vehicles with dual wheels on an axle. Unlike the NHTSA rule, the TREAD Act referred to ―new motor vehicles‖ without restriction regarding vehicle class.114 No rule or standard currently requires that large commercial vehicles, including motorcoaches, be equipped with TPMSs. The NTSB notes that the difference between the broad nature of the Congressional language in the TREAD Act and the specific and restrictive regulatory language used in NHTSA’s rulemaking leaves large commercial vehicles, including motorcoaches that carry many passengers, unaffected by this important safety requirement. Direct TPMSs have the potential to eliminate failures on commercial vehicles caused by tire underinflation or overloading through their ability to directly measure tire pressure and operating temperatures. Furthermore, direct TPMSs continuously monitor actual tire pressure in real time and can immediately relay information to the operator while the vehicle is en route. The accident vehicle’s tires were substantially underinflated on the tag axle and slightly overinflated on the drive axle. These conditions could have been detected either by a pretrip inspection using a tire gauge or by a TPMS. Moreover, the right steer axle tire experienced a slow leak from a puncture that may have occurred during the accident trip. A TPMS would have detected this critical safety problem en route. The NTSB concludes that if the driver had been aware of the motorcoach’s tire pressures, particularly the dangerously low pressure in the

112 Advanced TPMSs are equipped with central inflation systems that automatically maintain proper tire inflation pressures. 113 Federal Register, vol. 72, no. 133 (July 12, 2007), p. 38017. 114 See section 13 of Public Law 106-414.

NTSB Highway Accident Report 53 damaged right steer axle tire, then he would have had an opportunity to take corrective action, which might have prevented this accident. A direct TPMS could have provided such a warning. Therefore, the NTSB recommends that NHTSA require all new motor vehicles weighing over 10,000 pounds to be equipped with direct TPMSs to inform drivers of the actual tire pressures on their vehicles. Bridge Railings A bridge railing is a longitudinal barrier designed to prevent a vehicle from running off the edge of a bridge. Bridge railings typically differ from roadside barriers in that they are a physically integrated part of the roadway structure. The bridge railing on US-75 at the Post Oak Creek bridge failed to keep the motorcoach on the roadway, allowing it to penetrate the railing completely and to fall 8 feet to the earthen bridge abutment below, where it slid approximately 24 feet on its right side before coming to a stop. Additionally, the 7-inch-high, 18-inch-wide concrete curb above the bridge deck allowed the motorcoach to ramp upward before it struck the railing. A curb should not be used in front of a bridge railing, because it may result in a dynamic jump by the vehicle before it strikes the barrier.115 The failure of the bridge railing to keep the motorcoach on the roadway contributed to the severity of the accident. Although the Post Oak Creek bridge railing appears to have in the past kept striking passenger cars on the bridge, it has twice failed to retain large, heavy vehicles. The NTSB concludes that a higher performance bridge railing at the accident location might have prevented the motorcoach’s departure from the bridge. Design Guidelines The design of bridge railings is summarized in AASHTO’s Roadside Design Guide. More detailed information about the engineering performance and structural requirements for bridge railings is contained in a variety of supporting reference documents, including AASHTO’s Standard Specifications for Highway Bridges,116 the LRFD Bridge Design Specifications,117 and the Manual for Assessing Safety Hardware (MASH).118 The safety performance of a bridge railing is evaluated through crash testing. Since 1986, the FHWA has required that bridge railings used on Federal-aid projects meet full-scale crash- test criteria. A 1997 FHWA policy memorandum stated that all new or replacement safety features on the NHS should be in accordance with NCHRP Report 350, Recommended Procedures for the Safety Performance Evaluation of Highway Features, with the minimum acceptable bridge railing being TL-3 (as defined in NCHRP Report 350), unless supported by a rational selection procedure. The FHWA also stated, however, that it does not intend the

115 Highway Design and Operational Practices Related to Highway Safety (Washington, DC: American Association of State Highway and Transportation Officials, 1967), p. 30. 116 Standard Specifications for Highway Bridges, 17th edition (Washington, DC: American Association of State Highway and Transportation Officials, September 1, 2002). 117 The 2007 LRFD Bridge Design Specifications replaced the 1989 Guide Specifications for Bridge Railings, which relies on three levels of bridge railing performance (PL-1, PL-2, and PL-3). 118 The 2009 MASH is intended to replace NCHRP Report 350, Recommended Procedures for the Safety Performance Evaluation of Highway Features.

NTSB Highway Accident Report 54 requirement to result in the replacement or upgrading of existing installed features, beyond the course of normal improvements. The road design of US-75 at the Post Oak Creek bridge, including the bridge railing, was in compliance with the design standards for a principal urban artery at the time of the bridge’s construction in 1958. The bridge railing at the accident site was a Type II119 railing designed in accordance with the 1953 AASHO Bridge Specifications Manual. According to TxDOT, the bridge railing design used at the accident site had never been crash-tested; as such, when the accident occurred, the railing did not meet current NHS standards.120 Approximately one-quarter of the bridges in the NHS have been superseded by structural or test requirements associated with present highway design standards. If the current bridge railing standards were applied to all bridges in the United States (not just those in the NHS), approximately one-half would not meet current design standards.121 With over 100,000 bridges in the NHS and nearly 600,000 bridges in the United States, it would be impractical to update them as frequently as design standards improve. Design standards, when they are revised, generally apply to new construction projects and, when practical, to bridge rehabilitation and upgrade projects. Because the accident bridge railing had not undergone a qualifying bridge resurfacing, restoration, or rehabilitation project, it was not required to meet current design standards. Older bridge decks and structures that would not support larger, heavier barriers often have bridge railings with designs based on earlier specifications. Consequently, upgrade projects are postponed until a larger bridge rehabilitation project, such as lane widening and deck replacement, can be planned and funded. If a bridge meets the warrants for higher performance railings, as determined by the FHWA and AASHTO, designers integrate the new designs into rehabilitation or upgrade projects; if the upgraded railings cannot be integrated into a proposed highway improvement project, the FHWA may grant the bridge owner an exception. Warrants Bridge owners, usually state departments of transportation, are responsible for determining when bridge railing improvements are needed and what performance level is appropriate for the given location. The various guidance documents available concerning the design and construction of bridge railings, including the AASHTO Roadside Design Guide and the LRFD Bridge Design Specifications, indicate that the owner should develop the appropriate test level or warrant for the site in question. TxDOT, the owner of the Post Oak Creek bridge, has developed guidance for retrofit and rehabilitation bridge projects, but it has no selection criteria or warrants for the installation of

119 ―Type II‖ is an identifying name, not a category, and use of the term does not mean that the design met NCHRP Report 350 TL-2 design requirements. 120 The 2006 Roadside Design Guide states that bridge railing designs predating 1964 typically are considered substandard in that they have not been crash-tested in accordance with either NCHRP Report 230 or NCHRP Report 350 (section 7.7.1, pp. 7-8). 121 FHWA data from December 31, 2007, showed that the NHS contained 116,144 bridges; of these, 29,579 had bridge railings that did not meet current standards. The total number of bridges on NHS and non-NHS roads was 599,765; of these, 287,469 did not meet current bridge railing standards.

NTSB Highway Accident Report 55 high-performance barriers, including bridge railings. When NTSB investigators asked other state departments of transportation what guidance they use for selecting a barrier system for a specific site, many replied that they use the LRFD Bridge Design Specifications; however, that document contains only general guidance and directs state agencies to develop objective guidelines for bridge railing selection. In 2005, as a result of a multivehicle accident that took place in Fairfield, Connecticut,122 the NTSB issued Safety Recommendation H-05-31 to AASHTO, asking it to take the following action: Establish warrants in the Roadside Design Guide regarding the selection and use of high-performance barriers, including 42- and 50-inch-high concrete barriers, that are capable of redirecting heavy trucks. (H-05-31) In its recommendation response letter, AASHTO indicated that it would consider research on using standard and high-performance barriers for both permanent and temporary application and on providing enhanced barrier guidelines through an update to the Roadside Design Guide. The NTSB has classified Safety Recommendation H-05-31 ―Open—Acceptable Response.‖ Recent research activities as part of NCHRP Report 638, Guidelines for Guardrail Implementation,123 have resulted in the development of warrants indicating when some higher performance roadside safety hardware should be used, but bridge railings were not addressed in these activities. The 1989 Guide Specifications for Bridge Railings contained criteria for the selection of an appropriate bridge railing design for a specific project location, but their use is not mandatory. Currently, no mandatory warrants indicate when a higher performance bridge railing124 should be used. The 2007 LRFD Bridge Design Specifications and the 2006 Roadside Design Guide advise bridge owners to develop their own bridge railing warrants. Available bridge railing guidance focuses on the performance test level of railing designs, offering only a list of considerations to guide highway engineers in selection of appropriate designs based on location. The NTSB concludes that bridge owners lack warrants to guide them in making high-performance bridge railing selections for specific project applications. The NTSB recognizes that it may be necessary to conduct research and crash tests to support establishing warrants for higher performance bridge barriers appropriate for motorcoach traffic. For example, experimental tests conducted in 1978–1981 at the Texas Transportation Institute at Texas A&M University showed that a TL-3 (Texas Traffic-202) bridge railing modified with the addition of an aluminum rail to a height of 42 inches was able to redirect 32,000-pound motorcoaches operating at speeds up to 60 mph and encroachment angles up to

122 NTSB/HAR-05/03. 123 This research was conducted by the University of Nebraska for the TRB Research Committee. 124 Higher performance bridge railings would be those that conform to TL-4, TL-5, or TL-6 from NCHRP Report 350, Recommended Procedures for the Safety Performance Evaluation of Highway Features.

NTSB Highway Accident Report 56 15 degrees. However, motorcoaches of that period were smaller and lighter than current fleet vehicles.125 The NTSB recommends that the FHWA establish, in conjunction with AASHTO, performance and selection guidelines for bridge owners to use to develop objective warrants for high-performance TL-4, TL-5, and TL-6 bridge railings applicable to new construction and rehabilitation projects where railing replacement is determined to be appropriate, and that AASHTO include the guidelines in the LRFD Bridge Design Specifications. Also, the NTSB recommends that AASHTO revise section 13 of the LRFD Bridge Design Specifications to state that bridge owners shall develop objective warrants for the selection and use of high-performance TL-4, TL-5, and TL-6 bridge railings applicable to new construction and rehabilitation projects where railing replacement is determined to be appropriate. Commercial Vehicle Inspections The FMCSA has certified the state of Texas vehicle inspection program as an ―equivalent inspection program.‖ As such, it satisfies the annual commercial motor vehicle inspection requirements of appendix G to subpart B of the FMCSRs through the use of privately owned and operated garages and repair facilities designated by the state as authorized inspection facilities. The Sherman accident motorcoach was inspected 8 days before the accident; the July 31, 2008, inspection was conducted at 5 Minute Inspections, located in Houston, Texas. The available records from that inspection show omissions and errors that concern the NTSB: specifically, no odometer reading or TxDOT number was entered, and the recorded date of the insurance expiration was incorrect. NTSB investigators visiting the facility noted that it did not have a service pit or a commercial vehicle lift capable of lifting a motorcoach. Without such equipment, it would be very difficult to conduct a thorough inspection of a motorcoach. Although investigators cannot be sure of the condition of the motorcoach when the inspection took place, the motor carrier purchased four new Ling Long tires for the motorcoach on July 29, just 2 days before the annual inspection. It seems likely that they were installed for the purpose of the inspection and that any tire rotation would have been done when the new tires were mounted, prior to the inspection. Thus, it appears that the retread tire was probably on the right steer axle when the inspection took place and that it was not identified as a retread during the inspection. As has been noted earlier in this report, Federal regulations prohibit the use of a retreaded tire on the steer axle of a motorcoach, and a thorough inspection should have detected this problem. The serious underinflation of the tag axle tires and the undersized wheel assemblies on the tag axle also indicate that tire pressure measurements probably were not conducted during the inspection. Moreover, postaccident examination of the left axle brake drum and shoes found significant grease contamination with considerable buildup and caking, a condition that most likely had been in effect for much longer than 8 days but that was not identified during the inspection.

125 The Sherman motorcoach had a 54,000-pound GVWR.

NTSB Highway Accident Report 57 The 5 Minute Inspections station inspected and passed another motorcoach owned by the accident motor carrier in early August 2008. The day after it was certified by 5 Minute Inspections, that motorcoach underwent a MCSAP-sponsored inspection conducted by the Missouri Highway Patrol and was placed out of service due to numerous violations. Vehicle violations found during the MCSAP inspection that should have been identified during the annual inspection included the following items: an out-of-adjustment brake on the right steer axle and general poor condition of the left steer axle brake, general poor condition of the right tag axle brake, and a missing or defective automatic brake adjuster. In March 2009, at the request of NTSB staff, the TxDPS Houston Regional Office visited the 5 Minute Inspections station and interviewed the inspector who had inspected the Sherman accident motorcoach. The TxDPS took no corrective action against 5 Minute Inspections. The NTSB concludes that the commercial vehicle inspections conducted by the 5 Minute Inspections station failed to identify safety deficiencies, and the TxDPS review of the station did not identify any problems with its processes; therefore, at least in this instance, the state of Texas vehicle inspection program for commercial motor vehicles did not provide adequate oversight of the private garages it authorizes to conduct safety inspections. The NTSB is concerned that other states may have similar problems with oversight of their inspection programs. The NTSB recommends that the FMCSA require those states that allow private garages to conduct FMCSA inspections of commercial motor vehicles to have a quality assurance and oversight program that evaluates the effectiveness and thoroughness of those inspections. Occupant Protection Safety Standards Seventeen people died and many more were seriously injured in this accident. In the event of an accident, the vehicle’s occupant protection system serves to mitigate the crash forces that cause injury. A comprehensive occupant protection system considers many aspects of the vehicle, including roof strength, window glazing, seat strength, and restraint systems and their anchorage strengths—all working together to protect occupants should a crash occur. Generally, the NTSB has found that passengers who remain in their seating compartments sustain fewer injuries, while ejected passengers are more likely to be killed. NHTSA motorcoach testing using crash test dummies has confirmed NTSB findings, showing that a lap/shoulder-belted dummy on the far side of an impact had a much lower risk of sustaining injuries than an unrestrained dummy on the far side of an impact. Differences in the drop heights between the United Nations Economic Commission for Europe Regulation 66 (ECE R66) test (800 mm or about 2.6 feet) and this accident (8 feet) most likely would not change the improved injury results seen with lap/shoulder belts. If the energy is properly managed, passengers can survive an 8-foot fall, and in this accident, many passengers, especially those on the far side of the impact, survived the fall. A simplified analysis126 showed

126 The analysis is simplified in that it assumes the same motorcoach mass, but it neglects the longitudinal velocity, the roll velocity, and the asymmetry in the impact configuration.

NTSB Highway Accident Report 58 that the vertical impact velocity in this accident scenario would be less than two times the impact velocity in the ECE R66 crash test. In this accident, the motorcoach also had some forward velocity (29 mph) at the time of the fall from the bridge. This forward velocity would enable an occupant in a shoulder belt to engage the belt, providing better occupant restraint for a lap/shoulder-belted passenger than was seen for the restrained dummies in the ECE R66 test. Although the ECE R66 test requires a drop from only about 2.6 feet, similar improved results for lap/shoulder-belted passengers would be expected in an 8-foot drop, as experienced by the accident motorcoach passengers. With respect to this accident, interviews with first responders and passengers confirmed that some passengers in the accident motorcoach were ejected as a result of the accident. However, due to the circumstances of the accident, the NTSB could not determine the exact number of fully and partially ejected passengers.127 The FMVSSs contain 22 standards on vehicle crashworthiness. Most of these standards exempt motorcoaches with GVWRs over 10,000 pounds, and no Federal regulations require that motorcoaches in the United States be equipped with an occupant protection system for passengers. Although motorcoaches must comply with FMVSS 217, which establishes minimum requirements for motorcoach window retention and release; FMVSS 205, which covers windshields and glazing; and FMVSS 302, which establishes standards for the flammability of interior materials,128 motorcoaches do not have to comply with the many other FMVSSs concerning occupant protection standards that apply to school buses129 and passenger cars. In 1994, the ECE initiated a project to improve safety by fitting seat belts on motorcoaches.130 That study found that passenger ejection is a major cause of death and injury and that, although seat belts can significantly reduce or prevent passenger ejection, the whole system—seats, seat belts, and all anchorages—must be considered to ensure effectiveness. A more recent European Union (EU) study, by TNO-Automotive in the Netherlands,131 concluded that wearing either a lap or a lap/shoulder belt is safer than not wearing a seat belt and that the main advantage of wearing seat belts in a motorcoach is to prevent ejection during rollover accidents, as well as during frontal accidents. Since 1997, EU member states have required

127 Some of those passengers who were partially ejected were trapped under the vehicle, making it difficult for witnesses to identify how many passengers had been ejected. Also, first responders’ records of ejections were inconclusive because other passengers rendered immediate assistance to the injured, who were moved away from the motorcoach as quickly as possible due to passengers’ fears of a postcrash fire. 128 FMVSS 208, ―Occupant Crash Protection‖; FMVSS 209, ―Seat Belt Assemblies‖; and FMVSS 210, ―Seat Belt Assembly Anchorages‖ currently apply to the driver’s seat only. 129 Title 49 United States Code §30125 defines a ―school bus‖ as any vehicle that is designed for carrying a driver and more than 10 passengers and which, as NHTSA determines, is likely to be ―used significantly‖ to transport ―preprimary, primary, and secondary‖ students to or from school or related events (which include school-sponsored field trips and athletic events). This definition was enacted in 1974, as part of a comprehensive effort by Congress to enhance school bus safety. In 2007, Texas enacted legislation requiring school buses to be equipped with 3-point lap/shoulder seat belts. 130 D. Kecman and others, Study of the Technical Requirements for Fitment of Seat Belts on Minibuses and Coaches, Cranfield Impact Centre Report to European Commission, DGIII, Contract No. ETD/94/B5–3000/MI/05 (1994-1995). 131 C.G. Huijskens, M. Schrooten, and P. de Coo, ―Frontal Occupant Safety Simulation for Coach and Bus Passengers,‖ Proceedings: 18th International Technical Conference on the Enhanced Safety of Vehicles, Nagoya, Japan, May 19 through 22, 2003, Paper No. 284 (2003).

NTSB Highway Accident Report 59 2-point lap belts and energy-absorbing seats or 3-point lap/shoulder belts on all M3 motorcoaches.132 Australia applies a set of design rules in addition to ECE requirements.133 The Federal Office of Road Safety in Canberra conducted a 5-year study (1988 to 1993) of 23 motorcoach accidents to identify occupant protection issues involving long-distance coaches.134 Since 1994, Australian Design Rule 68/00 has required that all newly manufactured motorcoaches have lap/shoulder belt systems. Despite the lack of U.S. Federal requirements, manufacturers are proceeding to introduce lap/shoulder belt seats into the U.S. market,135 and states such as Texas are beginning to require lap/shoulder belt-equipped seats for motorcoach transport of students.136 In 1999, the NTSB conducted a bus crashworthiness special investigation and issued a series of safety recommendations to improve occupant protection in the event of an accident.137 In that report, the NTSB concluded that one of the primary causes of preventable injury in motorcoach accidents involving a rollover, ejection, or both, is occupant motion out of the seat during a collision when no intrusion into the seating area occurs. Safety Recommendations H-99-47, 48, -50, and -51 asked NHTSA to take the following actions: In 2 years, develop performance standards for motorcoach occupant protection systems that account for frontal impact collisions, side impact collisions, rear impact collisions, and rollovers. (H-99-47) Once pertinent standards have been developed for motorcoach occupant protection systems, require newly manufactured motorcoaches to have an occupant crash protection system that meets the newly developed performance standards and retains passengers, including those in child safety restraint systems, within the seating compartment throughout the accident sequence for all accident scenarios. (H-99-48)

132 Within the EU, the M-definition of buses provides a common classification of coaches based on weight. M3 coaches are defined as weighing more than 5 tons. The M-definitions are further separated into classes I through III based on application. ECE Regulation 80 specifies the strength of seats on large passenger buses (16 or more passengers), requiring passengers to remain in the predetermined zone in cases of a 30-kilometer-per-hour impact. 133 Australia requires 3-point seat belts and 20-g seats. 134 K.B. Smith, ―Fatal and Serious Injury Bus Crashes,‖ Working Document WD117 (Canberra, Australia: Federal Office of Road Safety, November 1993). 135 In January 2009, American Seating and SafeGuard introduced lap/shoulder belt-equipped seats on Prevost motorcoaches. In April 2009, Greyhound ordered 140 Prevost X3-45 motorcoaches with lap/shoulder belt-equipped seats. 136 The state of Texas has required that, by September 1, 2014, all charter (motorcoach) buses used by Texas schools to transport school children be equipped with 3-point lap/shoulder belts for passengers. 137 Bus Crashworthiness Issues, Highway Special Investigation Report NTSB/SIR-99/04 (Washington, DC: National Transportation Safety Board, 1999).

NTSB Highway Accident Report 60 In 2 years, develop performance standards for motorcoach roof strength that provide maximum survival space for all seating positions and that take into account current typical motorcoach window dimensions. (H-99-50) Once performance standards have been developed for motorcoach roof strength, require newly manufactured motorcoaches to meet those standards. (H-99-51) All of these recommendations are classified ―Open—Unacceptable Response.‖ Safety Recommendations H-99-47 and -50 are on the NTSB Most Wanted List of Transportation Safety Improvements. All four recommendations have been reiterated to NHTSA as a result of several motorcoach accident investigations over the last decade and as recently as this year in conjunction with the NTSB’s investigation of a motorcoach rollover accident near Mexican Hat, Utah.138 The Sherman accident motorcoach experienced multiple collisions, including a rollover with an 8-foot drop. Previous NTSB motorcoach investigations concluded that passengers would be safer with an occupant protection system and sufficient roof strength. Recent NHTSA crash testing showed that injury risk was much lower for lap/shoulder-belted dummies than for unrestrained dummies. The NTSB concludes that if NHTSA had implemented the requirements for motorcoach occupant protection systems following the issuance of Safety Recommendations H-99-47, -48, -50, and -51, fewer injuries and fatalities might have occurred because more occupants might have been retained within the accident motorcoach. Once again, the NTSB reiterates these safety recommendations, and they remain classified ―Open—Unacceptable Response.‖ In 2008, NHTSA briefed the NTSB regarding its plans to publish a Notice of Proposed Rulemaking in 2009 that would require motorcoach occupant restraints. Following the NTSB Board Meeting on the Mexican Hat accident investigation, the Secretary of Transportation on April 30, 2009, ordered a full departmental review of motorcoach safety. The Secretary established a Departmental Motorcoach Safety Action Group to develop an action plan. NHTSA, the FMCSA, the FHWA, and the Pipeline and Hazardous Materials Safety Administration have participated in creating the plan. The Secretary indicated that the report was expected to be completed and released by summer 2009. The Motorcoach Safety Action Group gave the NTSB a status briefing on October 16, 2009. During the briefing, action group representatives indicated that the group’s report was under review by the DOT’s Office of the Secretary. Luggage Rack Failure The 36-foot-long right side luggage rack was attached to the ceiling and sidewall by nine cast aluminum brackets. Each bracket was secured to the ceiling using two 1/2-inch bolts and secured to the sidewall using two inline 1/2-inch bolts. The overhead luggage rack on the right side of the motorcoach sustained failure damage at the anchorage points, became completely

138 (a) Motorcoach Rollover Near Mexican Hat, Utah, January 6, 2008, Highway Accident Report NTSB/HAR-09/01 (Washington, DC: National Transportation Safety Board, 2009); (b) NTSB/HAR-08/01; (c) Motorcoach Run-Off-The-Road and Overturn, Victor, New York, June 23, 2002, Highway Accident Report NTSB/HAR-04/03 (Washington, DC: National Transportation Safety Board, 2004).

NTSB Highway Accident Report 61 detached, and fell diagonally across the aisle onto the passengers. The fallen structure blocked the aisle near rows 3 and 4 as well as the right side emergency window exits. The fallen overhead luggage rack obstructed the evacuation route of those who were ambulatory and, based on interview evidence, impeded the efforts of first responders to evacuate injured passengers. The NTSB concludes that the failure of the luggage rack on the accident motorcoach impeded egress and rescue efforts. The NTSB recommends that NHTSA develop performance standards for newly manufactured motorcoaches to require that overhead luggage racks remain anchored during an accident sequence. The majority of the seriously and fatally injured passengers incurred blunt force trauma to the head, neck, chest, and spine. There was evidence that several passengers’ heads contacted the luggage rack and, although investigators were unable to determine exactly when in the accident sequence passenger injuries took place, it is possible that serious head or neck injury resulted from the interactions between the passengers and the luggage rack. In addition, recent motorcoach rollover testing performed by NHTSA using crash test dummies has demonstrated the potential for serious head injury to unrestrained dummies due to passenger interactions with luggage racks. Lap/shoulder-belted dummies showed low risk for head injury and were retained within the seating compartment. Currently, there are no U.S. standards for luggage rack design that would help to reduce potential injuries during a motorcoach crash sequence. The NTSB concludes that the Sherman accident and recent motorcoach testing indicate that the lack of standards for overhead luggage racks on motorcoaches leaves passengers at risk of serious injury from interaction with luggage racks in case of a crash. The NTSB recommends that NHTSA develop performance standards for newly manufactured motorcoaches that prevent head and neck injuries from overhead luggage racks. Motor Carrier Oversight New Entrant Program Iguala BusMex applied for authority to operate as a new entrant interstate passenger carrier on July 27, 2008,139 about a month after Angel Tours lost its authority to operate due to an unsatisfactory compliance review rating and its failure to submit a corrective action plan in a timely manner. The FMCSA issued a USDOT number to Iguala BusMex but advised the carrier that its authority to operate was pending because it did not fulfill the FMCSA’s requirement to prove financial responsibility; that is, it did not prove that it had proper insurance coverage. Consequently, at the time of the accident, Iguala BusMex’s operating authority was pending. However, because it had a valid USDOT number, the motor carrier was able to complete the required Texas vehicle inspection, which enabled it to obtain a Texas Commercial Vehicle Inspection Certificate sticker. In December 2008, the FMCSA published a final rule raising the standards of compliance for new entrant motor carriers. The rule requires that any carrier that attempts to register as a new

139 Records indicate that prior to making that application, Iguala BusMex improperly conducted operational trips in June 2008.

NTSB Highway Accident Report 62 entrant and evade an enforcement action or an out-of-service order is subject to revocation of its new entrant registration and/or civil penalties. The NTSB is aware that the FMCSA has taken several steps since this accident to improve new entrant registration processes to increase its ability to identify a carrier, such as Iguala BusMex, that is attempting to evade FMCSA enforcement actions by becoming a reincarnated carrier. The FMCSA’s New Applicant Screening Program uses data to identify newly registered carriers that may have a history of enforcement problems. The screening process seeks matches between new registrants and information provided by previously registered motor carriers. The NTSB notes that the FMCSA is developing verification procedures intended to ensure that unfit operators do not receive operating authority; however, these measures were not in place at the time of the accident. Therefore, the NTSB concludes that at the time Iguala BusMex applied as a new entrant motor carrier, the FMCSA processes were inadequate to identify the carrier as a company that evaded enforcement action. The NTSB has reviewed information provided by the FMCSA concerning its new entrant screening program.140 The FMCSA material described how information about carriers is used to develop a score for a ―suspect‖ carrier, but it provides no description of a performance evaluation process designed to indicate whether the program is effectively preventing carriers with a history of evading safety requirements from continuing to operate. The GAO’s recent report on reincarnated carriers also makes no assessment of the new entrant screening program. Information available to the FMCSA, in the form of safety audits, compliance reviews, and roadside inspection results, could be used to identify unfit operators that were not targeted by the New Applicant Screening Program. This information could then be used to evaluate any limitations or shortcomings in the program’s ability to identify unfit carriers. The NTSB concludes that until the New Applicant Screening Program of the FMCSA contains a performance evaluation component capable of showing the program’s effectiveness in identifying carriers with a history of enforcement evasion and preventing them from operating, the screening program’s value cannot be accurately assessed. Therefore, the NTSB recommends that the FMCSA develop an evaluation component to determine the effectiveness of its New Applicant Screening Program. Revocation of Operating Authority Not only did Iguala BusMex begin operations without obtaining operating authority, but also a review of Angel Tours’s driver logs showed that several of the carrier’s drivers continued to operate after Angel Tours was placed out of service. In 2006, following the investigation of a multivehicle accident in Hampshire, Illinois,141 the NTSB issued Safety Recommendation H-06-17, which called for the FMCSA to

140 Summary of Methodology for New Applicant Screening, FMCSA, June 16, 2009. 141 Multivehicle Collision on Interstate 90, Hampshire-Marengo Toll Plaza, Near Hampshire, Illinois, October 1, 2003, Highway Accident Report NTSB/HAR-06/03 (Washington, DC: National Transportation Safety Board, 2006).

NTSB Highway Accident Report 63 Establish a program to verify that motor carriers have ceased operations after the effective date of revocation of operating authority. (H-06-17) Although the motorcoach in the Hampshire accident was rear-ended and thus did not initiate the accident, the NTSB reviewed the motor carrier’s operations as part of the investigation. The review revealed that the motorcoach carrier had operated on revoked interstate authority at least eight times before the accident occurred. In the Hampshire accident report, the NTSB pointed out that after a carrier is deemed inactive per an out-of-service order, the FMCSA no longer targets that carrier for compliance review because it is not registered as an active carrier. In the Hampshire report, the NTSB described the FMCSA Performance and Registration Information Systems Management (PRISM) project. PRISM links FMCSA records on motor carrier safety with a state’s vehicle registration system so that a motor carrier with revoked authority will have its license plates revoked. Forty-seven states are participating in PRISM to some degree.142 In addition to PRISM, the FMCSA, in its August 3, 2006, response to the NTSB regarding the status of Safety Recommendation H-06-17, said that it was increasing its enforcement efforts upon motor carriers that have been issued out-of-service orders or that have had their operating authority revoked. The FMCSA issued memorandums on August 25, 2003, and April 6, 2005, directing FMCSA field administrators and division administrators to monitor motor carriers and to take appropriate enforcement action when evidence indicates a violation of an out-of-service order. Additionally, on May 24, 2006, the FMCSA issued a policy memorandum initiating a new procedure for Federal and state MCSAP inspectors to verify motor carrier operating and insurance status during roadside inspections. Safety Recommendation H-06-17 is classified as ―Open—Acceptable Response,‖ pending full implementation of the PRISM program or another comparable program by all states to prevent unauthorized motor carriers from operating. The NTSB encourages the FMCSA to complete its actions with regard to improving oversight to identify and remove from operation unauthorized motor carriers. Further, the NTSB notes that the FMCSA took some effective oversight actions with respect to the Sherman accident motor carrier. Before the accident, Angel Tours was identified as an unsafe carrier as a result of an FMCSA compliance review and was placed out of service, and the FMCSA identified Iguala BusMex as a new applicant with pending operating authority that required proof of insurance coverage to obtain active authority. Also, as a result of the postaccident compliance review, the FMCSA issued an imminent hazard shutdown order to Iguala BusMex. Further, because of Iguala BusMex’s use of another motor carrier’s operating authority, the FMCSA conducted a compliance review of that carrier and placed it out of service until it developed and enacted a corrective action plan.

142 As of July 2009, only 25 states have implemented PRISM to the extent that they can identify out-of-service carriers.

NTSB Highway Accident Report 64 Conclusions Findings

1. The weather did not cause or contribute to the accident.
2. The accident notification and emergency response by surface and air resources were timely

and adequate.

1. With the exception of the right steer axle tire, the mechanical condition of the motorcoach

did not contribute to the cause or severity of the accident.

1. The driver’s diabetes, high blood pressure, and high cholesterol were not factors in the

accident.

1. The driver used cocaine and alcohol either during or shortly before starting the trip, and he

may have been impaired by aftereffects from either or both drugs.

1. Fatigue was not a factor in the accident and, based on event timing in the accident

reconstruction analysis, even a well-rested, completely alert driver could not have reacted in time to affect the accident sequence.

1. If motor carriers cannot check the controlled substance testing backgrounds of prospective

employees, they cannot make well-informed decisions when attempting to hire safe drivers.

1. The difficulty in obtaining state records in connection with the controlled substance test

results for the driver of the accident motorcoach in this case highlights the National Transportation Safety Board’s need for investigative access to a national database of positive drug test results.

1. The tire on the accident motorcoach’s right steer axle experienced a puncture, and the

resultant gradual pressure loss led to severe overdeflection, which resulted in sidewall, belting, and body ply separations within the tire.

1. Given the limited distance between the roadway and the bridge curb and the lack of recovery

time, there is no evidence that the actions of the driver caused or contributed to the tire failure, and it is unlikely that the driver had sufficient time to respond to the tire failure and avoid the loss of control, the collision with the bridge railing, and the subsequent departure of the motorcoach from the bridge.

1. Although the use of a retreaded, recapped, or regrooved tire on the steer axle of a motorcoach

is prohibited, the right steer axle tire’s failure was not associated with its being a retreaded tire.

1. Failure of the tire on the steer axle resulted in the loss of control of the motorcoach.

NTSB Highway Accident Report 65

1. Underinflation of tires on commercial motor vehicles by even small margins can result in

dangerous overloading of the tires.

1. Because underinflated tires can lead to tire failure and because the currently approved

methods of visual inspection or ―thumping‖ tires with a mallet are inaccurate, a tire pressure gauge should be used to accurately assess tire pressure.

1. Until Motor Coach Industries, Inc., informs operators of the inaccuracies in the J4500

motorcoach maintenance manual, operators may be confused as to the proper tire pressures for these motorcoaches.

1. If the driver had been aware of the motorcoach’s tire pressures, particularly the dangerously

low pressure in the damaged right steer axle tire, then he would have had an opportunity to take corrective action, which might have prevented this accident.

1. A higher performance bridge railing at the accident location might have prevented the

motorcoach’s departure from the bridge.

1. Bridge owners lack warrants to guide them in making high-performance bridge railing

selections for specific project applications.

1. The commercial vehicle inspections conducted by the 5 Minute Inspections station failed to

identify safety deficiencies, and the Texas Department of Public Safety review of the station did not identify any problems with its processes; therefore, at least in this instance, the state of Texas vehicle inspection program for commercial motor vehicles did not provide adequate oversight of the private garages it authorizes to conduct safety inspections.

1. If the National Highway Traffic Safety Administration had implemented the requirements for

motorcoach occupant protection systems following the issuance of Safety Recommendations H-99-47, -48, -50, and -51, fewer injuries and fatalities might have occurred because more occupants might have been retained within the accident motorcoach.

1. The failure of the luggage rack on the accident motorcoach impeded passenger egress and

rescue efforts.

1. The Sherman accident and recent motorcoach testing indicate that the lack of standards for

overhead luggage racks on motorcoaches leaves passengers at risk of serious injury from interaction with luggage racks in case of a crash.

1. At the time Iguala BusMex, Inc., applied as a new entrant motor carrier, the Federal Motor

Carrier Safety Administration processes were inadequate to identify the carrier as a company that evaded enforcement action.

1. Until the New Applicant Screening Program of the Federal Motor Carrier Safety

Administration contains a performance evaluation component capable of showing the program’s effectiveness in identifying carriers with a history of enforcement evasion and preventing them from operating, the screening program’s value cannot be accurately assessed.

NTSB Highway Accident Report 66 Probable Cause The National Transportation Safety Board determines that the probable cause of this accident was the failure of the right steer axle tire, due to an extended period of low-pressure operation, which resulted in sidewall, belting, and body ply separation within the tire, leading to loss of vehicle control. Contributing to the severity of the accident was the failure of the bridge railing to redirect the motorcoach and prevent it from departing the bridge. The lack of an adequate occupant protection system contributed to the severity of the passenger injuries.

NTSB Highway Accident Report 67 Recommendations New Recommendations As a result of its investigation, the National Transportation Safety Board makes the following safety recommendations: To the Federal Highway Administration: Establish, in conjunction with the American Association of State Highway and Transportation Officials, performance and selection guidelines for bridge owners to use to develop objective warrants for high-performance Test Level Four, Five, and Six bridge railings applicable to new construction and rehabilitation projects where railing replacement is determined to be appropriate. (H-09-17) To the Federal Motor Carrier Safety Administration: Establish a regulatory requirement within 49 Code of Federal Regulations 382.405 that provides the National Transportation Safety Board, in the exercise of its statutory authority, access to all positive drug and alcohol test results and refusal determinations that are conducted under the U.S. Department of Transportation testing requirements. (H-09-18) Require that tire pressure be checked with a tire pressure gauge during pretrip inspections, vehicle inspections, and roadside inspections of motor vehicles. (H-09-19) Require those states that allow private garages to conduct Federal Motor Carrier Safety Administration inspections of commercial motor vehicles to have a quality assurance and oversight program that evaluates the effectiveness and thoroughness of those inspections. (H-09-20) Develop an evaluation component to determine the effectiveness of your New Applicant Screening Program. (H-09-21) To the National Highway Traffic Safety Administration: Require all new motor vehicles weighing over 10,000 pounds to be equipped with direct tire pressure monitoring systems to inform drivers of the actual tire pressures on their vehicles. (H-09-22) Develop performance standards for newly manufactured motorcoaches to require that overhead luggage racks remain anchored during an accident sequence. (H-09-23)

NTSB Highway Accident Report 68 Develop performance standards for newly manufactured motorcoaches that prevent head and neck injuries from overhead luggage racks. (H-09-24) To the American Association of State Highway and Transportation Officials: Work with the Federal Highway Administration to establish performance and selection guidelines for bridge owners to use to develop objective warrants for high-performance Test Level Four, Five, and Six bridge railings applicable to new construction and rehabilitation projects where railing replacement is determined to be appropriate, and include the guidelines in the Load and Resistance Factor Design (LRFD) Bridge Design Specifications. (H-09-25) Revise section 13 of the Load and Resistance Factor Design (LRFD) Bridge Design Specifications to state that bridge owners shall develop objective warrants for the selection and use of high-performance Test Level Four, Five, and Six bridge railings applicable to new construction and rehabilitation projects where railing replacement is determined to be appropriate. (H-09-26) To the American Association of Motor Vehicle Administrators: Revise the model Commercial Driver’s License Manual to stipulate that tire pressure be checked with a tire pressure gauge during pretrip inspections, vehicle inspections, and roadside inspections of motor vehicles. (H-09-27) To Motor Coach Industries, Inc.: Correct any inaccurate tire pressure and gross axle weight rating information in the maintenance manuals of your J4500 motorcoaches and make electronic versions of the revised manuals readily available on your website; in addition, review the maintenance manuals of your other motorcoaches for similar errors and make appropriate corrections. (H-09-28) Previously Issued Recommendations Reiterated in This Report As a result of its investigation, the National Transportation Safety Board reiterates the following safety recommendations: To the Federal Motor Carrier Safety Administration: Develop a system that records all positive drug and alcohol test results and refusal determinations that are conducted under the U.S. Department of Transportation testing requirements, require prospective employers to query the system before making a hiring decision, and require certifying authorities to query the system before making a certification decision. (H-01-25)

NTSB Highway Accident Report 69 To the National Highway Traffic Safety Administration: In 2 years, develop performance standards for motorcoach occupant protection systems that account for frontal impact collisions, side impact collisions, rear impact collisions, and rollovers. (H-99-47) Once pertinent standards have been developed for motorcoach occupant protection systems, require newly manufactured motorcoaches to have an occupant crash protection system that meets the newly developed performance standards and retains passengers, including those in child safety restraint systems, within the seating compartment throughout the accident sequence for all accident scenarios. (H-99-48) In 2 years, develop performance standards for motorcoach roof strength that provide maximum survival space for all seating positions and that take into account current typical motorcoach window dimensions. (H-99-50) Once performance standards have been developed for motorcoach roof strength, require newly manufactured motorcoaches to meet those standards. (H-99-51)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD DEBORAH A.P. HERSMAN ROBERT L. SUMWALT Chairman Member CHRISTOPHER A. HART

Vice Chairman

Adopted: October 27, 2009

NTSB Highway Accident Report 70 Appendix A Investigation The National Transportation Safety Board (NTSB) received notification of this accident on August 8, 2008. The NTSB launched a team of investigators to address motor carrier, survival factors, human factors, vehicle, vehicle recorder, and highway issues. The NTSB team also included staff from the public affairs and transportation disaster assistance offices. Board Member Deborah A.P. Hersman (now NTSB Chairman) and her assistant took part in the on-scene investigation. Parties to the investigation were the Federal Motor Carrier Safety Administration; the Texas Department of Public Safety; the Texas Department of Transportation; the Sherman, Texas, Police Department; Motor Coach Industries, Inc.; and Bridgestone Americas, Inc. No public hearing was held in connection with this accident.

FD07364 ｜ 2009_美国_HAR0903.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2009 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

Motorcoach Rollover on U.S. Highway 59 Near Victoria, Texas January 2, 2008

Highway Accident Summary Report NTSB/HAR-09/03/SUM PB2009-916203

National Transportation Safety Board

(This page intentionally left blank.)

NTSB/HAR-09/03/SUM PB2009-916203 Notation 8023A Adopted: December 8, 2009

Highway Accident Summary Report Motorcoach Rollover on U.S. Highway 59 Near Victoria, Texas January 2, 2008

National Transportation Safety Board

490 L’Enfant Plaza, S.W. Washington, D.C. 20594

National Transportation Safety Board. 2009. Motorcoach Rollover on U.S. Highway 59 Near Victoria, Texas, January 2, 2008. Highway Accident Summary Report. NTSB/HAR-09/03/SUM. Washington, DC.

Abstract: On January 2, 2008, about 4:13 a.m., a 2005 Volvo 47-passenger motorcoach carrying 47 passengers was proceeding northbound on U.S. Highway 59 (U.S. 59) about 5 miles south of Victoria, Texas, when the motorcoach driver partially drifted off the right edge of the roadway. As a result of the driver making a series of oversteers in an attempt to stay on the roadway, the motorcoach rotated counterclockwise and overturned onto its right side. The motorcoach’s right rear struck a guardrail as the motorcoach slid on its right side approximately 112 feet before coming to rest across the roadway. Within 5 minutes, and before emergency responders arrived on scene, a 2001 Ford Ranger pickup truck also traveling northbound on U.S. 59 struck the underside of the motorcoach forward of the rear axle. As a result of the initial motorcoach rollover, 1 passenger was fatally injured, and 46 passengers and the driver received injuries ranging from minor to serious. The driver of the pickup truck sustained minor injuries when the pickup truck struck the undercarriage of the motorcoach.

The investigation identified the following safety issues: the lack of federal oversight of passenger motor carrier leasing agreements and the registration and use of non-Federal Motor Vehicle Safety Standard-compliant, passenger-carrying vehicles in commercial motor carrier operations in the United States. The report also addresses continuing deficiencies in motor carrier operating authority issues, safety rating methodology, and the New Entrant Safety Assurance Program. As a result of its investigation, the National Transportation Safety Board makes recommendations to the U.S. Department of Transportation, the National Highway Traffic Safety Administration, the Federal Motor Carrier Safety Administration, the U.S. Customs and Border Protection Agency, the American Association of Motor Vehicle Administrators, the International Registration Plan, Inc., and the Commercial Vehicle Safety Alliance. The NTSB also reiterates two previously issued recommendations to the Federal Motor Carrier Safety Administration.

The National Transportation Safety Board (NTSB) 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 NTSB 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 Internet at http://www.ntsb.gov. Other information about available publications also may be obtained from the website or by contacting:

National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, SW Washington, DC 20594 (800) 877-6799 or (202) 314-6551

NTSB publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2009-916203 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 NTSB reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

NTSB

Highway Accident Summary Report i Contents Figures ........................................................................................................................................... iii Acronyms and Abbreviations ..................................................................................................... iv Executive Summary .................................................................................................................... vii The Accident ...................................................................................................................................1 Highway Information .......................................................................................................................5 Vehicle Information .........................................................................................................................8 Injuries .............................................................................................................................................9 Driver .............................................................................................................................................13 Fatigue............................................................................................................................................14 Issues .............................................................................................................................................21 Motor Carrier Operations ...............................................................................................................21 Federal Safety Oversight ........................................................................................................25 Scope of Operating Authority .................................................................................................28 New Entrant Safety Assurance Program ................................................................................31 Compliance Review Process and Safety Ratings ...................................................................34 State Commercial Motor Vehicle Registration Process.................................................................40 Non-FMVSS-Compliant Passenger-Carrying Commercial Motor Vehicles .................................47 U.S. Performance Standards and Operational Safety Requirements for Vehicles Operating in the United States ..................................................................................................................................52 History ....................................................................................................................................52 Foreign-Manufactured Vehicles .............................................................................................52 U.S. Vehicle Performance Standards and Regulations ...........................................................55 Federal Importation Definitions .............................................................................................58 Conclusions ...................................................................................................................................64 Findings..........................................................................................................................................64 Probable Cause...............................................................................................................................67 Recommendations ........................................................................................................................68 New Recommendations .................................................................................................................68 Previously Issued Recommendation Reiterated in This Report ....................................................71 Previously Issued Recommendation Reiterated and Reclassified in This Report .........................72 Appendix A ...................................................................................................................................73 Investigation and Public Hearing ...................................................................................................73 Appendix B ...................................................................................................................................75 Computer Simulation Study ...........................................................................................................75

NTSB

Highway Accident Summary Report ii Appendix C ...................................................................................................................................81 Form HS-7 .....................................................................................................................................81 Appendix D ...................................................................................................................................82 Form OP-1(P).................................................................................................................................82 Appendix E ...................................................................................................................................93 FMCSA Postaccident Compliance Review of International Charter Services, Inc. ......................93 Appendix F ...................................................................................................................................97 Compliance Review Process and Safety Ratings...........................................................................97 Appendix G .................................................................................................................................106 U.S. and European Safety Standards and U.S. Inspection Cross-References..............................106 Appendix H .................................................................................................................................110 U.S. and Mexico Border Crossing Data .......................................................................................110

NTSB

Highway Accident Summary Report iii Figures Figure 1. Accident motorcoach’s route. ............................................................................. 2 Figure 2. Accident motorcoach at final rest perpendicular to roadway ............................. 3 Figure 3. Collision damage to pickup truck. ...................................................................... 4 Figure 4. View of U.S. 59 roadway northbound (just before initial roadway departure location) .............................................................................................................. 6 Figure 5. Accident scene diagram. ..................................................................................... 7 Figure 6. Motorcoach seating chart.................................................................................. 11 Figure 7. Motorcoach driver’s 72-hour work and activity log. ........................................ 15 Figure 8. Motorcoach with printed regular route schedule. ............................................. 30

NTSB

Highway Accident Summary Report iv Acronyms and Abbreviations AAMVA

American Association of Motor Vehicle Administrators AASHTO

American Association of State Highway and Transportation Officials Baratta

Baratta Enterprises, LLC BASIC

Behavior Analysis and Safety Improvement Category CAPRI

Compliance Analysis and Performance Review Information Capricorn

Capricorn Bus Lines, Inc. CBP

U.S. Customs and Border Protection Agency CDL

commercial driver’s license CFR

Code of Federal Regulations Chavez

Transportes Chavez, Inc. CMV

commercial motor vehicle CVSA

Commercial Vehicle Safety Alliance CWS

collision warning system CSA 2010

Comprehensive Safety Analysis 2010 DOT

U.S. Department of Transportation DVIR

Driver’s Vehicle Inspection Reports ECE

Economic Commission for Europe EDA

evasion detection algorithm ECM

electronic control module Flores

Flores U.S. Bus Lines, Inc. FHWA

Federal Highway Administration FMCSA

Federal Motor Carrier Safety Administration FMCSR

Federal Motor Carrier Safety Regulation

NTSB

Highway Accident Summary Report v FMCSRs

Federal Motor Carrier Safety Regulations FMVSS

Federal Motor Vehicle Safety Standard FMVSSs

Federal Motor Vehicle Safety Standards Form OP-1(P) Application for Motor Passenger Carrier Authority Form HS-7 Declaration—Importation of Motor Vehicles and Motor Vehicle Equipment Subject to Federal Motor Vehicle Safety, Bumper, and Theft Prevention Standards Form MCS-150 Motor Carrier Identification Report (Application for USDOT Number) GAO

U.S. Government Accountability Office Global

Global Limo, Inc. Green River

Green River Buses, LLC IIT

instrument of international traffic International International Charter Services, Inc. IR

information request IRP

International Registration Plan [program] IRP, Inc.

International Registration Plan, Inc. [organization] ITS

intelligent transportation systems MC

motor carrier [number] MCMIS

Motor Carrier Management Information System MCSIA

Motor Carrier Safety Improvement Act NHTSA

National Highway Traffic Safety Administration NPRM

notice of proposed rulemaking NTSB

National Transportation Safety Board OIG

U.S. Department of Transportation Office of Inspector General OOS

out of service PCVP

Passenger Carrier Vetting Process

NTSB

Highway Accident Summary Report vi SafeStat

Motor Carrier Safety Status Measurement System SAFETEA-LU Safe, Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for Users SFD

safety fitness determination TxDOT

Texas Department of Transportation TxDPS

Texas Department of Public Safety U.S. 59

U.S. Highway 59 U.S.C.

United States Code USDOT number U.S. Department of Transportation number VI

verification inquiry VIN

vehicle identification number Volvo

Volvo de Mexico División Autobuses

NTSB

Highway Accident Summary Report vii Executive Summary On January 2, 2008, about 4:13 a.m., a 2005 Volvo 47-passenger motorcoach, operated by a 42-year-old driver and carrying 47 passengers, was proceeding northbound on U.S. Highway 59 (U.S. 59) about 5 miles south of Victoria, Texas, when the motorcoach driver partially drifted off the right edge of the roadway. The driver oversteered to the left to avoid leaving the roadway, resulting in the motorcoach coming back across both lanes, departing the left edge of the roadway, and partially entering an earthen median. The driver oversteered again to the right in an attempt to reenter the roadway and then oversteered to the left a second time upon realizing the motorcoach had gone too far right. As a result of the final oversteer, the motorcoach yawed to the left, rotated counterclockwise, and overturned onto its right side. The motorcoach’s right rear struck a guardrail as the motorcoach slid on its right side approximately 112 feet before coming to rest across the roadway. Within 5 minutes, and before emergency responders arrived on scene, a 2001 Ford Ranger pickup truck also traveling northbound on U.S. 59 struck the underside of the motorcoach forward of the rear axle. As a result of the initial motorcoach rollover, 1 passenger was fatally injured, and 46 passengers and the driver received injuries ranging from minor to serious. The driver of the pickup truck sustained minor injuries when the pickup truck struck the undercarriage of the motorcoach.

The National Transportation Safety Board determines that the probable cause of this accident was the driver’s falling asleep, which caused him to partially drift off the road, resulting in oversteer corrections when the driver regained awareness, and subsequent vehicle loss of control and overturn. Contributing to the severity of the unrestrained passengers’ injuries was their striking objects and other passengers inside the motorcoach, as well as the partial ejections that occurred when the motorcoach overturned during the accident.

The investigation identified safety issues that the NTSB has not previously addressed: the lack of FMCSA oversight of passenger motor carrier leasing agreements and the registration and use of non-Federal Motor Vehicle Safety Standard-compliant, passenger-carrying vehicles in commercial motor carrier operations in the United States. The report also addresses continuing deficiencies in motor carrier operating authority issues, safety rating methodology, and the New Entrant Safety Assurance Program. This summary report examines the Victoria accident and its proximate cause and then proceeds to explore, in depth, specific safety issues that were not being adequately addressed by Federal and state oversight authorities due to loopholes in safety processes. As a result of its investigation, the NTSB has made recommendations to the U.S. Department of Transportation, the National Highway Traffic Safety Administration, the Federal Motor Carrier Safety Administration, the U.S. Customs and Border Protection Agency, the American Association of Motor Vehicle Administrators, the International Registration Plan, Inc., and the Commercial Vehicle Safety Alliance. The NTSB also reiterated two previously issued recommendations to the Federal Motor Carrier Safety Administration.

NTSB

Highway Accident Summary Report viii

(This page intentionally left blank.)

NTSB Highway Accident Summary Report 1 The Accident Between 4:10 a.m. and 4:13 a.m.,1 on January 2, 2008, an accident consisting of two events occurred on U.S. Highway 59 (U.S. 59) near Victoria, Texas. The first event was a single-vehicle rollover of a 2005 Volvo de Mexico División Autobuses (Volvo) 47-passenger motorcoach. About 5 minutes later, a second event occurred when a 2001 Ford Ranger pickup truck collided with the wreckage from the first event.

About 7:30 p.m. on January 1, 2008, the motorcoach, operated by a 42-year-old driver and carrying 47 passengers, departed Monterrey, Mexico, on an approximately 456-mile-long trip to Houston, Texas. (See figure 1.) The motorcoach was operated by a company called Capricorn Bus Lines, Inc. (Capricorn), under the U.S. Department of Transportation (USDOT) number and operating authority of another company called International Charter Services, Inc. (International). By 10:30 p.m., the driver had arrived at the Laredo, Texas, border crossing location and, by 10:45 p.m., had finished U.S. Customs and Border Protection Agency (CBP) crossing processing. Approximately 4:10 a.m., about 9 hours after departing Monterrey, the accident sequence began as the driver was proceeding northbound on U.S. 59, about 5 miles south of Victoria, Texas. While traversing a 1,000-foot, 3.5-degree horizontal curve to the left on a 3-percent downgrade, the motorcoach driver drifted off the right edge of the roadway, oversteered to get back onto the roadway, and then came back across both lanes; the left side of the motorcoach then departed the left edge of the roadway and entered an earthen median. The driver oversteered again to the right and, after the motorcoach reentered the roadway for about 40 feet, oversteered once more. The motorcoach began to yaw to the left in a counterclockwise rotation and then overturned onto its right side. After overturning, the right rear of the motorcoach struck a guardrail on the right side of the roadway. The motorcoach slid on its right side approximately 112 feet, where it came to rest blocking the roadway. (See figure 2.)

1 Unless otherwise designated, all times in this report are central standard time.

NTSB Highway Accident Summary Report 2

Figure 1. Accident motorcoach’s route.2

2 According to PC*Miler for Windows 2000 (© 1999 by ALK Associates, Inc.), the trip from Monterrey, Mexico, to Houston, Texas, was 456 miles and should have taken 10 hours 28 minutes to travel (with the border open and two stops included).

NTSB Highway Accident Summary Report 3

Figure 2. Accident motorcoach at final rest perpendicular to roadway. (Photograph courtesy of Victoria Fire Department)

About 5 minutes after the motorcoach rolled over, and before emergency responders arrived on scene, a 2001 Ford Ranger pickup truck traveling northbound on U.S. 59 struck the underside of the overturned motorcoach forward of the rear axle. This collision resulted in damage to the motorcoach’s underside and cargo bay, and heavy damage to the front of the pickup truck. (See figure 3.) The NTSB interviewed the pickup truck driver, who reported that when he rounded the curve south of the overturned motorcoach, he was traveling about 50 mph and was about 50 feet away when he observed the overturned vehicle. He said that he began to brake and believed that his vehicle slid on broken glass from the motorcoach. Both portions of the accident sequence occurred during darkness. Local law enforcement responding to the scene reported unrestricted visibility and dry roadway conditions.

NTSB Highway Accident Summary Report 4

Figure 3. Collision damage to pickup truck.

As a result of the motorcoach rollover, one passenger was fatally injured and 46 passengers and the driver received injuries ranging from minor to serious. The driver of the pickup truck sustained minor injuries. The Victoria County Sheriff’s Department was notified of the accident via the 911 emergency response system at 4:10 a.m.3 Emergency responders were dispatched at 4:11 a.m., and the first responding fire department was on scene at 4:21 a.m., followed by ambulances arriving at 4:22 a.m. One medical flight helicopter transported a seriously injured passenger to a trauma facility due to the nature of that passenger’s injuries.

The NTSB has investigated another accident similar to the one that occurred in Victoria, in which a truck-tractor semitrailer combination unit rolled over across both lanes of an Osseo, Wisconsin, interstate approximately 1 minute before a motorcoach, traveling in the same direction at nighttime at highway speeds, collided with the underside of the overturned combination unit.4 In that accident, the NTSB found that it would have been hard for any driver to identify the overturned truck because there was no highway lighting in the vicinity and the truck’s retroreflective markings were invisible to approaching traffic. Similar conditions existed in this accident; there was no overhead lighting and no retroreflective marking on the underside of the motorcoach, making the overturned motorcoach not easily visible to approaching traffic. Collision warning systems (CWS) are designed to assist in these types of accidents by warning drivers of slowed or stopped objects in the vehicle’s forward path.

3 This time is as reported by the Victoria County Dispatch log; the time of the accident in this report is based upon the Texas Department of Public Safety (TxDPS) dispatch log. Clocks were not synchronized. 4 Truck-Tractor Semitrailer Rollover and Motorcoach Collision With Overturned Truck, Interstate Highway 94, Near Osseo, Wisconsin, October 16, 2005, Highway Accident Report NTSB/HAR-08/02 (Washington, DC: National Transportation Safety Board, 2008).

NTSB Highway Accident Summary Report 5

This secondary impact to the motorcoach might have been avoided had the pickup truck been equipped with a CWS. The pickup truck driver did not perceive the overturned motorcoach and, as a result, did not apply the brakes in time to slow his vehicle to avoid impacting the motorcoach. The NTSB has long been interested in how CWS and other technologies can prevent rear-end collisions. In 2001, the NTSB published a special investigation on such technologies.5 In 1999 and 2000, the NTSB 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 NTSB had already reported in a 1995 special investigation,6 and further discussed in its 1999 public hearing,7 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. Although the focus of the special investigation was accidents resulting from interference by sun glare, fog, smoke, fatigue, distractions, and work zones, the NTSB believes that developing and installing CWS and other new technologies in passenger vehicles, such as the pickup truck involved in this accident, will substantially reduce these types of accidents. The NTSB has issued recommendations to the National Highway Traffic Safety Administration (NHTSA) to develop and require such technologies in passenger vehicles.8

Although the NTSB cannot determine the extent to which the secondary collision from the pickup truck into the motorcoach contributed to the passengers’ injuries, the use of CWS to prevent this secondary impact might have prevented and/or mitigated the severity of some additional passenger injuries and might have prevented the pickup truck driver from sustaining his injuries. Highway Information The accident occurred on U.S. 59 northbound at milepost 642A, less than 1 mile from Texas Spur 91. The accident site was about 5 miles south of the city of Victoria in Victoria County, Texas. U.S. 59, a north–south highway that runs from the U.S.–Mexican

5 Vehicle- and Infrastructure-Based Technology for the Prevention of Rear-End Collisions, Highway Special Investigation Report NTSB/SIR-01/01 (Washington, DC: National Transportation Safety Board, 2001). 6 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: National Transportation Safety Board, 1995). 7 National Transportation Safety Board, docket no. DCA-99-SH-002. 8 Safety Recommendations H-01-6 through -8, which are currently classified ―Open—Acceptable Response.‖ Safety Recommendations H-01-7 and -8 were added to the NTSB’s Most Wanted List of Transportation Safety Improvements in 2007 in the issue area Prevent Collisions by Using Enhanced Vehicle Safety Technology. The NTSB’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.

NTSB Highway Accident Summary Report 6 border at Laredo, Texas, to the Texas–Arkansas border, was classified as a principal rural arterial road9 with limited controlled access.

Just south of the accident location, U.S. 59 became an overpass bridge (above Texas Spur 91). The roadway continued descending as a ramp to the left and then became a divided four-lane roadway with a grass and earthen median gore separating it from Texas Spur 91. (See figure 4.)

Figure 4. View of U.S. 59 roadway northbound (just before initial roadway departure location).

The two lanes in each direction were 12 feet wide delineated by 10-foot-long dashed white pavement stripes at 30-foot intervals. A solid, white pavement stripe separated the right-hand lane from the 11-foot-wide shoulder. Toward the end of the curve as the roadway straightens, the dual lanes merge to a single 23-foot-wide lane narrowing to approximately 17 feet. The U.S. 59 bridge overpass had a right-side positive barrier (guardrail), which ended where the motorcoach partially departed the roadway onto the shoulder to the right. There was no guardrail on the right for approximately

9 According to the American Association of State Highway and Transportation Officials (AASHTO), rural principal arterials include the interstate system and most rural freeways. They also include other multilane roadways and some two-lane highways that connect urban centers. Minor rural arterials link urban centers to larger towns and are spaced to provide a relatively high level of service to developed areas of the state.

NTSB Highway Accident Summary Report 7 246 feet in the area where the driver had overcorrected to the left side of the roadway; another guardrail was in place where the vehicle crossed back to the right. (See figure 5.)

Figure 5. Accident scene diagram.

NTSB Highway Accident Summary Report 8 This guardrail had a section of paint transfer from the accident. The accident location did not have rumble strips.10 The interchange was not illuminated with artificial safety lighting; safety lighting was not warranted for this location.11

The highway had a posted speed of 65 mph12 during nighttime hours; the accident occurred about 4:13 a.m., in darkness. The Texas Department of Transportation (TxDOT) conducted a speed survey on U.S. 59 on the ramp in the vicinity of the accident, and the 85th percentile speed was 72.7 mph. The driver stated that he was traveling about 80 kilometers13 per hour (47 mph) before the accident. The motorcoach’s tire marks measured a total of 262 feet. Based upon the distance the motorcoach skidded on the pavement and the grassy median, in combination with the radius of the tire marks on the roadway, the NTSB’s investigation determined that the motorcoach was traveling between 65 and 75 mph when it first skidded into the median.14 (See appendix B for the computer simulation.)

The NTSB investigation determined that the weather was clear and dry at the time of the accident, pavement markings were visible, and no highway design and construction defects existed in the area of the accident site. Therefore, the NTSB concludes that weather was not a factor in this accident, nor were any highway defects found that would have caused or contributed to the accident. Vehicle Information The accident vehicle was a 2005 Volvo, model 9700, 47-passenger, two-axle, intercity motorcoach. Capricorn’s owner traveled to Mexico to purchase the motorcoach, and, according to Volvo, the accident motorcoach was not manufactured for sale in the United States and therefore was not certified to have met U.S. Federal Motor Vehicle Safety Standards (FMVSSs).

10 Rumble strips, also called ―alert grooves,‖ are grooved patterns in the pavement that cause a vehicle to vibrate, alerting the driver. There were rumble strips on U.S. 59 north of the accident location. For further information, see J. Hickey, ―Shoulder Rumble Strip Effectiveness: Drift-Off-Road Accident Reductions on the Pennsylvania Turnpike,‖ Transportation Research Record 1573 (Washington, DC: National Research Council, 1997), pp. 105–109. 11 Texas Highway Illumination Manual (2008). 12 The daytime speed limit was 70 mph. Both daytime and nighttime speeds were posted in advance of the accident curve, but there were no advisory signs limiting the speed at which the curve could be negotiated. In the 5 years preceding the accident date, one accident occurred within 1 mile of the ramp and none on the ramp. 13 The motorcoach was manufactured with a speedometer that measured kilometers per hour. One kilometer equals 0.62137119 mile. 14 The TxDPS independently performed an accident reconstruction and determined that the initial braking speed of the motorcoach was 63 mph. The TxDPS determined this braking occurred after the driver had veered to the right, steered back to the left, and then initially applied his brakes at approximately 63 mph, after which the driver traveled into the median. The driver then corrected to the right and traveled onto the road, overcorrected back to the left, and entered a side skid, resulting in a rollover.

NTSB Highway Accident Summary Report 9 According to Federal regulation (49 Code of Federal Regulations [CFR] 396.17), all commercial vehicles operating in interstate commerce must receive a safety inspection annually by a qualified inspector (49 CFR 396.19). Additionally, Texas15 requires an annual inspection of commercial vehicles; vehicles, upon passing the vehicle safety inspection, receive a state decal on the lower left front corner of the windshield with the date of inspection and the inspector’s information written on the back. The inspection of motor vehicles, including motorcoaches, in Texas is conducted in state-approved, privately owned and operated inspection facilities, garages, and repair facilities, which are designated by the TxDPS under the Texas Vehicle Inspection Act.16 The accident vehicle passed the annual Texas vehicle inspection in November 2007.

After the accident, the motorcoach was towed to the Mack Truck dealership facility in Victoria, Texas, where NTSB investigators and personnel from the Volvo de Mexico División Autobuses and Prevost (a subsidiary of Volvo Bus Corporation), along with representatives from Bendix Commercial Vehicle Systems, inspected the vehicle on January 4, 2008. The vehicle’s engine was electronically controlled and had an electronic control module (ECM); however, the ECM did not have the ability to record accident-related data such as speed or braking.17 Postaccident mechanical inspection of the motorcoach did not reveal any mechanical conditions that would have contributed to the accident. The inspection was limited to those systems and components that could have contributed to a loss of vehicle control and caused the motorcoach to run off the road. The NTSB concludes that although the vehicle did not meet the FMVSSs, the mechanical condition of the accident motorcoach was not a factor in this accident. Injuries The motorcoach driver sustained minor injuries along with 29 of the motorcoach passengers. Two passengers sustained serious injuries consisting of severe injuries to their upper extremities, face, and back; 15 passengers sustained serious injuries including thoracic and lumbar spinal fractures. (See table 1 and figure 6.) The fatally injured passenger sustained blunt-force trauma injuries. The pickup truck driver sustained minor injuries.

15 Texas Transportation Code, ―Compulsory Inspection of Vehicles,‖ chapter 548. 16 A vehicle will meet Federal requirements if 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 states, Alabama, California, Connecticut, Michigan, Minnesota, New Jersey, New York, Ohio, and Wisconsin have inspection programs that do not cover all commercial motor vehicles. In three other states—Arkansas, Illinois, and Oklahoma— the inspection is not mandatory but will satisfy the Federal requirements. 17 The motorcoach was equipped with an electronic dash-mounted tachograph, capable of recording speed and stops for 7 days. This tachograph receives its input by an electrical pulse from a sensor in the transmission and is recorded on a circular paper card; however, the circular paper-graph recording card had not been installed.

NTSB Highway Accident Summary Report 10 Table 1. Injuries.

Injury severity Pickup truck driver Motorcoach driver Motorcoach passengers

Total Fatal 0 0 1 1 Serious 0 0 17 17 Minor 1 1 29 31 None 0 0 0 0 Total 1 1 47 49 Title 49 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.‖

NTSB Highway Accident Summary Report 11 HWY-08-MH-011 Victoria, Texas 12 F - UNK : Minor 3 F - 42 : Serious F - 45 : Serious M - 56 : Minor M - 60 : Minor M - 15 : Minor M - 45 : Serious F - 9 : Serious M - 23 : Minor M - 53 : Minor F - 54 : Serious M - 57 : Minor F - 50 : Serious F - 27 : Minor M - 6 : Minor F - 43 : Minor M - 42 : Minor F - 51 : Serious - E M - 20 : Minor M - 62 : Minor M - 36 : Minor M - 58 : Minor F - 54 : Serious 1 2 4 5 6 7 8 9 10 11 F - 9 : Minor M - 40 : Minor M - 62 : Serious F - 66 : Serious F - 36 : Serious M - 44 : Minor F - 9 : Minor M - 20 : Minor F - 14 : Serious - E M - 59 : Minor F - 20 : Minor F - 55 : Serious F - 71 : Minor F - 40 : Minor M - 50 : Serious M - 55 : Minor F - 19 : Minor M - 56 : Fatal - E M - 37 : Minor F - 17 : Minor F - 16 : Serious

• International Civil Aviation Organization

** Passengers known to have been partially ejected or most likely partially ejected based on medical records F - 52 : Serious M - 28 : Minor F - 60 : Minor F - 54 : Serious F = FEMALE M = MALE INJURY LEVEL* F - 14 : Serious - E GENDER AGE INDICATES EJECTION** Seating Chart Legend A B C D E

Figure 6. Motorcoach seating chart. .

NTSB Highway Accident Summary Report 12

According to passenger interviews and the emergency response incident commander, the fatally injured passenger had been partially ejected and pinned beneath the motorcoach. Passengers who sustained the severe upper extremity injuries stated that they were partially ejected out the right-side windows. The Volvo motorcoach was equipped with a three-point (lap and shoulder) belt for the driver and tour seat; the passenger seats were equipped with two-point (lap) belts.18 The driver reported to NTSB investigators that his seat belt was unlatched at the time of the accident.

Of the 46 surviving passengers, the NTSB interviewed 24 and sent out questionnaires to the other 22 passengers by mail. Of those interviewed and the four passengers who mailed back their completed questionnaires, most reported not being aware of the lap belts on the motorcoach. A few passengers stated they were aware of the lap belts and a few of those individuals could only find one portion of the belt because the other portion was tucked into the seat cushion. The passenger seated in the retractable tour seat next to the driver was interviewed by the NTSB and stated he was wearing his lap and shoulder belt. After the motorcoach came to rest, the driver helped him unbuckle his seat belt because he was still in his seat, hanging to the right. Only one other passenger (who sustained minor injuries) reported wearing the available lap-only belt at the time of the accident.

The motorcoach rolled 90 degrees onto its right side during the accident sequence. The bus sustained moderate damage to the entire right side from the rollover, and a portion of the undercarriage was damaged due to the impact from the pickup truck. Damage to the right side consisted of scrapes to the sheet metal with approximately 1–2 inches in deformation; the roof received very little deformation from the 90-degree roll. Damage to the undercarriage was more significant, with the sheet metal of the floor supports being pushed upward, causing the interior wooden floor in row seven on the right side to buckle upward. All of the windows on the right side were broken out during the rollover event and a passenger, using the small striker/hammer19 attached directly above another left-side window, shattered the third window on the left side and climbed out. According to the manufacturer, the windows were double-layered, tempered, thermal glass. Survivable space within the full length of the motorcoach’s passenger compartment was available during the rollover. The NTSB concludes that the cause of the unrestrained passengers’ injuries was their striking objects and other passengers inside the motorcoach, as well as their partial ejections from the motorcoach windows on the right side, most of which occurred when the motorcoach overturned.

18 No Federal regulations require lap or shoulder belts (other than for the driver) on motorcoaches manufactured for sale in the United States. 19 According to Volvo, the accident motorcoach was manufactured to Economic Commission for Europe (ECE) regulations. ECE regulations allow for an attached striker/hammer to be used to break open windows, whereas the U.S. FMVSS 217 (49 CFR 571.217) requires handles to open windows.

NTSB Highway Accident Summary Report 13 Driver The 42-year-old motorcoach driver provided a verbal statement in Spanish to a responding deputy sheriff at the accident scene. The deputy wrote in his accident report that the driver ―began to get teary eyed and stated that he was dozing off and finally fell asleep at the wheel. He woke up when he felt the bus running off the road. In a panic, he overcorrected and the bus overturned.‖ The driver provided a second statement later to police, written in Spanish, on January 4, 2008, which (translated) stated:

When I was driving on a curve, I lost control. The motorcoach went too far to the right side but I reacted quickly and tried to regain control to the left side to re-enter the freeway but could not. My nerves were such that I over-steered the wheel and this was where I could do nothing else.

Law enforcement officials present at the scene did not detect signs of alcohol or illicit drug use by the driver and, absent any reasonable suspicion of drug or alcohol use, the police did not believe that they had probable cause to obtain toxicological specimens.20 After the accident, the driver was charged by the TxDPS with ―Fatigued Driver (Federal Motor Carrier Safety Regulation [FMCSR] 391.11[b][5]).‖21

The motor carrier collected toxicological specimens from the motorcoach driver 17 hours after the accident; these specimens were tested and found to be negative for drugs of abuse, including alcohol. However, given the length of time that had passed between the accident and alcohol testing and the metabolization rates for alcohol, it is impossible to determine whether the driver had ingested alcohol before the accident. Therefore, the NTSB concludes that although the driver’s toxicological testing results were negative for alcohol and drug use and it was unlikely that the driver was under the influence of alcohol or drugs, the company’s delay in collecting toxicological specimens prevents the NTSB from conclusively ruling out alcohol use as a factor in this accident.

According to 49 CFR 382.303, the employer of a driver operating a commercial motor vehicle 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. If the alcohol test required by this section is not administered within 2 hours of the accident, the employer must prepare and maintain a record stating why the test was not promptly administered. If the alcohol test was not administered within 8 hours of the accident, the

20 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 as a direct result of the accident: (A) any individual has died or will die; or (B) an individual other than the person has suffered serious bodily injury; and (4) the person refuses the officer’s request to submit to the taking of a specimen voluntarily.‖ 21 As of October 22, 2009, the TxDPS reported that the charge of Fatigued Driver is still pending. The driver never answered the charge, and an arrest warrant was issued and is still outstanding.

NTSB Highway Accident Summary Report 14 employer must stop attempts to administer the test but still maintain the same record. These records shall be submitted to the Federal Motor Carrier Safety Administration (FMCSA) upon request.22 The FMCSA conducted a postaccident compliance review of International, which stated, ―the carrier is being cited for not complying with the postaccident testing requirements. The driver did not complete an alcohol test and did not document why the test was not done.‖ According to the FMCSA, the driver was in the custody of the TxDPS and/or at the hospital for several hours after the accident and, therefore, enforcement action was not taken on this violation.

At the time of the accident, the driver had accumulated 3.5 months of motorcoach driving experience after being hired by the accident motor carrier in September 2007; he did not have any other motorcoach driving experience.23 The driver possessed a valid Texas Class B commercial driver’s license (CDL) with an expiration date of September 7, 2008, and an intrastate commerce-only restriction, which prohibits the driver from exercising the privileges of the license outside of Texas.24 After the accident, the driver was charged by the TxDPS with violating the CDL restriction ―M‖ intrastate only.25 The driver also was cited for duty status not being current (49 CFR 395.8[f][1]) and was found to have no medical certificate card26 in his possession at the time of the accident (49 CFR 391.41[a]), although he did have a medical certificate issued September 6, 2007, that was valid for 2 years. Fatigue In the days preceding the accident, the driver had been working an overnight shift and had been off duty during daytime hours. (See figure 7.) On December 30, 2007, the driver drove from Monterrey, Mexico, to Freer, Texas, and returned to Monterrey, working an overnight shift beginning at 7:30 p.m. He finished work at 7:00 a.m. on December 31, 2007, and was off duty on January 1, 2008, until he reported to work at 7:30 p.m. that evening for the accident trip.

22 Title 49 CFR 382.303(d)(1). 23 The accident driver had experience driving large vehicles, including 2 years of experience driving dump trucks from 1997–1998. In early September 2007, the driver personally hired a motorcoach instructor from a private firm for $250 and obtained 1 hour of instruction in a school bus to prepare for the TxDPS practical examination. Following the training, the private firm’s instructor met the driver at a TxDPS location with a school bus, where the driver passed the driving examination. He was hired by Capricorn on September 16, 2007, and began driving motorcoaches. 24 The driver first held a Texas CDL (Class A) in 1993. In 1997, he received a Class B CDL, and on August 27, 2007, he applied for a ―P‖ endorsement, which was granted on September 4, 2007. 25 As of October 22, 2009, the TxDPS charge of violating the CDL restriction ―M‖ is still pending. The driver never answered the charge, and an arrest warrant was issued and is still outstanding. 26 As of April 1, 2009, this would be considered an out-of-service violation in accordance with the Commercial Vehicle Safety Alliance North American Standard Out-Of-Service Criteria.

NTSB Highway Accident Summary Report 15

Figure 7. Motorcoach driver’s 72-hour work and activity log.27

He then drove from Monterrey, Mexico, arriving at the U.S. border crossing at Laredo, Texas, about 10:30 p.m. After clearing the CBP port-of-entry border crossing checkpoint, the driver and bus passengers stopped for food in Laredo. The driver then continued driving from about 11:00 p.m. on January 1, 2008, until the time of the accident about 4:13 a.m.28

The motorcoach driver’s activities during the 3 days before the accident revealed that he had an inverted work/sleep cycle schedule29 in order to accommodate the carrier’s overnight scheduled line runs (regular routes).30 Although the driver’s available rest period to obtain sleep in those 3 days was close to 30 hours, it is unknown how many hours of sleep the driver actually obtained. Although 30 hours seems reasonable, science and medicine have long accepted that human beings are diurnal, biologically hard-wired to be active during the day and sleepy at night. Individuals who perform ―shift work‖ or work outside the normal ―day work‖ hours are therefore operating in an unnatural temporal environment. Surveys show that 60–70 percent of shift workers report difficulty sleeping, sleepiness on the job, or actually falling asleep unintentionally while at work.31 Even when a shift worker has a consistent schedule and stabilized wake-sleep patterns,

27 The table was reconstructed using toll and border crossing receipts and passenger lists that included departure times, dates, and locations to indicate approximate times. Table entries are primarily based on information provided by the logbook entries and known driving times. 28 According to 49 CFR 395.5, a passenger-carrying driver cannot drive more than 10 hours after 8 consecutive hours off duty, after being on-duty for 15 hours after 8 consecutive hours off duty, or after being on-duty 60 hours in 7 consecutive days or 70 hours in 8 consecutive days. 29 In this context, an inverted schedule is one where the driver’s work/rest cycle is inverted with respect to the day/night cycle; that is, the driver works through the night and sleeps through the day. 30 According to the driver’s logbook, for the 3 months prior to the accident, he worked only overnight shifts, with the exception of three daytime shifts between October and November. 31 T. Akerstedt and L. Torsvall, ―Shift Work. Shift-Dependent Well-Being and Individual Differences,‖ Ergonomics, vol. 24, no. 4 (1981), pp. 265–273.

NTSB Highway Accident Summary Report 16 the risk of substandard and potentially unsafe performance substantially increases32 unless the shift worker is able to obtain sufficient restorative sleep on a regular basis. Studies have shown that sleeping during the day results in less overall sleep and reduced quality of sleep because of light, noise, and other aspects of the physical environment.33,34 Studies of long-haul truck drivers showed that after 13 hours of driving overnight, drivers who had an 8.6-hour off-duty period during the day obtained an average of only 3.8 hours of sleep.35

Considerable research suggests there is a higher risk of fatigue-induced single-vehicle accidents at night; about three times as many fatalities occur per 1,000 accidents from midnight to 6:00 a.m.36 In addition to the problems associated with daytime sleeping, there are additional fatiguing effects associated with circadian disharmony that result from working and being awake at night. Examinations of accident risk relative to the time of day have indicated that accident risk peaks in the early morning from 2:00 a.m.37 to 4:00 a.m.38 The highest risk for a drowsy/dozing driver accident is between 4:00 a.m. and 6:00 a.m., and this accident occurred about 4:13 a.m.39

The driver initially admitted falling asleep at the wheel and waking up when the vehicle began to leave the roadway, but during a subsequent interview with NTSB investigators on January 5, 2008, the driver denied that he told the officer that he had been tired or had fallen asleep while driving. He also stated that after the motorcoach had drifted to the right, he feared the bus might go over the highway’s right side embankment, so his steering input back to the left was immediate and that the motorcoach went out of control and then rolled over into the roadway. There is no indication that the driver was engaged in nondriving tasks, such as text messaging or talking on a citizens band radio, loudspeaker, or cellular telephone, at the time of the accident. Postaccident examination of the roadway and the accident vehicle showed no evidence of braking or steering input by the motorcoach driver prior to departing the right side of the roadway, consistent with the driver’s description of the accident sequence

32 See http://www.fmcsa.dot.gov/spanish/english/science_main.htm, accessed May 7, 2009. 33 (a) T. Akerstedt, ―Adjustment of Physiological Circadian Rhythms and the Sleep-Wake Cycle to Shiftwork,‖ eds., S. Folkard and T. Monk, Hours of Work: Temporal Factors in Work Scheduling (New York: Wiley, 1985). (b) T. Akerstedt, ―Shift Work and Disturbed Sleep/Wakefulness,‖ Occupational Medicine, vol. 53, no. 2 (2003), pp. 89–94. 34 K.H.E. Kroemer, H.J. Kroemer, and K.E. Kroemer-Elbert, Engineering Physiology: Bases of Human Factors/Ergonomics, 2nd ed. (New York: Van Nostrand Reinhold, 1990), p. 176. 35 Compared to daytime shift of driving for 13 hours with an 8.9-hour off-duty period overnight where the average amount of sleep obtained was 5.6 hours. M.M. Mitler, J.C. Miller, J.J. Lipsitz, and others, ―The Sleep of Long-Haul Truck Drivers,‖ New England Journal of Medicine, vo1. 337, no. 11 (1997), pp. 755– 761. 36 See http://www.fmcsa.dot.gov/spanish/english/science_main.htm, accessed May 7, 2009. 37 J.A. Horne and L.A. Reyner, ―Sleep Related Vehicle Accidents,‖ British Medical Journal, vol. 310, no. 6979 (1995), pp. 565–567. 38 G. Kecklund and T. Akerstedt, ―Time of day and Swedish road accidents,‖ Shiftwork International Newsletter, vol. 12, no. 1 (1995), p. 31. 39 R.R. Mackie and J.C. Miller, Effects of Hours of Service Regularity of Schedules and Cargo Loading on Truck and Bus Driver Fatigue, DOT HS 803 799 (Washington, DC: NHTSA, 1978).

NTSB Highway Accident Summary Report 17 itself; however, in NTSB interviews, he did not offer any explanation for his loss of situational awareness or attention to the driving task that resulted in his drifting to the right out of the travel lane. Further, the NTSB interviewed several passengers who had either observed the driver falling asleep or heard others shouting to the driver just prior to the vehicle rolling over. One passenger seated two rows behind the driver reported that just before the driver ―over-steered the wheel,‖ she witnessed him falling asleep. Another passenger reported that after the driver drifted out of the travel lane, she felt the motorcoach swerve and heard a passenger scream for the driver to wake up.

The driver also stated in his interview with NTSB investigators that, upon hearing a passenger yell ―watch it‖ to him in Spanish, his steering input was immediate and rapid. Research has shown that a startled response (whether associated with a redirection of attention or sleep onset) is associated with overcorrection.40 The driver drifting off the roadway suggests that he had been nodding off and that when a passenger screamed and possibly awakened him, he observed the edge of the roadway. He may have immediately attempted to steer away from it as a reactive measure rather than in a deliberative manner, resulting in an overcorrection. This steering maneuver may have also been part of the wakening response. When individuals awaken from Stage 1 sleep (the first stage people enter as they transition from wakefulness to sleep), they frequently experience some degree of mental confusion and vague or fragmented imagery.41

The driver’s own initial on-scene statement, passengers’ reactions, statements regarding the driver’s behavior, and research studies regarding fatigue due to inverted schedules and human sleep cycles all indicate that the driver was most likely fatigued. Because of that fatigue, the driver fell asleep while operating the motorcoach, causing it to depart the roadway, initiating the accident sequence. Consequently, the NTSB concludes that the motorcoach driver fell asleep and partially drifted out of his travel lane. The NTSB further concludes that upon regaining awareness after partially drifting off the roadway, the accident driver overcorrected his steering, causing a loss of control of the motorcoach.

After the accident, Capricorn and International were involved in civil litigation brought by the families of the accident victims. During his civil case deposition,42 Capricorn’s owner was asked whether the company had policies or procedures in place should a driver become fatigued, sleepy, or overly tired before or during a scheduled trip. Capricorn’s owner stated that the company did not have such a policy but that he believed drivers should know what to do. He added that Capricorn’s ―persons in charge‖

40 L.K. Spainhour and A. Mishra, ―Analysis of Fatal Run Off The Road Crashes Involving Overcorrection,‖ Proceedings of the 2008 Transportation Research Board Annual Meeting (Washington, DC: Transportation Research Board, 2008). 41 M.A. Carskadon and W.C. Dement, ―Normal Human Sleep: An Overview,‖ in M.H. Kryger, T. Roth, and W.C. Dement, eds., Principles and Practices of Sleep Medicine, 4th ed. (Philadelphia: W.B. Saunders Company, 2005). 42 Sworn oral deposition taken July 9, 2008. The civil case was settled, and the insurance companies for both International Charter Services, Inc., and Transportes Chavez, Inc., paid a total of $10 million to the plaintiffs (motor carriers of passengers are required to have $5 million dollars in insurance in order to operate).

NTSB Highway Accident Summary Report 18 in Monterrey would not let a driver drive if they knew that he or she was tired. He also stated that he thought the accident driver had received plenty of rest because he was off for 2 days before the accident, although he did not know of the accident driver’s activities during that time.

However, as described earlier in this section, the very nature of overnight operations increases a driver’s level of fatigue and exposes drivers and passengers to increased risk. Moreover, any shift back of even a few hours to daylight activities would have reset the driver’s internal clock, undoing an adaptation to an inverted schedule almost immediately. Therefore, although the driver may have taken some steps to diminish fatigue and possibly reduced his risk of a fatigue-induced crash, there are still risks inherent to overnight operations.

The NTSB has long been concerned with commercial driver fatigue. As a result of the NTSB’s 1999 special investigation,43 the Board issued the following recommendation to the U.S. Department of Transportation (DOT):

Require that the Federal Highway Administration [FHWA]44 fatigue video for motorcoaches include the dangers of inverted duty-sleep periods. (H-99-4A)

On December 7, 2000, this recommendation was classified ―Closed—Acceptable Action.‖ During the course of the Victoria, Texas, investigation, the video was reviewed in an effort to determine what has changed in the study of inverted sleep schedules since the video’s release. The NTSB concludes that since the FMCSA’s fatigue video was created in 2000, scientific understanding of fatigue and fatigue countermeasures has improved, as well as distribution methods available45 for communicating this type of information, to include the Internet, which has the potential to reach even more commercial drivers. Therefore, the NTSB recommends that the FMCSA update and redistribute its ―Driver Fatigue Video‖ to include current information on fatigue and fatigue countermeasures and make the video available electronically; and implement a plan to regularly update and redistribute the video.

More recently, as a result of the investigation into the Osseo, Wisconsin, crash,46 the NTSB issued the following recommendations to the FMCSA:

Develop and implement a plan to deploy technologies in commercial vehicles to reduce the occurrence of fatigue-related accidents. (H-08-13)

43 Selective Motorcoach Issues, Special Investigation Report NTSB/SIR-99/01 (Washington, DC: National Transportation Safety Board, 1999). 44 Upon creation of the FMCSA, the recommendation was transferred from the FHWA to the FMCSA. 45 Such as podcasts, webinars, Internet video downloads, and DVDs. 46 NTSB/HAR-08/02.

NTSB Highway Accident Summary Report 19 Develop and use a methodology that will continually assess the effectiveness of the fatigue management plans implemented by motor carriers, including their ability to improve sleep and alertness, mitigate performance errors, and prevent incidents and accidents. (H-08-14)

On May 11, 2009, the FMCSA responded to these recommendations. In addressing Safety Recommendation H-08-13, the FMCSA indicated that the development of an advanced Drowsy Driver Warning System is underway, moving into principal research and prototype development in 2009. This phase is projected to last 2 years, after which a commercialization decision will be made. The FMCSA also stated that the agency is unaware of any currently available technology that could be used by commercial drivers for both day and night driving. Although the FMCSA is correct that no products are commercially available that could be used both day and night, the agency’s recent published review47 of activities currently underway to develop unobtrusive, in-vehicle, real-time, drowsy driver detection and alertness systems discussed at least five separate systems capable of functioning under a variety of conditions.48 Such systems would provide a significant safety benefit to the segment of commercial operations at greater risk for fatigue-related accidents, namely those that occur at night.49 The Board recognizes that a ―one size fits all‖ technology for detecting driver fatigue is not immediately available. Still, in the interim, the FMCSA should move ahead with the implementation of technologies that are ready today despite their time-of-day limitations. Given the increased fatigue risks inherent in nighttime operations, it is reasonable to believe that even a system that functions only at night could provide a substantial safety benefit as a stop-gap measure until a universal system is available.

The NTSB acknowledges the progress that the FMCSA has made toward meeting the intent of Safety Recommendation H-08-13; however, based on concerns that the FMCSA’s approach ignores technologies that could be more quickly deployed for nighttime use, a time when the majority of fatigue accidents can be expected to occur, the NTSB reclassified Safety Recommendation H-08-13 ―Open—Unacceptable Response‖ on October 2, 2009. Safety Recommendation H-08-14 remains classified ―Open—Acceptable Response,‖ based upon the FMCSA’s work with the North American Fatigue Management Program.50 The NTSB believes the circumstances of this

47 L. Barr, S. Popkin, and H. Howarth, An Evaluation of Emerging Driver Fatigue Detection Measures and Technologies, Report No. FMCSA-RRR-09-005 (Washington, DC: FMCSA, 2009). 48 All illumination conditions (from full sunlight to complete darkness), eyeglasses, contact lenses, most sunglasses, and variable subject distances. 49 (a) M. Mitler, C. Carskadon, C. Czeisler, W. Dement, D. Dinges, and R. Graeber, ―Catastrophes, Sleep, and Public Policy: Consensus Report,‖ Sleep, vol. 11, no. 1 (1988), pp. 100–109. (b) J. Horne and I. Reyner, ―Sleep Related Vehicle Accidents,‖ British Medical Journal, vol. 310, no. 6979 (1995), pp. 565–567. (c) G. Kecklund and T. Akerstedt, ―Time of Day and Swedish Road Accidents,‖ Shiftwork International Newsletter, vol. 12, no. 1 (1995), p. 31. 50 According to the FMCSA, this program is a collaborative effort aimed at reducing fatigue-related accidents and decreasing the personal and economic costs to drivers, companies, and workers’ compensation programs and insurance carriers (NTSB staff communication with FMCSA staff, June 13, 2008).

NTSB Highway Accident Summary Report 20 accident again demonstrate the serious nature of fatigue-related accidents and the need for both in-vehicle technologies and effective fatigue management programs; therefore, the Board urges the FMCSA to continue to work to meet the intent of Safety Recommendations H-08-13 and -14.

NTSB Highway Accident Summary Report 21 Issues The primary purpose of this summary report is to explore, in depth, the process by which a U.S.-based passenger motor carrier was permitted to operate in interstate commerce within the United States with a motorcoach that was not manufactured for use in the United States, and it had not been built to meet Federal safety standards, as required to protect motor vehicle occupants and the public. The owner of the motor carrier in this accident, unable to obtain the insurance that would have enabled him to receive authority to transport passengers as a motor carrier, entered into a lease with another authorized motor carrier in order to continue to operate his business under the other carrier’s authority. This report explores how this process worked and how the process shielded the accident motor carrier from effective safety oversight. Next, the report discusses how the accident motor carrier was able to improperly import motorcoaches into the United States that did not meet Federal safety standards and how the accident vehicle was registered in the United States and obtained license plates and remained undetected and operating in interstate commerce until discovered during the accident investigation. Motor Carrier Operations International Charter Services, Inc. (International), of Houston, Texas, obtained FMCSA operating authority as a for-hire interstate passenger carrier in June 2005.51 International was classified as a ―new entrant‖ to interstate passenger-carrying commerce under the FMCSA’s New Entrant Safety Assurance Program and underwent a safety audit on November 17, 2005.52 Upon meeting all of the new entrant requirements, the FMCSA sent International a letter53 informing the company president that the ―new entrant‖ designation had been changed to ―permanent‖ registration. The letter further stated,

you are reminded that while operating in the United States, you are required to comply with all U.S. Federal Motor Carrier Safety Regulations (FMCSRs), Federal Motor Vehicle Safety Standards (FMVSSs), and applicable Hazardous Materials Regulations (HMRs). The

51 Operating authority is indicated by a motor carrier (MC) number displayed on the vehicle that is distinct from the USDOT number and is separately required in the case of for-hire, interstate motor carriage of nonexempt commodities. The FMCSA grants different categories of operating authority, and the specific operating authority granted limits a company’s type of operation, the cargo it may carry, and the geographical area in which it may legally operate. A USDOT number is a unique identifier used to track safety information collected during audits, compliance reviews, accident investigations, and inspections. 52 When the FMCSA conducted the safety audit, International’s owner was the common-law spouse of the company’s safety manager, who, in turn, was also listed as owner of another motorcoach company, Transportes Chavez, Inc. Chavez had a separate USDOT number and operated a charter service and a scheduled line run from Houston, Texas, to San Luis Potosi, Mexico. Both companies had leased the accident Volvo motorcoach from Capricorn Bus Lines, Inc. 53 FMCSA letter (regarding notification of motor carrier’s status) to International, November 2, 2006.

NTSB Highway Accident Summary Report 22 FMCSA will continue to evaluate you on the same basis as any other carrier.

Eight of International’s motorcoaches54 were leased from Capricorn Bus Lines, Inc. (Capricorn), 55 a company that did not have intrastate operating authority in Texas or interstate operating authority from the FMCSA. According to the owners of International and Capricorn, the lease was a paper agreement, but no monies were ever paid, though the lease stipulated a period of 1 year with a monthly payment of $12,500.56 Capricorn’s owner stated in his civil case deposition that ―it was just an agreement to get the insurance,‖ noting that he conducted all of his lease agreements in this manner; that is, operators would obtain insurance for Capricorn’s buses and Capricorn would operate under their operating authority (in this case, International’s) and using their USDOT number.

The FMCSA has a dual path as part of its current registration process: companies are required to obtain a USDOT number by filling out and submitting an MCS-150 form (Motor Carrier Identification Report [Application for USDOT Number]) and some companies may be required to additionally obtain interstate operating authority by filing an OP-1(P) form (Application for Motor Passenger Carrier Authority). In general, companies that operate as ―for hire‖ carriers (for a fee or other compensation) and transport passengers or federally regulated commodities or arrange for their transport in interstate commerce are required to register for interstate operating authority. Once the FMCSA has furnished a USDOT number, companies must biennially furnish the FMCSA with updated MCS-150 forms.57

Capricorn’s owner further explained in his deposition that he had previously owned and operated another interstate passenger carrier called Flores Charters and Tours, Inc., which ceased operations because the company had a fatal accident in Mexico in

1. Capricorn’s owner thought he could obtain insurance again in the United States

under the new name of Capricorn Bus Lines, Inc., but he was unable to. He then entered a lease agreement with a company called Transportes Chavez, Inc. (Chavez), from June

54 International added several leased motorcoaches to its Texas carrier profile. The lease included a 1997 Van Hool; three model year 2005 Volvos (two were purchased in April 2006 in Mexico); two model year 2004 Scanias; and two model year 2008 Volvos, also purchased in Mexico. 55 Capricorn was incorporated in February 2004; however, in January 2006, the company’s intrastate authority was suspended in Texas for ―tax forfeiture.‖ In 2007, the company registered with the FMCSA for interstate operating authority; however, in July 2007, the company had withdrawn its request and was listed with the FMCSA as ―inactive.‖ The owner of Capricorn had also been listed as the owner of another bus company, Flores Charter and Tours in Houston, Texas (USDOT 827375), from 1999 until 2006, which overlapped the period that he was the owner of Capricorn. Flores Charter and Tours also had its intrastate operating authority suspended twice for ―tax forfeiture‖ in 2006; the company requested that the FMCSA rescind its operating authority due to going out of business. The name ―Flores‖ remained on the buses that were leased from Capricorn to International. 56 During the civil case deposition, Capricorn’s owner stated that he, not Capricorn, owned the accident vehicle because it was a Mexican motorcoach that he was financing in Mexico. 57 See http://www.fmcsa.dot.gov/documents/forms/r-l/MCS-150-Instructions-and-Form.pdf, accessed November 13, 2009.

NTSB Highway Accident Summary Report 23 2005 until June 2006.58 The FMCSA conducted a roadside inspection (Level 1)59 of the accident vehicle on February 22, 2006. The USDOT number recorded for this vehicle and driver was for a U.S.-domiciled carrier, Transportes Chavez, Inc. The FMCSA inspection resulted in the driver receiving an out-of-service (OOS) violation for operating a CMV without a CDL (49 CFR Part 383.23[A][2]); the accident vehicle also received an OOS violation for no or defective bus emergency exit windows (49 CFR Part 393.62[C]).

In 2006, Capricorn’s owner spoke with International’s new Director, who was Chavez’s owner’s common-law spouse and asked whether she could help him obtain insurance and allow Capricorn to use International’s USDOT number. She obtained insurance for Capricorn’s vehicles and entered into two separate yearly term leases with him from 2006 until the accident occurred in January 2008.60 Although Capricorn’s lease with International began in June 2006, Capricorn’s drivers and the accident vehicle underwent roadside inspections in November 2006 and April 2007, and the FMCSA assigned the roadside inspections to Chavez’s USDOT number, not International’s.61

At the NTSB’s public hearing on this accident,62 a witness representing the TxDOT stated the terms of this ―equipment lease‖ required that International carry and maintain public liability insurance but specified that the insurance costs would be paid by Capricorn. In addition to providing the motorcoaches (equipment), the lease required Capricorn to provide drivers and maintain vehicles (including all costs related to repairs, permits, and taxes). Capricorn was responsible for complying with all DOT regulations, hiring and paying drivers (including the accident driver), maintaining driver qualification files, conducting driver drug and alcohol testing, maintaining driver log books, obtaining DOT inspections, conducting posttrip vehicle inspections, obtaining state license plates, and maintaining passenger manifests. Capricorn was also responsible for paying tickets or fines resulting from vehicle or driver violations.

58 There was a documented lease agreement between Capricorn and Transportes Chavez, Inc., dated June 5, 2005; however, it was not signed by Transportes Chavez. 59 There are seven ―levels‖ (or categories) of roadside inspections. Level 1 includes the driver and vehicle (including an inspection of the components on the undercarriage, such as brake adjustment); Level 2 is a driver-and-vehicle walk-around inspection (does not include an inspection of the vehicle’s undercarriage components); Level 3 is the Driver/Credential Inspection only; Level 4 is a special investigation, typically including a one-time examination of a particular item and normally conducted in support of a study or to verify or to refute a suspected trend; Level 5 is a vehicle-only inspection; Level 6 is a Transuranic Waste and Highway Route Controlled Quantities of Radioactive Materials inspection; and Level 7 is a jurisdictional mandated commercial vehicle inspection. 60 These leases were reportedly in writing; however, the June 2006 through May 2007 lease could not be produced by Capricorn during the NTSB’s investigation. The NTSB was able to obtain a copy of the lease beginning June 2007. 61 The April 25, 2007, Level 2 roadside inspection resulted in one driver violation (logbook) and one vehicle violation (windshield); the windshield violation was an OOS violation. The November 9, 2006, Level 2 roadside inspection recorded no OOS violations. 62 The NTSB 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 NTSB investigative staff, designated representatives from the parties to the investigation, and additional parties to the hearing can ask questions to obtain additional factual information (see appendix A). A hearing is not intended to analyze factual information for cause. For more information, refer to NTSB docket no. 67330, files 407014–15, ―Public Hearing—Transcript of Hearing Proceedings and Witness Testimony, October 7-8, 2008, Washington, D.C.,‖ http://www.ntsb.gov/Dockets/Highway/HWY08mh011/default.htm, accessed January 8, 2010.

NTSB Highway Accident Summary Report 24 Capricorn advertised its motorcoach services and sold one-way and roundtrip tickets to the public under the name Capricorn (a U.S.-domiciled company).63 All of these line runs were being operated on U.S. roads under the USDOT number and operating authority assigned to International because the vehicles were being leased on paper to International. A line run, also called a regular route, is a regularly scheduled trip from one or more locations and then back to the original location. If a carrier has FMCSA-issued regular route operating authority, this is the only destination(s) to which the company operates under its FMCSA route designation certificate. Table 2 summarizes the working relationship between International and Capricorn.

Table 2. International and Capricorn working relationship. Dates Event June 2005 International, of Houston, Texas, obtained FMCSA operating authority as a for-hire interstate passenger carrier. June 2006 Capricorn entered into two 1-year ―leasing‖ agreements with International. The paperwork agreement (no monies were exchanged) allowed Capricorn to ―lease‖ buses to International. In turn, International obtained insurance (paid for by Capricorn) for the leased buses and allowed Capricorn to operate them using International’s USDOT number and operating authority.

While operating under International’s USDOT number, Capricorn exercised total operational control of the business, maintaining buses, hiring and training drivers, directing drivers, arranging transportation, keeping records, obtaining state and USDOT inspections, and paying tickets or fines resulting from violations. June 2006–January 2008 Using International’s USDOT number, Capricorn made daily line runs between Houston, Texas; Nuevo Laredo, Mexico; and Monterrey, Mexico, and back. However, International only had operating authority for charter and special operations, not regular routes.

63 Capricorn’s owner also sold tickets to the public under the name Turismo Capricornio (his Mexico-domiciled motor carrier) and Autobuses Flores (a third company that he established for advertising purposes). The three companies were owned by the same person. Tickets sold under the operator name Capricorn were for the portion of the trip made in the United States from Houston, Texas, to the border crossing at Laredo, Texas. Turismo Capricornio tickets were sold (in the United States and at the same time) for the portion of the trip past the border crossing at Laredo, Texas, into Nuevo Laredo, Mexico. The same drivers and vehicles conducted all of the daily line runs (regular routes); only the name of the company on the tickets reportedly changed depending on the portion of the trip.

NTSB Highway Accident Summary Report 25 Federal Safety Oversight After the Victoria accident, the FMCSA conducted a compliance review of International. Capricorn, per the lease with International, was responsible for recordkeeping, so the FMCSA reviewed Capricorn’s vehicle and driver documentation for International’s compliance review rating (recordkeeping is inspected during a compliance review). According to the FMCSA, the agency conducts compliance reviews of the full range of carriers subject to the FMCSRs, including for-hire, exempt for-hire, and private motor carriers; not all motor carriers need operating authority to engage in interstate operations, and the FMCSA routinely conducts compliance reviews of such companies. FMCSA officials also informed the NTSB64 that it takes into consideration which company has control over the driver and ―arranging the transportation‖ in determining the company that is acting as the motor carrier. Although the motor carrier is determined on a case-by-case basis, to a large extent it is the company with ―direction of the driver.‖ However, in the case of International and Capricorn, the FMCSA stated that

In the case of International, the Agency based its decision to conduct the compliance review on International (not Capricorn) on statements made by International’s Manager (who was also the owner of Transportes Chavez, Inc.). The Manager stated the bus involved in the crash had been operated by International and he could provide all the documents for the review.

Capricorn was not subjected to a compliance review nor given a safety rating.

Title 49 CFR 390.5 defines a motor carrier as a for-hire motor carrier or a private motor carrier, including:

A motor carrier’s agents, officers and representatives as well as employees responsible for hiring, supervising, training, assigning, or dispatching of drivers and employees concerned with the installation, inspection, and maintenance of motor vehicle equipment and/or accessories.

In addition, the FMCSA defines65 a company operating with authority as:

Companies that operate as ―for hire‖ carriers (for a fee or other compensation) that transport passengers or federally regulated commodities, or arrange for their transport, in interstate commerce are also required to have interstate operating authority.

64 During July 28, 2009, meetings between FMCSA and NTSB staff. 65 For further information, see http://www.fmcsa.dot.gov/registration-licensing/registration-OP.htm, accessed November 12, 2009.

NTSB Highway Accident Summary Report 26 Title 49 CFR Part 365 requires an operator to hold an appropriate operating authority certificate to transport passengers for compensation or hire. The terms of International’s vehicle ―lease‖ with Capricorn required Capricorn to fulfill all the duties, responsibilities, and operations as defined above of a motor carrier for hire. According to International and Capricorn, Capricorn operated all of its regular route passenger-carrying trips under International’s USDOT number and operating authority certificate,66 for which it agreed to pay International a flat monthly fee (although Capricorn did not actually pay this fee).67 Under the agreement, International effectively relinquished operational control as Capricorn performed all operations. Of significance is that International provided no oversight role over the safety of Capricorn’s operations while Capricorn was operating under International’s certificate.

The FMCSA determined the final compliance review, enforcement action, violation, or penalty based upon its decision regarding which company constituted the motor carrier; in this case, the operating authority certificate holder International. (See the ―FMCSA Remarks‖ section in appendix E.) However, the FMCSA had the discretion, which it has used in other accidents, to conduct an additional compliance review of, and assign a safety rating to, Capricorn. The postaccident compliance review of International revealed that the FMCSA was aware of the lease agreement between International and Capricorn and did not object to the details of that agreement concerning not only equipment but also which company had directional control over the drivers and vehicle maintenance, and, effectively, control over regular route operations. Capricorn’s lease with International constituted an arrangement enabling Capricorn to operate virtually independently, without operational control from International. Based on information obtained during this investigation, Capricorn was never required to demonstrate to the FMCSA that it was capable of safety fitness as required of a motor carrier; the lease agreement effectively kept Capricorn’s operations at arm’s length from International and shielded Capricorn from appropriate FMCSA oversight. In examining the FMCSA’s definitions of a motor carrier and the companies’ roles as outlined in the lease agreement, it is evident Capricorn was operating independently from International as a motor carrier. The owner of International had certified on the application for operating authority it would have in place a system for the safe operation of commercial vehicles, specifically ―policies and procedures consistent with DOT regulations governing driving and operational safety of motor vehicles, including driver’s hours of service and vehicle inspection and repair and maintenance.‖ Multiple critical and acute safety violations were found during International’s compliance review when the FMCSA examined Capricorn’s vehicles and drivers, showing that International was not ensuring that the FMCSRs were being followed and that International did not have a system in place for making sure Capricorn’s operations followed the FMCSRs. The NTSB therefore concludes that International failed to maintain operational control and safety oversight of Capricorn’s

66 Granted upon submission to the FMCSA of Form OP-1(P), ―Application for Motor Passenger Carrier Authority.‖ See . 67 Title 49 CFR Part 365, Subpart D, establishes the transfer rights under 49 United States Code (U.S.C.) 10926 that define the procedures to enable motor carriers of passengers to obtain the approval from the FMCSA to merge, transfer, or lease their operating rights in financial transactions not subject to 49 U.S.C. 11343.

NTSB Highway Accident Summary Report 27 operations, including its drivers and vehicles, as required by the safety certification completed by International in its operating authority application (Form OP-1[P], section 4).

International received an ―unsatisfactory‖ rating for the compliance review’s ―driver‖ factor due to Capricorn’s ―false, incomplete, and/or missing driver log pages.‖ International also received a ―conditional‖ rating for the ―vehicle‖ factor due to Capricorn’s incomplete vehicle documentation and failure to document repairs. International paid a settled fine of $5,84068 and was issued an overall rating of conditional.69 (See appendix E.) Further, International was given a Motor Carrier Safety Status Measurement System (SafeStat) category B rating, which is considered an ―at- risk‖ carrier.70 Although the violations or other enforcement action resulting from a roadside inspection or compliance review may eventually be linked to the person or entity that applied for the USDOT number, this discretionary, case-by-case decision as to which motor carrier should receive a postaccident compliance review (rather than both) does not protect against de facto carriers such as Capricorn that lease a USDOT number to evade detection and enforcement action. Capricorn had clearly defined safety oversight responsibilities in its arrangements to operate under International’s certificate of authority; Capricorn had directional control over the drivers and was responsible for the safety of the vehicles. Therefore, the NTSB concludes that the FMCSA had the authority to conduct a compliance review of Capricorn, but did not, thereby failing to assign the appropriate safety rating for an ―at-risk‖ carrier to a carrier with serious safety violations.

Even if an OOS order is issued to a certificated carrier (in this case, International) based on violations caused by a noncertificated carrier’s drivers or vehicles (in this case, Capricorn), the noncertificated carrier can simply sign another lease with a new carrier or apply for its own operating authority without any link to the safety violations or OOS order. This practice negates the enforcement effect of the OOS order or civil penalties for safety-critical violations. It also has little effect on improving the noncertificated carrier’s safety management behavior because it allows the noncertificated carrier’s management and employees in safety-sensitive positions to avoid accountability for safety violations, deficiencies, and poor management practices. The NTSB notes that, although the postaccident compliance review of International made this lease arrangement clear to the FMCSA, the agency’s inaction in addressing this issue indicated its tacit approval of these arrangements. The Federal government has regulated the leasing of motor vehicles

68 See the FMCSA Motor Carrier Management Information System (MCMIS) Company Safety Profile Enforcement Data Report, p. 6 (July 28, 2009). 69 Safety ratings are as follows: A satisfactory rating means a motor carrier has in place and functioning adequate safety management controls to meet the safety fitness standard prescribed in §385.5. A conditional rating means that a motor carrier does not have adequate safety management controls in place to ensure compliance with the safety fitness standards that could result in occurrences listed in §385.5 (a) through (k). An unsatisfactory rating means that a motor carrier does not have adequate safety management controls in place to ensure compliance with the safety fitness standard, which has resulted in occurrences listed in §385.5 (a) through (k). 70 SafeStat is a data-driven analysis system that determines the current relative safety status of individual motor carriers. SafeStat categories are A, B, and C. Carriers identified in these categories by SafeStat scoring have higher crash rates than carriers that are not identified as category A, B, or C rated carriers http://ai.fmcsa.dot.gov/SafeStat/SSLonger_4-00.pdf, accessed September 29, 2009.

NTSB Highway Accident Summary Report 28 to provide interstate for-hire transportation for more than 50 years.71 Currently, 49 CFR Part 376 applies only to motor carriers registered with the Secretary of Transportation to transport property. Among the provisions contained in the leasing regulations is the requirement that the authorized carrier ―shall assume complete responsibility for the operation of the equipment for the duration of the lease.‖ Further, the lessee-authorized carrier must control the operation and, since it is functioning as the motor carrier, must comply with the FMCSRs.72 However, these regulations allow a loophole for leasing oversight between motor carriers of passengers because they apply only to cargo motor carriers.

The NTSB believes that a motor carrier with OP-1(P) operating authority should be required to exercise documented full operational control over all drivers, vehicles, and trip operations being conducted under its operating authority. The NTSB is concerned that allowing a noncertificated carrier to receive no enforcement action73 while clearly running its business outside of the scope of its operating authority does not provide safety oversight of passenger-carrying operators currently on the road. The NTSB concludes that the FMCSA, by its tacit approval of lease agreements for interstate passenger carriers that are broader in scope than the equipment leases regulated for cargo carriers, in effect provides a lower level of safety oversight to motor carriers that transport passengers than to those that transport cargo. To close this leasing regulation loophole and provide the same level of safety for passengers as is already required for cargo, the NTSB recommends that the FMCSA revise 49 CFR Part 376 to require that passenger motor carriers are subject to the same limitations on the leasing of equipment as interstate for-hire motor carriers of cargo. Scope of Operating Authority To obtain FMCSA interstate operating authority, a passenger carrier must submit a Form OP-1(P) ―Application for Motor Passenger Carrier Authority.‖ Applicants applying for operating authority online must choose the scope of operation for the type of operating authority certificate to be granted:

71 See http://www.fmcsa.dot.gov/about/news/testimony/tst-050608.pdf, accessed September 28, 2009. 72 See http://www.fmcsa.dot.gov/documents/foia/eFOTM-redacted-7-08_pg797-866.pdf, accessed September 28, 2009. 73 Although the FMCSA did not take enforcement action against Capricorn because the agency did not consider Capricorn to be the motor carrier, Texas did. On May 15, 2008, TxDOT informed Capricorn’s owner that the company was being fined a $65,200 administrative penalty after an audit of Capricorn business records resulted in the determination that Capricorn had, in part: failed to prepare and maintain at its principal place of business in Texas documents supporting fee payments and the original registration receipts issued for an interstate carrier; failed to maintain all records and information required by the department at the motor carrier’s principal office in Texas; failed to maintain all books and records generated by a motor carrier at its principal business address for at least 2 years; and failed to register a vehicle required to be registered.

NTSB Highway Accident Summary Report 29

• Charter and Special Transportation Operation,
• Regular Route Transportation, or
• Both.

―Charter and Special Transportation‖ means all types of passenger transportation not on fixed routes. ―Regular Route Transportation‖ is service as a common carrier over regular routes, which permits the carrier to operate only on routes designated by the carrier between fixed facilities.74

International filed an OP-1(P) form requesting charter and special operations service; on June 16, 2005, the FMCSA issued Certificate MC-519270-C to International stating that the carrier had the authority to ―engage in transportation as a common carrier of passengers, in charter and special operations, by motor vehicle in interstate or foreign commerce.‖ Although International provided approximately five charters per month, the main business being conducted under International’s operating authority was Capricorn’s daily route from Houston, Texas, to Monterrey, Mexico.75 However, International did not request regular route authority separately. Capricorn’s motorcoaches advertised the line run service in large lettering on the side and rear of the motorcoaches, listing cities of service and schedules. (See figure 8.) In addition, Capricorn’s driver’s logs clearly showed the dates and times of service, pickup and drop-off locations, and other documentation for the regular route service being provided.

74 Route descriptions are published in the FMCSA Register, and interested parties may file protests to an application within 10 days of publication. The FMCSA must deny the application if a protest or information independently developed by the FMCSA demonstrates that the applicant is not willing or able to comply with safety fitness requirements or with the applicable commercial, safety, or financial responsibility regulations (49 CFR Parts 356 through 396). 75 Two vehicles were in operation at the same time, one departing from Houston, Texas, at 7:00 p.m. and the other departing from Monterrey, Mexico, also at 7:00 p.m. Both schedules required overnight driving, and the motorcoaches would arrive at their respective opposite destinations in about 9–10.5 hours, including time spent at the CBP port-of-entry checkpoint.

NTSB Highway Accident Summary Report 30

Figure 8. Motorcoach with printed regular route schedule.

When the FMCSA conducted its postaccident compliance review of International, it noted specifically that International was operating as both a charter and regular route carrier. However, in the postaccident compliance review, the FMCSA did not cite International for not properly applying for regular route authority nor discuss enforcement action against International for operating outside the scope of its authority. Section 205 of the Motor Carrier Safety Improvement Act (MCSIA), codified at 49 U.S.C. 13902 (e), requires that the FMCSA assess penalties for failure to comply with the motor carrier registration requirements.

Specifically, if a motor carrier operates beyond the scope of its authority, the carrier is subject to certain enforcement penalties.76 In order to restrict commercial highway transportation to those entities having the appropriate operating authority and possessing adequate insurance, the FMCSA specifically mandates placing out of service any driver and vehicle discovered to be operating beyond the scope of the carrier’s authority. Operating outside the scope of a carrier’s authority constitutes a violation of operating authority and is subject to a fine or revocation of that authority. The NTSB concludes that because the FMCSA was aware during International’s postaccident compliance review that regular route service was being provided regularly without International’s having applied for this type of operating certificate, and therefore the carrier was operating beyond its scope of authority, the FMCSA should have taken enforcement action as required by the MCSIA.

76 Federal Register, vol. 71, no. 166 (August 28, 2006), p. 50864.

NTSB Highway Accident Summary Report 31 New Entrant Safety Assurance Program As of January 1, 2003, all new motor carriers operating in interstate commerce must apply for registration as a ―new entrant.‖ As a new entrant, the carrier is subject to an 18-month safety-monitoring period during which the carrier receives a safety audit; 77 in addition, roadside crash and inspection data are evaluated. On December 16, 2008, the FMCSA published a final rule addressing the New Entrant Safety Assurance Program,78 which is intended to improve the FMCSA’s ability to ―identify at-risk new entrant motor carriers and ensure deficiencies are corrected before granting them permanent registration. It also ensures that applicants will become knowledgeable about Federal Safety regulations before they commence interstate operations.‖

The final rule specifically addresses ―reincarnated carriers,‖ defined by the FMCSA as ―a carrier that attempts to register as a new entrant and operate as a different entity under a new USDOT Number in an effort to evade enforcement action and/or out-of-service orders issued against it by the [FMCSA].‖ The new regulations state that any carrier providing false or misleading information or concealing information is subject to revocation of its new entrant registration and civil/criminal penalties.79 The FMCSA also provided additional information on how it has improved the new entrant application vetting process.80 According to the FMCSA, as part of the new entrant screening process, applicants are subjected to a Passenger Carrier Vetting Process (PCVP), an ―in depth investigation of passenger carrier applications for authority to determine if the applicant is a reincarnated carrier.‖

For each application submitted for passenger carrier authority, the FMCSA completes an entire vetting process, including reviewing applications for completeness, sending applications to Division Offices for review, and contacting state agencies to obtain information. The process also includes using an evasion detection algorithm (EDA) to compare the application with other database information against poorly performing carriers dating to 2003.81 Between August 13, 2008, and July 15, 2009,

77 This audit is to ensure compliance with the FMCSRs and Hazardous Materials Regulations and with overall safety management. At a minimum, the safety audit covers driver qualifications, driver duty status, vehicle maintenance, accident register, and controlled substances and alcohol use and testing requirements. During the audit, the carrier is to list any vehicles that it owns, as well as the vehicles leased. For leased vehicles, carriers are to report whether the vehicle is leased ―per trip‖ or ―by term.‖ The carrier must provide evidence to the FMCSA that deficiencies found during the audit are being corrected. A carrier will be granted permanent registration only after the carrier successfully completes an 18-month monitoring period. 78 Federal Register, vol. 73, no. 242 (December 16, 2008), p. 76472. 79 The FMCSA stated that it was planning to address reincarnated carriers under a separate rulemaking in response to the Safe, Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for Users (SAFETEA-LU), section 4113, regarding patterns of safety violations by motor carrier management. The FMCSA also said that it was in the process of revising its registration process to more efficiently track motor carriers. 80 FMCSA presentation by the Motor Carrier Safety Advisory Committee (December 10, 2008). 81 FMCSA defines a poorly performing carrier as: a carrier that has lost its authority to operate or that has a pending revocation; a carrier with an overall rating of conditional or unsatisfactory; a carrier that has

NTSB Highway Accident Summary Report 32 873 new entrant passenger carrier applications were received by FMCSA; 92 percent of these applications were incomplete.82 Of the 873 new entrant applications, 326 were vetted at all levels and are proceeding through the approval process, 101 applications were dismissed for failure to respond to a verification inquiry (VI) or information request (IR), and 17 applications were withdrawn by the applicant. The FMCSA issued a Show Cause Order against one applicant. As of July 15, 2009, 428 applications remained to be vetted.

The NTSB’s investigation revealed that the type of arrangement that the PCVP was designed to detect existed between International Charter Services, Inc.; Transportes Chavez, Inc.; and a newly established company called Bus Trips of Texas. International’s owner is the common-law spouse of Transportes Chavez’s owner; the two companies shared the same terminal, and Chavez’s owner was also the manager for International. Ten months after the Victoria accident, a son of Chavez’s owner, who was the bus maintenance manager (employee) for Transportes Chavez, Inc., and who was known to have run the charter operations for International, applied for and, by June 2009, was granted interstate operating authority to start a new company called Bus Trips of Texas.83 On October 22, 2009, the FMCSA conducted a compliance review, and the company received a satisfactory rating.

According to the FMCSA,84 ―staff thoroughly vetted the Bus Trips of Texas application. The agency’s investigation did not uncover a legally sufficient relationship between International Charter Services, Inc., and Bus Trips of Texas.‖ According to FMCSA officials, ―…International and Bus Trips of Texas have different owners, officers, and managers. For this reason, the FMCSA did not deny Bus Trips of Texas interstate operating authority.‖ The agency further stated, ―the FMCSA’s investigation did not reveal a basis to question the fitness, willingness, and ability of [Bus Trips of Texas’s owner] to comply with the applicable regulations.‖ The FMCSA also stated, ―he did not work for those two companies [International and Capricorn],‖ but then stated ―although the son was an employee of the old company [International], that is not enough to deny operating authority‖; however, the FMCSA also cited during International’s postaccident compliance review that Bus Trips of Texas’s owner also ran the charter operation for International. Further, Bus Trips of Texas’s applicant is the son of Chavez’s and International’s owners (Chavez’s owner was also the manager of International). However, the FMCSA documented that the ―two prior compliance reviews on Transportes Chavez, the company for whom the applicant did work as a bus maintenance manager, resulted in satisfactory ratings.‖ Although Chavez had received a satisfactory compliance review overall, the review cited several vehicle safety regulation violations. The FMCSA documented within International’s postaccident compliance review that International’s owner had informed FMCSA investigators that his son ―runs the charter

prior enforcement action taken against it; and carriers identified by SafeStat as posing the highest potential risk to highway safety. 82 Meetings between FMCSA and NTSB staff members on December 18, 2008, and July 28, 2009. 83 USDOT number 1828782. 84 Meeting between FMCSA and NTSB staff members, July 28, 2009.

NTSB Highway Accident Summary Report 33 operation‖ for International; consequently, the FMCSA had sufficient reason to question the new owner of Bus Trips of Texas regarding his company’s ability to comply with applicable regulations based upon his direct impact as bus maintenance manager for Chavez and as the person responsible for running International’s charter operations. The FMCSA currently has the statutory authority to deny operating authority to an applicant who is unwilling or unable to comply with the safety regulations, other applicable DOT regulations, and the safety fitness requirements. In addition, under 49 CFR 385.306, a carrier that furnishes false or misleading information, or conceals material information in connection with the registration process, is subject to revocation or assessment of civil and/or criminal penalties.

However, the FMCSA contends that its scope of authority to deny or revoke the operating authority of suspected reincarnated carriers is limited. According to a U.S. Government Accountability Office (GAO) report, complexities regarding the application of state laws concerning corporate successorship may, in certain instances, affect the FMCSA’s ability to deny operating authority to or to pursue enforcement against unsafe, reincarnated motor carriers.85 The FMCSA reported that this standard differs between the states, and certain states require very high standards of proof. Even if such a determination is made, the GAO report further notes, the ―FMCSA still faces legal hurdles, such as proving corporate successorship, to deny the company operating authority.‖

The FMCSA also reported that there are legitimate reasons for motorcoach carriers to transfer ownership, or reincorporate, or both, such as new business opportunities or a change in corporate leadership. However, there is already a process in place for these legitimate transfers, under 49 CFR 365 Subpart D, which governs the transfer and/or lease of interstate operating rights for commercial passenger carrier companies. Consequently, new applicants who are existing carriers but choose not to use this process should be subjected to closer scrutiny regarding why the new entrant process was chosen. According to the GAO, many of these carriers are attempting to reenter interstate passenger commerce to evade an OOS order or to avoid paying fines or taking corrective action for previous safety violations found in roadside inspections or compliance reviews.

In 49 CFR Part 365 Subpart D governing the transfer of operating rights, section 365.409(c), applications for one company to transfer its operating rights to another that contain false or misleading information are considered to be void from the beginning. This approach to the submission of false or misleading information, finding the application void from the beginning, should also apply to false or misleading new entrant application information, such as the failure to disclose a relationship with a prior carrier on section 8 of the OP-1(P) form. If an affiliation with another carrier is not disclosed, the FMCSA should be authorized to deny or revoke the operating authority of the applicant based on the FMCSA’s authority for voiding applications under Part 365, potentially

85 Motor Carrier Safety: Reincarnating Commercial Vehicle Companies Pose Safety Threat to Motoring Public; Federal Safety Agency Has Initiated Efforts to Prevent Future Occurrences, GAO Report GAO-09-924 (Washington, DC: U.S. Government Accountability Office, July 2009).

NTSB Highway Accident Summary Report 34 preempting the complexities regarding the application of state laws concerning corporate successorship. In essence, along with the ―leasing‖ of operating authority rights, such as occurred between International and Capricorn, reincarnating carriers may attempt to transfer operating rights from their old companies to new ones by circumventing the process in Part 365 Subpart D.

The FMCSA says that it currently must prove that a new carrier is the corporate successor to the old carrier in order to deny or revoke the operating authority of the new carrier. However, the FMCSA does have a process available for those legitimate transfers of operating rights and the remedy of voiding applications and the revocation of registration and assessment of civil and criminal penalties for applications containing false or misleading information (such as leaving blank the question of affiliation with other carriers or having been previously issued a USDOT number) that could be used in conjunction with the new entrant vetting process.

For other carriers who apply for operating authority through the new entrant program and the PCVP process, the FMCSA should have the authority to prevent reincarnated carriers from receiving approval for operating authority in addition to retroactively revoking operating authority from carriers who received this authority before the vetting system was implemented in August 2008. In its report, the GAO stated that ―the threat these operators pose to the public has proven deadly,‖86 and the NTSB agrees. The NTSB concludes that some motor carriers are circumventing the legitimate corporate succession processes established in 49 CFR Part 365 by reapplying for FMCSA interstate operating authority through the New Entrant Safety Assurance Process, a loophole that may permit unsafe passenger motor carriers to transfer operating rights to newly established motor carriers that may otherwise be prevented by 49 CFR Part 365. Therefore, the NTSB recommends that to help prevent reincarnated carriers from receiving new operating authority, the FMCSA should seek statutory authority to deny or revoke operating authority for commercial interstate motor carriers found to have applications for operating authority in which the applicant failed to disclose any prior operating relationship with another motor carrier, operating as another motor carrier, or being previously assigned a USDOT number. Compliance Review Process and Safety Ratings The NTSB has issued two prior recommendations regarding the importance of driver and vehicle safety violations found during compliance reviews and has stated that such serious violations should result in an unsatisfactory rating. Following a 2005 motorcoach fire in Wilmer, Texas,87 the FMCSA conducted a postaccident compliance review of Global Limo, Inc. (Global), an authorized interstate for-hire passenger motor carrier. The compliance review stated that Global’s driver and vehicle violations were ―so widespread as to demonstrate a continuing and flagrant disregard for compliance‖ and a

86 GAO-09-924. 87 Motorcoach Fire on Interstate 45 During Hurricane Rita Evacuation Near Wilmer, Texas, September 23, 2005, Highway Accident Report NTSB/HAR-07/01 (Washington, DC: National Transportation Safety Board, 2007).

NTSB Highway Accident Summary Report 35 management philosophy ―indifferent‖ to motor carrier safety. The FMCSA determined that the violations detected in the compliance review, both individually and cumulatively, were likely to have resulted in serious injury or death to Global’s drivers and the motoring public. The FMCSA 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 FMCSA determined that Global failed to comply with Federal regulations on drug and alcohol testing, driver qualifications, and hours of service and that Global’s vehicles that were mechanically unsafe due to lack of vehicle maintenance, inspection, and repair. The compliance review cited Global for not retaining vehicle maintenance and repair records, as required; the FMCSA also reported that without pretrip inspections or the required Driver’s Vehicle Inspection Reports (DVIR), Global could not ensure vehicle safety. The same lack of safety oversight was cited in International’s compliance review due to Capricorn’s insufficient DVIR and maintenance records and the absence of a regular vehicle maintenance schedule. However, the FMCSA rated International ―conditional‖ overall; did not issue an OOS; and did not conduct a compliance review of Capricorn, the entity responsible for driver oversight and vehicle maintenance and repairs.

In fiscal year 2008, the passenger motor carrier vehicle national OOS rate was 7.7 percent. In just over 1 year (December 31, 2006, to January 8, 2008), International received 80 vehicle and 103 driver inspections (including inspections of Capricorn’s drivers and vehicles). As a result, International had a vehicle OOS rate of 11.2 percent,88 which was above the national average. This accident once again shows that carriers with driver and/or vehicle factor violations are those more likely to be involved in fatal accidents. The Wilmer, Texas, motorcoach fire and the Victoria, Texas, accident are two of the most recent accidents89 in which the NTSB has focused on the FMCSA’s safety oversight of motor carriers and found inconsistencies based on a safety rating process that fails to ensure the removal of unsafe motor carriers from the nation’s highways.

As expressed in the reports cited earlier, the NTSB has long taken the position that violations of safety regulations are indicative of a motor carrier’s lack of safety management controls. During the Wilmer investigation, the NTSB found that the FMCSA’s safety fitness rating process does not assign numerical value to safety regulation violations that are classified as neither ―acute‖ nor ―critical,‖ thereby allowing potentially unsafe carriers that violate safety regulations to continue operating.

As a result of the Wilmer, Texas, investigation, the NTSB made the following recommendation to the FMCSA:

88 Obtained from the Safety and Fitness Electronic Records (SAFER) System website http://safer.fmcsa.dot.gov/, accessed February 8, 2008. 89(a) Motorcoach Run-off-the-Road and Overturn, Victor, New York, June 23, 2002, Highway Accident Report NTSB/HAR-04/03 (Washington, DC: National Transportation Safety Board, 2004). (b) Collision Between Truck-Tractor Semitrailer and School Bus Near Mountainburg, Arkansas, May 31, 2001, Highway Accident Report NTSB/HAR-02/03 (Washington, DC: National Transportation Safety Board, 2002). (c) NTSB/SIR-99/01.

NTSB Highway Accident Summary Report 36

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)

In addition, the NTSB reiterated another recommendation to the FMCSA.90 This recommendation, which has appeared on the Most Wanted List of Transportation Safety Improvements since 2000, is as follows:

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)

At the NTSB’s August 2006 public hearing on the Wilmer, Texas, accident, the FMCSA explained that when it originally developed the current safety fitness determination (SFD) process, driver OOS rating information was found to be insufficient to accurately determine a driver’s safety performance; the FMCSA has since developed and is pilot testing a data-driven SFD process, which includes items such as vehicle and driver OOS rates, as part of its comprehensive examination of compliance review and enforcement oversight. According to the Comprehensive Safety Analysis 2010 (CSA 2010) initiative website,91 the FMCSA expects to complete the operational model test by June 2010. The University of Michigan Transportation Research Institute will then evaluate the program’s effectiveness (that is, potential for improving safety) and efficiency (that is, impact on scarce resources). The FMCSA expects to fully implement CSA 2010 by the end of 2010. However, until rulemaking has been completed on the new SFD methodology, CSA 2010 implementation will not address the NTSB’s recommendations.

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 timeframe for full implementation of the new program, including the new SFD process, may be another year or more away. 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 are necessary until the new rules are enacted. The FHWA (FMCSA’s predecessor) set a precedent for the issuance of interim rules to improve safety programs when, 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.

90 In a January 9, 2003, letter, the FMCSA informed the NTSB that the Secretary of Transportation had recently reassigned Safety Recommendation H-99-6 to the FMCSA and asked the agency’s administrator to respond to the NTSB directly. 91 For further information, see http://csa2010.fmcsa.dot.gov, accessed November 13, 2009.

NTSB Highway Accident Summary Report 37 Further, in response to Safety Recommendation H-07-3, the FMCSA acknowledged the need to establish an SFD process that better identifies at-risk carriers than the current process under 49 CFR Part 385. However, the FMCSA replied that it was in the best interest of highway safety to focus its resources on implementing CSA 2010 rather than on diverting resources to an interim final rule to make modifications to the SFD process. The NTSB disagreed and classified Safety Recommendation H-07-3 ―Open— Unacceptable Response‖ on September 4, 2008.

And so, as it has done in several accident investigations over the past 10 years, the NTSB again concludes that the current FMCSA compliance review process does not effectively identify unsafe motor carriers and prevent them from operating. The NTSB recognizes the progress that the FMCSA has made with CSA 2010 and the agency’s expected on-time full implementation. The NTSB believes that, to maintain safety in the interim, the FMCSA should focus resources toward changing the current rating methodology by instituting an interim rule that makes adverse vehicle and driver performance-based data alone sufficient to result in an overall unsatisfactory rating for a carrier, while continuing to incorporate the principles of the NTSB’s recommendations into the agency’s new system being field tested and evaluated in CSA 2010. Therefore, the NTSB reiterates Safety Recommendation H-07-3 and both reiterates and reclassifies Safety Recommendation H-99-6 from ―Open—Acceptable Response‖ to ―Open—Unacceptable Response.‖

The NTSB is concerned that motor carriers with significant regulatory violations for drivers and vehicles are still receiving satisfactory and conditional ratings; therefore, the NTSB will continue to highlight accidents in which the postaccident compliance review resulted in a conditional or satisfactory overall rating because it did not take into account the critical nature of the vehicle and driver safety violations. (See appendix F.) The importance of this is evident when taking into account the history of these violations, as well as the impact of the compliance review process on the New Entrant Safety Assurance Program and the vetting of potential reincarnated carriers.

Had the FMCSA adopted the NTSB’s recommendations, Transportes Chavez could have received an unsatisfactory rating based on the vehicle violations found during its compliance review and the roadside inspections of Capricorn’s vehicles and drivers. From this enforcement action, the FMCSA may then have had a basis to question whether Bus Trips of Texas’s owner was sufficiently qualified to adhere to the FMCSRs as required, given his direct connection to the vehicle safety issues of one OOS company (Chavez) and his involvement running the operations of another OOS company (International). International and Capricorn could have received unsatisfactory ratings due to Capricorn’s driver and vehicle violations; instead, Capricorn was not rated and International received a conditional rating, even with the scope-of-authority violation.

In addition, Capricorn’s ―lease‖ arrangement with International also potentially circumvents the New Entrant Safety Assurance Program. The NTSB has discovered that Capricorn is now operating as a new passenger motor carrier named Flores U.S. Bus

NTSB Highway Accident Summary Report 38 Lines Inc. (Flores).92 According to the FMCSA’s database, within 6 months of the Victoria, Texas, accident, Capricorn’s owner had received a certificate to operate another passenger carrier company93 and, on July 8, 2008, Flores conducted its first line run under this operating authority. Capricorn’s (now Flores’s) owner was able to obtain insurance in California and, using two of the same Capricorn drivers and several non-FMVSS-compliant commercial motorcoaches, resumed the same route service from Houston, Texas, to Monterrey, Mexico, that Capricorn had operated.94,95

The reincarnation of carriers such as Capricorn into Flores and International and Chavez potentially as Bus Trips of Texas underscores the need and urgency for the FMCSA to move forward more expeditiously on Safety Recommendations H-99-6 and H-07-3, recommendations that could enhance the effectiveness of the New Entrant Safety Assurance Program in removing unsafe carriers from the nation’s highways. The NTSB concludes that until the FMCSA consistently enforces OOS orders, the New Entrant Safety Assurance Program will be unsuccessful in screening for and vetting carriers with a history of poor safety management controls that attempt to reenter interstate passenger operations as reincarnated carriers.

As has been discovered since the Victoria accident, Capricorn is now operating as Flores with no negative safety associations from the Victoria accident. Because Flores received its operating authority certificate several weeks before the PCVP began in

92 Flores’s USDOT number is 1776152 and its MC number is 648083. On April 30, 2009, its vehicle OOS rate was 23 percent from 17 inspections, as compared to the 2005–2006 national average of 23.1 percent. Flores’s driver OOS rate was 0 percent from 37 inspections compared to the 2005–2006 national average of 6.8 percent. These statistics cover the 24 months prior to April 30, 2009, yet they applied to the Form MCS-150, Motor Carrier Identification Report (Application for USDOT Number) (MCS-150), date of November 26, 2008. Flores underwent a compliance review on October 7, 2008, and received a satisfactory review on October 27, 2008 (just after the public hearing), and after the vetting process began. Flores has the same owner as Capricorn and Flores Charters and Tours, as well as Turismo Flores LLC. 93 Of particular relevance to this accident was that Flores’s insurance broker stated to NTSB investigators that it again assisted Flores in obtaining registration and license plates for the Volvo vehicles in California. 94 Oral deposition taken in the Victoria accident victim families’ civil suit, July 9, 2009. 95 On November 26, 2008, Flores informed the FMCSA via its MCS-150 form that its new physical and mailing addresses were in California; however, the carrier currently operates in Texas, not California, and it has six vehicles in operation, four with California-apportioned plates and two with Texas state plates. The NTSB contacted the Flores’ insurance company and was informed that it assists carriers with registering their vehicles in California and receives their mail. Neither the mailing nor the physical addresses provided on the Flores OP-1(P) form adhere to the FMCSA’s principal place of business definition (49 CFR 390.5). August 2009 regulatory guidance issued by the FMCSA states it has been the agency’s position that a motor carrier’s principal place of business is a physical location where management reports to work and where the motor carrier conducts a significant portion of its business and maintains company records. A motor carrier may not designate as its principal place of business any location where the motor carrier is not engaged in business operations related to the transportation of persons or property. For example, post office centers or commercial courier service establishments that receive and hold mail or packages for third-party pickup may not be designated as a ―principal place of business.‖ A motor carrier may not designate the office of a consultant, service agent, or attorney as the motor carrier’s principal place of business, if the motor carrier is not engaged in operations related to the transportation of persons or property at that location. In the event a carrier does not designate a qualifying location as its principal place of business, the FMCSA may initiate enforcement action or take action regarding the carrier’s USDOT registration (U.S. Department of Transportation, Federal Motor Carrier Safety Administration; 49 CFR Part 390 Regulatory Guidance on the Definition of “Principal Place of Business,” Federal Register, vol. 74, no. 144 [July 29, 2009], p. 37653).

NTSB Highway Accident Summary Report 39 August 2008, the company was not subjected to the New Applicant Screening Process. Yet, the FMCSA has stated that ―experience has taught the FMCSA that carrier noncompliance with the operating authority requirements correlates with carrier noncompliance with the safety regulations.‖96 Even in light of this experience and Capricorn’s affiliation with the Victoria accident and the vehicle and driver violations found, the FMCSA conducted a compliance review of Flores on October 10, 2008, which resulted in a satisfactory rating. Flores was fined for using a driver before receiving a preemployment drug screening test result, one of the same driver safety violations attributable to Capricorn’s drivers found by the FMCSA during International’s postaccident compliance review. This type of violation is critical enough that when Flores failed to pay the October 2008 compliance review fine, its operating authority was suspended on March 31, 2009, and only after paying the fine on April 7, 2009, was its authority reinstated.

The NTSB believes that had the FMCSA, after the Victoria accident, used its statutory authority97 to declare both International and Capricorn as ―imminent hazards‖ and placed the carriers out of service, perhaps these safety violations would not be continuing under the same safety management (Capricorn’s owner is Flores’s owner). Capricorn should have been considered an at-risk carrier because of the numerous acute, critical, and other driver and vehicle safety violations found in its affiliate International’s postaccident compliance review. Yet, because Flores was able to obtain an operating certificate before the FMCSA instituted its vetting of new applicants in the New Entrant program, Flores was not flagged as a reincarnated carrier because Capricorn was never assigned any enforcement action for its violations found in the Victoria accident, and Flores is operating today with a satisfactory rating. Many carriers such as Flores have reapplied to the FMCSA and have either withheld their affiliations with other motor carrier companies (including those with OOS orders) or provided misleading or false information, such as omitting their own previous USDOT numbers to obtain new operating authority.98 This type of omission or false information (including Capricorn’s omission in listing its affiliation with International and Chavez and applying for the Flores operating authority using a nonqualifying principal place of business in California for its same operations out of Texas) is subject to FMCSA enforcement or revocation proceedings, if the FMCSA were to use its PCVP against all carriers currently in the system, not just those who applied for new authority after the screening process was implemented.

The NTSB concludes that there is no effective program or process currently in place to identify reincarnated carriers that reentered interstate passenger operations through the New Entrant Safety Assurance Program before the August 2008

96 Federal Register, vol. 71, no. 166 (August 28, 2006), p. 50864. 97 49 U.S.C. §521(b)(5)(a); Public Law 105-109 §4114; 119 Stat 1144 (Aug. 10, 2005); and 49 CFR 386.72(b)(1). 98 This assertion is based upon the 101 applicants who, during the PCVP process, were shown to have not provided adequate information when requested by a VI or IR letter that potentially may have linked the carrier to a previous carrier with an OOS order or other enforcement action. These applications were dismissed for failure to respond.

NTSB Highway Accident Summary Report 40 implementation of the FMCSA’s New Applicant Screening Process. Therefore, with the FMCSA’s current process of applying the EDA algorithm to match new applicant carriers to carriers in the system dating to 2003, EDA data points can be applied to identify ―reincarnated‖ carriers such as Capricorn that were able to obtain certificates prior to the start date of the New Applicant Screening Process. Therefore, the NTSB recommends that the FMCSA apply the EDA process against all interstate passenger carriers that obtained FMCSA operating authority, after the New Entrant Safety Assurance Program began in 2003 but before the program began vetting those carriers, to verify that those new entrant carriers do not have a concealed history of poor safety management controls because they were able to reenter interstate commerce undetected as reincarnated carriers.

As was discussed earlier in the report, the FMCSA’s New Entrant Safety Assurance Program and compliance review process should also function as a system to evaluate and modify or remove lease arrangements that allow, in effect, an unauthorized entity to operate as a passenger carrier, either in charter or regular route operations. However, the FMCSA would first need to know the extent to which these lease arrangements currently exist. Without such an assessment, the FMCSA is unable to ensure that arrangements permitting unauthorized carriers to operate via paper leases are terminated. By requiring that authorized passenger-carrying operators maintain full operational control of all of their charters and regular route service, the FMCSA will help to ensure that customers who contract with an interstate passenger motor carrier are traveling with a carrier that has exhibited a level of safety approved by the FMCSA. This oversight is not intended to prevent temporary ―per charter‖ or other ―leasing‖ of vehicles or drivers between companies that both have operating authority to fulfill specific charter operations or emergency transportation.

The NTSB concludes that without clear and specific guidance on appropriate lease agreements between OP-1(P) certificate holders and companies providing equipment for charters or regular route service, noncertificated companies could still be performing most, if not all, of the functions of an interstate passenger-carrying operator without regulatory oversight. Therefore, the NTSB recommends that the FMCSA establish a requirement to review all passenger carrier lease agreements during new entrant safety audits and compliance reviews to identify and take action against carriers that have lease agreements that result in a loss of operational control by the certificate holder. State Commercial Motor Vehicle Registration Process Capricorn’s owner purchased the accident vehicle, drove it across the border from Mexico, and operated it in the United States outside of the commercial zone99 with

99 The commercial zone is an area in which passengers or property in interstate or foreign commerce may be transported, in interstate or foreign commerce, when not under a common control, management, or arrangement for a continuous carriage or shipment to or from a point without such zone, that is exempt from all provisions of 49 U.S.C. subtitle IV, part B. Commercial zones generally range from 3–20 miles outside the corporate limits of a municipality, depending upon the municipality’s population. For more information on commercial zones, refer to 49 CFR 372.241.

NTSB Highway Accident Summary Report 41 registration and license plates from Mexico. The owner did not obtain U.S. jurisdictional (state-issued) registration or license plates for his vehicle for over a year while operating in the United States. The accident vehicle was subjected to a roadside inspection in Victoria, Texas, by a TxDPS officer on October 20, 2006. A citation was issued to the driver for an ―unregistered vehicle‖ because the coach had ―only Mexico plates, no Texas permit or registration.‖ The accident vehicle was also subject to two Level 2 inspections100 conducted by the FMCSA101 in 2007 at the Lincoln-Juarez bridge border crossing facility in Laredo, Texas, on January 24, 2007, and May 8, 2007; no violations were noted. A Level 2 inspection includes a driver and vehicle ―walk-around‖ inspection, but it does not include an inspection of the vehicle’s undercarriage.

At the NTSB’s public hearing on this accident,102 the witness representing the TxDPS stated that if a TxDPS officer finds there is intent to operate outside the commercial zone, such as a fixed and permanent line run to a destination outside the commercial zone, the vehicle is required to be appropriately registered with Texas plates.103 In October 2007, Capricorn’s owner utilized the services of the owner of Green River Buses, LLC104 (Green River), in Dallas, Texas, who represented himself (on paper) as Capricorn’s safety manager. Green River next sent the Capricorn accident Volvo’s and another 2005 Volvo’s registration paperwork to a Long Beach, California, company called Baratta Enterprises, LLC (Baratta), which provides registration assistance services. Baratta subsequently processed the documentation through the California Department of Motor Vehicles under the International Registration Plan (IRP) program. The vehicles were registered using the name ―Capricorn‖ and a California address (a requirement for

100 There are seven ―levels‖ (or categories) of roadside inspections. Level 1 includes the driver and vehicle (including an inspection of the components on the undercarriage, such as brake adjustment); Level 2 is a driver-and-vehicle walk-around inspection (does not include an inspection of the vehicle’s undercarriage components); Level 3 is the Driver/Credential Inspection only; Level 4 is a special investigation, typically including a one-time examination of a particular item and normally conducted in support of a study or to verify or to refute a suspected trend; Level 5 is a vehicle-only inspection; Level 6 is a Transuranic Waste and Highway Route Controlled Quantities of Radioactive Materials inspection; and Level 7 is a jurisdictional mandated commercial vehicle inspection. 101 Capricorn drivers were also subjected to three FMCSA roadside inspections at the Lincoln-Juarez bridge while driving the accident vehicle: November 20, 2007; April 9, 2007; and February 7, 2007. No OOS violations were noted. 102 Transcript of Victoria, Texas, public hearing, October 7–8, 2008, Washington, D.C. (See day 1, p. 74, TxDOT.) 103 The TxDPS testified that if a commercial motor vehicle has only Mexican plates and is determined to have a fixed and persistent intent of transportation outside of the commercial zone, it would have to be appropriately registered or the driver would be issued a ticket. The TxDPS would then require the vehicle to obtain appropriate Texas-recognized registration and could order the vehicle ―parked‖ under an OOS order until proper Texas registration was obtained in accordance with Texas Transportation Code 648.101 and 502.002. 104 Green River was placed OOS in April 2008. In August 2008, Autobuses Rio Verde of Irving, Texas, was issued an OOS order by the FMCSA due to its link to Green River, with vehicles, drivers, and management in common. Autobuses Rio Verde’s owner had previously been the terminal manager for Green River; Green River’s owner was the manager and safety director for Autobuses Rio Verde and Capricorn. Autobuses Rio Verde received operating authority on June 5, 2008, after Green River had been placed OOS in April 2008. The FMCSA investigation into Autobuses Rio Verde was due to a roadside inspection that revealed a connection to Green River.

NTSB Highway Accident Summary Report 42 registration) belonging to another bus company;105 the license plates and registration were then forwarded to Green River’s owner.106 Once Capricorn obtained the California registration and IRP-apportioned license plates, Green River’s owner went to the TxDOT in November and December 2007 and had the 2005 vehicles re-registered in Texas107 and obtained Texas (intrastate) license plates.108 The process by which the accident vehicle came to be registered in Texas is summarized in table 3.

Table 3. Accident vehicle registration process. Date(s) Event April 2006 Accident motorcoach purchased in Mexico. April–October 2006 Accident motorcoach operated in the United States with Mexico plates. October 2006 Accident motorcoach ticketed by the TxDPS for lacking Texas plates. October 2007 Accident bus obtained California registration using an intermediary company, Green River. Representing himself on paper as Capricorn’s safety manager, the owner of Green River registered the vehicle in California via the IRP process. At that time, a California registration loophole did not require confirmation of FMVSS compliance or declaration of import for IRP-registered vehicles. November–December 2007 Accident motorcoach’s registration was transferred to Texas; the vehicle obtained Texas intrastate license plates. Because the vehicle was previously registered in California, Texas did not confirm FMVSS compliance before granting Texas registration.

The IRP is a reciprocal agreement providing for commercial vehicle registration among member jurisdictions (U.S. states, District of Columbia, and Canadian provinces). The IRP permits carriers to register their vehicles in one state and operate in several or all other states or Canadian provinces; Mexico does not participate in the IRP.109 Carriers estimate the amount of time (or miles) that they will be operating in any state in which their vehicles travel. The registration fee is then ―apportioned‖ to those states through the ―base state‖ completing the registration. The vehicles(s) is then issued the base state’s license plate, which is embossed with the word ―apportioned,‖ indicating to enforcement

105 The company was Salcido Tours (USDOT 1505841), and its owner stated he did not know anyone from Capricorn. Two rental receipts were provided for documentation according to Green River’s owner. 106 The Dallas business address given for accident vehicle registration in Texas belonged to neither Capricorn nor International, which operate out of two separate physical addresses in Houston. However, the Dallas address was the registered business address for three other companies: Green River Buses, LLC; Autobuses Zacatecanos; and Century Bus Lines. The owner of Autobuses Zacatecanos stated to NTSB investigators that he also helped as many as 50 other bus companies register their vehicles in California, just as Green River’s owner had, before assisting with the transfer of vehicle registrations to other states for interstate (not IRP-apportioned) license plates. In addition, according to documents provided to the NTSB by Baratta, on February 7, 2008 (after the Victoria accident), Transportes Chavez had used a California address and Baratta to register two other vehicles in California through the IRP program. 107 Through the Dallas County Tax Assessor-Collector. 108 The two model year 2008 Volvos remain registered in California. 109 The American Association of Motor Vehicle Administrators (AAMVA) established the IRP in 1973 and recommended it for adoption by all jurisdictions, including Mexico http://www.irponline.org, accessed September 21, 2009.

NTSB Highway Accident Summary Report 43 personnel that the vehicle has registered in and paid fees owed to the states listed on the registration cab card. At the NTSB public hearing on this accident,110 a witness representing the IRP explained that the program promotes the most efficient and economical use of the highway system and revenue sharing based upon mileage operations by motor carriers, so that all jurisdictions receive their fair share of the revenue.

NHTSA is the Federal agency that issues the FMVSSs, which establish the minimum performance requirements for motor vehicle safety systems and components. The agency also regulates the manufacture and importation of motor vehicles to assure compliance with these standards. A vehicle is required to have a certification label meeting the requirements of 49 CFR Part 567 that, among other things, identifies the vehicle’s manufacturer (that is, the actual assembler of the vehicle), states the vehicle’s manufacture date (month and year), and contains the following statement, ―This vehicle conforms to all applicable Federal Motor Vehicle Safety Standards (FMVSS) in effect on the date of manufacture shown above.‖111

However, the process of vehicle registration and license plate issuance is a state function. States individually determine the requirements for registration and license plate issuance, including state-specific requirements to register vehicles in the IRP program. For example, California’s Department of Motor Vehicles reported that requirements for registering vehicles in California under ―non-apportioned‖ intrastate operations differ from those for a vehicle to be operated interstate and thus registered through the IRP. Some states require a manufacturer’s certificate of origin or manufacturer’s state of origin documents to register a newly imported motor vehicle to verify that it meets the FMVSSs. Texas, along with the other three southern border-crossing states (California, Arizona, and New Mexico), all require proof that a vehicle was manufactured using the appropriate FMVSS before being registered with intrastate-only license plates.112

The California Division of Motor Vehicles defines a direct import vehicle as a vehicle that is not manufactured to meet the FMVSSs or California emissions standards and is not intended by the manufacturer to be used or sold in the United States. Currently, an HS-7 form113 is required to register a foreign import vehicle in California for a vehicle to be titled as intrastate, unless the vehicle is exempt due to age. The HS-7 form confirms compliance with the FMVSSs when the vehicle is presented for import by the owner or

110 Victoria, Texas, public hearing, October 7–8, 2008, Washington, D.C. 111 See , accessed on November 13, 2009. 112 During this investigation, NTSB investigators also asked Arizona and New Mexico officials whether they conduct a physical inspection for FMVSS compliance of commercial vehicles registered in the IRP program. Arizona physically conducts an inspection of Mexican-titled vehicles for an FMVSS-compliant certification prior to permitting registration in Arizona for IRP-apportioned plates, while New Mexico does not. 113 Form HS-7, ―Declaration—Importation of Motor Vehicles and Motor Vehicle Equipment Subject to Federal Motor Vehicle Safety, Bumper, and Theft Prevention Standards,‖ http://www.nhtsa.dot.gov/cars/rules/import/hs799short.pdf is required by NHTSA (49 CFR Part 591) and the CBP (19 CFR 12.80).

NTSB Highway Accident Summary Report 44 importer to the CBP at the border crossing from Mexico into the United States. However, when the accident vehicle was registered, California did not require vehicles registered in the IRP to be titled in the state and, therefore, did not require the HS-7 form for the accident motorcoach. As a result of California’s not requiring the HS-7 form, Capricorn’s owner was able to obtain a California-based IRP registration and apportioned IRP license plates114 without proof that the accident vehicle met FMVSSs, which it did not.

Texas considers a vehicle with a non-U.S. title to be imported; to obtain registration, the owner must also apply for Texas title or apply for a registration-only certificate. The TxDOT website states, ―If you purchased a vehicle in another country, you are required to meet all Federal and state importation requirements before you can title and/or register it in the state of Texas.‖ The website specifies that the vehicle must meet the FMVSSs, pass a Texas vehicle safety inspection and visual vehicle identification number (VIN) verification, pass Federal and state inspections, and meet customs requirements before an owner can apply for Texas registration.115 Both processes require the owner or importer to have the vehicle inspected for FMVSS compliance or to submit an HS-7 form. However, Texas’s intrastate registration does not require that the vehicle be physically examined (such as for FMVSS compliance) when the registration is transferred from another state, as when the accident vehicle was transferred from California with apportioned IRP registration and license plates.116

The process used to register the accident motorcoach, along with the others discovered in this investigation, bypassed the regular registration process that newly registered nonapportioned vehicles must undergo. Had Capricorn’s owner gone directly to the TxDOT to register the Volvo after being ticketed by the TxDPS, he would not have been able to register the vehicle using Texas’s IRP process117 because, unlike California’s IRP process, he would have been required to prove that the vehicle had been declared for import to the CBP, had cleared U.S. Customs through the filing of an HS-7 form,118 and had complied with all applicable FMVSSs. Because the Mexican-manufactured Volvo accident vehicle was not intended for the U.S. market and thus was not manufactured to

114 The registration paperwork included estimated miles for apportionment within the United States, not Mexico, based upon the actual mileage accumulated in the states where the vehicle had traveled during the same 6 months of the previous year. However, both International and Capricorn were based in Texas, and Capricorn’s regular route, or line run, did not enter California at all—it operated strictly from Texas to Mexico and back. 115 For further information regarding Texas importation requirements, see http://www.txdot.gov/drivers_vehicles/consumer_protection/importing.htm, accessed September 22, 2009. 116 Texas does require any vehicle that is transferred into the state for operation with Texas registration (interstate or intrastate) to be inspected by a TxDPS licensed inspection facility for basic safety equipment operation, such as lights, horn, windshield wipers, and brakes. 117 The following documentation is required to obtain nonapportioned vehicle registration and license plates: (1) Proof that the vehicle had cleared U.S. Customs and complied with the FMVSSs as evidenced by the Federal certification label affixed to the vehicle itself or a copy of a letter from the manufacturer certifying the vehicle complies with the FMVSSs; (2) a copy of the DOT bond release letter issued by NHTSA; (3) a Certificate of Conformance issued by the California Air Resources Board; (4) evidence of compliance with U.S. Environmental Protection Agency or California emissions standards; and (5) a smog certificate. 118 U.S. Customs forms 6059, 3299, or 3311, stamped or endorsed by U.S. Customs.

NTSB Highway Accident Summary Report 45 meet the FMVSSs, it would not have been permitted to receive Texas registration. Therefore, had the vehicles not been registered via the California IRP process, and then transferred to Texas, the four Volvo motorcoaches119 used in Capricorn’s regular line runs would not have been able to obtain Texas license plates and likely would have been subject to repeated tickets by the TxDPS for failure to have Texas registration. To circumvent this issue, Capricorn’s owner obtained California IRP plates and transferred them to Texas, bypassing Texas’s FMVSS verification process.

Although the state of Texas does inspect IRP vehicles for FMVSS compliance as part of verifying that a vehicle with a foreign title was imported properly, it did not physically inspect the accident motorcoach (or any of the other Capricorn vehicles) for FMVSS compliance because Texas accepted California’s registration and IRP license plates. When asked during the public hearing about this policy, Texas officials answered that because the vehicle had already obtained registration and license plates in another U.S. jurisdiction, Texas assumed that the license plates had been issued based upon verification of the vehicle’s compliance with the FMVSSs. However, that had not occurred because California does not physically inspect vehicles (as Texas does) for FMVSS compliance when a vehicle is registered for IRP-apportioned plates. Had the vehicle been registered in California for nonapportioned intrastate plates, Texas would have been correct in relying upon California’s having verified FMVSS compliance before issuing the registration and license plates.

When the NTSB contacted Green River’s owner, he stated that he registered the vehicles in California because that state only requires a few documents for registration and that he knew of an address in California120 where he could establish a paperwork business ―base‖ for Capricorn. He noted that he had helped about 20 other bus companies121 initially register their buses in California using the same process to obtain a U.S. jurisdictional license plate, eventually transferring them to Texas. The NTSB concludes that when the owner of Capricorn failed to declare importation of the accident vehicle with the CBP upon entering the United States and subsequently obtained vehicle registration using a loophole in California’s IRP program, he intentionally bypassed Federal and state requirements for an imported vehicle to comply with the FMVSSs.

Although California’s IRP registration process did not specifically require documentation that the vehicle met the FMVSSs, it did require that the application include a verification of the vehicle’s VIN. This ―verification‖ consists of comparing the

119 In addition to the accident vehicle and the Volvo registered though the IRP in October 2007, two additional Volvos were registered by Capricorn via the IRP in November and December 2007. 120 He stated that the company at the address that he used was Luna Tours; however, Luna Tours is listed in the FMCSA SAFER database as being located at a residential address in Victorville, California. An Internet search of Luna Tours brought up two other Los Angeles addresses, one of which was the Green River address used for Capricorn’s California registration. The address in the FMCSA database used by the Green River owner was for Salcido Tours. When contacted, Salcido’s owner said that he thought that Luna Tours was located in Chicago, Illinois, or Denver, Colorado, and that the address given for Luna Tours was the residential address for a relative of Luna Tours’s owner. 121 Green River’s owner further informed the NTSB that he is not a Capricorn employee and had received a set fee for registering the vehicles.

NTSB Highway Accident Summary Report 46 VIN on the registration form to the VIN on the vehicle, using a California database to determine whether there were any ―negative‖ entries regarding theft, collisions, nonpaid fees, and so on. Although the VIN itself is designed to provide certain information regarding the vehicle’s manufacture and country of manufacture, no VIN coding expressly identifies whether a vehicle is FMVSS compliant. A law enforcement or Department of Motor Vehicles representative usually determines this via a dealer’s and/or importer’s submission or required documentation or by a physical inspection for a FMVSS certification ―plate‖ affixed to the vehicle.

At the NTSB’s public hearing, California representatives testified that the loophole in the IRP registration process that existed at the time of the Victoria accident has been closed by use of a software program called ―VINA,‖ which is designed to validate and decode the VIN. When the software determines that the vehicle is a direct import, it alerts the technician processing the transaction. However, according to the public hearing testimony, this system is triggered only for new vehicle applications, permitting those non-FMVSS-compliant vehicles already in the country to remain undetected and in possession of current registration and license plates. Consequently, although the new system has closed the loophole in California for new vehicles, it has not addressed the issue for vehicles already operating on U.S. highways.

Interviews conducted during the Victoria accident investigation with Green and other companies led to the discovery of more than 20 other non-FMVSS-compliant foreign-manufactured motorcoaches being used regularly in the United States that were registered the same way as Capricorn’s buses. Many of these vehicles, such as the accident motorcoach, had been stopped and inspected by both state and FMCSA enforcement officials before the Victoria accident. However, once these vehicles obtained U.S. jurisdictional license plates, enforcement officials relied on the U.S. jurisdictions issuing the license plates to have verified FMVSS compliance. The NTSB concludes that because many non-FMVSS-compliant motorcoaches found during this investigation still display U.S. jurisdictional (state) registrations and license plates, inspectors and law enforcement personnel do not have cause to suspect such vehicles of not conforming with Federal law.

The AAMVA represents U.S. and Canadian state and provincial officials who administer and enforce motor vehicle laws.122 The AAMVA’s Vehicle Registration and Title Committee conducts projects affecting vehicle titling and registration issues and promotes AAMVA titling and registration policies. The AAMVA’s policy positions and bylaws include the suggestion that all AAMVA member jurisdictions take steps to withhold registration of any vehicle not originally manufactured for U.S. distribution until the owner presents satisfactory evidence, issued by the Federal government, that all requirements for permanent entry into the United States have been met. Although most states’ procedures for registering nonapportioned commercial vehicles include verifying the VIN and FMVSS conformance through either a physical examination or CBP

122 The AAMVA is a voluntary, tax-exempt, nonprofit educational organization that develops model programs affecting motor vehicle administration, police traffic services, and highway safety. See for more information.

NTSB Highway Accident Summary Report 47 importation paperwork (HS-7 form), New Mexico’s IRP program does not require physical examination for FMVSS compliance and California’s program requires physical examination only for newly registered and re-registered vehicles, not for currently registered vehicles.

Some states, such as New Mexico and California, have apportioned (IRP) registration methodologies that lack the necessary processes to detect conformance with the FMVSSs. NHTSA considers the FMVSSs relevant to a vehicle’s safety such that when the process of vehicle manufacturing is completed, a motor vehicle must comply with the FMVSSs to be legally sold in the United States. In addition, all motor vehicles operated in the U.S. must comply with the FMVSSs.123 Therefore, FMVSS certification is not only important but also required by law. Due to the lack of consistent state verification processes during registration found along the southern border states, non- FMVSS-compliant motorcoaches are being registered and operated in U.S. passenger- carrying service by U.S.-domiciled carriers. The NTSB concludes that some states lack conformity when verifying FMVSS compliance during IRP-apportioned vehicle registrations, permitting U.S.-domiciled companies to operate non-FMVSS-compliant vehicles daily throughout the United States. Therefore, the NTSB recommends that the IRP, Inc., in conjunction with the AAMVA, develop and distribute to the states and the District of Columbia, a model policy, within the IRP registration process, for verifying that newly registered passenger-carrying commercial motor vehicles are certified as having complied with the appropriate FMVSSs in effect at the time of manufacture, as referenced in Title 49 CFR Part 567. Further, the NTSB recommends that the AAMVA assist the IRP, Inc., in developing and distributing this model policy. Non-FMVSS-Compliant Passenger-Carrying Commercial Motor Vehicles The FMCSA and NHTSA, although separate agencies, have complementary responsibilities to ensure vehicle safety. The FMCSA prescribes minimum safety standards for commercial vehicles to ensure that they are maintained, equipped, loaded, and operated safely while in interstate and foreign commerce. NHTSA prescribes vehicle manufacturing standards (FMVSSs) under the authority of the Vehicle Safety Act.124 These systems, under the umbrella of the DOT, are intended to be a combined system of regulations and standards for safety in vehicle operations and manufacturing.

123 See http://www.fmcsa.dot.gov/spanish/english/pdfs/cb_req_eng.htm, accessed November 13, 2009. 124 The Vehicle Safety Act stipulates that motor vehicles and motor vehicle equipment may not be manufactured, sold, or otherwise introduced into interstate commerce or imported into the United States unless the vehicle or equipment complies with the applicable motor vehicle standard and is covered by a certification issued under section 30115 (49 U.S.C § 30112).

NTSB Highway Accident Summary Report 48 The FMVSSs, which deal with the performance of a vehicle and its safety systems, are considered an important safety protection for the public.125 (For more information on FMVSSs applicable to motorcoaches, see appendix G.) The Vehicle Safety Act (49 U.S.C. §30112 and 30115)126 requires that vehicles manufactured for sale in and/or imported into the United States are built to U.S. safety standards (vehicles operating in the United States must be certified by the manufacturer as being built in compliance with the U.S. safety standards). To readily demonstrate compliance with vehicle manufacturing standards, Federal law requires that all vehicles display a certification label permanently affixed to the motor vehicle by the original manufacturer (49 CFR Part 567). Since the introduction of motor vehicle safety regulations, manufacturers have certified compliance with regulatory requirements based on robust design processes and testing protocols and manage production compliance through rigorous manufacturing processes.127 The Vehicle Safety Act’s statutory requirement applies to all vehicles, including passenger-carrying commercial motor vehicles presented for import at border crossings into the United States.

In order to permanently import a vehicle purchased abroad that does not have a certificate label, the vehicle cannot be imported as a conforming vehicle. Importers must contract with a registered importer128 to modify such vehicles and post a DOT conformance bond in the amount equivalent to one and a half times the vehicle’s dutiable value, which is in addition to the normal U.S. Customs entry bond. Under the contract, the registered importer must modify the vehicle and certify that it conforms to all applicable FMVSSs. But before a registered importer can modify a vehicle, NHTSA must have determined that the vehicle is eligible for importation based on its capability of being modified to conform to all applicable FMVSS; NHTSA maintains a database and list of vehicles that have been determined eligible for importation.129

Multiple border crossings throughout the southern United States are utilized by passenger-carrying commercial carriers. (See appendix H.) According to the CBP, 36,955 bus crossings occurred in fiscal year 2006 from Mexico into the United States at the Lincoln-Juarez Bridge, where the accident motorcoach crossed. This is in addition to the other ports of entry into Texas,130 where 55,254 registered bus crossings occurred. In addition, 144,405 bus crossings occurred through California, 17,988 through Arizona,

125 NHTSA has authority over the manufacture and importation of motor vehicles to assure compliance with the FMVSSs; however, NHTSA has no authority over in-service operations and does not conduct inspections on vehicles in use. 126 Originally enacted as part of Section 108, Vehicle Safety Act. 127 M. Schmidt and R. Havelaar, Review of Canadian/Mexican Commercial Motor Vehicle Compliance With FMVSS: Final Report, Texas Transportation Institute, Texas A&M University System submission to the FMCSA (April 30, 2006), p. 71. 128 See http://www.nhtsa.dot.gov/cars/rules/import/web_complete_RI_list062609.pdf, accessed November 13, 2009. 129 See http://www.nhtsa.dot.gov/cars/rules/import/FAQ%20Site/index.html, accessed November 13, 2009. 130 Texas ports of entry are El Paso, Presidio, Del Rio, Eagle Pass, Roma, Rio Grande City, McAllen, Pharr, Progreso, and Brownsville.

NTSB Highway Accident Summary Report 49 and 2,097 through New Mexico’s ports of entry, for a total of 256,699 bus crossings occurring in the United States during fiscal year 2006. As of March 31, 2008, staffing levels at these ports of entry totaled 112 Federal inspectors and 26 state inspectors.131

At the NTSB’s public hearing, the Assistant Inspector General for Surface and Maritime Program Audits, DOT Office of Inspector General (OIG), testified that, in 2005, the OIG conducted an audit of FMCSA’s border crossing inspections and determined that insufficient staff prevented the FMCSA and state officials from inspecting passenger buses at certain designated southern border crossings. Further, in 2007, the OIG identified a major crossing in Texas where inspections could not be done during high volume holidays; thus, passenger bus carriers could avoid inspections during these periods.

U.S. Department of Commerce statistics show that a yearly average of 5,500 motorcoaches were declared for import into the United States from 2004–2008. The majority were declared by their importers as vehicles manufactured to comply with all applicable FMVSSs and certified as such by the original manufacturer.132 NHTSA regulations include a requirement that the importer of a motor vehicle (such as the owner) report the vehicle’s FMVSS conformity status on a DOT HS-7 declaration form to be presented to the CBP at the time of importation (49 CFR 591.5).

During the NTSB’s public hearing, the CBP reported that the accident motorcoach had entered the United States 28 times between September and December 2007 as part of interstate commercial passenger service (line runs averaging 2 roundtrips per week over 16 weeks) without filing a formal HS-7 declaration form. When asked whether the accident motorcoach had NHTSA approval to operate in the United States, Capricorn’s owner stated in his civil case deposition133 that it did not. He added that he did not make sure that the Volvo met the U.S. requirements, even though he knew that he would be operating the vehicle in the United States. Explaining further, he stated that the vehicle was inspected in Texas and was registered in the United States. He said that the first time the vehicle crossed the bridge from Mexico into the United States, the DOT inspected the vehicle and allowed it to continue its trip into the United States. The owner stated that he did not know why the DOT let the motorcoach pass, but he believed that meant he could operate the vehicle in the United States without the certification. When asked how he was able to operate a motorcoach purchased in Mexico within the United States, Capricorn’s owner explained his belief that the lease agreement with International, allowing use of the company’s USDOT number, permitted it.

131 ―U.S. Southern Border Crossings, Truck & Bus Entries from Mexico, FY06 (February 21, 2007)‖ and ―U.S. Southern Border Inspection Staffing (March 31, 2008),‖ (Bethesda, Maryland: Economic Data Resources, 2007–2008). 132 In addition, a few vehicles were imported on a temporary basis for purposes such as research, investigations, demonstrations, or training. According to a NHTSA posthearing submission, in the last 6 years, the agency has investigated 1,200 vehicles, resulting in the vehicles (nonspecified vehicle type) being denied entry, ordered delivered to ports of entry for exportation, or seized. 133 Oral deposition taken in the Victoria accident victim families’ civil suit, July 9, 2009.

NTSB Highway Accident Summary Report 50 During the NTSB’s public hearing, NHTSA stated it did not know the number of non-FMVSS-compliant commercial motor vehicles operating on U.S. highways, either as part of a charter and tour or regular route operation, from Mexico or Canada. In addition, NHTSA does not have statistics reflecting how many non-FMVSS-compliant vehicles have been brought into the United States by U.S.-domiciled companies after having been purchased in another country, driven across the border, and permanently domiciled (without being declared for import) in the United States for use in interstate commerce. According to posthearing data provided by the FMCSA, 265,162 buses entered the United States at the U.S.–Mexico border (California, Arizona, New Mexico, and Texas ports of entry) in calendar year 2007. Of these 265,162 entries, 24,332 buses were inspected (10,832 by the states and 13,500 by the FMCSA), which accounts for 7.4 percent of the entering buses:

 1.2 percent inspected at Level 1;  4.6 percent inspected at Level 3; and,  1.6 percent inspected at Level 5. The TxDPS testified during the public hearing that motorcoaches and buses enter Texas from Mexico at the passenger car border crossings, not the commercial vehicle crossings. Although there are more than 200 TxDPS personnel dedicated to border enforcement at the eight major ports of entry, all of these personnel are at the commercial vehicle crossing. The TxDPS does partner regularly with the FMCSA at the other crossing locations, but only during set ―shift‖ hours, even though motorcoaches are able to cross the border 24 hours a day, 7 days a week.

During its investigation, NTSB staff traveled to the Lincoln-Juarez Bridge crossing and observed motorcoaches with both Mexico and Texas license plates entering the United States; undergoing an FMCSA inspection in conjunction with the TxDPS; and, upon passing the inspection, continuing to Houston, Texas, which is outside of the commercial zone.134 None of these motorcoaches had a visible label bearing a statement certifying FMVSS compliance. The FMCSA does not have the statutory authority to prohibit such vehicles (non-FMVSS-compliant) from entering or operating in the United States.

The current FMCSA vehicle inspection program was not developed, nor does it operate with a component part, for determining FMVSS compliance; therefore, a non-FMVSS-compliant vehicle operating outside of the commercial zone in a line run or scheduled service by a U.S.-domiciled motor carrier with state registration and license plates, such as the accident motorcoach, would not be issued an OOS order by the FMCSA.135 However, the FMVSSs explicitly establish a minimum level of motor vehicle safety in the United States, as explained by 49 CFR Part 571, which states that the

134 August 26–29, 2008, at the Laredo, Texas, border crossing, Lincoln-Juarez Bridge facility. 135 Victoria, Texas, public hearing, October 7–8, 2008, Washington, D.C. (FMCSA testimony).

NTSB Highway Accident Summary Report 51 FMVSSs ―protect the public against unreasonable risk of accidents occurring because of the design, construction, or performance of a motor vehicle, and against unreasonable risk of death or injury in an accident, and include non-operational safety of a motor vehicle.‖ Therefore, the NTSB concludes that current Federal safety oversight programs and importation regulations pertaining to passenger commercial motor vehicles are flawed because improperly imported (that is, not declared for importation) non-FMVSS-compliant motorcoaches operated by U.S.-domiciled motor carriers on U.S. highways in commercial passenger service are not being identified, placed out of service, and subjected to current laws by the agencies responsible for the oversight of safety and importation: the FMCSA, NHTSA, and the CBP.

Currently, even if states put in place a process for checking FMVSS compliance, no method exists to perform that verification, short of also requiring a physical examination of each vehicle for a proper certification label (49 CFR Part 567). In addition, no processes are currently performed during roadside vehicle inspections to verify compliance with these rules, absent checking a label. Although the certification label assures 100 percent FMVSS-compliance, there are vehicles permitted to be imported that do not have a certification label. Such vehicles may be imported solely for the purposes of research, investigations, demonstrations, training, or competitive racing events. In addition, some vehicles purchased outside the United States for temporary use in the United States may not have a certification label. For example, the vehicle would be eligible for import if the owner was a member of the armed forces of a foreign country on assignment in the United States and the vehicle was being imported for temporary and personal use only. (See appendix C.) The NTSB concludes that not having an electronic FMVSS verification process available to Federal, state, and local law enforcement personnel to use during roadside vehicle inspections makes it difficult to verify whether passenger-carrying commercial motor vehicles meet the FMVSSs. Therefore, the NTSB recommends that NHTSA develop, in conjunction with the FMCSA, a Web-based database of FMVSS-compliant passenger-carrying commercial motor vehicles that can be utilized by Federal, state, and local enforcement inspection personnel to identify non-FMVSS-compliant passenger-carrying commercial motor vehicles so that these vehicles (other than exempted vehicles) are placed out of service and cease operating in the United States and implement a process to periodically update this database; and that the FMCSA assist NHTSA in developing and updating this database. The NTSB further recommends that when the database requested in Safety Recommendation H-09-30 is completed, NHTSA make the database known and accessible to state vehicle registration agencies and to Federal, state, and local enforcement inspection personnel for their use during both roadside inspections and compliance reviews to identify non-FMVSS-compliant passenger-carrying commercial motor vehicles. The NTSB also recommends that the FMCSA require that Federal and state inspectors utilize the database requested in Safety Recommendation H-09-37 during both roadside and compliance review inspections of passenger-carrying commercial motor vehicles to identify and place out of service non-FMVSS-compliant vehicles. In addition, the NTSB recommends that the FMCSA institute a requirement for Federal and state enforcement officials to obtain training on a procedure to physically inspect passenger-carrying commercial motor vehicles for an FMVSS compliance label, and work with the CVSA to

NTSB Highway Accident Summary Report 52 develop and provide this training. The NTSB further recommends that the CVSA assist the FMCSA in developing and providing this training. U.S. Performance Standards and Operational Safety Requirements for Vehicles Operating in the United States History According to the FMCSA,136 from about 1975 to 2005, the DOT believed that when a motor carrier used a commercial vehicle to transport passengers or freight into the United States, it should be construed as importation. The DOT undertook rulemakings in 2002 to establish a mechanism to ensure that Mexican carriers transporting passengers into the United States complied with importation regulations and to require that these vehicles display an FMVSS certification label. In addition, the DOT sought to introduce a definition for ―import‖ into the regulations. However, both the FMCSA’s and NHTSA’s notices of proposed rulemaking (NPRM) were withdrawn. The withdrawals137 stated that the DOT, after reviewing the public comments, determined that alternate interpretations of ―import‖ existed and that it no longer considered a foreign carrier’s simply operating a truck or bus in the United States to be ―importation.‖ Part of the justification for this change was that these vehicles would be classified strictly as instruments of international traffic (IIT), as defined by CBP regulations.138 These regulations permit a vehicle to come into the United States to bring in cargo or passengers, but once the cargo or passengers have been transferred, the vehicle would have to leave the United States and return to its country of origin. The vehicle may also take out cargo or passengers when leaving for its country of origin. Moreover, the FMCSA determined there was no need to impose a requirement for the display of a statement label certifying compliance with the FMVSS as proof. The withdrawal notice indicated that the FMCSA was not focusing on certification labels but on making sure the vehicles complied with the FMCSRs while in the United States. Foreign-Manufactured Vehicles The FMCSA’s and NHTSA’s 2005 NPRM withdrawals state that, generally, only commercial motor vehicles (CMVs) manufactured for sale or use in the United States may be registered in the United States. The NPRM withdrawal language continues that the laws and regulations concerning the importation of vehicles for sale or use effectively preclude U.S.-based motor carriers from purchasing or leasing vehicles for use in the United States unless the vehicles were originally manufactured for, or subsequently modified for, such use. Under 49 U.S.C. §30112, §30115, and §30141, and 49 CFR

136 Transcript of Victoria, Texas, public hearing, October 7–8, 2008, Washington, D.C., p. 94. 137 For further information, see Federal Register, vol. 70, no. 165 (August 26, 2005), pp. 50269– 50290, docket nos. FMCSA-01-10886 and NHTSA-2005-22197. 138 See 19 U.S.C. 1322(a) and 19 CFR 10.41, 123.14, and 123.16.

NTSB Highway Accident Summary Report 53 Parts 567, 591, and 592, a U.S. motor carrier cannot import a vehicle manufactured in a foreign country for use in the United States unless (1) the original manufacturer certified, at the time of manufacture, that the vehicle complied with the applicable FMVSSs, or (2) a registered importer certified that the vehicle was modified to comply with applicable U.S. safety standards.139 However, as discovered in this accident, foreign- manufactured motorcoaches have been and are still being purchased by U.S.-based carriers and brought into U.S. jurisdictions and registered.

The FMCSA stated that U.S. jurisdictional registration documents could be used by Federal and state inspectors to verify a CMV’s model year and VIN and, by extension, the FMVSSs applicable to the particular CMV. However, Volvo did not manufacture the accident vehicle to meet the FMVSSs, as it was not intended for sale in the United States. Though the vehicle had undergone both Federal and state safety inspections in which inspectors had access to the VIN and Texas registration documents, no one recorded that the vehicle was not FMVSS compliant. However, a VIN alone cannot be used for FMVSS certification. This contradicts the FMCSA’s statement in its NPRM withdrawal that ―Federal and state enforcement officials conducting roadside inspections could rely on a VIN and registration in a U.S. jurisdiction as evidence of FMVSS compliance.‖ This is a loophole that the FMCSA had not addressed in its NPRM withdrawal or since to ensure that U.S. jurisdictions only register vehicles imported properly into the United States.

So, although the accident motorcoach was not presented to the CBP for import, it was purchased by a U.S. carrier as a vehicle manufactured for sale and use in a foreign country—a practice that the DOT was clear is not permitted. The FMCSA also states that motor carriers are responsible for ensuring vehicles introduced into their fleets are maintained to the safety standards of the FMCSRs, including those that cross-reference the FMVSSs. However, vehicles manufactured for sale in a foreign country that are not certified by the manufacturer for FMVSS compliance because the vehicle did not meet the FMVSSs in manufacturing or was not certified by the manufacturer or importer as having met the FMVSSs post-manufacturing, cannot be maintained to the safety standards for systems they do not possess or pass an inspection based upon maintenance of nonexistent systems or manufacturing standards. Because the FMCSA, by virtue of its own statements in the 2005 NPRM withdrawal determination, does not permit a U.S. motor carrier to purchase, import, or operate a non-FMVSS-compliant vehicle in the United States, the NTSB concludes that the accident vehicle and all other non-FMVSS-compliant buses inspected by the FMCSA should be detected during FMCSA roadside inspections and compliance reviews and subsequently reported to the proper Federal and state agencies for enforcement.

The FMCSA’s 2005 NPRM withdrawal stressed that if the FMCSA finds, during the preauthority audit140 or subsequent inspections, that a Mexico-domiciled carrier has

139 Federal Register, vol. 70, no. 165 (August 26, 2005), p. 50274. 140 Mexico-domiciled carriers seeking U.S. authority to operate in the United States under the North American Free Trade Agreement cross-border demonstration project were required to receive and pass an FMCSA safety audit before receiving provisional operating authority. The safety audit consisted of a

NTSB Highway Accident Summary Report 54 falsely certified its vehicles as FMVSS compliant, the FMCSA ―may use this information to deny, suspend, or revoke the carrier’s operating authority or certification of registration or issue appropriate penalties for the falsification.‖ Further, the FMCSA was very specific in its NRPM withdrawal that it must rely on a strong verification program to confirm certifications by Mexico-domiciled carriers (on the application form for FMCSA operating authority) so that they will operate only FMVSS-compliant CMVs in the United States beyond the border commercial zones. Currently, U.S.-domiciled motor carriers operating for hire do not have to certify on their OP-1(P) forms that they use only FMVSS-compliant vehicles (self-certification). This position would seem to discount the importance of FMVSS compliance, contradicting the FMCSA’s repeated statements during the NTSB’s public hearing that the FMCSRs cross-reference some FMVSSs and, therefore, that the inspections and inspection criteria evaluate the current operational safety status and ensure that motor carriers maintain the safety performance features of the vehicle and equipment. The NTSB concludes that the lack of a requirement for U.S.-domiciled carriers to certify the use of FMVSS-compliant passenger vehicles in interstate commerce has created a gap in safety oversight, allowing non-FMVSS-compliant commercial passenger vehicles to be used by U.S.-domiciled carriers on U.S. highways. This loophole is evidenced by the fact that, during the Victoria accident investigation, even when notified of the non-FMVSS-compliant accident motorcoach, the FMCSA did not pursue FMVSS certification verification. Therefore, the NTSB recommends that the FMCSA require that passenger motor carriers certify on their OP-1(P) forms and initial MCS-150 form (Motor Carrier Identification Report [Application for USDOT Number]) and subsequent required biennial submissions that all vehicles operated, owned, or leased per trip or per term met the FMVSSs in effect at the time of manufacture. The NTSB further recommends that the FMCSA seek statutory authority to suspend, revoke, or withdraw a carrier’s operating authority upon discovering the carrier is operating any non-FMVSS-compliant passenger-carrying commercial motor vehicles, a violation of the FMVSS-compliant certification requested in Safety Recommendation H-09-40.

The Commercial Vehicle Safety Alliance (CVSA)141 is an international not-for-profit organization comprising local, state, provincial, territorial, and Federal motor carrier safety officials and industry representatives from the United States, Canada, and Mexico. Specially trained inspectors in each state, jurisdiction, and province inspect vehicles based on criteria created by the CVSA. CVSA inspectors are currently verifying a motor carrier’s operating authority during roadside inspections and are taking enforcement action against carriers found to be operating without authority, with inactive authority, or beyond the scope of their authority.

review of the carrier’s safety data, a review of requested motor carrier documents, vehicle inspections, and an interview session with the motor carrier’s safety official by a trained safety auditor. This demonstration project was terminated effective March 11, 2009, and the FMCSA revoked all registrations issued in connection with it. For further information on this program, see http://www.fmcsa.dot.gov/spanish/english/pdfs/cb_req_eng.htm and , accessed November 13, 2009. 141 See http://www.cvsa.org/about/index.aspx, accessed September 28, 2009.

NTSB Highway Accident Summary Report 55 Once a U.S.-domiciled passenger motor carrier has attested on its OP-1(P) form and subsequent MCS-150 forms that it will only operate an FMVSS-compliant vehicle, and NHTSA has created an FMVSS-compliance database, the compliance status of a carrier’s vehicle can be verified. Thereafter, if during the roadside inspection, a carrier’s vehicle is determined to be noncompliant, the vehicle can be placed out of service because it is being operated in violation of its operating authority. The resulting OOS order will then be directed back to the FMCSA, enabling the agency to revoke the carrier’s operating authority for operating without or beyond the scope of authority granted under the OP-1(P) and MCS-150 forms. The NTSB recommends that the CVSA revise the North American Standard Out-of-Service Criteria to include passenger motor carriers discovered to be violating their operating authority by operating non-FMVSS-compliant passenger-carrying commercial motor vehicles. U.S. Vehicle Performance Standards and Regulations Although FMCSA representatives stated during the NTSB’s public hearing that the FMCSA could effectively ensure a motor carrier’s compliance with applicable FMVSSs through continued vigorous enforcement of the FMCSRs, the NTSB notes that the U.S. Government relies upon the criteria established by the FMVSSs to show that a vehicle meets minimum acceptable safety requirements during crash and other testing. Although proper maintenance helps to ensure that non-FMVSS-compliant components will not malfunction, it cannot be determined, unless independently tested or involved in a real-world crash, whether the components would meet FMVSS criteria for preventing unreasonable risk of injury or death to vehicle occupants.

Without FMVSS certification and vehicle inspections (an unlikely occurrence given the low numbers of roadside passenger commercial motor vehicle inspections performed at border crossings), no consistent or mutually supportive set of regulations or procedures ensures FMVSS compliance, which is incongruent with the intent of the Vehicle Safety Act. The Vehicle Safety Act’s language is explicit in stating that preexisting motor carrier safety regulations should not differ in substance or impose any lesser standard of performance than manufacturing standards.142 In its 2005 NPRM withdrawal, the FMCSA concluded that FMVSS certification labels were not needed and that the enforcement of the FMCSRs would ensure compliance with the FMVSSs with which they were cross-referenced. However, according to NHTSA’s public hearing testimony, an inspection cannot determine the dynamic capabilities of certain FMVSSs, and it would be very difficult to determine compliance with certain FMVSSs unless an inspector specifically looked for the certification label found inside the vehicle, which would definitively establish that the vehicle was originally manufactured to meet applicable FMVSS standards. Further, due to regulatory limitations (49 CFR 350.201[y]), unless a serious safety defect is observed, the FMCSA can only perform bus or motorcoach roadside inspections at terminals or destination stops, which include border crossings. In 2007, the FMCSA conducted only 13,500 vehicle inspections of the 265,162 total bus crossings (5.09 percent).

142 M. Schmidt and R. Havelaar, p. 80.

NTSB Highway Accident Summary Report 56 Some FMCSRs address the current operational safety of components that wear out over the life and use of the vehicle, while others cross-reference the FMVSSs to ensure that required equipment is in place and maintained. Even though certain FMCSRs cross-reference the FMVSSs during an inspection, there are fundamental problems in relying on this system to verify FMVSS compliance. Some FMVSSs cannot be verified by FMCSRs because a visual inspection cannot detect whether the vehicle meets a performance standard—such as the 60-mph stopping distance (49 CFR 571.121 [S5.31]). Further, other FMVSS items exist that are not cross-referenced with the FMCSRs and, therefore, are not inspected, including flammability of materials, controls, and displays. Finally, although a violation of an FMCSR that happens to cross-reference an FMVSS should result in bringing that FMVSS violation to the minimum safety standard, not all FMCSR violations are serious enough to place the vehicle out of service and therefore there is no guarantee that the item will be brought to the minimum safety standard. Also, for those FMCSR violations that cross-reference the FMVSS and constitute a serious enough safety hazard to cause an OOS order, there is no system to permanently remove the vehicle from service until the problem is remedied, especially if it is a design or manufacturing issue that cannot be resolved and therefore never be made FMVSS compliant.

The statistical likelihood of a Level 1, Level 2, or Level 5 inspection occurring at a border crossing is very low (about 2.8 percent).143 The FMCSA indicated at the public hearing that its roadside inspectors who check for operational compliance with the FMCSRs are qualified to determine the performance safety of the vehicle and therefore may supersede the requirement for the vehicle to meet the NHTSA performance standards in the FMVSSs. Although the FMCSRs focus upon a company’s operating safety and vehicle maintenance, the FMVSSs are integrated into a vehicle’s manufacturing and, therefore, are also applicable to a vehicle’s everyday level of safety. This cannot be minimized by stating that the FMCSRs are a better barometer of a vehicle’s safety. The FMVSSs and FMCSRs are meant to work together; therefore, not requiring safety standards for commercial passenger vehicles defeats the purpose of these regulations. The NTSB disagrees with the FMCSA’s policy of not enforcing the requirement for passenger-carrying CMVs to display a label of certification documenting the vehicle’s compliance with all applicable motor vehicle safety standards and concludes that the FMCSA’s policy of not enforcing the requirement for passenger-carrying commercial motor vehicles to display a label of certification documenting the vehicle’s compliance with all applicable motor vehicle safety standards and its failure to help identify and place out of service non-FMVSS-compliant vehicles undermine NHTSA’s efforts as a partner safety agency.

By granting a ―passing grade‖ to non-FMVSS-compliant motorcoaches inspected roadside at the border or during annual or periodic inspections when they do not meet the FMVSSs (easily identifiable by the lack of a certification label), such as was the case with the accident bus, the FMCSA is tacitly permitting any non-FMVSS-compliant vehicle to operate on U.S. roads.

143 FMCSA bus inspection data provided during public hearing for 2007 calendar year at the U.S. and Mexico borders.

NTSB Highway Accident Summary Report 57 During its investigation, the NTSB discovered numerous passenger-carrying vehicles operating in commercial interstate commerce that were not manufactured to FMVSS criteria; however, they were based, registered, and operated in the United States by domestic carriers, which appears contradictory to 49 U.S.C 30112, which states:

A person may not manufacture for sale, sell, offer for sale, introduce or deliver for introduction in interstate commerce, or import in to the United States, any motor vehicle or motor vehicle equipment manufactured on or after the date an applicable motor vehicle safety standard prescribed under this chapter takes effect unless the vehicle or equipment complies with the standard and is covered by a certification…

Vehicles entering the United States from Mexico present specific difficulties in safety oversight for both the states and the FMCSA. Although the CBP inspects every vehicle for contraband, spending approximately 30 minutes per vehicle, the FMCSA does not conduct a roadside inspection of every vehicle to determine whether it complies with the FMCSRs, which are the regulations that establish safe operating and maintenance requirements for vehicles and their equipment.144 This practice leaves an enormous gap in a system meant to improve the safety of commercial vehicles and reduce crashes, injuries, and fatalities.

The CBP does not initiate an importation process for vehicles until an owner or importer declares a vehicle for importation.145 The regulations pertaining to imported vehicles state that they must either be FMVSS compliant or be brought in through the Registered Importer Program. Although some motorcoaches are currently being operated outside of the commercial zone (during cross-border line runs) by foreign-domiciled carriers under the IIT provisions, the IIT exemption has created a regulatory situation that is being exploited by U.S.-domiciled carriers.

NHTSA stated at the NTSB’s public hearing146 that it can work with the CBP, U.S. Immigration and Customs Enforcement, and the U.S. Environmental Protection Agency when it learns of vehicles being brought into the United States permanently without being declared and that do not have labels certifying compliance with applicable FMVSSs affixed by the original manufacturer. In the past, NHTSA’s Import and Certification Division has taken action upon learning that imported, noncompliant motorcoaches were being operated in the United States, including seizing noncompliant motorcoaches.

144 Only 7.4 percent of motorcoaches entering the United States were stopped in 2007 for inspection, with only 1.2 percent of those motorcoaches receiving an inspection sufficient to detect potential problems with FMCSR items that cross-reference the FMVSSs. 145 A vehicle owner or importer must declare the vehicle for importation to the CBP within 15 days of the vehicle’s being brought into the United States. 146 Victoria, Texas, public hearing, October 7–8, 2008, Washington, D.C.

NTSB Highway Accident Summary Report 58 Well-established law and regulation147 require that all vehicles, including motorcoaches, operate in the United States only with appropriate certification provided by their original or final-stage manufacturers or by their importers. The NTSB concludes that current DOT policy allowing the FMCSA to cross-reference the FMVSSs during a vehicle’s inspection and, if the vehicle is not placed out of service, accept that as evidence of adherence to FMVSS performance standards, is faulty based on the FMCSRs’ lack of performance testing during a vehicle inspection. Given the low likelihood of a full vehicle inspection at the U.S.–Mexico border crossings, there is no guarantee of adherence to the FMVSSs or of disincentives for not doing so, such as penalties. The NTSB recommends that the DOT direct NHTSA and the FMCSA to work in conjunction with the CBP to develop and implement a process to detect motor carriers that are currently operating non-FMVSS-compliant motorcoaches or other passenger-carrying commercial motor vehicles, other than exempted vehicles, in the United States (outside of the commercial zone), and when such vehicles are detected, to ensure that the FMCSA has the authority to place such vehicles out of service and require that these motor carriers cease operating those vehicles in commercial interstate passenger service or face revocation of their operating authority. The NTSB also recommends that the CBP assist the DOT in developing a process to detect and report to the DOT information on motor carriers identified during its border crossing inspections of passenger-carrying commercial motor vehicles to be currently operating non-FMVSS-compliant passenger-carrying commercial motor vehicles, other than exempted vehicles, in the United States (outside of the commercial zone), and assist the Department in ensuring such vehicles are placed out of service and requiring these motor carriers cease operating those vehicles in commercial interstate passenger service. Federal Importation Definitions In 1975, NHTSA interpreted 49 U.S.C. 30112 (Vehicle Safety Act) as applying to all vehicles entering the United States. This law prohibits a motor vehicle from being placed into interstate commerce or imported into the United States unless it is certified as complying with the FMVSSs applicable at the time of manufacture. NHTSA also explained that the Vehicle Safety Act’s prohibition against noncomplying vehicles entering the United States is similar to laws against contraband.148

NHTSA’s 2005 NPRM was focused on whether the word ―import,‖ as used in the statute, necessarily applied to commercial motor vehicles that are used temporarily in the

147 Title 49 CFR Parts 591-593, 49 U.S.C 30112A and 30115, and SAFETEA-LU Section 4139(c). NHTSA’s 2002 NPRM on FMVSS certification (Federal Register, vol. 67, no. 53 [March 19, 2002], pp. 12789–12797) stated: ―Neither the statute nor any agency regulation exempts commercial vehicles domiciled in Canada or Mexico from the requirement that the vehicles must have been manufactured to meet the FMVSSs in order to be imported into the United States.‖ 148 NHTSA’s 2002 NPRM on FMVSS labeling (docket no. 02-11593) stated, ―In particular, we believe that the Vehicle Safety Act’s prohibition on the importation of non-complying vehicles is analogous to contraband laws that prohibit the importation of dangerous items.‖ The CBP website http://www.cbp.gov/xp/cgov/trade/basic_trade/importing_car.xml, accessed September 29, 2009, states, ―Vehicles entering the United States that do not conform with U.S. safety standards must be brought into compliance, exported, or destroyed.‖

NTSB Highway Accident Summary Report 59 United States and subject to an alternative regulatory program designed to ensure the vehicles operate safely while on U.S. roads. NHTSA pointed to the U.S. Customs classification of such vehicles as ―instruments of international commerce,‖ as there is no NHTSA definition of the term ―import.‖ Therefore, in its 2005 NPRM, NHTSA evaluated three separate issues when reviewing the 1975 interpretation, as follows:

• The language of the Vehicle Safety Act and Congressional intent;
• A reevaluation of existing case law relevant to the use of the term ―import‖

outside of the context of tariff law to see whether and how other statutes defined the term; and

• Additional factors and interpretations not taken into account in 1975.

As a result, NHTSA withdrew its 1975 interpretation altogether and decided against placing a definition of the term ―import‖ in the CFR after concluding that creating a new regulation to define the term serves no regulatory function and was unnecessary for motor vehicle safety. NHTSA also determined that its previous interpretation of the importation restriction on noncertified foreign-domiciled commercial motor carriers may be overly encompassing and place unreasonable restrictions on foreign-based motor carriers.149 The NPRM explained that since 1926, courts have consistently held that in tariff cases, unless it clearly appears that Congress intended otherwise, the term ―importation‖ means the bringing of goods within the jurisdictional limits of the United States with the intent to unlade. The courts have given deference to a Treasury Department ruling cited in Estate of Levi H. Pritchard v. United States,150 which states,

If coming into this country temporarily as carriers of passengers or merchandise, they (vessels) are not subject to customs entry or the payment of duty, but if brought into the United States permanently they are to be considered and treated as imported merchandise.

The court said that the question as to whether a vessel is brought into the United States ―permanently‖ must be determined on the basis of intent.

NHTSA went on to state that when the Vehicle Safety Act was enacted, the U.S. Customs regulations 1963 Tariff Schedule151 was in effect, which specifically excluded commercial motor vehicles from entry requirements so long as the vehicles did not engage in local traffic in the United States. This exclusion was adopted as part of the implementation of the Tariff Act of 1930, which provided that

Vehicles and other instruments of international traffic, of any class specified by the Secretary of the Treasury, shall be granted the customary exceptions from the application of customs laws to such extent and subject

149 NHTSA’s NPRM withdrawal notice did not specifically discuss U.S.-based carriers operating noncompliant vehicles. 150 Federal Register, vol. 67, no. 53 (March 19, 2002), pp. 12782–12787, docket no. FMCSA-01- 10886 (p. 50286). Case 43 CCPA 85, 87-88, CAD612 (1956). 151 Federal Register, vol. 28 (December 31, 1963), p. 14663.

NTSB Highway Accident Summary Report 60 to terms and conditions as may be prescribed in regulations or instructions of the Secretary of the Treasury [19 U.S.C 1322(a)].

Using this argument, NHTSA stated that when the Vehicle Safety Act was passed, foreign-domiciled commercial motor vehicles were not subject to entry under the existing Tariff Schedule, therefore ―prohibition on allowing non-compliant commercial motor vehicles into the United States could not be enforced at the border without significantly amending those regulations in a manner inconsistent with the Tariff Act of 1930.‖

However, the Victoria accident vehicle was owned and operated by a U.S-domiciled motor carrier; thus, the vehicle and others brought into the United States by the same method and by U.S.-domiciled motor carriers do not fall under the intent of the Tariff Schedule. Further, U.S. Customs regulations currently provide that buses or motorcoaches in international traffic shall not be treated as imported (19 CFR 10.41[a]), and can be admitted without formal entry of the payment of duty (19 CFR 123.14[a]), but only if the vehicle is owned by a foreign-domiciled carrier.

The operator/owner of a vehicle can be established during inspections by several methods already in place, such as through the U.S. insurance paperwork that must be submitted to the FMCSA and carried in the vehicle, the U.S. jurisdictional registration carried in the vehicle, and the FMCSA’s MC number on the vehicle. In addition, the driver’s logs can establish whether a vehicle is engaged in transporting passengers in interstate commerce outside of a commercial zone. In combination, these factors can establish that the vehicle belongs to a U.S.-domiciled carrier; therefore, a vehicle manufactured outside of the United States should meet the FMVSSs and have been properly imported.

The Victoria accident vehicle was not used on a temporary basis; it was purchased by the owner of a U.S.-based motor carrier to conduct a scheduled regular route (―line run‖) weekly between Houston, Texas, and Monterrey, Mexico. The NTSB was unable to interview the owner of the vehicle to ask specifically why he purchased vehicles in Mexico that were not FMVSS compliant, as he was unavailable for medical reasons. However, company documents uncovered during the NTSB’s investigation determined that the accident vehicle was purchased new in Mexico at a cost of $211,809 (USD) although comparable new motorcoaches for sale in the United States that meet the FMVSSs are typically sold for about $450,000. The owner took advantage of the administrative loophole in California IRP registration and subsequently obtained Texas registration, avoiding the verification of FMVSS compliance in order to obtain registration, the benefit of which was to avoid alerting inspection and enforcement personnel to the vehicle’s weekly regular route into and out of Mexico and avoiding receiving additional violations and fines, such as the ticket issued by the TxDPS for not having a U.S. license plate outside of the commercial zone in October 2006. As a result of obtaining U.S. jurisdictional license plates and registration, the accident vehicle was not checked for compliance with the FMVSSs, but only inspected for FMCSR operational safety on six occasions, though the vehicle made multiple trips, including at

NTSB Highway Accident Summary Report 61 least 28 trips into and out of Mexico and beyond the commercial zone during the approximately 4 months from September–December 2007.

Complicating the issue of importation is that the CBP considers the terms ―import‖ and ―importation‖ to be as defined in the 1975 NHTSA interpretation, which states that ―importation‖ is ―bringing an article into the country from the outside‖ and ―as merchandise that has been brought within the limits of a port of entry from a foreign country.‖ However, NHTSA eliminated this definition in its 2005 NPRM withdrawal. As a result, and as evidenced by the NTSB’s investigation and the testimony from the FMCSA, NHTSA, and the CBP during the public hearing, no uniform, cohesive definition exists for an imported vehicle between the three Federal agencies charged with the importation oversight of commercial passenger-carrying vehicles.

The CBP initially determined, according to CBP’s regulations,152 that the motorcoach involved in the January 2, 2008, accident was not ―imported‖ because it qualified as an ―instrument of international traffic‖ under 19 CFR 10.41.153 The CBP further stated that other possible exceptions to the importation rules may have applied to the accident vehicle because it was considered a vehicle used in ―international traffic‖ and Congress exempted certain vehicles from the application of U.S. Customs laws if such vehicles were engaged in international traffic (19 U.S.C.§1322). This statute, as implemented by 19 CFR 123.14, states that foreign-based vehicles engaged in international traffic may be admitted without formal entry. However, qualifying criteria for the international traffic exception can be found in 49 CFR 123.14(c) and 123.16(b) for vehicles used in ―local traffic.”154 The CBP noted that section 12.80 of the FMVSSs provides an exception to importation regulations for ―foreign-based‖ vehicles only, which was established to allow foreign-based carriers to operate in the United States on a

152 Numerous other sections of 19 CFR pertain to this vehicle and whether it was considered imported. The CBP determined that the definition of interstate commerce in 19 U.S.C. 1308 would not have been applicable to the accident vehicle. Interstate commerce, as defined in 19 U.S.C. 1308, is only applicable to the prohibition on importation of dog and cat fur products and would not apply to buses being used as instruments of international traffic, as referenced in 19 CFR 10.41(a). 153 Title 19 CFR 10.41 states: ―(a) locomotives and other railroad equipment, trucks, buses, taxicabs, and other vehicles used in international traffic shall be subject to the treatment provided for in part 123 of this chapter.‖ “Part 123.16 Entry of returning trucks, buses, or taxicabs in international traffic. (a) Admission without entry or payment of duty. Trucks, buses and taxicabs, whether of foreign or domestic origin, taking out merchandise or passengers for hire or leaving empty for the purpose of bringing back merchandise or passengers for hire shall on their return to the United States be admitted without formal entry or the payment of duty upon their identity being established by state registration cards.‖ 154 49 CFR 123.14(c) and 123.16(b) state: ―Foreign based trucks, buses, and taxicabs admitted under this section shall not engage in local traffic in the United States…[However] The vehicle may carry merchandise or passengers between points in the United States if the carriage is incidental to the immediately prior or subsequent engagement of that vehicle in international traffic. Trucks, buses and taxicabs in use in international traffic, which may include the incidental carrying of merchandise or passengers for hire between points in a foreign country, or between points in this country, shall be admitted under this section. However, such vehicles taken abroad for commercial use between points in a foreign country, otherwise than in the course of their use in international traffic, shall be considered to have been exported for and must be regularly entered on return.‖

NTSB Highway Accident Summary Report 62 limited or short-term basis and then return to their home country, such as in the case of charter tours or privately owned vehicles not in commerce.155

Based on a review of investigative information provided by the NTSB, the CBP has reconsidered its position regarding the accident motorcoach’s import status.156 The CBP states, ―Evidence provided to CBP following the investigation by the NTSB shows a clear intent on the part of the owner of the motorcoach to circumvent CBP’s laws,‖ further stating that

As long as an operator has demonstrated the intention to establish a vehicle’s base of operations and operate out of that location, and presents sufficient evidence to support that intention, CBP will generally point to that location as being the vehicle’s base of operations. The preponderance of evidence provided to us in this case clearly indicates an intention on the part of the motorcoach’s owner to establish its base of operations in the United States.

Consequently, the provisions found in Title 19 Code of Federal Regulations, section 123.14 (19 CFR 123.14) governing the use of foreign-based vehicles as instruments of international traffic (IIT) and their attendant exemption from the customs laws do not apply in this instance. Furthermore, the purchase of the bus, as reflected in documentary evidence provided, would have necessitated the making of a formal entry upon the vehicle’s initial arrival in the United States, something which did not occur. The burden of making an entry is placed upon the importer and failure to do so subjects the importer to an assessment of a penalty.

On November 13, 2009, NHTSA informed the NTSB that, based upon CBP’s decision that the accident motorcoach owner intended to establish its base of operations within the United States and that the accident motorcoach should have been presented to the CBP for formal entry (import), NHTSA is considering whether enforcement action against the motorcoach owner is warranted. Although the CBP has determined, in this case, that the accident motorcoach should have been declared for import by Capricorn’s owner (and thereby the NTSB believes this determination would apply to the other 2005 and two 2008 Volvo motorcoaches that Capricorn operated), such decisions are made on a case-by-case basis. A disconnect exists between the definition of interstate commerce in 49 CFR 390.5 (b), upon which the FMCSA bases its enforcement actions, and the

155 Section 12.80 of the CFR states ―(b) Requirements for entry and release. (1) Unless the requirement for filing is waived by the port director as provided for in paragraph (f) of this section, each vehicle or equipment item offered for introduction into the Customs territory of the United States shall be denied entry unless the importer or consignee files with the entry a declaration, in duplicate, which declares or affirms one of the following: (f) Waiver of declaration requirements. The requirement that declaration be filed under paragraph (b)(1)(i), (b)(1)(ii), or (b)(1)(v) of this section as a condition to the introduction of a vehicle or equipment item into the Customs territory of the United States may be waived by the port director for a United States, Canadian, or Mexican registered vehicle arriving via land borders.‖ 156 CBP letter (regarding import status of accident vehicle) to NTSB, September 4, 2009.

NTSB Highway Accident Summary Report 63 definition of interstate commerce found in 19 CFR 12.80, upon which the CBP bases its enforcement actions, which has led to the loophole currently being taken advantage of by some passenger motor carriers, as was discovered during the Victoria, Texas, accident investigation.

The NTSB believes that if the CBP integrated the definition from 49 CFR 390.5 into the CBP regulations, it could utilize that information when inspecting vehicles at border crossings to determine whether foreign-manufactured vehicles being operated by U.S.-domiciled companies with destinations outside of the commercial zone should be FMVSS compliant and declared for import during entry. A CBP officer, upon determining that a vehicle is not FMVSS compliant and has not yet been through the importation process, could then prevent the vehicle from entering the United States until it is declared.157 Further, if a vehicle has not entered through the proper importation process before or cannot provide documentation of compliance with the FMVSS standards set forth in Title 49 CFR, the CBP could, with cause, seize the vehicle for failure to declare. The NTSB concludes that the lack of a uniform, coherent definition for what constitutes an imported vehicle, in addition to a definition-of-use loophole in the NHTSA, FMCSA and CBP regulations, has allowed some U.S.-domiciled motor carriers to effectively bypass the importation laws and inspection processes established to verify conformance with the FMVSSs and register their Mexican-manufactured vehicles within the United States. Currently, this is the only class of commercial and private vehicle able to make use of this safety loophole. The NTSB therefore recommends that the CBP incorporate the definition of interstate commerce from 49 CFR 390.5 into 19 CFR 12.80 in order to provide a uniform, coherent definition for what constitutes an imported vehicle.

157 If the vehicle owner can provide the documents necessary to indicate the bus has made entry under the importation process, the vehicle can continue.

NTSB Highway Accident Summary Report 64 Conclusions Findings

1. Weather was not a factor in this accident, nor were any highway defects found that

would have caused or contributed to the accident.

Although the vehicle did not meet the Federal Motor Vehicle Safety Standards (FMVSSs), the mechanical condition of the accident motorcoach was not a factor in this accident.

The cause of the unrestrained passengers’ injuries was their striking objects and other passengers inside the motorcoach, as well as their partial ejections from the motorcoach windows on the right side, most of which occurred when the motorcoach overturned.

Although the driver’s toxicological testing results were negative for alcohol and drug use and it was unlikely that the driver was under the influence of alcohol or drugs, the company’s delay in collecting toxicological specimens prevents the National Transportation Safety Board from conclusively ruling out alcohol use as a factor in this accident.

The motorcoach driver fell asleep and partially drifted out of his travel lane.

Upon regaining awareness after partially drifting off the roadway, the accident driver overcorrected his steering, causing a loss of control of the motorcoach.

Since the Federal Motor Carrier Safety Administration’s fatigue video was created in 2000, scientific understanding of fatigue and fatigue countermeasures has improved, as well as distribution methods available for communicating this type of information, to include the Internet, which has the potential to reach even more commercial drivers.

International Charter Services, Inc., failed to maintain operational control and safety oversight of Capricorn Bus Lines, Inc.’s, operations, including its drivers and vehicles, as required by the safety certification completed by International Charter Services, Inc., in its operating authority application (Form OP-1[P], Application for Motor Passenger Carrier Authority [section 4]).

The Federal Motor Carrier Safety Administration had the authority to conduct a compliance review of Capricorn Bus Lines, Inc., but did not, thereby failing to assign the appropriate safety rating for an ―at-risk‖ carrier to a carrier with serious safety violations.

NTSB Highway Accident Summary Report 65

1. The Federal Motor Carrier Safety Administration, by its tacit approval of lease

agreements for interstate passenger carriers that are broader in scope than the equipment leases regulated for cargo carriers, in effect provides a lower level of safety oversight to motor carriers that transport passengers than to those that transport cargo.

Because the Federal Motor Carrier Safety Administration was aware during International Charter Services, Inc.’s, postaccident compliance review that regular route service was being provided regularly without International’s having applied for this type of operating certificate, and therefore the carrier was operating beyond its scope of authority, the Federal Motor Carrier Safety Administration should have taken enforcement action as required by the Motor Carrier Safety Improvement Act.

Some motor carriers are circumventing the legitimate corporate succession processes established in 49 Code of Federal Regulations Part 365 by reapplying for Federal Motor Carrier Safety Administration interstate operating authority through the New Entrant Safety Assurance Process, a loophole that may permit unsafe passenger motor carriers to transfer operating rights to newly established motor carriers that may otherwise be prevented by 49 Code of Federal Regulations Part 365.

The current Federal Motor Carrier Safety Administration compliance review process does not effectively identify unsafe motor carriers and prevent them from operating.

Until the Federal Motor Carrier Safety Administration consistently enforces out-of-service orders, the New Entrant Safety Assurance Program will be unsuccessful in screening for and vetting carriers with a history of poor safety management controls that attempt to reenter interstate passenger operations as reincarnated carriers.

There is no effective program or process currently in place to identify reincarnated carriers that reentered interstate passenger operations through the New Entrant Safety Assurance Program before the August 2008 implementation of the Federal Motor Carrier Safety Administration’s New Applicant Screening Process.

Without clear and specific guidance on appropriate lease agreements between OP-1(P) certificate holders and companies providing equipment for charters or regular route service, noncertificated companies could still be performing most, if not all, of the functions of an interstate passenger-carrying operator without regulatory oversight.

When the owner of Capricorn Bus Lines, Inc., failed to declare importation of the accident vehicle with the U.S. Customs and Border Protection Agency upon entering the United States and subsequently obtained vehicle registration using a loophole in California’s International Registration Plan program, he intentionally bypassed Federal and state requirements for an imported vehicle to comply with the FMVSSs.

NTSB Highway Accident Summary Report 66

1. Because many non-FMVSS-compliant motorcoaches found during this investigation

still display U.S. jurisdictional (state) registrations and license plates, inspectors and law enforcement personnel do not have cause to suspect such vehicles of not conforming with Federal law.

Some states lack conformity when verifying FMVSS compliance during International Registration Plan-apportioned vehicle registrations, permitting U.S.-domiciled companies to operate non-FMVSS-compliant vehicles daily throughout the United States.

Current Federal safety oversight programs and importation regulations pertaining to passenger commercial motor vehicles are flawed because improperly imported (that is, not declared for importation) non-FMVSS-compliant motorcoaches operated by U.S.-domiciled motor carriers on U.S. highways in commercial passenger service are not being identified, placed out of service, and subjected to current laws by the agencies responsible for the oversight of safety and importation: the Federal Motor Carrier Safety Administration, the National Highway Traffic Safety Administration, and the U.S. Customs and Border Protection Agency.

Not having an electronic FMVSS verification process available to Federal, state, and local law enforcement personnel to use during roadside vehicle inspections makes it difficult to verify whether passenger-carrying commercial motor vehicles meet the FMVSSs.

The accident vehicle and all other non-FMVSS-compliant buses inspected by the Federal Motor Carrier Safety Administration should be detected during Federal Motor Carrier Safety Administration roadside inspections and compliance reviews and subsequently reported to the proper Federal and state agencies for enforcement.

The lack of a requirement for U.S.-domiciled carriers to certify the use of FMVSS-compliant passenger vehicles in interstate commerce has created a gap in safety oversight, allowing non-FMVSS-compliant commercial passenger vehicles to be used by U.S.-domiciled carriers on U.S. highways.

The Federal Motor Carrier Safety Administration’s policy of not enforcing the requirement for passenger-carrying commercial motor vehicles to display a label of certification documenting the vehicle’s compliance with all applicable motor vehicle safety standards and its failure to help identify and place out of service non-FMVSS-compliant vehicles undermine the National Highway Traffic Safety Administration’s efforts as a partner safety agency.

Current U.S. Department of Transportation policy allowing the Federal Motor Carrier Safety Administration to cross-reference the FMVSSs during a vehicle’s inspection and, if the vehicle is not placed out of service, accept that as evidence of adherence to FMVSS performance standards, is faulty based on the Federal Motor Carrier Safety Regulations’ lack of performance testing during a vehicle inspection.

NTSB Highway Accident Summary Report 67

1. The lack of a uniform, coherent definition for what constitutes an imported vehicle, in

addition to a definition-of-use loophole in National Highway Traffic Safety Administration, Federal Motor Carrier Safety Administration and U.S. Customs and Border Protection Agency regulations, has allowed some U.S.-domiciled motor carriers to effectively bypass the importation laws and inspection processes established to verify conformance with the FMVSSs and register their Mexican-manufactured vehicles within the United States. Probable Cause The National Transportation Safety Board determines that the probable cause of this accident was the driver’s falling asleep, which caused him to partially drift off the road, resulting in oversteer corrections when the driver regained awareness, and subsequent vehicle loss of control and overturn. Contributing to the severity of the unrestrained passengers’ injuries was their striking objects and other passengers inside the motorcoach, as well as the partial ejections that occurred when the motorcoach overturned during the accident.

NTSB Highway Accident Summary Report 68 Recommendations New Recommendations As a result of its investigation, the National Transportation Safety Board makes the following safety recommendations:

To the Department of Transportation:

Direct the National Highway Traffic Safety Administration and the Federal Motor Carrier Safety Administration to work in conjunction with the U.S. Customs and Border Protection Agency to develop and implement a process to detect motor carriers that are currently operating non-FMVSS-compliant motorcoaches or other passenger-carrying commercial motor vehicles, other than exempted vehicles, in the United States (outside of the commercial zone), and when such vehicles are detected, to ensure that the Federal Motor Carrier Safety Administration has the authority to place such vehicles out of service and require that these motor carriers cease operating those vehicles in commercial interstate passenger service or face revocation of their operating authority. (H-09-29)

To the National Highway Traffic Safety Administration:

Develop, in conjunction with the Federal Motor Carrier Safety Administration, a Web-based database of FMVSS-compliant passenger-carrying commercial motor vehicles that can be utilized by Federal, state, and local enforcement inspection personnel to identify non-FMVSS-compliant passenger-carrying commercial motor vehicles so that these vehicles (other than exempted vehicles) are placed out of service and cease operating in the United States. Implement a process to periodically update this database. (H-09-30)

When the database requested in Safety Recommendation H-09-30 is completed, make the database known and accessible to state vehicle registration agencies and to Federal, state, and local enforcement inspection personnel for their use during roadside inspections and compliance reviews to identify non-FMVSS-compliant passenger-carrying commercial motor vehicles. (H-09-31)

To the Federal Motor Carrier Safety Administration:

Update and redistribute your ―Driver Fatigue Video‖ to include current information on fatigue and fatigue countermeasures and make the video

NTSB Highway Accident Summary Report 69 available electronically. Implement a plan to regularly update and redistribute the video. (H-09-32)

Revise 49 Code of Federal Regulations Part 376 to require that passenger motor carriers are subject to the same limitations on the leasing of equipment as interstate for-hire motor carriers of cargo. (H-09-33)

Seek statutory authority to deny or revoke operating authority for commercial interstate motor carriers found to have applications for operating authority in which the applicant failed to disclose any prior operating relationship with another motor carrier, operating as another motor carrier, or being previously assigned a U.S. Department of Transportation number. (H-09-34)

Apply the evasion detection algorithm process against all interstate passenger carriers that obtained Federal Motor Carrier Safety Administration operating authority, after the New Entrant Safety Assurance Program began in 2003 but before the program began vetting those carriers, to verify that those new entrant carriers do not have a concealed history of poor safety management controls because they were able to reenter interstate commerce undetected as reincarnated carriers. (H-09-35)

Establish a requirement to review all passenger carrier lease agreements during new entrant safety audits and compliance reviews to identify and take action against carriers that have lease agreements that result in a loss of operational control by the certificate holder. (H-09-36)

Assist the National Highway Traffic Safety Administration in developing a Web-based database of FMVSS-compliant passenger-carrying commercial motor vehicles that can be utilized by Federal, state, and local enforcement inspection personnel to identify non-FMVSS-compliant passenger-carrying commercial motor vehicles so that these vehicles (other than exempted vehicles) are placed out of service and cease operating in the United States. Implement a process to periodically update this database. (H-09-37)

Require that Federal and state inspectors utilize the database requested in Safety Recommendation H-09-37 during both roadside and compliance review inspections of passenger-carrying commercial motor vehicles to identify and place out of service non-FMVSS-compliant vehicles. (H-09-38)

Institute a requirement for Federal and state enforcement officials to obtain training on a procedure to physically inspect passenger-carrying commercial motor vehicles for an FMVSS compliance label, and work

NTSB Highway Accident Summary Report 70 with the Commercial Vehicle Safety Alliance to develop and provide this training. (H-09-39)

Require that passenger motor carriers certify on their OP-1(P) forms (Application for Motor Passenger Carrier Authority) and initial MCS-150 form (Motor Carrier Identification Report [Application for USDOT Number]) and subsequent required biennial submissions that all vehicles operated, owned, or leased per trip or per term met the FMVSSs in effect at the time of manufacture. (H-09-40)

Seek statutory authority to suspend, revoke, or withdraw a motor carrier’s operating authority upon discovering the carrier is operating any non-FMVSS-compliant passenger-carrying commercial motor vehicles, a violation of the FMVSS-compliant certification requested in Safety Recommendation H-09-40. (H-09-41)

To the U.S. Customs and Border Protection Agency:

Assist the U.S. Department of Transportation in developing a process to detect and report to the Department of Transportation information on motor carriers identified during your border crossing inspections of passenger-carrying commercial motor vehicles to be currently operating non-FMVSS-compliant passenger-carrying commercial motor vehicles, other than exempted vehicles, in the United States (outside of the commercial zone), and assist the Department in ensuring such vehicles are placed out of service and requiring these motor carriers cease operating those vehicles in commercial interstate passenger service. (H-09-42)

Incorporate the definition of interstate commerce from 49 Code of Federal Regulations 390.5 into 19 Code of Federal Regulations 12.80 in order to provide a uniform, coherent definition for what constitutes an imported vehicle. (H-09-43)

To the American Association of Motor Vehicle Administrators:

Assist the International Registration Plan, Inc., in developing and distributing to the states and the District of Columbia a model policy for verifying that newly registered passenger-carrying commercial motor vehicles are certified as having complied with the appropriate FMVSSs in effect at the time of manufacture, as referenced in Title 49 Code of Federal Regulations Part 567. (H-09-44)

NTSB Highway Accident Summary Report 71 To International Registration Plan, Inc.:

In conjunction with the American Association of Motor Vehicle Administrators, develop and distribute to the states and the District of Columbia, a model policy, within the International Registration Plan registration process, for verifying that newly registered passenger-carrying commercial motor vehicles are certified as having complied with the appropriate FMVSSs in effect at the time of manufacture, as referenced in Title 49 Code of Federal Regulations Part 567. (H-09-45)

Commercial Vehicle Safety Alliance:

Revise the North American Standard Out-of-Service Criteria to include passenger motor carriers discovered to be violating their operating authority by operating non-FMVSS-compliant passenger-carrying commercial motor vehicles. (H-09-46)

Work with the Federal Motor Carrier Safety Administration to develop and provide training on a procedure for Federal and state enforcement officials to physically inspect passenger-carrying commercial motor vehicles for an FMVSS compliance label. (H-09-47)

Previously Issued Recommendation Reiterated in This Report As a result of its investigation, the National Transportation Safety Board reiterates the following safety recommendation:

To the Federal Motor Carrier Safety Administration:

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)

NTSB Highway Accident Summary Report 72 Previously Issued Recommendation Reiterated and Reclassified in This Report As a result of its investigation, the National Transportation Safety Board reiterates and reclassifies Safety Recommendation H-99-6. This recommendation, previously classified ―Open—Acceptable Response,‖ is reclassified ―Open—Unacceptable Response.‖

To the Federal Motor Carrier Safety Administration:

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)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD DEBORAH A.P. HERSMAN ROBERT L. SUMWALT Chairman Member CHRISTOPHER A. HART

Vice Chairman

Adopted: December 8, 2009

NTSB Highway Accident Summary Report 73 Appendix A Investigation and Public Hearing Investigation The National Transportation Safety Board (NTSB) was notified of the Victoria, Texas, accident on January 2, 2008. An investigative team was dispatched with members from the Washington, D.C.; Denver, Colorado; Gardena, California; and Arlington, Texas, offices. Groups were established to investigate human performance factors; motor carrier operations; and highway, vehicle, and survival factors.

Participating in the investigation were representatives of the Federal Motor Carrier Safety Administration (FMCSA), the Texas Department of Public Safety (TxDPS), the Texas Department of Transportation (TxDOT), Volvo de Mexico División Autobuses, Prevost (a subsidiary of Volvo Bus Corporation), and Bendix Commercial Vehicle Systems. Public Hearing The NTSB held a public hearing on this accident on October 7–8, 2008, in Washington, D.C. NTSB Chairman Deborah A.P. Hersman presided over the hearing. The issues presented at the hearing included safety concerns related to the accident motorcoach and other similar passenger-carrying commercial motor vehicles not built in compliance with the Federal Motor Vehicle Safety Standards (FMVSSs) that enter from Mexico, register and obtain U.S. jurisdictional license plates, and consequently operate permanently in commercial passenger-carrying service in the United States. In addition, the public hearing addressed the processes involved in the registration of non-FMVSS-compliant motorcoaches by two U.S. jurisdictions (states of California and Texas); Federal, state, and local agency policies regarding cross border operations of U.S. motorcoach operators; the International Registration Plan; and the identification, during state and Federal roadside inspections, of non-FMVSS-compliant passenger-carrying vehicles that operate in interstate commercial passenger service by a U.S-domiciled carrier.

NTSB investigators were members of the technical panel. Parties to the public hearing included the U.S. Department of Transportation Office of Inspector General, Office of Surface and Maritime Program Audits; U.S. Department of Homeland Security Customs and Border Protection Agency (CBP); FMCSA; National Highway Traffic Safety Administration (NHTSA); Prevost/Volvo de Mexico División Autobuses; American Bus Association; United Motorcoach Association; and International Registration Plan, Inc. Witnesses who participated in the hearing included representatives from the following organizations: the U.S. Department of Transportation, Office of

NTSB Highway Accident Summary Report 74 Inspector General, Assistant Inspector General for Surface and Maritime Program Audits; CBP; FMCSA; NHTSA; state of California Department of Motor Vehicles; TxDPS; TxDOT; 5 Star Specialty Programs (a division of Crump Insurance Services); and IRP, Inc.

NTSB Highway Accident Summary Report 75 Appendix B Computer Simulation Study Although the physical evidence in this case included several feet of tire marks indicating the path of the motorcoach (report figure 1) from where it departed the left side of the roadway to the point of rollover, there was no physical evidence indicating the path of the vehicle before the tire marks began. Further, following the accident, the driver provided several differing statements regarding his actions before the accident. Therefore, to learn more about the motions of the motorcoach prior to its departure from the roadway, NTSB staff conducted a series of simulations using the TruckSim program from Mechanical Simulation.

The primary issues addressed by the simulation data presented in this study concern the motion of the motorcoach and the driver’s steering actions before the vehicle departed the roadway. Vehicle parameters used to model the accident motorcoach in the simulations—such as brakes, tires, steering, suspension, and inertia—were based on actual vehicle data received from the manufacturer. Simulation results were compared to the physical evidence gathered on scene during the investigation. Motorcoach Modeling Software Motorcoach dynamics were modeled using TruckSim simulation software. This software is widely used by industry to model three-dimensional tractor-trailer, truck, and motorcoach responses to driver inputs, terrain, and external inputs, such as wind. TruckSim is a robust model that can model a variety of suspension and tire characteristics, including both linear and nonlinear properties. Further, terrain geometry can be entered directly into TruckSim to model the tire/ground interaction more accurately. TruckSim can also provide visualizations of simulation results and of performing hardware-in-the-loop simulations. Vehicle Parameters The following vehicle parameters for the model bus involved in the accident, a 2005 Volvo Model 9700, 47-passenger motorcoach manufactured in Tultitlan, Mexico, were obtained from Volvo and used in the simulations:  Suspension properties;  Steering properties;  Tire force versus slip data (both longitudinal and lateral) for the original equipment manufacturer’s tires (Michelin 295/80 XZA1);

NTSB Highway Accident Summary Report 76  Vehicle weights for both loaded and unloaded configurations;  Moments of inertia for the unladen vehicle; and  Approximations of moments of inertia for the accident loading condition. For the loaded condition, Volvo assumed a 190 pounds-per-passenger load with 47 passengers. The accident bus was modeled using the default two-axle truck from the TruckSim database. The suspension, tire, steering, inertial, and weight properties of the vehicle were modified to more closely approximate the data provided by Volvo. Braking Data The motorcoach was equipped with disk brakes controlled by an electronic braking system with integral antilock braking system (ABS) functionality. The ABS was modeled using the default ABS model in TruckSim. Data for the accident vehicle’s disk brakes were obtained from Meritor Wabco and used to model brake torques in the simulations. Road Geometry and Physical Data The road and terrain geometry used in the simulations was based on survey data gathered at the scene during the investigation (report figure 1). Included in the survey data were approximately 339 feet of tire marks from the bus. The tire marks began just before the point at which the bus departed the roadway and continued up to the point of rollover. The final several feet of these tire marks contained diagonal striation marks, which are characteristic of a vehicle that is rotating or yawing while making the marks.

The physical evidence indicated that, after overturning onto its right side, the bus slid approximately 112 feet before coming to rest and that the radius of the tire marks (yaw marks) immediately preceding the rollover was between 225 and 300 feet. The track of the bus immediately before the accident was a 1,000-foot, 3.5-degree, left-hand curve. Road and Terrain Friction Input To account for uncertainties, the tire/ground coefficients of friction for the road surface and grassy median were evaluated over a wide range of values.1 The range of values used to simulate the road surface friction was from 0.65–0.85. The range of values used to simulate the grassy median was from 0.40–0.65.

1 Because braking capability was limited by the available brake torque and cornering during the maneuver, the coefficients of friction did not greatly impact speed estimates over the ranges discussed here.

NTSB Highway Accident Summary Report 77 Driver Behavior Driver steering control is represented within the TruckSim model by a closed-loop driver model that mimics basic preview path-following behavior. The model ―looks ahead‖ at the upcoming path and attempts to steer in a manner to cause the vehicle to follow the path. The driver model reacts to any external disturbances (such as crosswinds and road slope) by steering the vehicle in a corrective manner, within its limits. Open-Loop Controller TruckSim also has a built-in open-loop vehicle controller, which allows the user to specify all the normal functions provided by a driver—steering, braking, throttle, automatic transmission mode, gear setting, and clutch control—by entering these values in tables. In this study, the open-loop controller was used to steer the vehicle along the accident vehicle trajectory as indicated by the tire marks. Simulation Results Criteria Used to Evaluate Simulation Results In this accident, the motorcoach overturned onto its side and slid for approximately 112 feet before coming to rest. TruckSim software is not designed to model contact between the ground and the body of the vehicle and, therefore, the simulations were stopped at the point of rollover. Simulation results were considered to be consistent with the physical evidence if the simulated vehicle’s trajectory up to the point of rollover correlated with the physical evidence and any one of the following conditions were met:  The simulation predicted wheel lift at any single wheel position at the point where the physical evidence indicated that rollover occurred.  The vehicle was traveling at least 36 mph when it reached the point of rollover.  The vehicle attained a minimum lateral acceleration greater than 0.46 just before rollover.2 These criteria account for earlier calculations performed by the Office of Highway Safety,3 which indicated that the static rollover threshold was approximately

2 To account for uncertainties, the rollover threshold for lateral acceleration was lowered to 0.46 g.

NTSB Highway Accident Summary Report 78 0.56 g and that the bus was traveling approximately 36 mph when it began sliding on its side.4 In general, these broader criteria reduced the lower limit of the speed range below what it would have been using stricter criteria, such as requiring a two-wheel lift. However, simulation results indicated that requiring a two-wheel lift in the simulations might rule out certain situations which, with small changes in steering, would result in two-wheel lift. Using these criteria also helped account for uncertainty in limit behavior of vehicle components by giving the driver the benefit of the doubt. Contribution of Speed to Initial Loss of Control The overall results of the simulations indicate that for the motorcoach to have traveled the accident vehicle’s trajectory, a large steering input to the left had to precede the departure of the motorcoach from the road. This type of steering maneuver would be consistent with the motorcoach’s initially drifting off the roadway onto the right shoulder and the driver’s overcorrecting as he attempted to steer back onto the roadway. It is not consistent with a scenario in which the vehicle initially drifted off the left side of the roadway because the driver fell asleep or was incapacitated.

The results of the simulations indicated a speed in the range of 65–73 mph. To study how speed contributed to the initial loss of control, a series of simulations was conducted. In the simulations, a motorcoach (traveling on the right shoulder of the roadway) was subjected to a left steering input similar to the driver’s attempt to steer off the right shoulder as calculated to model the driver’s overcorrection. Immediately following the steering input, the driver model attempted to steer the vehicle down the middle of the roadway.

Two different speeds were evaluated as part of this study: 65 mph, which was the posted speed limit, and 76 mph, which was the maximum speed calculated from a previous study. Driver steering control in the simulations was represented by a driver preview time of 1.5 seconds, which is commonly used to represent human behavior, and a driver lag time of 0.15 second, which is typically used to represent the neuromuscular delay in human response.5

At both 65 and 76 mph, the driver model was able to maintain control of the vehicle on the roadway. The results of the maximum lateral accelerations and lateral movement are shown in table B-1:

3 Highway Factors Group Analysis Report of Investigation, Victoria, Texas, January 2, 2008 (HWY-08-MH-011). 4 This criterion is based on the distance that the motorcoach slid on its side, 112 feet, and a deceleration rate of approximately 0.4 g, which is based on data for a bus sliding on pavement. 5 See the TruckSim simulation software reference manual.

NTSB Highway Accident Summary Report 79 Table B-1. Results of steering manuever.

Maximum Lateral Peak Lateral Accelerations Speed (mph) Movement (feet) First Peak (g) Second Peak (g) 65 22 0.45 -0.27 76 24 0.46 -0.30

As indicated by the data in the table, the simulated motorcoach experienced large lateral movements at both speeds as the result of the initial left steer, and the motorcoach moved laterally across almost the entire width of the traveled portion of the roadway as the result of the initial left steering input.6 The maximum lateral acceleration, which is often used as a metric when gauging the severity of a steering maneuver, exceeded 0.4 g for both speeds. This acceleration is beyond the magnitude that is commonly used in highway design at these speeds (less than 0.08 g) 7 It is also above the driver discomfort threshold8 of 0.3 g, which is used as a loss-of-control threshold for certain highway design studies, and above the lateral acceleration threshold setting of approximately 0.3 g of many truck stability control systems.9

As the data in the table show, reducing the speed of the motorcoach to the posted speed limit of 65 mph would not substantially reduce lateral movement or the peak lateral accelerations. (While it did reduce the lateral movement slightly, the motorcoach still traveled from the right shoulder across the entire width of the traveled portion of the road in the simulation.) These findings suggest that the severity of the situation was largely due to the magnitude of the driver’s steering input and that even at the posted speed limit of 65 mph, recovery would have been difficult. This situation would be even more difficult if the driver were unalert or drowsy. Findings The results of the simulations support the following conclusions:

 The range of speeds for the motorcoach indicated by the simulations and earlier studies is 65–75 mph.

6 The entire width of the travel lanes was approximately 20 feet. The motorcoach was traveling on the right shoulder when the steering maneuver was initiated. 7 AASHTO Green Book criteria limit the unbalanced lateral acceleration to a maximum of 0.175 g at 15 mph, decreasing to a maximum of 0.08 g at 80 mph. For a discussion, see D.W. Harwood, D.J. Torbic, K.R. Richard, W.D. Glauz, and L. Elefteriadou, A Review of Truck Characteristics as Factors in Roadway Design, National Cooperative Highway Research Program Report 505 (Washington, DC: Transportation Research Board, National Academy of Sciences, 2003). 8 J.C. Glennon, T.R. Neuman, R.R. McHenry, and B.G. McHenry, Highway-Vehicle-Object Simulation Model (HVOSM) Studies of Cross-Slope Breaks on Highway Curves, contract no. DOT-FH-11- 9575 (Washington, DC: Federal Highway Administration, 1982). 9 This finding is based on a previous meeting with stability control manufacturers.

NTSB Highway Accident Summary Report 80  The theory that the motorcoach initially drifted off the right side of the roadway and that the driver overcorrected in an attempt to steer back onto the road is consistent with the physical evidence found on the roadway and in the grassy median.  The results of the simulations indicate that the primary cause of the loss of control was a large steering input to the left that preceded the departure of the vehicle from the left side of the roadway. This steering input resulted in large lateral movements and high lateral accelerations, both of which can contribute to loss of control.

NTSB Highway Accident Summary Report 81 Appendix C Form HS-7

NTSB Highway Accident Summary Report 82 Appendix D Form OP-1(P)

NTSB Highway Accident Summary Report 83

NTSB Highway Accident Summary Report 84

NTSB Highway Accident Summary Report 85

NTSB Highway Accident Summary Report 86

NTSB Highway Accident Summary Report 87

NTSB Highway Accident Summary Report 88

NTSB Highway Accident Summary Report 89

NTSB Highway Accident Summary Report 90

NTSB Highway Accident Summary Report 91

NTSB Highway Accident Summary Report 92

NTSB Highway Accident Summary Report 93 Appendix E FMCSA Postaccident Compliance Review of International Charter Services, Inc.

The Federal Motor Carrier Safety Administration (FMCSA) conducted a postaccident compliance review of International Charter Services, Inc. (International), on January 24, 2008, resulting in an overall rating of ―conditional.‖ The following violations, shown in table E-1, were discovered during the review and are keyed to relevant sections of Part 49 Code of Federal Regulations.

NTSB Highway Accident Summary Report 94 Table E–1. Violations found in January 2008 compliance review. Acute and Critical Violationsa CFR Reference Deficiency Noted 383.37(a)—Acute Knowingly allowing, requiring, permitting, or authorizing an employee with a commercial driver’s license that is suspended, revoked, or canceled by a state or who is disqualified to operate a commercial motor vehicle. (Example given: Accident driver on January 1, 2008, accident trip.) 391.51(b)(2)—Critical Failing to maintain inquiries into driver’s driving record in driver’s qualification file. 396.11(a)—Critical Failing to require driver to prepare driver vehicle inspection report. Other Violations CFR Reference Deficiency Noted 382.105 (Primary) 40.13(c)/ 40.47(a) (Secondary) Failing to ensure that alcohol or controlled substances testing complies with the procedures set forth in 49 CFR Part 40. 382.301(a) Using a driver before the motor carrier has received a negative preemployment controlled substance test result. 382.303(d)(1) Failing to prepare and maintain on file a record stating the reasons the alcohol postaccident test was not properly administered. 383.35(b) Failing to request employment history information for the last 10 years preceding the date of the application for employment. 391.21(a) Using a driver who has not completed and furnished an employment application. 391.23(e)(1) Failing to investigate the driver’s alcohol and controlled substance history for the previous 3 years. 391.25(c)(2) Failing to maintain a record of annual review in the driver’s qualification file. 391.51(b)(1) Failing to maintain the driver’s employment application in driver’s qualification file. 391.51(b)(3) Failing to maintain a road test certificate in the driver’s qualification file or a copy of the license or certificate that the motor carrier accepts as equivalent. 391.51(b)(5) Failing to maintain a note relating to the annual review of the driver’s driving record, as required by 49 CFR 391.25(c)(2). 391.51(b)(6) Failing to maintain a list or certificate relating to violations of motor vehicle laws and ordinances, as required by 49 CFR 391.27. 392.16 Failing to use seat belt while operating a commercial motor vehicle. 395.8(e) Maintaining false reports of record-of-duty status. 395.8(f) Failing to require a driver to prepare a record-of-duty status in the form and manner prescribed. 395.8(i) Failing to require the driver to forward, within 13 days of completion, the original of the record-of-duty status. 396.3(b)(1) Failing to keep a maintenance record that identifies the vehicle, including make, serial number, year, and tire size. 396.11(c) Failing to correct safety-related defects listed on vehicle inspection reports(s). aRecurring violations of the same or related acute or critical regulations that result in three enforcement actions within a 6-year period will trigger the maximum penalties allowed by law to be assessed for the third enforcement action.

NTSB Highway Accident Summary Report 95 Safety Rating Factors The FMCSA rated International as follows on the six safety rating factors in the January 2008 postaccident compliance review:

Table E-2. FMCSA safety compliance ratings for International. Factor Rating Acute Critical 1—General Satisfactory 0 0 2—Driver Unsatisfactory 1 2 3—Operational Satisfactory 0 0 4—Vehicle Conditional 0 1 5—Hazardous materials N/A 0 0 6—Accident rate

Satisfactory

--

FMCSA Remarks The FMCSA made the following remarks regarding International’s operations in the January 2008 postaccident compliance review:

International Charter Services, Inc. (ICSI) was contacted at approximately 1:00 pm on 01/02/08 via a face to face meeting with [the owner of Transportes Chavez]. [The owner of Chavez] is the Manager of the company. The CR began the next morning at the carrier’s PPOB [Principal Place of Business]. Prior to meeting [the Manager], a couple of hours were spent at a terminal being operated by Capricorn Bus Lines, Inc. At this location a CMV bus marked with ICSI name and USDOT # were viewed and a log book indicating ICSI was the carrier was obtained. This info was given to the division and an address for ICSI was obtained. During the initial meeting…[the Manager] stated the crash was the responsibility of ICSI and the bus was being operated by ICSI. He went on to state he was the manager of ICSI and that he would be available to provide any and all records for the review. FMCSA records indicate that [the Manager] has been the subject of two CRs as the President of Transportes Chavez Incorporated. He received a satisfactory rating on both occasions.

The investigation revealed that the carrier has two different types of CMV bus operations going on at the same time. The carrier operates a charter business and a dedicated scheduled bus service. The charter business has been in operation since the beginning and it is where the company originated at. This part of the operation is run from the PPOB on Archer Rd and a terminal shared with Transportes Chavez Incorporated one block away. [The owner of Chavez’s] son runs the charter operation. [The owner of Chavez’s] common law wife…is the only corporate officer for ICSI. This is a recent change. [The owner of Chavez] was originally listed as a

NTSB Highway Accident Summary Report 96 Director for ICSI. He stated he had his name removed from being a Director. The carrier has one bus dedicated to charters. They do approximately 5 trips a month. Last year the company partnered with Capricorn Bus Lines and began operating 1–2 daily scheduled runs from Houston to Monterrey, MX.…This part of the operation is run by [the owner of Capricorn] and his extended family. [The owner of Capricorn] owns 4 buses and leases them to ICSI. [The owner of Capricorn’s] 2 sons, a daughter and several other extended family members work in the office selling tickets and managing the day to day operations of the business. At least one bus leaves Houston, TX everyday going to a Capricornio Bus Lines terminal in Monterrey, MX. A bus then returns to Houston from Monterrey everyday.

The carrier estimated the company gross revenue and mileage using this schedule run plus the charters.

NTSB Highway Accident Summary Report 97 Appendix F Compliance Review Process and Safety Ratings The Federal Motor Carrier Safety Administration (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 identifies high-risk carriers through on-site compliance reviews and roadside program inspections of a carrier’s vehicles and drivers. Compliance Review Process The safety fitness rating process begins with a compliance review conducted by the FMCSA, as specified in 49 Code of Federal Regulations (CFR) Part 385, appendix A. A carrier may be selected for a compliance review if it is identified as a high-risk carrier because of (1) a Motor Carrier 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 hazardous materials accident. In addition, a carrier may be selected as a result of a U.S. Department of Transportation Office of Inspector General request, a congressional inquiry, or a carrier’s request. Safety Rating Process The FMCSA applies six factors (general, driver, operational, vehicle, hazardous materials, and accident rate) to rate a carrier’s compliance with the Federal Motor Carrier Safety Regulations (FMCSRs), determining the degree to which a carrier complies with the FMCSRs and meets the Federal safety fitness standards. (See table F-1.) Within each factor, the FMCSRs are rated as either acute2 or critical3 regulations, in accordance with 49 CFR Part 385, appendix B II(b). Each instance of noncompliance with an acute regulation or each pattern of noncompliance with a critical regulation during the compliance review will be assessed one point.4 Two points are assessed for noncompliance with a ―critical‖ regulation in 49 CFR Part 395 for hours of service. According to the FMCSA, noncompliance with acute regulations and patterns of noncompliance with critical regulations are quantitatively linked to inadequate safety

1 The SafeStat analysis program uses data from Federal and state sources, including roadside inspections, accident data, and enforcement actions to develop a safety fitness assessment for all carriers. 2 Acute violations of the FMCSRs (or Hazardous Materials Regulations) are defined as those that demand immediate corrective action, such as requiring or permitting the operation of an out-of-service (OOS) vehicle before repairs are made, regardless of the motor carrier’s overall safety posture. 3 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)). 4 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.

NTSB Highway Accident Summary Report 98 management controls and usually higher-than-average accident rates.5 The FMCSA has used noncompliance with acute regulations and patterns of noncompliance with critical regulations since 1989 to determine a motor carrier’s adherence to the safety fitness standard in §385.5.

Table F-1. Factors for FMCSA safety compliance. 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

The ratings for all six factors are given equal weight and entered into a rating table. Table F-2 summarizes the FMCSA rating process. 6 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 of satisfactory, conditional, or unsatisfactory is computed for each applicable factor. The Compliance Analysis and Performance Review Information (CAPRI) computer program is used to organize and record compliance information and determine the proposed safety rating.7

5 For further explanation of the safety rating process, see , accessed August 25, 2009. 6 For more detailed information on the safety fitness procedures, see , accessed August 25, 2009. 7 The compliance review itself is conducted at the carrier’s business location; the actual safety rating is determined and issued by FMCSA headquarters in Washington, D.C.

NTSB Highway Accident Summary Report 99 Table F-2. Motor carrier safety ratings. Number of Factors With Unsatisfactorya Ratings Number of Factors With Conditionalb Ratings Safety Rating 0 2 or less Satisfactoryc 0 More than 2 Conditional 1 2 or less Conditional 1 More than 2 Unsatisfactory 2 or more 0 Unsatisfactory aAn 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. bA conditional rating indicates that the carrier has violated one acute regulation or has a pattern of noncompliance with critical regulations. cA satisfactory rating indicates that the carrier has not violated any acute regulations or shown a pattern of noncompliance with critical regulations.

The rating table establishes the motor carrier’s overall final safety rating: as satisfactory, conditional, or unsatisfactory. When the FMCSA issues a final unsatisfactory safety rating to an owner or operator of a commercial vehicle that is designed or used to transport passengers, the carrier is deemed unfit to operate and is allowed 45 days to correct the violation. If no proof of correction is submitted within the 45-day timeframe, beginning on the 46th day after the date of the unsatisfactory safety rating, the carrier remains unfit and may not operate in interstate commerce and may not reestablish interstate operations until proving itself fit for such transportation.

Because of their importance to safe motor carrier operations, the NTSB is particularly interested in how the ratings for driver and vehicle factors are calculated. For factor 4, vehicle, the carrier’s 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 toward the OOS calculation.8 If a carrier’s OOS rate exceeds 34 percent, and the carrier has a pattern of critical or acute violations or both, the carrier’s rating is ―unsatisfactory.‖ If the carrier’s OOS rate exceeds 34 percent, but the carrier does not have a pattern of violations, the carrier’s rating is ―conditional.‖ If the carrier’s OOS rate is less than 34 percent, the carrier receives a ―satisfactory‖ rating unless the carrier has a pattern of critical or acute vehicle violations or both, in which case the carrier’s rating is still conditional.

Factor 6, accident rate, may be 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

8 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.

NTSB Highway Accident Summary Report 100 1 million and dividing that number by the fleet’s total interstate miles. If a carrier’s accident rate exceeds 1 per 1.5 million miles for a company that operates over a 100-mile radius or 1 per 1.7 million miles for a company that operates in less than a 100-mile radius, an unsatisfactory rating is given.9 The NTSB has investigated numerous accidents where driver and vehicle factors were involved, which will be discussed in more detail in the sections that follow.

NTSB Recommendation History on the FMCSA Compliance Review Process 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 factored10 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 two most important factors in safe motor carrier operations are the operational status of the vehicles (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.

As was discussed in the Victoria, Texas, accident summary report, the NTSB has investigated a number of accidents and found that several unsafe carriers were permitted to continue operating as a result of a final satisfactory compliance review safety rating regardless of driver- or vehicle-related safety violations. Two key recommendations in

9 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 per 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]). 10 When asked during the NTSB’s public hearing on the ―Motorcoach Accident and Selected Federal Motor Carrier Safety Administration Oversight Issues, Wilmer, Texas,‖ regarding 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).

NTSB Highway Accident Summary Report 101 this area, which are being reiterated in the Victoria accident report, are further discussed in the sections that follow. Safety Recommendation H-99-6 In 1995, the NTSB investigated an accident in Indianapolis, Indiana,11 in which a motorcoach overturned when it entered an exit ramp; 2 passengers were killed, and 13 were seriously injured. The Federal Highway Administration (FHWA) 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 NTSB recommended that the U.S. Department of Transportation (DOT):

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)

On December 14, 1999, the FHWA responded that it expected to issue a notice of proposed rulemaking (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 NTSB’s recommendation, including any comments received, in developing a new system. On March 17, 2000, based on the expected NPRM, the NTSB classified Safety Recommendation H-99-6 ―Open─Acceptable Response.‖ The recommendation has been on the NTSB’s Most Wanted List of Transportation Safety Improvements since 2000.12

On September 4, 2002, the NTSB reiterated Safety Recommendation H-99-6 to the FMCSA as a result of its investigation into a 2001 accident in Mountainburg, Arkansas,13 when a commercial truck, operated by Stuart Trucking (Stuart), collided with a school bus and killed three children. The FMCSA’s postaccident compliance review of the motor carrier resulted in an overall conditional rating; however, the FMCSA staff did not inspect any vehicles during this review despite the fact that the accident was vehicle related. The FMCSA relied instead on the motor carrier profile report, which listed

11 Selective Motorcoach Issues, Special Investigation Report NTSB/SIR-99/01 (Washington, DC: National Transportation Safety Board, 1999). 12 The NTSB’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. 13 Collision Between Truck-Tractor Semitrailer and School Bus Near Mountainburg, Arkansas, May 31, 2001, Highway Accident Report NTSB/HAR-02/03 (Washington, DC: National Transportation Safety Board, 2002).

NTSB Highway Accident Summary Report 102 29 roadside inspections in the previous 12 months,14 resulting in 4 OOS vehicles (14 percent). The NTSB 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 the 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 NTSB investigated an accident in Victor, New York,15 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 also 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.‖

Following the NTSB’s September 2002 reiteration of Safety Recommendation H-99-6 in the Victor, New York, accident report, the FMCSA advised that it intended to issue an NPRM on its safety fitness rating methodology in late 2003. In June 2004, the FMCSA notified the NTSB that it anticipated making a final determination concerning changes to the safety fitness rating methodology by the end of the year. The FMCSA also indicated that it was considering whether to seek additional comments through a supplemental advance NPRM or to proceed directly to an NPRM and that it expected to complete the rulemaking process in 2005. Following another accident investigation in April 2006 involving a carrier that received a conditional rating, though numerous driver and vehicle safety violations were found during its postaccident compliance review and the carrier was operating in violation of its revoked operating authority,16 the NTSB expressed disappointment that the FMCSA had still not acted on Safety Recommendation H-99-6.

14 At the time of issuance of the NTSB 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 NTSB recommended that the FMCSA require that a motor carrier’s fleet be inspected during compliance reviews (Safety Recommendation H-02-16). 15 Motorcoach Run-off-the-Road and Overturn, Victor, New York, June 23, 2002, Highway Accident Report NTSB/HAR-04/03 (Washington, DC: National Transportation Safety Board, 2004). 16 Multivehicle Collision on Interstate 90, Hampshire–Marengo Toll Plaza Near Hampshire, Illinois, October 1, 2003, Highway Accident Report NTSB/HAR-06/03 (Washington, DC: National Transportation Safety Board, 2006).

NTSB Highway Accident Summary Report 103 Safety Recommendation H-07-3 On June 27, 2007, as a result of the NTSB’s investigation and public hearing on the Wilmer, Texas, bus fire,17 another accident involving a passenger motor carrier with numerous driver and vehicle safety violations and insufficient safety oversight of its operations, the NTSB issued the following safety recommendation to the FMCSA:

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)

The FMCSA’s December 3, 2007, response acknowledged the need to establish a safety fitness determination (SFD) process that better identifies at-risk carriers than the current process under 49 CFR Part 385; however, the FMCSA believed that rather than diverting resources to issue an interim final rule on modifying the SFD process, it would be in the best interest of highway safety for the agency to focus its resources on implementing the Comprehensive Safety Analysis 2010 (CSA 2010) initiative. The FMCSA indicated that the implementation of H-07-3 in the SFD process would result in a significant increase in the number of motor carriers rated ―conditional‖ and ―unsatisfactory‖ without regard to crash rates and would demand a substantial increase in resources for administrative reviews to perform compliance reviews to ensure due process for motor carriers. Starting in September 2005, the FMCSA began briefing the NTSB on its plans for evaluating the compliance review process as part of CSA 2010. According to the FMCSA, CSA 2010 is designed to evaluate the effectiveness of current Federal safety compliance and enforcement programs, such as compliance reviews and roadside inspections, and to identify better methods for achieving an accident-free environment. According to the FMCSA, CSA 2010, which would include a complete evaluation of the compliance review process, should lead to the development of a new performance-based operational model for determining motor carrier safety, with an emphasis on preventative measures and early detection of unsafe driver and motor carrier conditions.

The NTSB disagreed with the FMCSA’s response. Safety Recommendation H-07-3 was intended to remedy deficiencies in the current compliance review system and to help prevent unsafe motor carriers with significant regulatory violations for drivers and vehicles from continuing to still receive satisfactory ratings. Although the NTSB has been aware that the conceptual model for CSA 2010 is significantly different from the current operational model in that safety fitness ratings will be independent of the compliance review and are intended to take into account safety violations through a weighted rating system still being developed, the expected implementation date, now

17 Motorcoach Fire on Interstate 45 During Hurricane Rita Evacuation, Near Wilmer, Texas, September 23, 2005, Highway Accident Report NTSB/HAR-07/01 (Washington, DC: National Transportation Safety Board, 2007).

NTSB Highway Accident Summary Report 104 scheduled for the end of December 2010,18 has allowed unsafe carriers to continue to operate. As the FMCSA is responsible for ensuring that motor carriers operate safely, temporary measures to improve the compliance review process should be put in place to account for implementation delays until new rules are enacted. CSA 2010 Initiative The FMCSA recently updated its website with information explaining CSA 2010.19 According to the posting, ―CSA 2010 re-engineers the existing enforcement and compliance business process to provide a better view into how well large commercial motor vehicle (CMV) carriers and drivers are complying with safety rules, and to intervene earlier with those who are not.‖ The FMCSA acknowledges that the current compliance review program is resource-intensive and reaches only a small percentage of motor carriers20 and that increased attention needs to be given to CMV drivers.

The FMCSA believes that CSA 2010 will address the issues in Safety Recommendations H-99-6 and H-07-3 through the development of new performance-based systems for determining motor carrier and driver safety that emphasize preventative measures, motor carrier education, and early detection of unsafe driver and carrier conditions. The Safety Measurement System, which will replace SafeStat under CSA 2010, (1) measures safety performance using all roadside inspection safety-based violations, (2) weights time and severity of violations based on relationship to crash risk, and (3) calculates safety performance in seven Behavior Analysis and Safety Improvement Categories (BASICs). These BASICs include unsafe driving, fatigued driving, driver fitness, drugs and alcohol, vehicle maintenance, cargo securement, and crash experience. The Comprehensive Intervention Process provides tools to educate carriers and compel safety compliance before crashes occur. A new safety fitness rating methodology, the SFD, is being developed through the rulemaking process. In February 2008, the FMCSA launched a pilot test of the CSA 2010 operational model in four states: Colorado, Georgia, Missouri, and New Jersey, and more states are being added as the testing continues. Preliminary results indicate that nearly half of the test carriers have logged onto the Comprehensive Safety Information System website to view their violations data, as suggested in a warning letter, and have replied to the FMCSA describing the corrective actions they have taken or are initiating in response to the warning. The FMCSA expects to complete pilot testing of its new operational model by June 2010 and to implement CSA 2010 nationwide during July through December 2010; however, until rulemaking is completed on the SFD, all enforcement action of any discovered violations must be processed through the current safety fitness methodology.

18 The implementation date for CSA 2010 was originally announced as January 1, 2010; it has since been extended to December 31, 2010. 19 See http://csa2010.fmcsa.dot.gov/, accessed August 25, 2009. 20 In calendar year 2005, fewer than 1 percent of the 910,866 registered motor carriers underwent compliance reviews (8,097 reviews conducted).

NTSB Highway Accident Summary Report 105 The NTSB is concerned with the FMCSA’s continued slow progress in addressing this issue over the past 10 years. The long time between the issuance of the recommendations and final action by the FMCSA jeopardizes the safety of the traveling public through unnecessary exposure to possibly unsafe CMVs. Although the agency has assured the NTSB that it is on schedule to begin implementing the new compliance review program in 2010, until the SFD rulemaking is complete, the FMCSA must rely on the current rating system, which lacks sufficient driver and vehicle qualifications emphasis. The NTSB will continue to monitor the FMCSA’s actions to recognize the importance of driver and vehicle factors in addressing motor carrier safety as CSA 2010 pilot testing continues and until the rulemaking is completed.

NTSB Highway Accident Summary Report 106 Appendix G U.S. and European Safety Standards and U.S. Inspection Cross-References The accident motorcoach was a Volvo manufactured in Mexico. Although the motorcoach did not meet the Federal Motor Vehicle Safety Standards (FMVSSs), it did meet the European vehicle manufacturing standards—Economic Commission for Europe (ECE) and European Economic Community (EEC) regulations. Table G-1 shows the FMVSSs applicable to motorcoaches; table G-2 shows European and U.S. manufacturing standard equivalents, along with the applicable Federal Motor Carrier Safety Regulation (FMCSR) inspection cross-reference.

NTSB Highway Accident Summary Report 107 Table G-1. FMVSSs applicable to motorcoaches. Standard Summary FMVSS 101—Controls and Displays Controls must be operable by driver with the seat belt fastened; contains requirements for telltales and indicators. FMVSS 102—Transmission Shift Lever Sequence, Starter Interlock, and Transmission Braking Effect Vehicles equipped with automatic transmissions must have transmission braking at vehicle speeds below 40 km/h (25 mph). FMVSS 106—Brake Hoses Air brake hoses must meet performance requirements. FMVSS 108—Lamps, Reflective Devices, and Associated Equipment Lamps, reflective devices, and associated equipment must meet performance and location-on-vehicle requirements. FMVSS 111—Rearview Mirrors Rearview mirrors must have unit magnification of specified size and may have additional mirrors (such as convex). FMVSS 119—New Pneumatic Tires for Vehicles Other Than Passenger Cars Tires must meet performance and labeling requirements. FMVSS 120—Tire Selection and Rims for Motor Vehicles Other Than Passenger Cars Tire sum of load ratings must be equal to or greater than the gross axle weight ratings to prevent vehicle overloading. FMVSS 121—Air Brake Systems Air brake systems must meet stopping distance requirements, and vehicles must be equipped with an antilock brake system. FMVSS 124—Accelerator Control Systems Removing force on an accelerator requires return to idle within specified time. FMVSS 205—Glazing Materials Glazing must meet performance requirements. FMVSS 207—Seating Systems Driver’s seat must meet performance requirements. FMVSS 208—Occupant Crash Protection Driver’s seat must be equipped with Type 1 or Type 2 seat belt assembly. FMVSS 209—Seat Belt Assemblies Driver’s belt must meet performance requirements. FMVSS 210—Seat Belt Assembly Anchorages Seat belt assembly anchorages for driver’s belt must meet strength requirements. FMVSS 217—Bus Emergency Exits and Window Retention and Release Emergency exits must meet size, location, performance, and labeling requirements. FMVSS 302—Flammability of Interior Materials Interior materials must meet performance requirements for burn resistance.

NTSB Highway Accident Summary Report 108 Table G-2. U.S. and European inspection standard cross-references. Component NHTSA European FMCSA Controls and displays FMVSS 101 EEC 94/53 No Transmission shift lever sequence FMVSS 102 Nonea No Windshield defrosting and defogging system FMVSS 103 None FMCSR 393.79 Windshield wiping and washing systems FMVSS 104 Noneb FMCSR 78 Hydraulic brake system

FMVSS 105

FMCSR 40 Brake hoses FMVSS 106 Nonec FMCSR 45 Lamps, reflective devices, and associated equipment FMVSS 108 ECE 48-02d FMCSRs 24-26, 9, 11, 19, 22-23 Rearview mirrors FMVSS 111 ECE 46-02e FMCSR 80 Hood latch system

FMVSS 113

No Hydraulic brake fluids

FMVSS 116

No New pneumatic tires for motor vehicles other than passenger cars

FMVSS 119

FMCSR 75 Tire selection and rims for motor vehicles other than passenger cars FMVSS 120 EEC 92/23 FMCSRs partially cover Air brake system FMVSS 121 ECE 13f FMCSR 40-55 Accelerator control systems FMVSS 124 Noneg No Warning devices FMVSS 125

ECE 27h

Steering control rearward displacement

FMVSS 204

No Glazing materials FMVSS 205 EEC 92/22 FMCSR 60 Seating systems FMVSS 207 ECE 80-01i FMCSR 93 Occupant crash protection

FMVSS 208

FMCSR 93

aAccording to Volvo, this standard would be met if verified only for its manufactured vehicles. bAccording to Volvo, this standard would be met if verified only for its manufactured vehicles. cAccording to Volvo, its brake hoses are made by the same manufacturers as in the United States. dAccording to Volvo, the number of lamps and locations are similar; however, FMVSS 108 is very specific and some lamps are not U.S. Department of Transportation (DOT) compliant. eConvex mirrors are permitted. f According to Volvo, ECE 13 is at least the equivalent of FMVSS 121; however, tests must be performed to confirm this. The fittings are most likely not DOT marked. gAccording to Volvo, this standard would be met if verified only for its manufactured vehicles. hAccording to Volvo, it is unknown whether the accident vehicle was delivered with ECE 27 warning devices. iAccording to Volvo, ECE-80-01 is the European equivalent standard, although it is not as stringent as FMVSS 207.

NTSB Highway Accident Summary Report 109

Component NHTSA European FMCSA Seat belt assemblies FMVSS 209 EEC 77 FMCSR 93 Seat belt assembly anchorage FMVSS 210 ECE 80-01j FMCSR 93 Bus emergency exits and window retention FMVSS 217 ECE 36k FMCSR 62 Flammability of interior materials FMVSS 302 ECE 118l No

jAccording to Volvo, ECE-80-01 is the European equivalent standard, although it is not as stringent as FMVSS 207. kECE 36 regulation has the option of breakable glazing. The accident motorcoach was altered by an after-market entity to install two roof hatches and modified windows that open in order to meet FMVSS 217. lAccording to Volvo, while ECE 118 is the European equivalent of FMVSS 302, the accident motorcoach was manufactured in Mexico and it is not known what materials were used to complete the interior and whether the materials would have met either standard or regulation.

NTSB Highway Accident Summary Report 110 Appendix H U.S. and Mexico Border Crossing Data Table H–1. Annual summary of southern border roadside inspections (commercial zone) for passenger-carrying vehicles in 2008. Inspections United States Mexico Totals

Federal State Federal State United States Mexico Driver 13,030 2,936 1,531 330 15,966 1,861 Driver OOS 2.8% 4.1% 11.6% 13.6% 3.0% 12.0% Vehicle 4,811 5,665 914 272 10,476 1,186 Vehicle OOS 13.4% 21.0% 8.2% 18.8% 17.5% 10.6%

Table H–2. Annual summary of roadside inspections (commercial zone) for passenger-carrying vehicles in 2008 by southern border state. Inspections United States Mexico Arizona Federal State Total Federal State Total Driver 6,229 425 6,654 20 4 24 Driver OOS 1.0% 9.2% 1.5% 35.0% 0.0% 29.2% Vehicle 835 1,976 2,811 15 4 19 Vehicle OOS 14.1% 39.9% 32.3% 33.3% 0.0% 26.3%

California Federal State Total Federal State Total Driver 232 1,008 1,240 31 132 163 Driver OOS 4.3% 2.2% 2.6% 6.5% 0.8% 1.8% Vehicle 201 2,248 2,449 5 108 113 Vehicle OOS 24.9% 5.6% 7.1% 0.0% 17.6% 16.8%

New Mexico Federal State Total Federal State Total Driver 40 366 406 4 38 42 Driver OOS 5.0% 6.3% 6.2% 0.0% 71.1% 64.3% Vehicle 38 236 274 3 13 16 Vehicle OOS 13.2% 5.9% 6.9% 0.0% 23.1% 18.8%

Texas Federal State Total Federal State Total Driver 6,529 1,137 7,666 1,476 156 1,632 Driver OOS 4.4% 3.2% 4.2% 11.4% 10.9% 11.4% Vehicle 3,737 1,205 4,942 891 147 1,038 Vehicle OOS 12.6% 21.7% 14.8% 7.9% 19.7% 9.5%

DATA SOURCES: Federal Motor Carrier Safety Administration (FMCSA) Motor Carrier Management Information System (MCMIS) and June 26, 2009, snapshot, and http://ai.fmcsa.dot.gov/International/border.asp?redirect=FedStCommZone.asp, accessed September 18, 2009.

NTSB Highway Accident Summary Report 111 Table H–3. Commercial zone roadside inspections (passenger-carrying vehicles). Inspection Level 2006 2007 2008 2009a Level 1: Full 3,892 3,298 3,426 1,862 Level 2: Walk-around 8,893 4,656 4,488 1,984 Level 3: Driver 16,658 12,207 9,921 4,586 Level 4: Special 12 8 3 0 Level 5: Vehicle 3,508 4,216 3,751 795 Total 32,963 24,385 21,589 9,227 Vehicle OOS Rate 13.3% 13.0% 16.8% 12.6% Driver OOS Rate 2.2% 3.5% 4.0% 3.4%

aAs of June 26, 2009, http://ai.fmcsa.dot.gov/international/border.asp?redirect=FedStInspDom.asp, accessed September 19, 2009.

Table H–4. U.S. border crossing entries of buses at U.S.–Mexican border. State Number of Crossings 2006 Number of Crossings 2007 Number of Crossings 2008a

Number Percent Number Percent Number Percent Arizona 18,536 7.1% 16,913 6.4% 15,658 5.9% California 148,998 56.7 147,367 55.6 138,855 52.1 New Mexico 2,436 0.9 2,885 1.1 2,958 1.1 Texas 92,892 35.3 97,997 36.9 108,916 40.9

Total 262,862 265,162 266,387

aAs of April 9, 2009, http://www.transtats.bts.gov/BorderCrossing.aspx, accessed September 18, 2009. DATA SOURCES: U.S. Department of Transportation, Research and Innovative Technology Administration, Bureau of Transportation Statistics, Border Crossing/Entry Data, based on data from U.S. Department of Homeland Security, U.S. Customs and Border Protection Agency, Operations Management Reporting, database and http://ai.fmcsa.dot.gov/International/border.asp?dvar=2&cvar=bus&sy=2006&redirect=Crossings.asp, accessed September 18, 2009.

NTSB Highway Accident Summary Report 112 Table H–5. Annual summary of southern border roadside inspections (commercial zone) for passenger-carrying vehicles in 2009 (January 1–June 26, 2009). Inspections United States Mexico Totals

Federal State Federal State United States Mexico Driver 6,224 1,367 727 133 7,591 838 Driver OOS 2.7% 2.6% 11.8% 1.8% 2.6% 10.5% Vehicle 2,352 1,673 498 116 4,025 614 Vehicle OOS 12.0% 14.1.0% 8.2% 21.6% 12.9% 10.7%

Table H–6. Annual summary of roadside inspections (commercial zone) for passenger-carrying vehicles in 2009 by southern border state (January 1–June 26, 2009). Inspections United States Mexico Arizona Federal State Total Federal State Total Driver 2,940 169 3,109 12 0 12 Driver OOS 0.9% 9.5% 1.4% 50.0% 0.0% 50.0% Vehicle 417 146 563 10 0 10 Vehicle OOS 13.2% 6.8% 11.5% 60.0% 0.0% 60.0%

California Federal State Total Federal State Total Driver 234 298 532 15 61 76 Driver OOS 4.3% 0.7% 2.3% 6.7% 0.0% 1.3% Vehicle 200 593 793 7 45 52 Vehicle OOS 23.5% 6.7% 11.0% 28.6% 8.9% 11.5%

New Mexico Federal State Total Federal State Total Driver 8 227 235 1 7 8 Driver OOS 25.0% 4.8% 5.5% 0.0% 28.6% 25.0% Vehicle 44 169 213 0 6 6 Vehicle OOS 2.3% 3.0% 2.8% 0.0% 0.0% 0.0%

Texas Federal State Total Federal State Total Driver 3,042 673 3,715 699 43 742 Driver OOS 4.2% 1.0% 3.6% 11.3% 0.0% 10.6% Vehicle 1,691 765 2,456 481 65 546 Vehicle OOS 10.6% 23.7% 14.7% 6.9% 32.3% 9.9%

DATA SOURCES: FMCSA MCMIS and June 26, 2009, snapshot, and http://ai.fmcsa.dot.gov/International/border.asp?redirect=FedStCommZone.asp, accessed September 18, 2009.

FD07365 ｜ 2009_美国_NTSB_HAR1101_Rollover_of_a_TruckTractor_and_Cargo_Tank_Semitrailer_Carryi.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2009 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

Rollover of a Truck-Tractor and Cargo Tank Semitrailer Carrying Liquefied Petroleum Gas and Subsequent Fire Indianapolis, Indiana October 22, 2009

Accident Report NTSB/HAR-11/01 PB2011-916201

National Transportation Safety Board

NTSB/HAR-11/01 PB2011-916201 Notation 8202A Adopted July 26, 2011

Highway Accident Report Rollover of a Truck-Tractor and Cargo Tank Semitrailer Carrying Liquified Petroleum Gas and Subsequent Fire Indianapolis, Indiana October 22, 2009

National Transportation Safety Board

490 L’Enfant Plaza, S.W. Washington, DC 20594

National Transportation Safety Board. 2011. Rollover of a Truck-Tractor and Cargo Tank Semitrailer Carrying Liquefied Petroleum Gas and Subsequent Fire, Indianapolis, Indiana, October 22, 2009. NTSB/HAR-11/01. Washington, DC.

Abstract: On October 22, 2009, about 10:38 a.m. eastern daylight time, a 2006 Navistar International truck-tractor in combination with a 1994 Mississippi Tank Company MC331 specification cargo tank semitrailer (the combination unit), operated by AmeriGas Propane, L.P., and laden with 9,001 gallons of liquefied petroleum gas, rolled over on a connection ramp after exiting Interstate 69 (I-69) southbound to proceed south on Interstate 465 (I-465), about 10 miles northeast of downtown Indianapolis, Indiana. The truck driver was negotiating a left curve in the right lane on the connection ramp when the combination unit began to encroach upon the left lane, occupied by a 2007 Volvo S40 passenger car. The truck driver responded to the Volvo’s presence in the left lane by oversteering clockwise, causing the combination unit to veer to the right and travel onto the paved right shoulder. The truck driver’s excessive, rapid, evasive steering maneuver to return the combination unit to the roadway triggered a sequence of events that caused the cargo tank semitrailer to roll over, decouple from the truck-tractor, penetrate a steel W-beam guardrail, and collide with a bridge footing and concrete pier column supporting the southbound I-465 overpass. The collision entirely displaced the outside bridge pier column from its footing and resulted in a breach at the front of the cargo tank that allowed the liquefied petroleum gas to escape, form a vapor cloud, and ignite. The truck driver and the Volvo driver sustained serious injuries in the accident and postaccident fire, and three occupants of passenger vehicles traveling on I-465 received minor injuries from the postaccident fire.

Major safety issues were identified in this investigation were cargo tank rollover prevention as they relate to highway and vehicle design. As a result of its investigation, the National Transportation Safety Board has issued safety recommendations to the U.S. Department of Transportation, Federal Motor Carrier Safety Administration, Pipeline and Hazardous Materials Safety Administration, National Highway Traffic Safety Administration, Federal Highway Administration, and American Association of State Highway and Transportation Officials.

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 NTSB 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 Internet at http://www.ntsb.gov. Other information about available publications also may be obtained from the website or by contacting:

National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, SW Washington, DC 20594 (800) 877-6799 or (202) 314-6551

NTSB publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2011-916201 from:

National Technical Information Service 5301 Shawnee Road Alexandria, Virginia 22312 (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.

NTSB Highway Accident Report i

Contents Figures ........................................................................................................................................... iii Acronyms and Abbreviations .......................................................................................................v Executive Summary ................................................................................................................... viii

1. Factual Information ...................................................................................................................1
2. 1 Accident Narrative .....................................................................................................................1
3. 2 Emergency Response .................................................................................................................5
4. 3 Injuries .......................................................................................................................................7
5. 4 Survival Factors .........................................................................................................................8
6. 5 Scene Evidence ..........................................................................................................................8
7. 6 Weather ......................................................................................................................................8
8. 7 Damage ......................................................................................................................................9
9. 8 Vehicle Information (Cargo Tank Combination Unit) ............................................................12
10. 8.1 Truck-Tractor .................................................................................................................12
11. 8.2 Cargo Tank Semitrailer..................................................................................................14
12. 8.3 Periodic Testing and Refurbishment .............................................................................16
13. 9 Truck Driver Information ........................................................................................................16
14. 9.1 Driving Experience ........................................................................................................17
15. 9.2 Medical Information ......................................................................................................17
16. 9.3 72-Hour History .............................................................................................................18
17. 9.4 Toxicology .....................................................................................................................22
18. 10 Motor Carrier Operations .......................................................................................................22
19. 10.1 Driver Training ............................................................................................................24
20. 10.2 Hours-of-Service Records ...........................................................................................24
21. 10.3 Vehicle Maintenance ...................................................................................................25
22. 11 Highway Information .............................................................................................................26
23. 11.1. Cross-Slope Break ......................................................................................................27
24. 11.2 Protection of Bridge Pier Columns ..............................................................................30
25. 12 Cargo Tank Motor Vehicles...................................................................................................34
26. 12.1 DOT Specification Cargo Tanks .................................................................................34
27. 12.2 Crashworthiness of DOT Specification Cargo Tanks .................................................35
28. 12.3 Hazardous Materials Carrier Registration ...................................................................36
29. 12.4 Rollover Awareness .....................................................................................................37
30. 13 Vehicle-Based Rollover Prevention .......................................................................................39
31. 13.1 Stability Control Systems ............................................................................................39
32. 13.2 Vehicle Design .............................................................................................................43
33. 13.3 Performance-Based Standards .....................................................................................49
34. 13.4 Partial Loads ................................................................................................................51
35. Analysis .....................................................................................................................................53
36. 1 Exclusions ................................................................................................................................53
37. 2 Accident Discussion.................................................................................................................55

NTSB Highway Accident Report ii

1. 2.1 Rollover Speed ...............................................................................................................58
2. 2.2 Driver Fatigue ................................................................................................................59
3. 3 Cargo Tank Rollover Prevention .............................................................................................63
4. 3.1 Rollover Prevention Programs .......................................................................................64
5. 3.2 Stability Control Systems ..............................................................................................66
6. 3.3 Vehicle Design ...............................................................................................................67
7. 3.4 Partial Loads ..................................................................................................................69
8. 3.5 Cross-Slope Break .........................................................................................................71
9. 4 Crashworthiness of DOT Specification Cargo Tanks ..............................................................73
10. 4.1 Cargo Tank Breach ........................................................................................................73
11. 4.2 Population of Cargo Tanks by DOT Specification ........................................................74
12. 4.3 Cargo Tank Head Protection (MC331)..........................................................................75
13. 4.4 Cargo Tank Crash Performance .....................................................................................76
14. 5 Protection of Bridge Pier Columns ..........................................................................................77
15. 5.1 Past Accident Investigations ..........................................................................................79
16. 5.2 Risk Assessment ............................................................................................................81
17. Conclusions ...............................................................................................................................82
18. 1 Findings....................................................................................................................................82
19. 2 Probable Cause.........................................................................................................................84
20. Recommendations ....................................................................................................................85
21. 1 New Recommendations ...........................................................................................................85
22. 2 Previously Issued Recommendations Reclassified in This Report ..........................................88
23. Appendixes................................................................................................................................90

Appendix A: Investigation and Public Hearing .............................................................................90 Appendix B: Improvements to Connection Ramp ........................................................................ 92 Appendix C: Outdoor Advertising Signs ...................................................................................... 94

NTSB Highway Accident Report iii

Figures Figure 1. Accident location ............................................................................................................ 2 Figure 2. Plan view of connection ramp and direction of travel and final rest positions of the truck-tractor and cargo tank semitrailer ................................................................................ 3 Figure 3. Tire marks indicating redirection of combination unit from the right shoulder to the right lane ............................................................................................................................... 4 Figure 4. Truck-tractor and cargo tank semitrailer at final rest ..................................................... 5 Figure 5. Fire-damaged truck-tractor ............................................................................................. 9 Figure 6. Collision damage and breach at the lower right side of the cargo tank ........................ 10 Figure 7. Displaced bridge pier column struck by cargo tank semitrailer ................................... 11 Figure 8. Aerial view of the connection ramp and Interstate 465 overpasses ............................. 11 Figure 9. Fifth wheel plate ........................................................................................................... 13 Figure 10. Cargo tank semitrailer (MC331)................................................................................. 15 Figure 11. Location of loading terminal in relation to October 19–22 deliveries ....................... 19 Figure 12. Truck driver’s 72-hour history of activities before the accident ................................ 20 Figure 13. Cross-slope break ....................................................................................................... 27 Figure 14. Bridge pier column protection (before accident). ....................................................... 31 Figure 15. Fundamental design considerations for improving the roll stability of cargo tank motor vehicles ............................................................................................................................... 43 Figure 16. Double tapered cargo tank with dropped center ......................................................... 45 Figure 17. Roll stability improved by increased track width of 102-inch-wide vehicles ............ 46 Figure 18. Lower CG height and increased track width .............................................................. 48 Figure 19. Rollover sequence....................................................................................................... 55 Figure 20. Tire imprints in the right lane and on the shoulder indicating where the combination unit rolled over onto its right side ............................................................................ 56 Figure 21. Final rest position of cargo tank semitrailer ............................................................... 57

NTSB Highway Accident Report iv

Figure 22. Mounting pad and rear-facing fold above upper coupler assembly ........................... 74 Figure B-1. Cross-slope break and bridge pier column protection (before improvements) ........ 92 Figure B-2. Cross-slope break and bridge pier column protection (after improvements) ........... 93

NTSB Highway Accident Report v

Acronyms and Abbreviations AAR Association of American Railroads AASHO American Association of State Highway Officials AASHTO American Association of State Highway and Transportation Officials ABS antilock braking system AmeriGas/PTI AmeriGas Propane, L.P./Propane Transport International API American Petroleum Institute ASME American Society of Mechanical Engineers BMCS Bureau of Motor Carrier Safety BP blood pressure CAMI Civil Aerospace Medical Institute CDL commercial driver’s license CDLIS Commercial Driver’s License Information System CFR Code of Federal Regulations CG center of gravity DOT U.S. Department of Transportation DVIR Driver Vehicle Inspection Report EDT eastern daylight time EIGA European Industrial Gases Association ESC electronic stability control [system] FHWA Federal Highway Administration FMCSA Federal Motor Carrier Safety Administration FMCSRs Federal Motor Carrier Safety Regulations g acceleration of gravity GES General Estimates System GVWR gross vehicle weight rating HMIS Hazardous Materials Information System hp horsepower HVOSM Highway-Vehicle-Object-Simulation Model I-69 Interstate 69

NTSB Highway Accident Report vi

I-465 Interstate 465 IFD Indianapolis Fire Department IMPD Indianapolis Metropolitan Police Department INDOT Indiana Department of Transportation IN-TIME Indiana Traffic Incident Management Effort ISP Indiana State Police LRFD Load and Resistance Factor Design LTCCS LTFD Large Truck Crash Causation Study Lawrence Township Fire Department MC motor carrier [number] MCMIS Motor Carrier Management Information System MECA Metropolitan Emergency Communications Agency mg/dL milligrams per deciliter m/s2 meters per second/per second MUTCD Manual on Uniform Traffic Control Devices MY model year NADS National Advanced Driving Simulator NASS National Accident Sampling System NCHRP National Cooperative Highway Research Program NHS National Highway System NHTSA National Highway Traffic Safety Administration NQT nonquenched and tempered NTSB National Transportation Safety Board NTTC National Tank Truck Carriers PCP phencyclidine PHMSA Pipeline and Hazardous Materials Safety Administration psig pounds per square inch, gauge PTI QT Propane Transport International quenched and tempered RSC rollover stability control [system] RSPA Research and Special Programs Administration SAFER Safety and Fitness Electronic Records

NTSB Highway Accident Report vii

STAA-82 Surface Transportation Assistance Act TL test level TRB Transportation Research Board UCP unified command post UMLER Universal Machine Language Equipment Register UMTRI University of Michigan Transportation Research Institute UN United Nations UNECE United Nations Economic Commission for Europe USDOT U.S. Department of Transportation [number] VDANL Vehicle Dynamics Analysis, Non-Linear

NTSB Highway Accident Report viii

Executive Summary On October 22, 2009, about 10:38 a.m. eastern daylight time, a 2006 Navistar International truck-tractor in combination with a 1994 Mississippi Tank Company MC331 specification cargo tank semitrailer (the combination unit), operated by AmeriGas Propane, L.P., and laden with 9,001 gallons of liquefied petroleum gas, rolled over on a connection ramp after exiting Interstate 69 (I-69) southbound to proceed south on Interstate 465 (I-465), about 10 miles northeast of downtown Indianapolis, Indiana. The truck driver was negotiating a left curve in the right lane on the connection ramp, which consisted of two southbound lanes, when the combination unit began to encroach upon the left lane, occupied by a 2007 Volvo S40 passenger car. The truck driver responded to the Volvo’s presence in the left lane by oversteering clockwise, causing the combination unit to veer to the right and travel onto the paved right shoulder. Moments later, the truck driver steered counterclockwise to redirect and return the combination unit from the right shoulder to the right lane. The truck driver’s excessive, rapid, evasive steering maneuver triggered a sequence of events that caused the cargo tank semitrailer to roll over, decouple from the truck-tractor, penetrate a steel W-beam guardrail, and collide with a bridge footing and concrete pier column supporting the southbound I-465 overpass. The collision entirely displaced the outside bridge pier column from its footing and resulted in a breach at the front of the cargo tank that allowed the liquefied petroleum gas to escape, form a vapor cloud, and ignite. The truck-tractor came to rest on its right side south of the I-465 overpasses, and the decoupled cargo tank semitrailer came to rest on its left side, near the bridge footing supporting the southbound I-465 overpass. The truck driver and the Volvo driver sustained serious injuries in the accident and postaccident fire, and three occupants of passenger vehicles traveling on I-465 received minor injuries from the postaccident fire. At the time of the accident, the sky was overcast, winds were calm, pavement was dry, and the temperature was about 58° F. The National Transportation Safety Board determines that the probable cause of this accident was the excessive, rapid, evasive steering maneuver that the truck driver executed after the combination unit began to encroach upon the occupied left lane. Contributing to the rollover was the driver’s quickly steering the combination unit from the right shoulder to the right lane, the reduced cross slope of the paved right shoulder, and the susceptibility of the combination unit to rollover because of its high center of gravity. Mitigating the severity of the accident was the bridge design, including the elements of continuity and redundancy, which prevented the structure from collapsing.

NTSB Highway Accident Report ix

The following safety issues were identified in this investigation:  Essential elements of a comprehensive rollover prevention program.  Rollover propensity of cargo tank motor vehicles, which provides little tolerance for operator error.  Safety implications of reduced shoulder cross slope on the roll stability of heavy commercial vehicles with a high center of gravity.  Lack of quality data necessary for conducting meaningful risk analyses to evaluate the crash performance of U.S. Department of Transportation specification cargo tanks.  Absence of guidelines for identifying and protecting bridges vulnerable to collapse if struck by errant heavy commercial vehicles negotiating direct and semi-direct connection ramps. As a result of its investigation, the National Transportation Safety Board has issued safety recommendations to the U.S. Department of Transportation, Federal Motor Carrier Safety Administration, Pipeline and Hazardous Materials Safety Administration, National Highway Traffic Safety Administration (NHTSA), Federal Highway Administration, and American Association of State Highway and Transportation Officials (AASHTO). Additionally, this report reclassifies previously issued recommendations to NHTSA and AASHTO.

NTSB Highway Accident Report 1

• Factual Information

1. 1 Accident Narrative

On October 22, 2009, about 10:38 a.m. eastern daylight time (EDT),1 a 2006 Navistar International truck-tractor in combination with a 1994 Mississippi Tank Company MC331 specification 11,600-gallon cargo tank semitrailer2 (the combination unit), operated by AmeriGas Propane, L.P., and laden with 9,001 gallons of liquefied petroleum gas,3 rolled over on a connection ramp after exiting Interstate (I-69) southbound to proceed south on Interstate 465 (I-465), about 10 miles northeast of downtown Indianapolis, Indiana (see figure 1).4 The truck driver was negotiating a left curve in the right lane on the connection ramp, which consisted of two southbound lanes, when the combination unit began to encroach upon the left lane, occupied by a 2007 Volvo S40 passenger car (see figure 2).5 During a postaccident interview, the Volvo driver told National Transportation Safety Board (NTSB) investigators that he sounded the horn a few times when the rear of the cargo tank (which was initially observed ahead of the Volvo in the right lane) started to move into the left lane. The truck driver responded to the Volvo’s presence in the left lane by oversteering clockwise, causing the combination unit to veer to the right and travel onto the paved right shoulder. Moments later, the truck driver steered counterclockwise—as indicated by tire marks—to redirect the combination unit from the right shoulder to the right lane (see figure 3). 1 Unless otherwise designated, all times in this report are eastern daylight time. 2 Cargo tank semitrailers are the most common articulated commercial vehicles used to transport bulk liquids. Another type of vehicle used to transport bulk liquids, the single-unit cargo tank truck, consists of a power unit with a tank that is not coupled to a trailer. Cargo tank motor vehicles refer to the entire population of heavy trucks equipped with cargo tanks (regardless of size, configuration, and whether the commodity transported is a hazardous material). 3 Liquefied petroleum gas is a flammable gas that is transported under pressure as a liquid with a lower explosive limit of 2.1-percent concentration with air and a flash point of -219.9° F. Liquefied petroleum gas is 270 times more compact as liquid than as gas, making it more economical to store and transport. 4 The accident occurred at the transition between I-69, which runs in a north-south direction, and the west and south segments of I-465, a beltway around Indianapolis (see figure 2). 5 No physical evidence or witness reports were available to independently corroborate the preaccident placement of vehicles and sequence of events that may have led to the encroachment of the combination unit upon the left lane; consequently, it is not known to what extent, if any, the combination unit had entered the left lane.

NTSB Highway Accident Report 2

Figure 1. Accident location.

NTSB Highway Accident Report 3

Figure 2. Plan view of connection ramp and direction of travel and final rest positions of the truck-tractor and cargo tank semitrailer.

NTSB Highway Accident Report 4

Figure 3. Tire marks indicating redirection of combination unit from the right shoulder to the right lane. (Source: Indiana State Police.) The truck driver’s excessive, rapid, evasive steering maneuver6 triggered a sequence of events that caused the cargo tank semitrailer to roll over, decouple from the truck-tractor, penetrate a steel W-beam guardrail, and collide with a bridge footing and concrete pier column supporting the southbound I-465 overpass. The collision entirely displaced the outside bridge

6 A rapid, evasive maneuver is defined by the National Highway Traffic Safety Administration (NHTSA) as steering, braking, accelerating, or any combination of control inputs that approaches the limits of a vehicle’s capabilities. For further information, see Evaluating the Relationship Between Near-Crashes and Crashes: Can Near-Crashes Serve as a Surrogate Safety Metric for Crashes? DOT-HS-811-382 (Washington, DC: U.S. Department of Transportation, National Highway Traffic Safety Administration, 2010).

NTSB Highway Accident Report 5

pier column from its footing and resulted in a breach at the front of the cargo tank, which allowed the liquefied petroleum gas to escape, form a vapor cloud, and ignite. The truck-tractor came to rest on its right side south of the I-465 overpasses, and the decoupled cargo tank semitrailer came to rest on its left side, near the bridge footing supporting the southbound I-465 overpass (see figure 4).

Figure 4. Truck-tractor and cargo tank semitrailer at final rest. (Source: Lawrence Township Fire Department.) After witnessing the cargo tank semitrailer rollover, the Volvo driver stated that he immediately stopped his vehicle but did not have time to call 911 before the vapor cloud that had emitted from the cargo tank was ignited. The Volvo driver immediately exited his vehicle and ran north on the connection ramp to get away from the fire. The vapor ignited and created a fireball that extended approximately 250 feet above the I-465 overpasses. The truck driver and the Volvo driver sustained serious injuries in the accident and from the postaccident fire; and three occupants of passenger vehicles traveling above the connection ramp on I-465 received minor injuries from the postaccident fire. At the time of the accident, the sky was overcast, the winds were calm, the pavement was dry, and the temperature was about 58° F. 1.2 Emergency Response The accident was reported at 10:41 a.m. to the Marion County Sheriff’s Department 911 system as a tanker spill on southbound I-465. The Indianapolis Metropolitan Police Department (IMPD) was notified moments later and arrived on scene at 10:47 a.m. The IMPD initially assumed command for law enforcement until a commander with the Indiana State Police (ISP) arrived on scene. The ISP sent approximately 25 units to the accident site, with the first 3 units dispatched at 10:41 a.m. and simultaneously arriving on scene at 10:48 a.m.

NTSB Highway Accident Report 6

After arriving on scene, ISP troopers provided first aid and spoke with the truck driver, who told them he could not remember what happened. At 10:58 a.m., traffic approaching the interchange was diverted from southbound I-69 and, at 11:08 a.m., from both directions of I-465. The ISP incident commander arrived on scene at 11:19 a.m. and deployed the Indiana Traffic Incident Management Effort (IN-TIME)7 traffic management plan to establish traffic control in the accident vicinity, alleviate traffic congestion in northeast Indianapolis, and initiate a contingency plan for road closures. The fire department was notified at 10:42 a.m. and, moments later, the Lawrence Township Fire Department (LTFD)8 and Indianapolis Fire Department (IFD) were dispatched. Shortly after that, the City of Lawrence and Town of Fishers fire departments were also dispatched. Four fire departments responded to the scene with approximately 39 firefighting apparatus units. A LTFD captain, who arrived on scene at 10:44 a.m., was the initial incident commander. The IFD firefighter hazardous materials team, which arrived on scene at 10:48 a.m., was notified en route that the cargo tank displayed a placard with United Nations (UN) identification number 1075.9 The placard’s UN identification number, tank shape, and eruption of a fireball after impact indicated to firefighters that the incident involved liquefied petroleum gas. The firefighters also observed a boiling fog escaping from a breach near the front head of the cargo tank. The first of five ambulances arrived on scene at 10:50 a.m. Three ambulances transported occupants with injuries to area hospitals (Wishard Hospital, Clarian Methodist Hospital, and Community North Hospital). The Chief of the LTFD assumed command after arriving on scene at 11:04 a.m. as the unified command post (UCP) was being established east of the southbound I-465 overpass. Fire suppression units were located primarily north and south of the accident location to extinguish fires at the locations where the truck-tractor and the cargo tank semitrailer came to rest. At 11:08 a.m., the incident commander reported that the fires were primarily under control, with the exception of small brush fires that continued to burn until 12:10 p.m. Combustible gas meter testing indicated the presence of flammable vapors in the area.10 The IFD then focused on deploying water to cool the tank and dissipate flammable vapors. At 11:19 a.m., the IFD safety coordinator reported that liquefied petroleum gas vapors continued to accumulate near the damaged cargo tank. For 30–40 minutes, while fog continued escaping from

7 IN-TIME is a public–private sector group that develops and recommends policy and operational protocols for the safe and efficient mitigation of traffic incidents. 8 The LTFD merged with the Indianapolis Fire Department on January 1, 2011. 9 The four-digit numbers that follow UN letters are displayed on package labels and placards attached to the external surface of commercial motor vehicles to identify the presence and type of hazardous materials being transported. Firefighters can utilize UN numbers to obtain information about how to respond to hazardous material releases. 10 The combustible gas meter detects the presence of gas concentrations up to 100 percent of the lower explosive limit, which is the lowest concentration of a flammable gas or vapor emitted into the air capable of producing a flash of fire in the presence of an ignition source.

NTSB Highway Accident Report 7

the tank, burning embers falling from a nearby outdoor advertisement sign caused at least three minor flashbacks of the vapor trail. Meanwhile, the UCP was transferred into the Metropolitan Emergency Communications Agency (MECA)11 van at 11:47 a.m. At 2:50 p.m., the fire department was still measuring flammable vapor concentrations at the cargo tank. The flammable vapor was eliminated once the City of Lawrence Fire Department and the IFD established a steady supply of water from a fire hydrant at a nearby apartment complex. When no flammable vapor levels were measured at 4:18 p.m., water operations were terminated. Unified command was transferred to the ISP at 6:59 p.m. By 8:00 p.m., the Indiana Department of Transportation (INDOT) and the ISP had opened the majority of the ramps that had been closed, except for the connection ramp (where the accident occurred) from southbound I-69 to southbound I-465, which was repaired and opened by 7:00 a.m. on October 27, 2009. I-465 remained closed to traffic for at least 1 day after the accident.12 The ISP and the LTFD had conducted recent disaster drills. A post-incident analysis of this accident was held by responding fire departments on October 28, 2009, to review the response, lessons learned, and problems encountered. The ISP facilitated an after-action review with all first responders on November 19, 2009. 1.3 Injuries The truck driver sustained serious injuries, including multiple contusions, heat blistering to his shoulders and upper back, and a laceration to the right ear. The driver of the 2007 Volvo sustained second-degree burns to his face, head, and arms. Three occupants in passenger vehicles traveling above the connection ramp on I-465 sustained minor burns (see table 1). Table 1. Injuries. Injury Severity Truck Driver Passenger Vehicle Occupants Total Fatal 0 0 0 Serious 1 1 2 Minor 0 3 3 None 0 0 0 Total 1 4 5 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 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 the 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.

11 The MECA vehicle is equipped with the necessary equipment and personnel to provide emergency communication and record management services. 12 Correspondence received from INDOT, June 9, 2011.

NTSB Highway Accident Report 8

1. 4 Survival Factors

Motorists traveling on I-465 stopped and walked to where the truck-tractor came to rest on its right side. They observed the truck driver inside the cab compartment leaning against the passenger door attempting to reach the steering wheel, with his seat belt slightly outstretched. One motorist first used his foot to dislodge and then his hands to remove the windshield from the truck-tractor before helping the truck driver exit the cab compartment. The truck driver was able to walk with assistance from others to move away from the truck-tractor. The truck driver stated in a postaccident interview with NTSB investigators that he was wearing his seat belt.13 1.5 Scene Evidence The ISP reconstruction team documented evidence at the accident scene using close-range photogrammetry.14 Tire marks extended in an arc from the right shoulder to the right lane, with the longest (on a scaled diagram prepared by ISP) measuring approximately 322 feet. Gouge marks were adjacent to where the right W-beam guardrail was damaged, and tire imprints were on the right shoulder and in the right lane directly north of the westbound I-465 overpass. Three scrape marks, 13–35 feet long, were in the right lane below the westbound I-465 overpass. The cargo tank semitrailer came to rest on its left side under the southbound I-465 overpass, with the front of the tank near the I-465 bridge footing and the rear bumper approximately 2 feet from railroad tracks. The rearmost axle15 on the cargo tank semitrailer (axle 5) separated and came to rest straddling the centerline on the connection ramp. The truck-tractor came to rest across both lanes of the ramp, approximately 135 feet from the front head of the cargo tank semitrailer. With the exception of the right rear tire, the Volvo passenger car was stopped entirely on the left paved shoulder adjacent to the left W-beam guardrail and below the westbound I-465 overpass, approximately 103 feet from where the cargo tank came to rest. 1.6 Weather Astronomical data reported near the accident location on October 22, 2009, the day of the accident, showed that sunrise occurred at 8:03 a.m. and that the sun’s altitude was 33.5° and azimuth was 149.1° east of true north at 10:45 a.m.16 A weather station near the accident site

13 Title 49 CFR 392.16 states that ―a commercial motor vehicle which has a seat belt assembly installed at the driver’s seat shall not be driven unless the driver has properly restrained himself/herself with the seat belt assembly.‖ The 2009 overall seat belt usage rate for drivers of all medium and heavy duty trucks and buses combined was 74 percent. For more information, see Commercial Motor Vehicle Driver Safety Belt Usage, Commercial Truck and Bus Safety Synthesis 8 (Washington, DC: Transportation Research Board) and Seat Belt Usage by Commercial Motor Vehicle Drivers, 2009 Survey, December 2009 (Washington, DC: Federal Motor Carrier Safety Administration). 14 Photogrammetry takes two or more two-dimensional images from different angles, with at least one known distance within the field of view, and translates them into three-dimensional models to analyze and obtain measurements of objects or distances within a spatial area. 15 For reference purposes, the five axles on the articulated combination unit are referred to by a single-digit number beginning with the steering axle (axle 1), followed by the first drive axle (2), second drive axle (3), first semitrailer axle (4), and second semitrailer axle (5). 16 Information obtained from the U.S. Naval Observatory website http://aa.usno.navy.mil, accessed October 25, 2009.

NTSB Highway Accident Report 9

reported a temperature of 58° F, a dew point of 54° F, and southerly winds of 4 mph at 10:44 a.m. No precipitation was recorded on October 22, 2009. At 10:54 a.m. that day, the Indianapolis International Airport—located approximately 16 miles southwest of the accident scene—reported overcast, dry conditions and visibility of 10 statute miles. 1.7 Damage The entire cab of the three-axle truck-tractor, upper sections of the fuel tanks, and combustible materials near the engine compartment—including brake system air lines—were consumed by the postaccident fire (see figure 5). The brake chamber mounting brackets on the steering axle were bent. The left- and right-quarter fenders on the truck-tractor were damaged. The frame rails at the rear of the truck-tractor were twisted, and the fifth wheel plate was entirely separated from the slide rail bracket. The tires on the steering axle were almost completely destroyed by fire. The inboard and outboard tires on the right side of axle 2 and the outboard tire on axle 3 were deflated, and the outboard right wheels were damaged.

Figure 5. Fire-damaged truck-tractor. The lower front head of the MC331 cargo tank semitrailer was deformed after impacting the bridge pier column. The impact resulted in a breach at the lower and right side of the front head, which generally followed the fillet weld around the perimeter of the mounting pad that attached the bottom of the tank to the upper coupler assembly.17 The majority of the opened portion of the breach measured approximately 20 inches by 29 inches, with the adjacent head and shell material peeled outward (see figure 6).

17 The upper coupler assembly, which consists of the coupler plate, kingpin, and supporting framework at the front of a semitrailer, interfaces with and couples to a truck-tractor’s fifth wheel.

NTSB Highway Accident Report 10

Figure 6. Collision damage and breach at the lower right side of the cargo tank. The flammable gas placard on the right side of the tank was destroyed. A wide scrape extended along the entire right shell of the cargo tank. The rear head sustained a cylindrically shaped transverse dent centered near the edge of the head, measuring approximately 37 inches long, 18 inches wide, and 4 inches deep. Black soot coated the right two-thirds of the rear head. The transverse baffles inside the tank were bowed forward about 6 inches. Axle 5 separated from the semitrailer during the crash, and axle 4 became detached when the cargo tank trailer was recovered from the scene. All outboard tires on axles 4 and 5 and the inboard left tire on axle 4 were deflated, and all outboard wheels were damaged. The outboard tire on the right side of axle 4 was detached from the wheel, and the outer sidewall of the outboard tire on the left side of axle 4 was lacerated. The steel W-beam guardrail along the connection ramp was damaged, and the outermost concrete bridge pier column that supported the southbound I-465 overpass separated from the bridge footing and pier cap (see figure 7). The heat of the postaccident fire damaged two outdoor advertisement signs and a telecommunication tower (see figure 8). Eight passenger vehicles traveling on the connection ramp and on the I-465 overpasses received minor-to-extensive heat-related damage, with two vehicles being towed from the accident scene. Damage from the fire extended approximately 280 feet north and 110 feet south of where the cargo tank semitrailer came to rest under the I-465 overpasses.

NTSB Highway Accident Report 11

Figure 7. Displaced bridge pier column struck by cargo tank semitrailer. (Source: Indiana State Police.)

Figure 8. Aerial view of the connection ramp and Interstate 465 overpasses. (Source: Indiana State Police.)

NTSB Highway Accident Report 12

1. 8 Vehicle Information (Cargo Tank Combination Unit)

The 2006 Navistar International truck-tractor and 1994 Mississippi Tank Company cargo tank semitrailer were operated by AmeriGas Propane, L.P./Propane Transport International (AmeriGas/PTI), which has a corporate office in King of Prussia, Pennsylvania. The five-axle articulated combination unit was approximately 8 feet wide, with an overall length of approximately 60 feet. NTSB investigators, together with the ISP and a representative of the Mississippi Tank Company, conducted a postaccident examination of the combination unit. 1.8.1 Truck-Tractor The three-axle truck-tractor, manufactured in October 2005 by Navistar International Corporation, had a shipped weight18 when built of 16,921 pounds. The truck-tractor was factory-equipped with a 430-horsepower (hp) Caterpillar C13 diesel engine, 10-speed manual transmission, leaf spring suspension on the steer axle, air ride suspension on the drive axles, air brake system with S-cam service brakes, and antilock braking system (ABS). The truck-tractor received its last periodic inspection on May 22, 2009 (invoice date June 3, 2009), from Selking International, Fort Wayne, Indiana. The odometer was destroyed in the postaccident fire; maintenance records indicated an odometer reading of 268,713 miles when the truck-tractor was serviced on October 13, 2009 (invoice date October 22, 2009), by Star Truck Rentals, Inc., Grand Rapids, Michigan. Damage from the fire restricted testing on the pneumatic portion of the truck-tractor’s braking system. All service brakes, except for the brakes on the steering axle, which were damaged and could not be measured, were found to be within proper adjustment limits.19 The steering linkage was intact despite damage at both outboard ends and the underside of the front axle. The steering gear (R.H. Sheppard model M100PMX3) was removed and an internal examination was conducted in the presence of an NTSB investigator by a representative of R.H. Sheppard Company, Inc., Hanover, Pennsylvania. The internal examination revealed signs of excessive heat throughout the steering gear. No damage or cracks were observed on the pitman arm splines, sector teeth, or piston teeth. In addition, no damage was observed to the upper thrust bearing or washers, rotary valve, and lower thrust washer.

18 Shipped weight is a vehicle’s unladed dry weight with minimal or no fuel, fluids, or optional equipment. 19 The applied pushrod stroke of each brake chamber that could be measured was within the maximum applied readjustment limits specified in 49 CFR Part 396, Appendix G, and the North American Out-of-Service Criteria that are utilized by the Commercial Vehicle Safety Alliance at roadside inspections.

NTSB Highway Accident Report 13

During the accident, the truck-tractor and cargo tank semitrailer decoupled at the fifth wheel before coming to rest. The fifth wheel coupler assembly20 was examined by NTSB investigators and a Fontaine Fifth Wheel Company representative. Postaccident examination revealed that the frame rails at the rear of the truck-tractor were twisted (left rail higher than right rail), and the cross bars at the base of the mounting brackets of the fifth wheel plate were significantly buckled and deformed (see figure 9). Signs of deformation were also observed on the frame rails and tracks where the slide rail bracket was fastened to the rear of the truck-tractor. The examination also found that the locks that keep the fifth wheel plate in a fixed position on the slide rail bracket were fully engaged in the locked position. The welded stop bars on the slide rail bracket that prevent the fifth wheel plate from inadvertently separating from the slide rail bracket were intact and undamaged. Observations made during the examination were consistent with the extended outboard edges of the cross bars of the fifth wheel plate becoming deformed and the grooved section of the slide rail bracket twisting sufficiently for the fifth wheel plate to separate from the slide rail bracket during the rollover sequence.

Figure 9. Fifth wheel plate. In addition to separating from the slide rail bracket, the fifth wheel plate also separated from the cargo tank semitrailer’s kingpin. The fifth wheel plate was found, with the pull handle severely deformed, approximately 70 feet north of where the cargo tank semitrailer came to rest. The jaw-and-wedge mechanism found in the open position at the scene and the deformation of

20 The fifth wheel coupler assembly at the rear of a truck-tractor consists of two joined components. The cross bars at the base of the fifth wheel plate (upper section) fit within metal slotted grooves on each side of the slide rail bracket (lower section). The fifth wheel plate is therefore connected to the slide rail bracket, which, in turn, is mounted to the frame rails at the rear of the truck-tractor with high-grade hexagonally shaped bolts. The fifth wheel plate is equipped with a jaw-and-wedge mechanism to allow the truck-tractor to couple to the cargo tank semitrailer’s kingpin, which serves as an anchor pin and articulation point and is located behind and under the front of the tank.

NTSB Highway Accident Report 14

the pull handle (as noted in figure 9) suggest that the pull handle became snagged as the cargo tank semitrailer slid on its right side, allowing the fifth wheel plate to separate from the trailer kingpin. The pull handle, located on the right side of the truck-tractor, is physically extended outward by a driver to release the fifth wheel plate from the kingpin to decouple the truck-tractor from the semitrailer. The truck-tractor’s Eaton Fuller 10-speed transmission was examined to determine the gear position at the time of the accident. The most forward of three synchronizers was observed to be engaged in fourth or ninth gear, depending on whether the vehicle was in low or high range, respectively. The Caterpillar C13 diesel engine had the capability, if enabled, of recording time-series and vehicle-related speed data that may have been instrumental in reconstructing accident events. Fire damage to the unit prevented NTSB investigators from recovering data that may have been captured from the engine’s electronic control module. 1.8.2 Cargo Tank Semitrailer The MC331 cargo tank semitrailer was manufactured in March 1994 by the Mississippi Tank Company. The chassis was factory-equipped with a tandem three-leaf spring suspension and an adjustable kingpin, which appeared undamaged. The hubometer on axle 4 displayed 298,827 miles when examined after the accident. Class 2 flammable gas placards with identification number 1075 and the words LIQUEFIED PETROLEUM GAS were displayed on the front, rear, and sides of the cargo tank. The empty weight of the MC331 cargo tank semitrailer was 21,860 pounds. The bill of lading indicated that the cargo tank was loaded with 9,001 gallons of liquefied petroleum gas weighing approximately 37,900 pounds. The estimated weight of the combination unit laden with 9,001 gallons of liquefied petroleum gas was 76,681 pounds. The MC331 cargo tank was fabricated of quenched and tempered (QT)21 SA 517E steel segments joined by butt welds that satisfied applicable American Society of Mechanical Engineers (ASME) code requirements and Federal regulations (49 CFR 178.337). The 0.25-inch-thick hemispherical front and rear heads were each constructed from a central circular plate and six approximately identical trapezoidally shaped gores. The tank’s shell consisted of four 0.378-inch-thick shell sections that were cut and shaped into cylinders to match the diameter of the head (see figure 10). The tank was 43 feet 11.5 inches long and had an inside diameter of 83.5 inches. The tank’s water capacity was 11,600 gallons, with a maximum allowable working pressure of 250 pounds per square inch, gauge (psig).

21 Quenching is the process of heating and rapidly cooling steel to increase hardness. Tempering is a heat treatment that follows quenching to reduce the brittleness of steel without significantly lowering its hardness or strength. Quenched and tempered (QT) and nonquenched and tempered (NQT) carbon steel plate is commonly used in the construction of MC330 and MC331 cargo tanks.

NTSB Highway Accident Report 15

Figure 10. Cargo tank semitrailer (MC331). Two X-shaped transverse baffles divided the interior volume of the MC331 cargo tank by thirds to minimize the longitudinal surge of liquid in the tank against the front and rear heads. The baffles were bolted to support clips and fastened to the tank shell by fillet-welded mounting pads. Four pipe lines and fixtures used to load and unload product were contained in a steel piping protection device. The cargo tank semitrailer was equipped with a pump to offload product and aftermarket equipment designed to automatically close internal valves when a leak is detected. Brake interlock devices were installed to prevent the trailer from being moved when loading and unloading lines are connected. Postaccident examination by the NTSB found that the head and shell cracks in the area of impact were consistent with ductile overstress, with no indications of preexisting damage or degradation. The majority of the cracking occurred along the fillet welds where the support structure was attached to the tank, which is to be expected because the support structure creates reinforcement where bending stresses are maximized. The weld geometry also introduces a stress concentration, and the welding process could alter the microstructure of the steel to reduce the material’s toughness. Cracking was also observed in the head of the tank within deep folds caused by the impact with the bridge pier column, away from any fillet or butt welds. No evidence was found of physical damage to the external piping and fittings, corrosion pitting on the interior or exterior of the shell or heads of the tank, or weld defects in the tank structure, such as lack of fusion. Postaccident examination of the two spring-loaded Fisher type H732-250 pressure relief valves mounted on the top center of the tank revealed that the plastic rain cap remained fully inserted in the forward pressure relief valve cup, but the rain cap and specification tag for the rearmost pressure relief valve were missing.22 The internal valve stems and springs of both valves revealed no visible signs of damage, such as corrosion, bending, marks, or chipped paint. Postaccident bench testing determined that both valves functioned as designed by opening within 110 percent of the maximum allowable working pressure of 250 psig.

22 The plastic cap is fully inserted into a cup located at the top of a pressure relief valve to seal and prevent rainwater from accumulating and leaking into the valve, which could lead to corrosion and affect the ability of a valve to function as designed.

NTSB Highway Accident Report 16

1. 8.3 Periodic Testing and Refurbishment

Title 49 CFR Part 180.407 requires that MC330 and MC331 semitrailer pressure vessels receive annual external visual inspections and leakage tests. Additionally, the following must be completed every 5 years: an internal visual inspection, a wet fluorescent magnetic particle inspection23 of all welds in and on the interior of QT and NQT cargo tanks, and a hydrostatic pressure test. The accident vehicle’s most recent cargo tank test inspections were conducted when the MC331 semitrailer’s chassis and cargo tank were refurbished by the Mississippi Tank Company (Indiana Division) in July 2009. The cargo tank refurbishment included the installation of several new components, including two pressure relief valves and a tank pressure gauge. Once the refurbishment was completed, the wet fluorescent magnetic particle inspection and hydrostatic pressure test were performed, and external and internal visual inspections of the tank were conducted to check for weld defects, evidence of corrosion, abrasion, dents, and gouges. The refurbishment of the chassis primarily involved installing new brake hardware, fabricating a new steel plate and kingpin, and retrofitting the chassis with an ABS. The cargo tank and chassis were sandblasted and repainted and passed all U.S. Department of Transportation (DOT) mandated inspections. 1.9 Truck Driver Information The truck driver was 73 years old and held a valid class ―A‖ Indiana commercial driver’s license (CDL) with an expiration date of December 3, 2011,24 which had a restriction requiring him to wear corrective lenses while driving. The truck driver also held endorsements for operating a cargo tank motor vehicle and transporting hazardous materials. There were no suspensions or disqualifications on the license. Information from the Indiana Department of Motor Vehicles and the Commercial Driver’s License Information System (CDLIS) database indicated that the truck driver had accumulated three moving violations during the 5 years before the accident (see table 2). Two of the violations were for speeding, and one was for failure to signal. Table 2. Moving violations (2004–2009). Violation Travel Above Posted Speed Limit Vehicle Type Conviction Date Failure to use/improper signal N/A Commercial vehicle October 29, 2007 Speeding* 16 mph Commercial vehicle June 7, 2007 Speeding* 17 mph Commercial vehicle May 13, 2004 *Withdrawn after the truck driver attended a safe driving course.

23 A wet fluorescent magnetic particle inspection is a nondestructive testing process for detecting surface and near-surface flaws. 24 An Indiana CDL must be renewed every 4 years.

NTSB Highway Accident Report 17

1. 9.1 Driving Experience

At the time of the accident, the truck driver had been driving heavy trucks for about 45 years, with the past 15 years spent transporting bulk liquid hazardous materials in cargo tank motor vehicles. The truck driver said he had been involved in two accidents while driving commercial vehicles, with the most recent occurring more than 5 years before this accident. The truck driver had been employed by AmeriGas/PTI for about 14 years.25 He delivered liquefied petroleum gas for AmeriGas/PTI from loading terminals in Huntington, Griffith, and Milford, Indiana, to customer locations throughout Indiana, Illinois, and Ohio. He received delivery assignments each day from a dispatch office in Houston, Texas, which were transmitted to an onboard Qualcomm vehicle-tracking system26 that provided details about each load and delivery location. Although the truck driver could be dispatched anywhere if required, most loads were delivered within the state, allowing him to become familiar with Indiana’s network of highways. The truck driver was allowed to set his own work hours as long as he complied with delivery schedules. Most working days were 14 hours. When the combination unit was not in service, it was parked at a local AmeriGas Propane, L.P., retail facility located approximately 13 miles from the truck driver’s residence. Depending on workload, he either slept at home or in the sleeper berth of his truck-tractor. The truck driver had been driving the same truck-tractor for approximately 2 years before the accident occurred. 1.9.2 Medical Information The truck driver had a 15-year history of hypertension and Type II diabetes controlled by prescription medication. He was prescribed enalapril, hydrochlorothiazide, and atenolol to control high blood pressure (BP) and glyburide and metformin to control blood glucose. He also took tamsulosin to control symptoms of an enlarged prostate. The truck driver told NTSB investigators that he tested his blood glucose level twice daily and had two pill carriers—one for daytime and one for nighttime medication. Although he acknowledged taking all prescribed medication at the usual times during the 3 days before the accident, he did not test his blood glucose level on the morning that the accident occurred. The truck driver had undergone cataract surgery on his left eye in 1995 and his right eye in 1998. A complete ophthalmological exam in 2007 revealed no evidence of diabetic retinopathy, and another eye exam in 2009 found the truck driver to have 20/20 corrected distance visual acuity. The truck driver experienced an ischemic stroke approximately 10 years

25 The truck driver completed an application for employment with AmeriGas/PTI on June 23, 1995. 26 AmeriGas/PTI vehicles are equipped with a wireless communication device that provides two-way text data messaging and automatic satellite-tracking capabilities that include periodic reporting of the date, time, vehicle’s approximate location in relation to a nearby town, and status of the ignition key. Vehicle position history data can be used to locate the vehicle in real-time, later determine the route and time required to travel between two points, or review handwritten logbooks completed by commercial drivers.

NTSB Highway Accident Report 18

before the accident.27 Medical records indicate that he had a complete recovery from the stroke except for dysarthria.28 The accident truck driver possessed a current medical certificate (signed April 21, 2009), which expired in April 2010. The truck driver was required to be examined yearly (rather than the typical 2-year examination period for commercial drivers)29 because of his hypertension and diabetes.30 Commercial driver fitness examinations at AmeriGas/PTI are completed by a physician retained by the company for that purpose. The truck driver’s most recent commercial driver medical examination report noted his diabetes, high BP, and stroke but did not mention any abnormalities with his extremities. An orthopedic clinic note of July 22, 2009, reported the truck driver’s height as 72 inches and weight as 210 pounds. The truck driver was on a 6-month medical leave in 2009 to have knee replacement surgery for severe and painful arthritis of both knees. The right knee surgery was performed on May 4, 2009, and the left knee on June 1, 2009. The truck driver underwent physical therapy and was allowed by his surgeon to return to regular duties on September 28, 2009. Postaccident hospitalization records indicated that the truck driver did not lose consciousness, and an inpatient postaccident evaluation did not identify any neurologic or cardiologic abnormalities that may have contributed to the accident. The truck driver’s weight was noted as 224 pounds and his blood sugar as 258 milligrams per deciliter (mg/dL) at the time of arrival at the emergency room. The hospital records also noted his most recent meal was at 9:45 a.m., and a laboratory record indicated his hemoglobin A1C was 6.3 percent.31 1.9.3 72-Hour History From October 19–22, 2009, the truck driver received six loads of liquefied petroleum gas from Dome Petroleum Corporation (the loading terminal), located approximately 2.6 miles east of Huntington, Indiana. Five of the six loads were delivered to four locations in Indiana (see figure 11). The one-way travel distance from the loading terminal to each of the four delivery locations ranged from 30–133 miles.

27 Ischemic strokes account for approximately 85 percent of all stroke cases and occur when there is an obstruction by blood clots or fatty deposits within a blood vessel that supplies blood to the brain. 28 Dysarthria is characterized by distorted speech that results from the inability to properly move the muscles of the tongue and mouth to produce speech. 29 Title 49 CFR 391.45 requires a 2-year examination cycle, unless the examining physician recommends a shorter time period. 30 Title 49 CFR 391.43 requires a driver diagnosed with stage 1 hypertension (BP 140/90–159/99) to be certified for 1 year only. Upon recertification, if the driver’s BP is 140/90 or lower, he or she may be certified for a 1-year reexamination cycle. However, if the driver’s BP is greater than 140/90 but less than 160/100, a one-time certificate for 3 months can be issued. A driver diagnosed with stage 2 hypertension (BP 160/100–179/109) should be treated and a one-time certificate for 3 months issued. Once the driver has reduced his or her BP to 140/90 or lower, the driver may be recertified annually thereafter. A driver diagnosed with stage 3 hypertension (BP 180/110 or higher) should not be certified until his or her BP is 140/90 or lower and should be recertified every 6 months. 31 The A1C is a common blood test that reflects the average blood sugar level for the past 2–3 months. Diabetics are recommended to maintain an A1C level below 7 percent.

NTSB Highway Accident Report 19

Figure 11. Location of loading terminal in relation to October 19–22 deliveries.

NTSB Highway Accident Report 20

A review of information recorded by the Qualcomm vehicle-tracking system revealed that data and time-stamped information about the accident vehicle’s approximate location were recorded approximately 80 times in the 3 days before the accident, with the first available record generated at 11:48 a.m. near Columbia City, Indiana, on October 19, 2009, and the last at 8:44 a.m. near Chesterfield, Indiana, on October 22. NTSB investigators utilized a software program (PC*MILER) to verify distances and the approximate time for the truck driver to travel from the loading terminal to deliver five loads throughout Indiana during the 3 days before the accident.32 NTSB investigators also reviewed hours-of-service records that were provided by AmeriGas/PTI for trips that had been completed by the truck driver in March 2009 (before the medical leave) and during the 2 weeks before the accident. These records indicate that the truck driver worked on October 9, 12, 15, and 16, 2009, and 3 consecutive days (October 19–21, 2009) before the accident occurred on October 22. Hours-of-service logbooks completed by the truck driver from October 19–22, 2009, were destroyed in the postaccident fire. Consequently, NTSB investigators obtained copies of shipping documents, information from a postaccident interview, and Qualcomm vehicle position history data from AmeriGas/PTI to reconstruct a 72-hour history of the truck driver’s activities before the accident (see figure 12 and table 3). While the reconstruction of the truck driver’s activities provides general information about his schedule, including available time for sleep, it does not necessarily reflect the actual time that sleep was initiated or duration of sleep during the 3 nights before the accident. Based on the reconstruction of the handwritten hours-of-service logbooks, the truck driver had driven the combination unit approximately 63 hours during 7 of 14 days from October 9–22, 2009.

Figure 12. Truck driver’s 72-hour history of activities before the accident.

32 PC*MILER is a routing and mapping software that is used by motor carriers for route navigation, rate calculation, fuel tax reporting, mileage verification, bid preparation, and freight auditing purposes.

NTSB Highway Accident Report 21

Table 3. Reconstruction of accident truck driver’s activities, October 19–22, 2009 (based on postaccident interview, shipping documents, and Qualcomm vehicle position history data). Monday, October 19 Time (EDT) Activities Location 7:00 a.m. Awakens at residence Syracuse, IN 11:00 a.m. Begins driving Goshen, IN 12:30 p.m. On duty, loading (load #1) Huntington, IN 1:00 p.m. Begins driving Huntington, IN 2:15 p.m. On duty, unloading Ft. Wayne, IN 3:00 p.m. Begins driving Ft. Wayne, IN 4:15 p.m. On duty, loading (load #2) Huntington, IN 5:00 p.m. Begins driving Huntington, IN 8:15 p.m. On duty, unloading Lebanon, IN 8:45 p.m. Time available for sleep (3 hours 30 minutes) Lebanon, IN Tuesday, October 20 Time (EDT) Activities Location 12:15 a.m. Begins driving Lebanon, IN 1:00 a.m. Time available for sleep (6 hours) Westfield, IN 7:00 a.m. Begins driving Westfield, IN 9:30 a.m. On duty, loading (load #3) Huntington, IN 10:00 a.m. Begins driving Huntington, IN 2:00 p.m. On duty, unloading Danville, IN 3:00 p.m. Begins driving Danville, IN 8:30 p.m. Time available for sleep (45 minutes) Huntington, IN 9:15 p.m. On duty, loading (load #4) Huntington, IN 9:45 p.m. Begins driving Huntington, IN 10:15 p.m. Time available for sleep (6 hours 45 minutes) Wabash, IN Wednesday, October 21 Time (EDT) Activities Location 5:00 a.m. Begins driving Wabash, IN 5:30 a.m. Off duty, not driving Mexico, IN 9:00 a.m. Begins driving Mexico, IN 11:00 a.m. On duty, unloading Lebanon, IN 12:00 p.m. Begins driving Lebanon, IN 2:45 p.m. On duty, loading (load #5) Huntington, IN 4:30 p.m. Begins driving Huntington, IN 6:00 p.m. On duty, unloading Fort Recovery, OH 7:15 p.m. Begins driving Fort Recovery, OH 9:00 p.m. Time available for sleep (1 hour) Huntington, IN 10:00 p.m. On duty, loading (load #6) Huntington, IN 11:00 p.m. Begins driving Huntington, IN Thursday, October 22 Time (EDT) Activities Location 12:00 a.m. (midnight) Time available for sleep (8 hours 15 minutes) Gaston, IN 8:15 a.m. Begins driving Gaston, IN 10:38 a.m.* Accident occurs I-69 connection to I-465 *The accident truck driver took more than 2 hours to travel approximately 45 miles, possibly due to an unscheduled stop between exit 45 and I-69 and the accident location. Vehicle position history data recorded by the Qualcomm vehicle-tracking system at 8:44 a.m. on October 22 and the truck driver’s last meal before the accident at approximately 9:45 a.m. (according to postaccident hospital records) suggest that he did not travel directly from a rest area at exit 45 and I-69 near Gaston, Indiana, to the accident location but instead stopped for a meal at exit 34 and I-69 near Chesterfield, Indiana.

NTSB Highway Accident Report 22

The truck driver told NTSB investigators that there were no internal or external distractions before the accident and that he was not using the citizens band radio, manipulating the controls of an AM/FM radio, using the Qualcomm vehicle-tracking system to send text messages, or engaging in a cellular telephone conversation. He also said that his vision was not temporarily obscured by sun glare nor was his concentration reduced or shifted by the large outdoor advertising sign located directly in the line of sight of motorists traveling south on the connection ramp. A review of the truck driver’s cellular telephone record indicated that he was not using the telephone for talking or texting at the time of the accident. 1.9.4 Toxicology During a postaccident interview with NTSB investigators, the truck driver indicated that he had not consumed alcohol during the 3 days before the accident. A blood sample, taken at the request of the ISP, was obtained from the truck driver at Clarian Methodist Hospital approximately 3 hours after the accident (1:38 p.m.) and split into two samples. Toxicological testing on one sample by the Indiana University Department of Pharmacology and Toxicology did not detect alcohol or 17 other drug types.33 Toxicological testing of the other sample by the Civil Aerospace Medical Institute (CAMI) in Oklahoma City, Oklahoma, was negative for a wide range of legal and illegal drugs.34 The CAMI blood sample detected an antihypertensive prescription medication, atenolol. 1.10 Motor Carrier Operations The combination unit was operated by Propane Transport International (PTI), the transportation division of AmeriGas Propane, L.P. PTI was established in the 1950s and operated as a common carrier until it was acquired by AmeriGas Propane, L.P., in 1987 (referred to as AmeriGas/PTI). AmeriGas Propane, L.P., is a subsidiary of AmeriGas Partners, L.P., a retail propane marketer with distribution locations in 50 states.35 AmeriGas Propane, L.P. (legal name), doing business as PTI, was assigned U.S. Department of Transportation (USDOT) number 388004 and motor carrier (MC) number 114969.36 AmeriGas/PTI delivers bulk commodities such as propane, butane, and liquid asphalt as a common and contract carrier within the United States, several Canadian provinces,

33 Amphetamines, barbiturates, benzodiazepines, cocaine, methadone, opiates, phencyclidine (PCP), cannabinoids (marijuana), oxycodone, opioids, LSD, fentanyl, MDMA (colloquially known as ―Ecstasy‖), propoxyphene, methqualone, buprenorphine, and ketamine. 34 Amphetamines, opiates, marijuana, cocaine, PCP, benzodiazepines, barbiturates, antidepressants, antihistamines, meprobamate, methaqualone, and nicotine. 35 2010 Annual Report, AmeriGas Partners, L.P. 36 A USDOT number is a unique identifier used to track safety information collected during carrier audits, compliance reviews, accident investigations, and vehicle inspections. The MC number is required to operate as a ―for-hire‖ motor carrier of regulated commodities or passengers in interstate commerce, unless the ―for-hire‖ operation is limited to transportation of exempt commodities, or the area operated within is exempt from interstate operating authority rules (49 CFR 392.9a).

NTSB Highway Accident Report 23

and Mexico. According to Safety and Fitness Electronic Records (SAFER)37 data administered by the Federal Motor Carrier Safety Administration (FMCSA), AmeriGas/PTI operated 2,761 power units with 3,645 drivers, for 45,657,197 total miles traveled in 2007. The overall distance traveled by AmeriGas/PTI increased significantly in 2010 to 92,109,000 miles, with additional power units (5,272) and fewer drivers (3,510). AmeriGas/PTI vehicles were involved in 84 recordable accidents, including three fatal accidents, 34 injury accidents, and 47 tow-away accidents from October 25, 2007, to October 25, 2009. SAFER data indicate that AmeriGas/PTI received 3,468 roadside inspections during the 24 months before the accident. The company’s out-of-service inspection rates for vehicles (10.7 percent), drivers (1 percent), and hazardous materials (2.5 percent) were lower than the national average out-of-service inspection rates (22.2, 6.6, and 5.0 percent, respectively). AmeriGas/PTI received satisfactory ratings for FMCSA compliance reviews conducted on February 19, 1998, and September 2, 2010.38 The FMCSA also conducted nonrated safety reviews at AmeriGas/PTI on May 24, 2006,39 and February 5, 2010.40 AmeriGas/PTI has developed criteria for the hiring of all new company drivers, fleet operators, and owner-operators. In addition to meeting Federal requirements (Federal Motor Carrier Safety Regulations [FMCSRs], Part 391), new drivers must have at least 3 years and 150,000 miles of recent verifiable over-the-road experience driving a tractor-trailer and no more than two moving violations within the last 2 years. The accident truck driver received a satisfactory rating from the company during a road test on July 27, 1995. AmeriGas/PTI drivers are paid by the mile and on a set scale for loading and unloading. The company does not compensate drivers with premium pay (overtime) for working beyond regular hours. AmeriGas/PTI conducts preemployment, random, postaccident, and reasonable cause drug and alcohol testing. The company contracts with a substance abuse screening company to select employees for random testing and comply with requirements of 49 CFR Part 382 to test a percentage of employees every year. Selected management personnel are trained for ―reasonable cause‖ drug detection.

37 SAFER is an FMCSA summary of a company’s Motor Carrier Management Information System data that includes roadside inspections and accident history. For further information, see , accessed April 11, 2011. 38 A compliance review is an on-site examination of a motor carrier’s operations that includes—but is not limited to—examining hours-of-service, maintenance, inspection, and other safety and transportation records; driver qualification and CDL requirements; and hazardous materials training to determine whether a carrier meets safety fitness standards. The results of a compliance review are used to assign a motor carrier a safety rating of satisfactory, conditional, or unsatisfactory. 39 The FMCSA conducted a nonrated security contact review on May 24, 2006, at an AmeriGas/PTI terminal located in Columbia Station, Ohio. 40 The FMCSA conducted a nonrated compliance review focusing on Parts 382 and 383 on February 5, 2010, because of a recordable accident involving the arrest of an AmeriGas/PTI driver for driving under the influence.

NTSB Highway Accident Report 24

1. 10.1 Driver Training

AmeriGas/PTI drivers are required to attend four separate in-service training sessions annually, lasting 8–72 hours and covering topics such as safe loading procedures and driving, with each session requiring the driver to pass a written test. Drivers are also provided employee training that meets the requirements of 49 CFR Part 172.41 The company has a committee that reviews accidents and recommends remedial actions. AmeriGas Propane, L.P., management told NTSB investigators that the company does not have a formal fatigue management program. The company developed a Vehicle Incident Prevention Training program for preventing backing, rear-ending, and rollover accidents. Materials to support the program include a slide presentation, participant handbook, and instructor guide. The company also displays safety posters and provides information in a safety bulletin about what can be done to prevent, as noted in a company newsletter, ―an epidemic‖ of rollover accidents that have occurred in recent years, including the rollover of 19 single-unit cargo tank trucks in 2009. Driver training handouts identify excessive speed, inattention, and overcorrected steering as the root causes of rollovers. The company’s training recommends that drivers not swerve to avoid an animal or debris on the road because the inertia of the propane load could shift and lead to a rollover. Drivers were also informed that the shifting of a partially filled tank can make a rollover situation even more likely once the vehicle starts to tip. The accident truck driver attended the company’s rollover awareness and prevention training and completed a Vehicle Incident Prevention Posttest on August 15, 2008. 1.10.2 Hours-of-Service Records AmeriGas/PTI drivers must submit handwritten logbooks to the company weekly, which are then monitored and audited with a computer-based program (Rapid Log). Each logbook page is reviewed for hours-of-service violations, and drivers are disciplined using a sliding scale system if violations are found. AmeriGas/PTI provided the handwritten logs that had been completed by the accident truck driver when he worked on October 9, 12, 15, and 16, 2009.42 The NTSB also received shipping documents and a vehicle position history report generated by the Qualcomm vehicle-tracking system for the months of March 2009 and October 2009.43 A detailed review that compared the truck driver’s handwritten logbook entries with shipping documents and vehicle position history data revealed five instances of false log entries and hours-of-service violations on 3 separate days in October 2009 (see table 4).

41 Title 49 CFR Part 172 requires that employees who work with hazardous materials receive training including general awareness/familiarization, function-specific information, emergency response procedures, hazardous materials protection, and accident prevention. 42 Title 49 CFR 395.8(K) requires the carrier to retain drivers’ records of duty (logbooks) for 6 months. 43 NTSB investigators did not receive hours-of-service records for the 6 months the driver was on medical leave (April–September 2009).

NTSB Highway Accident Report 25

Table 4. Discrepancies between handwritten logbook and Qualcomm vehicle position history data. Date Driver Status (handwritten log) Truck Status (Qualcomm vehicle position history data)* Discrepancy October 9, 2009 Departed Huntington, Indiana, at 1:30 p.m. Departed Huntington, Indiana, ~1:06 p.m. ~24 minutes Departed Noblesville, Indiana, at 6:30 p.m. Departed Noblesville, Indiana, ~7:18 p.m. ~48 minutes Arrived Goshen, Indiana, at 9:30 p.m. Arrived Goshen, Indiana, ~11:05 p.m. ~95 minutes October 12, 2009 Off duty, Goshen, Indiana, at 7:30 p.m. Parked in White Pigeon, Michigan, ~10:01 p.m. on October 12 until ~5:06 a.m. and returned to Goshen, Indiana, ~6:18 a.m. on October 13 ~642 minutes October 15, 2009 Off duty, Huntington, Indiana, at 8:30 p.m. Parked in New Paris, Indiana, ~7:57 p.m. on October 15 until ~5:07 a.m. and returned to Huntington, Indiana, ~10:09 a.m. on October 16 ~819 minutes *Vehicle position history data, which are captured approximately every 60 minutes, do not reflect the specific time that the combination unit departed from or arrived at a particular location. 1.10.3 Vehicle Maintenance The 2006 International truck-tractor was leased by AmeriGas/PTI from Star Truck Rentals in Grand Rapids, Michigan, as a new truck-tractor and brought into fleet service in January 2006. The regular preventative maintenance on the truck-tractor was outsourced by AmeriGas/PTI to Star Truck Rentals, Inc., in Grand Rapids, Michigan, and Donlen Corporation in Northbrook, Illinois. The last preventative maintenance service on the truck-tractor occurred on February 20, 2009 (invoice date February 26, 2009). The FMCSRs require that AmeriGas/PTI and other commercial motor vehicles be inspected annually.44 The truck-tractor received its most recent periodic inspection on May 22, 2009, and the cargo tank semitrailer, on July 8, 2009. The most recent repairs to the truck-tractor were performed by Star Truck Rentals, Inc., on September 18, 2009 (invoice date October 1, 2009), to resolve an electrical problem and axle leak; and on October 13, 2009 (invoice date October 22, 2009), to install new lining and wheel seals on the steering axle, repair rear shocks, and tighten air tanks. Three Driver Vehicle Inspection Reports (DVIR) (October 9, 12, and 15, 2009) were obtained from AmeriGas/PTI and reviewed. No maintenance-related concerns were noted by the accident truck driver on these reports. DVIRs for October 19–22, 2009, were not available for review and presumed to have been destroyed in the postaccident fire. The truck driver told NTSB investigators that there were no mechanical problems with the combination unit on the day of the accident.

44 Title 49 CFR 396.17 requires that all components identified in appendix G, 49 CFR Subtitle B, Subchapter B, Chapter III, be inspected yearly and that the vehicle comply with out-of-service criteria for the brake system, coupling devices, exhaust system, fuel system, lighting devices, safe loading, steering mechanism, suspension, frame, tires, wheels and rims, and windshield wipers. Documentation of this inspection must be carried in the vehicle.

NTSB Highway Accident Report 26

1. 11 Highway Information

The accident occurred on an urban interstate approximately 10 miles northeast of downtown Indianapolis, Indiana, at the I-69/I-465 interchange, on a semi-direct connection ramp that carries the southbound lanes of I-69 to the southbound lanes of I-465 (the connection ramp).45 The connection ramp was constructed in 1970. The twin bridges that carry the westbound and southbound lanes of I-465 over the ramp, including the bridge pier columns that support the superstructure and deck, were constructed in 1968. (See figure 8.) The ramp is a one-way, two-lane roadway consisting of 12-foot-wide left and right lanes. The ramp’s paved shoulders range from 8–9.5 feet on the right and 6–7.5 feet on the left. The design speed for I-69 southbound approaching the connection ramp is 70 mph. The posted regulatory speed limit for I-69 southbound north of the ramp is 55 mph. The posted speed limit sign is on the right side of the southbound lanes of I-69, approximately 2,700 feet north of the accident site. Approximately 0.5 mile north of the I-69 and I-465 interchange, the four southbound lanes of I-69 expand to five lanes before splitting into two left lanes continuing south and becoming Binford Boulevard and the three right lanes becoming a connection ramp to channel vehicles westbound or southbound on I-465. (See figure 2.) The three lanes of the connection ramp expand to four lanes before splitting into two right lanes curving to the right to direct vehicles westbound on I-465 and two left lanes curving to the left to guide vehicles southbound on I-465. Two advisory speed limit signs posted for 50 mph are on the right side of the ramp approximately 650 feet and 1,500 feet north of the accident site. The computed effective design speed for the connection ramp is approximately 53 mph. Two spot-speed studies46 conducted on the ramp by INDOT at separate locations on November 2, 2009, indicated that the 85th percentile speed at the first location (approximately 750 feet north of the accident site) was 56 mph for passenger cars and 53 mph for heavy trucks. The study further indicated that the 85th percentile speed at the second location (approximately 2,450 feet south of the accident site) was 58 mph for passenger cars and 55 mph for heavy trucks. The connection ramp north of the accident location has a −0.8 percent downgrade slope. The radius of the ramp’s leftward horizontal curve (direction of travel) is 881 feet. The ramp has the following markings: a 6-inch-wide solid yellow line separating the left lane from the left paved shoulder; 6-inch-wide, 10-foot-long broken white lines every 30 feet separating the left lane from the right lane; and a 6-inch-wide solid white line separating the right lane from the

45 A semi-direct connection ramp channels vehicles from one high-speed highway to another by negotiating two curves—the first headed in a direction away from the intended route and the second gradually reversing back to connect with the other high-speed highway. For further information, see A Policy on Geometric Design of Highways and Streets, 5th ed. (Washington, DC: American Association of State Highway and Transportation Officials, 2004), p. 824. 46 A spot speed study uses automated methods with radar or laser speed detection equipment to measure the speed characteristics of vehicles at a specified location under the traffic and environmental conditions prevailing at the time of the study.

NTSB Highway Accident Report 27

right paved shoulder. No longitudinal rumble strips are on the ramp’s shoulders.47 The average daily traffic on the ramp increased from 25,000 vehicles per day on April 1, 1998, to 34,000 vehicles per day on October 28, 2009. A full vehicle classification study conducted by INDOT from October 28–30, 2009, found that traffic on the connection ramp consisted of approximately 87.5 percent passenger vehicles (class 1–3) and 12.5 percent trucks (class 4–13).48 From 2004–2008, 122 accidents occurred on the ramp, including one fatal accident in 2006.49 1.11.1. Cross-Slope Break The cross-slope break, located at the edge of the paved traveled way or at the interface between the traveled way and the shoulder, is calculated by taking the algebraic difference in traverse grades between the traveled way and the shoulder. For example, a cross-slope break for a traveled way with a positive 8 percent cross slope, sloped upward from left to right (in the direction of travel), and a shoulder that has a negative 2 percent cross slope, sloped downward from left to right (in the direction of travel)—such as existed in the vicinity of the connection ramp—would be 10 percent (see figure 13).

Figure 13. Cross-slope break. On straight roads, right shoulders are usually sloped downward to provide water drainage away from the roadway. On curved roads, travel lanes should be sloped (superelevated) to reduce the instability that could result in spinout or rollover accidents as vehicles negotiate curves, and shoulders should be sloped sufficiently to prevent excessive rainwater drainage onto the traveled way, but not so much as to create a hazard for vehicles that drive onto the shoulder.

47 Longitudinal rumble strips are raised or grooved patterns in the pavement that cause vehicles traveling over them to vibrate, alerting the driver. INDOT does not typically install longitudinal rumble strips on the shoulders of ramps. 48 The FHWA 13-category classification system includes class 1–3 vehicles, consisting of motorcycles, passenger cars, and four-tire single unit vehicles, and class 4–13 vehicles, consisting of buses, multi-axle single-unit trucks, and articulated heavy combination vehicles. 49 The fatality resulted from a high-speed, run-off-the-road motorcycle accident.

NTSB Highway Accident Report 28

During the on-scene investigation, measurements were taken with a standard survey level rod every 20 feet along the connection ramp up to the location where the cargo tank semitrailer collided with the bridge pier column. These measurements found that the cross slope of the left southbound lane varied from +7.20 to +8.27 percent, sloping upward from left to right (in the direction of travel); the cross slope of the right southbound lane on the ramp varied from +6.58 to +8.25 percent, sloping upward from left to right (in the direction of travel); and the cross slope of the right shoulder varied from −1.25 to −2.75 percent, sloping downward from left to right (in the direction of travel). Cross-slope measurements obtained on the connection ramp after the accident indicated a cross-slope break between the right southbound lane and right shoulder varying from 8.08–10.75 percent. AASHTO Standards for Cross-Slope Break. The design plans for the connection ramp developed in 1968 followed the 1957 American Association of State Highway Officials (AASHO) A Policy on Arterial Highways in Urban Areas (commonly known as the Red Book) and the 1965 AASHO A Policy on Geometric Design of Rural Highways (commonly known as the Blue Book). Both the AASHO 1957 Red Book and 1965 Blue Book recommended a maximum cross-slope break of 7 percent. Little change in the standards and philosophy of cross-slope breaks has occurred from 1957 to the present, with the exception of a decision published in the 2004 American Association of State Highway and Transportation Officials (AASHTO)50 A Policy on Geometric Design of Highways and Streets51 (commonly known as the Green Book) recommending that ―the grade break at the edge of the paved surface be limited to approximately 8 percent.‖ Cross-Slope Break in Original Design Plans. INDOT’s original design plans for construction of the connection ramp where this accident occurred included a +8 percent cross slope for the left and right southbound lanes and a −4 percent cross slope for the right shoulder, equaling a cross-slope break between the right southbound lane and right shoulder of approximately 12 percent. Following this accident, INDOT conducted a records search to determine why the ramp’s cross-slope break differed from the 7 percent maximum recommended by AASHO standards developed in 1957 (Red Book) and 1965 (Blue Book). The cross-slope break on the connection ramp was designed using a standard INDOT ramp section sheet dated June 19, 1968,52 which appears as Sheet Number 5 on the original design plans. The June 1968 standard INDOT ramp section sheet indicates that the ramp’s traveled way was designed with a +8 percent cross slope and its right shoulder with a −4 percent cross slope, corresponding to an original cross-slope break of approximately 12 percent between the traveled way and right shoulder. The as-built plans confirmed that the cross-slope break was constructed as shown on the original design plans. However, sometime after the connection ramp was constructed with a 12 percent cross-slope break in 1970, the right shoulder on the ramp was

50 AASHTO (formerly AASHO) is a nonprofit, nonpartisan association representing highway and transportation departments in the 50 states, the District of Columbia, and Puerto Rico that fosters the development, operation, and maintenance of an integral national transportation system. 51 A Policy on Geometric Design of Highways and Streets, 5th ed. (2004), p. 316. 52 The standard INDOT ramp section sheet dated June 19, 1968, would only have been used in situations where the traveled way was in full superelevation or +8 percent cross slope.

NTSB Highway Accident Report 29

modified by INDOT from a −4 percent cross slope, as illustrated on the original design plans for the ramp, to a −2 percent cross slope. INDOT could not determine from available records when the right shoulder was modified, resulting in a 10 percent cross-slope break; the agency surmised that it occurred when the most recent work on the ramp—a 1997 pavement resurfacing project—was conducted. INDOT also determined from a records search that two changes occurred after the original plans were developed in June 1968. A standard INDOT ramp section sheet, dated August 12, 1968, illustrates the traveled way with a +8 percent cross slope and the right shoulder with a cross slope dependent on the ramp degree of curvature. Had the ramp been designed using the August 1968 standard INDOT ramp section sheet with a ramp curvature of 6° 30' (radius of 881 feet), the slope of the right shoulder would have been flat or zero percent. Another standard INDOT ramp section sheet, dated October 3, 1968, illustrates the right shoulder following the same 8 percent plane of superelevation53 as the traveled way. Had the ramp been designed and built using the October 1968 standard INDOT ramp section sheet, the right shoulder would have been superelevated +8 percent in the same direction as the traveled way. INDOT records revealed that the October 1968 standard INDOT ramp section sheet was utilized for designing cross-slope breaks on fully superelevated ramps until December 1, 1986, when the standard drawings for typical cross-sections were developed and included in the Indiana Design Manual, 54 which contains a list of typical applications for determining cross slopes on shoulders based on the superelevation of the traveled way. If the ramp had been designed today using the standards contained in the current Indiana Design Manual (January 2010), the right shoulder would have been superelevated +1 percent, resulting in a cross-slope break between the traveled way and the right shoulder of 7 percent. Cross-Slope Break Research. A limited Federal Highway Administration (FHWA) study was conducted in 1981 to verify the adequacy of a maximum 7 percent cross-slope break requirement in the 1965 AASHO Blue Book.55 A Highway-Vehicle-Object-Simulation Model (HVOSM) was used to evaluate various cross-slope break designs by testing the effects of curvature, speed, and path of a simulated passenger car. The simulations were performed with a moderate (rather than shallow or severe) departure from the travel lane onto the shoulder.56 Because a moderate traversal is not a single definitive path but could be an infinite number of paths, the study selected a nominal path that had a smaller radius than the highway curve and permitted the simulated vehicle to come within 1.6 feet of the outside edge of the shoulder before returning to the travel lane. The simulated vehicle traveled at the design speed, and the simulated

53 Superelevation, or cross slope, is expressed as a decimal and represents the ratio of the pavement width to elevation. 54 ―Horizontal Alignment,‖ Section 43-3.06(01) ―High-Side Shoulder,‖ Indiana Design Manual, Part 5, Chapter 43, January 21, 2010 http://www.in.gov/dot/div/contracts/standards/dm/2011/index.html, accessed April 28, 2011. 55 J.C. Glennon and others, HVOSM Studies of Cross-Slope Breaks on Highway Curves, DOT-FH-11-9575 (Washington, DC: U.S. Department of Transportation, Federal Highway Administration, 1981). 56 A moderate departure onto the shoulder occurs when the vehicle could be steered back to the pavement if the shoulder is wide enough, and the cross-slope break and shoulder slope do not cause the vehicle to exceed available skid resistance or result in intolerable centrifugal force on the driver.

NTSB Highway Accident Report 30

driver released its foot from the accelerator pedal at the first point of encounter with the cross-slope break. A series of HVOSM runs were performed to compare the dynamic differences between partial (straddling with right side wheels only) and full placement (entire vehicle) traversals onto the shoulder. A maximum 0.3 g lateral acceleration for driver discomfort was established, which was considered to be the level of apprehension most drivers could withstand during shoulder traversals without the driver subsequently initiating a hard brake application or excessive steer input that could result in a loss of control maneuver. The 0.3 g criterion was found to correspond with the 1965 AASHO Blue Book recommendation for a maximum 7 percent cross-slope break. The four-wheel traversals onto the shoulder (rather than two-wheel traversals) produced the most extreme dynamic responses. Driver discomfort mainly increased with shoulder slope and very little, if any, with the amount of cross-slope break. Thus, for a given design speed and superelevation of a horizontal curve, the maximum tolerable cross-slope break was a function of the shoulder cross slope. The most important conclusion from the study (according to the authors) is that for a negative shoulder cross slope to be tolerable for a recovery maneuver, it should be designed with just the minimum cross slope necessary to keep water from pooling in the travel lanes. 1.11.2 Protection of Bridge Pier Columns The support structure for the southbound I-465 overpass consisted of a concrete bridge footing (crash wall), seven concrete cylindrical pier columns, and a pier cap. The bridge footing was raised approximately 1.5 feet from the ground. The reinforced pier columns were 24 inches in diameter and stood approximately 14.3 feet high, as measured from the top of the bridge footing to the bottom of the pier cap. The outermost bridge pier column on the southbound I-465 overpass, which was struck by the cargo tank, was the first in a row of seven uniformly spaced columns approximately 10 feet on center. Strong post blocked-out W-beam guardrails were located on both sides of the connection ramp adjacent to the paved shoulders to protect the bridge pier columns from vehicle impacts. The strong posts that were connected to the steel W-beam rail element consisted of steel I-beams spaced 6.25 feet apart and embedded approximately 4–5 feet in the ground. The W-beam rail element was extended away (blocked out) from the posts with steel or timber spacer blocks. The W-beam guardrail was 30 inches tall, as measured from the pavement surface to the top of the W-beam rail element. The W-beam guardrail on the right side of the ramp began approximately 340 feet north of the I-465 overpasses, and the W-beam guardrail on the left side, approximately 930 feet. The concrete bridge pier column impacted by the semitrailer was offset from the W-beam guardrail by approximately 6 feet (see figure 14).

NTSB Highway Accident Report 31

Figure 14. Bridge pier column protection (before accident). Temporary construction shoring was erected after the accident behind the bridge pier column to provide vertical support for the three outside beam lines of the southbound I-465 overpass. A reinforced concrete wall, measuring approximately 14 feet high by 12 feet long by 2 feet wide, was then erected between the bridge footing and pier cap to fill the void space created after the bridge pier column was struck. I-465 remained closed to traffic for at least 1 day after the accident. The connection ramp was reopened on October 27, 2009. AASHTO Standards. Since the adoption of the first AASHO specifications in 1931, the body of knowledge in bridge research and design has grown significantly. The most recent framework—Load and Resistance Factor Design (LRFD) Bridge Design Specifications—utilizes state-of-the-art analysis and design methodologies and makes use of load and resistance factors based on the known variability of applied loads and material properties.57 A phased approach was taken to implement the requirements of LRFD Bridge Design Specifications, with a transition schedule extending from 1994–2007. All five editions of the LRFD Bridge Design Specifications58 contain similar provisions for bridge pier protection, with the most recent edition published by AASHTO in 2010. AASHTO and the FHWA determined that, after October 1, 2007, all new bridges and replacements of existing bridges should be designed using the most current edition of the LRFD Bridge Design Specifications,59 which requires that bridge pier columns be protected if located within an area that extends approximately 30 feet from the edge of the traveled way (clear zone). Further, obstacles located within the clear zone should be removed, relocated, redesigned, or shielded by traffic barriers or crash cushions.

57 LRFD Implementation Plan, Initial Draft, Federal Highway Administration. http://www.fhwa.dot.gov/bridge/lrfd/plan.cfm, accessed June 22, 2011. 58 Publication dates for the LRFD Bridge Design Specifications are as follows: 1st ed. (1994), 2nd ed. (1998), 3rd ed. (2004), 4th ed. (2007), and 5th ed. (2010). 59 Design Standards for Highways, 23 CFR Part 625.

NTSB Highway Accident Report 32

The Transportation Research Board (TRB) National Cooperative Highway Research Program (NCHRP) has established the following criteria for barrier protection testing:60  Test levels 1–3 (TL-1, TL-2, and TL-3): An 1,800-pound car striking a barrier at a 20° angle and a 4,400-pound pickup truck striking a barrier at a 25° angle at speeds of 30 mph (TL-1), 45 mph (TL-2), and 60 mph (TL-3), respectively.  Test level 4 (TL-4): A 17,600-pound single-unit truck striking a barrier at an angle of 15° at 50 mph.  Test level (TL-5): An 80,000-pound truck-tractor and a van-type semitrailer striking a barrier at an angle of 15° at 50 mph.  Test level (TL-6): An 80,000-pound truck-tractor and a cargo tank semitrailer striking a barrier at an angle of 15° at 50 mph. Minimum height requirements for bridge railings, which are contained in the AASHTO LRFD Bridge Design Specifications, are as follows: TL-1, TL-2, and TL-3 barriers—27 inches; TL-4 barrier—32 inches; TL-5 barrier—42 inches; and TL-6 barrier—90 inches. Bridge pier columns in the clear zone can be protected by either providing structural resistance to the bridge pier column or by redirecting or absorbing an impact from an errant vehicle. The option to redirect or absorb can be provided with an embankment or a 54-inch-high concrete barrier if the bridge pier column is located within 10 feet of the edge of the traveled way or a 42-inch-high concrete barrier if the bridge pier column is located more than 10 feet but less than 30 feet from the edge of the traveled way.61 These barriers must be structurally and geometrically capable of withstanding the impact specified for a TL-5 barrier. The option to provide structural resistance requires that the bridge pier column be designed for an equivalent static force of 400 kips62 (400,000 pounds), acting in any direction in a horizontal plane at a distance of 4 feet above the ground. Based on the results of a Transportation Pooled Fund Program63 study entitled Guidelines for Designing Bridge Piers and Abutments for Vehicle Collisions,64 a recommendation was made to AASHTO’s Subcommittee on Bridges and Structures in May 2010 that the equivalent static force of 400 kips be increased to 600 kips. New and Replacement Bridges. The LRFD Bridge Design Specifications contain Federal requirements for the protection of bridge pier columns on approximately 500 new and replacement bridges built in the United States each year (see table 5).65 This new construction

60 Recommended Procedures for the Safety Performance Evaluation of Highway Features, NCHRP Report 350 (Washington, DC: Transportation Research Board, 1993). 61 The requirements of AASHTO LRFD Bridge Design Specifications for protecting bridge pier columns differ and are independent from test levels for roadside barriers. 62 A kip is a unit of force equaling 1,000 pounds. 63 A Transportation Pooled Fund Program study is generally conducted to solve transportation-related problems with significant or widespread interest and may be funded jointly by several Federal, state, regional, and local transportation agencies. The Texas Department of Transportation was the sponsoring agency for this study. 64 Guidelines for Designing Bridge Piers and Abutments for Vehicle Collisions (College Station, Texas: Texas Transportation Institute, Texas A&M University, December 2009). 65 FHWA Office of Bridge Technology, e-mail to the NTSB (November 17, 2010).

NTSB Highway Accident Report 33

represents a small percentage of the approximately 41,000 bridges in the United States66 with a roadway passing underneath bridge spans, where intermediate columns are subject to vehicle impacts.67 Table 5. New and replacement of bridges built in the United States, 2005–2009. Year New and Replacement Bridges 2009 476 2008 640 2007 540 2006 597 2005 548

The AASHTO Roadside Design Guide provides guidance to highway agencies on the use of roadside barriers to protect bridge pier columns that are part of new projects and major projects involving the addition of a lane, significant changes to a roadway’s horizontal or vertical alignment, or reconstruction of an interchange. The 2006 Roadside Design Guide does not contain objective warrants but suggests that higher performance traffic barriers (TL-4 and above) be utilized at locations with above-average heavy truck traffic, adverse geometrics with poor sight distance, or severe consequences associated with the penetration of a barrier by a large vehicle. Existing Bridges. Although AASHTO’s LRFD Bridge Design Specifications and Roadside Design Guide are adequate for planned highway improvements, documentation is limited for assessing the protection of bridge pier columns on existing bridges not scheduled for construction. The FHWA Office of Bridge Technology did indicate, however, that the criteria contained in the LRFD Bridge Design Specifications, which specifies minimum requirements for new bridges, may also be used by bridge owners to evaluate existing bridges,68 including structures and piers. An inventory conducted by INDOT on December 3, 2009, of all direct and semi-direct connection ramps and roadside bridge pier protection revealed that approximately 44 direct or semi-direct connection ramps were classified as underpasses69 in Indiana and each had some type of roadside barrier for protecting bridge pier columns. The level of protection varied from a W-beam guardrail (TL-3) to a concrete barrier (TL-4 or TL-5). INDOT indicated that ramps in Indiana cannot be systematically ranked in terms of traffic safety performance when a systemwide evaluation of roads is conducted because the large number of accidents on ramps makes it impossible to assign precise latitude and longitude coordinates. This limitation restricts the ability to compare accidents that occur on a particular

66 New and replacement bridges or other structures are built because of substandard load-carrying capacity or substandard bridge roadway geometry (FHWA Office of Safety e-mail to the NTSB, November 4, 2010). 67 The National Bridge Inventory, which aggregates structure inventory and appraisal data collected by each state, consists of approximately 600,000 bridges. 68 FHWA Office of Bridge Technology e-mail to the NTSB (December 9, 2010). 69 Underpasses are considered direct or semi-direct connection ramps when the ramp is carried under another roadway, rather than over.

NTSB Highway Accident Report 34

ramp with other types of ramps or road segments, road intersections, and road interchanges. To address this circumstance unique to ramps, INDOT plans to use supplementary analysis to gauge the performance of ramps when it conducts future evaluations of the traffic safety performance of its road system. The objective of such analysis will be to identify ramps operating poorly so that they can be improved with infrastructure or engineering treatments, modification of traffic control devices, enforcement, or other measures.70 1.12 Cargo Tank Motor Vehicles Cargo tank motor vehicles represented 8.3 percent of the national fleet with five axles or more in 1997; approximately 80 percent of these vehicles transport bulk liquids or gases and approximately 20 percent, dry bulk materials.71 About 85 percent of all tractor-semitrailers traveling with hazardous materials are cargo tank motor vehicles; the remainder are van-type semitrailers.72 1.12.1 DOT Specification Cargo Tanks Federal regulations for the design and construction of cargo tanks that transport bulk liquid hazardous materials (―DOT specification cargo tanks‖) are established by the Pipeline and Hazardous Materials Safety Administration (PHMSA). Design requirements for cargo tanks contained in 49 CFR Part 178 (specifications for packaging) are supported by ASME standards. Testing and inspection requirements for cargo tanks are contained in 49 CFR Part 180 (continuing qualification for maintenance of packaging). Depending on the specification of the cargo tank, the following tests and inspections are required either annually or every 5 years: periodic external and internal visual inspection, lining inspection, leakage testing, thickness testing, wet fluorescent magnetic particle inspection of interior welds, and a hydrostatic pressure test. The MC331 cargo tank and its predecessor, the MC330, transport liquefied compressed gases73 in a smooth-bore (single) compartment, noninsulated, straight round cargo tank with hemispherical (half dome) or torispherical (shallow dome) heads and a maximum allowable working pressure between 100 and 500 psig. The average useful life of an MC331 cargo tank ranges from 25–50 years.74 MC330 cargo tanks, which were last manufactured in 1965, still

70 INDOT Director of Bridge Design, Inspection, Hydraulics, and Technical Support, response (September 2, 2010) to a question during the August 2010 NTSB public hearing on the Indianapolis rollover accident. For further information, see ―Rollover and Fire of a Truck-Tractor and Cargo Tank Semitrailer Carrying Liquefied Petroleum Gas in Indianapolis, Indiana, October 22, 2009,‖ public hearing, Washington, DC, August 3–4, 2010 http://www.ntsb.gov/events/2010/Indianapolis-IN/Default.html, accessed June, 22, 2011. 71 Analysis of the Vehicle Inventory and Use Survey for Trucks with Five-Axles or More (Washington, DC: U.S. Department of Transportation, Federal Highway Administration, May 2001). 72 K.L. Campbell, National Estimates of the Number of Trucks, Travel, and Accident Experience of Tractor Semitrailers Used to Transport Hazardous Materials, Report No. UMTRI-89-1 (Ann Arbor, Michigan: University of Michigan Transportation Research Institute, 1989). 73 Compressed gases such as propane, butane, anhydrous ammonia, chlorine, and sulphur dioxide are transported in a liquid form under pressure. 74 Testimony delivered by cargo tank manufacturers on August 4, 2010, at the NTSB public hearing concerning the Indianapolis rollover accident.

NTSB Highway Accident Report 35

represent approximately 15–20 percent of the cargo tanks currently transporting liquefied compressed flammable gases.75 The most common articulated commercial motor vehicle for transporting liquefied petroleum gas is a three-axle truck-tractor and two-axle cargo tank semitrailer, the type of combination unit involved in this accident. 1.12.2 Crashworthiness of DOT Specification Cargo Tanks The NTSB examined the crashworthiness of DOT specification cargo tanks in its investigation of a 1994 accident76 involving a cargo tank motor vehicle rollover. In that accident, a truck-tractor in combination with a specification MC331 cargo tank semitrailer transporting 9,200 gallons of liquefied petroleum gas, drifted across the left lane and left shoulder, struck a guardrail, rolled over, and collided with a cylindrically shaped concrete bridge pier column. The front head of the tank fractured, releasing liquefied petroleum gas, which vaporized and ignited. The blast propelled the tank approximately 300 feet onto a wood-framed house. The driver was killed, 23 people were injured, and an area with a radius of approximately 400 feet was engulfed by fire. As a result of its investigation, the NTSB issued the following recommendation to the Research and Special Programs Administration (RSPA)77: In cooperation with the Federal Highway Administration, study methods and develop standards to improve the crashworthiness of front heads on cargo tanks used to transport liquefied flammable gases and potentially lethal nonflammable compressed gases. (H-95-37) The recommendation prompted RSPA to sponsor two studies to determine the response of MC331 cargo tank heads when striking various obstacles and the effect of head shielding on improving the crashworthiness of cargo tanks in various impact scenarios. The first study established a correlation between analytical models and damage resulting from actual accidents, examined failure criteria for the puncture of unprotected heads and those with a full or partial shield, compared the shape and thickness of heads to determine practical designs for unprotected heads, and evaluated head shielding at various distances and energy-absorbing material.78 The work involved developing a three-dimensional finite element model to determine the speed at which the unprotected hemispherically shaped front head of an MC331—similar to the cargo tank involved in the White Plains, New York, accident—would fail during four accident scenarios: (1) frontal impact with a rigid wall, (2) angled impact at 45° into a rigid wall, (3) impact into a 6-inch-diameter immovable circular post, and (4) impact with the tank rotated onto its side into a 42-inch-diameter cylindrical column. The models indicated that the front head

75 Testimony delivered by Mike Pitts, Vice-President, Sales, Mississippi Tank Company, on August 4, 2010, at the NTSB public hearing concerning the Indianapolis rollover accident. 76 Propane Truck Collision with Bridge Column and Fire, White Plains, New York, July 27, 1994, Highway Accident Report NTSB/HAR-95/02 (Washington, DC: National Transportation Safety Board, 1995). 77 Within DOT, RSPA was reorganized in 2004 into PHMSA and the Research and Innovative Technology Administration. 78 A. Selz and C.F. Heberling, Pressure Sciences Incorporated, Improving Crashworthiness of Front Head of MC331 Cargo Tank Motor Vehicles (Washington, DC: Research and Special Programs Administration, February 2000).

NTSB Highway Accident Report 36

would fail at approximately 25 mph after striking a rigid wall and at less than 15 mph after impacting a 42-inch-diameter concrete column. Despite concerns about the adequacy of minimum construction requirements allowing the front head to be thinner than the tank shell, researchers were surprised to find that the thicker hemispherical head—as revealed by the models—had a lower failure speed than the thinner one when both struck a rigid wall; and, furthermore, that the 0.25-inch and 0.378-inch-thick hemispherical front heads of the cargo tanks both failed at impact speeds below 15 mph when a cylindrical concrete column was struck. The study results indicated that protection against angled impacts into rigid surfaces or collisions with bridge pier columns may be enhanced by placing energy-absorbing material between the front head and a secondary head on the MC331 cargo tank. Researchers recommended that a cost-benefit analysis be conducted for a conceptual head shielding design to improve the crashworthiness of MC331 cargo tanks. The second study sponsored by RSPA evaluated the feasibility, manufacturing costs, and marketability considerations for reducing the probability of fractures and/or penetrations to the front heads and adjacent structure of the MC331 cargo tank.79 Finite element models were again used to evaluate different approaches to protect the front heads of MC331 cargo tanks. Various densities and thicknesses of foam were examined to determine which configuration of energy-absorbing material would prevent a cargo tank from rupturing during a collision. It was determined that a foam thickness of 18 inches would protect the front head of the tank from failure during a 45° angle impact into a rigid wall at 52 mph and into a rigid 42-inch-diameter column at up to 59 mph. The estimated cost of installing an 18-inch-thick layer of energy-absorbing foam covered with a 0.060-inch-thick layer of sheet steel over the head of an MC331 cargo tank was $27,939 per trailer. The study concluded that although the modification would protect the tank from failure during the crash and impact scenarios that were studied, at speeds up to approximately 55 mph, the increased manufacturing cost and weight of 4,376 pounds of additional material for each cargo tank would not be cost effective. In an August 18, 2003, letter to the Acting Administrator, RSPA, the NTSB acknowledged the cost constraints of improving cargo tank crashworthiness but also asserted that crashworthiness remains a critical issue for cargo tanks transporting liquefied petroleum gas, with the concomitant potential for flammable gas explosions, toxic gas releases, and rocketing of cargo tanks. Consequently, Safety Recommendation H-95-37 and its companion recommendation to the FHWA, H-95-35, were classified ―Closed—Unacceptable Action.‖ 1.12.3 Hazardous Materials Carrier Registration An objective assessment of DOT specification cargo tank involvement in reportable incidents requires access to accurate information about the population of cargo tanks by DOT specification. Information associated with the operation of DOT specification cargo tanks is collected and maintained by the FMCSA and PHMSA. According to the FMCSA, approximately

79 A. Selz and P. Burnside, Pressure Sciences Incorporated, Further Work to Improve Crashworthiness of Front Head of MC331 Cargo Tank Motor Vehicles (Washington, DC: Research and Special Programs Administration, March 2001).

NTSB Highway Accident Report 37

6,500 motor carriers operate a fleet of cargo tank motor vehicles that transport liquefied petroleum gas.80 The FMCSA registration process requires all interstate motor carriers, commercial motor vehicle registrants from select states, and commercial intrastate hazardous materials carriers hauling quantities requiring a safety permit to complete and submit a Motor Carrier Identification Report (MCS-150) to obtain a USDOT number. Carriers are also required to file biennial updates to report changes in operations, including the number of vehicles operated in the United States. Data contained on the MCS-150 form are stored in the Motor Carrier Management Information System (MCMIS), a system of databases containing information from field offices and other sources. These data include police-reported accidents involving cargo tank motor vehicles in which no release of hazardous materials occurred. MCMIS is a source of inspection, crash, compliance review, safety audit, and registration data. Since 1992, PHMSA has required entities transporting certain hazardous materials, including hazardous wastes, to submit a Hazardous Materials Registration Statement (DOT Form F 5800.2) and pay an annual registration fee. DOT Form F 5800.2 requests the identity of the hazardous materials carrier, the mode(s) of transportation used, business category, basic description of hazardous materials activity, and states where operations are conducted. Registration fees collected from hazardous materials carriers provide funding for grants distributed to states and other professional organizations for hazardous materials emergency response planning and for training through the Hazardous Materials Emergency Preparedness Grants Program. 1.12.4 Rollover Awareness More than 1,300 rollovers involving cargo tank motor vehicles occur yearly in the United States.81 Approximately 60 percent of these rollovers involve semitrailers and 40 percent, single-unit trucks.82 The rollover rate of cargo tank semitrailers is more than double that of all other semitrailers.83 Rollovers occur in 24 percent of all hazardous material accidents and account for 75 percent of all spills.84 About 50 percent of truck driver deaths and 47 percent of

80 ―Effectiveness of Driver Training for Preventing Rollover Accidents,‖ PowerPoint presentation delivered by James O. Simmons, FMCSA, on August 3, 2010, at the NTSB public hearing concerning the Indianapolis rollover accident. 81 ―Tank Truck Drivers: This Sign’s for You!‖ Safety News (Washington, DC: U.S. Department of Transportation, Federal Motor Carrier Safety Administration, May 13, 2008). 82 D.B. Pape and others, Battelle, Cargo Tank Roll Stability Study, final report, contract no. GS23-F-0011L (Washington, DC: U.S. Department of Transportation, Federal Motor Carrier Safety Administration, April 30, 2007). 83 UMTRI-89-1. 84 Hazardous Materials Serious Crash Analysis: Phase 2, final report (Washington, DC: U.S. Department of Transportation, Federal Motor Carrier Safety Administration, April 2005).

NTSB Highway Accident Report 38

incapacitating injuries occur from rollovers.85 Driver error (such as decision or recognition error) was found to be a factor in approximately 75 percent of cargo tank rollovers.86 Government and industry have been involved in a number of rollover awareness initiatives. In 2005, the National Tank Truck Carriers (NTTC) partnered with J.J. Keller & Associates, Inc., to develop an educational campaign consisting of a monthly poster, fact sheet, and payroll stuffers to raise the awareness of drivers on how to prevent cargo tank rollovers.87 In 2006, the FMCSA sponsored a Cargo Tank Roll Stability Study to learn more about the factors contributing to and strategies for reducing cargo tank rollovers.88 The study examined how rollovers can be reduced by outfitting cargo tank motor vehicles with stability control systems, enhancing the basic roll stability of cargo tank motor vehicles, employing strategies to address difficult geometric and surface challenges, and improving driver training. The Cargo Tank Roll Stability Study concluded that although the tasks of safely operating a cargo tank motor vehicle are essentially the same as those for operating other class A heavy trucks, they must be mastered to a greater proficiency. To date, traditional approaches for raising cargo tank vehicle driver skills, such as disseminating instructional materials, have been employed in this effort. For example, the FHWA’s Office of Motor Carriers (predecessor to the FMCSA) has issued educational materials on the skills required for operating and controlling cargo tank motor vehicles through its On Guard bulletins. Following its investigation of a 1991 tractor-semitrailer (cargo tank) rollover,89 the NTSB issued the following recommendation to the FHWA: Issue periodic On Guard bulletins to remind all carriers and drivers to be attentive and aware of the conditions that can lead to a loss of stability and rollover in a tank truck. (H-91-33) In response to the recommendation, the FHWA published two additional safety bulletins, in August 1992 and March 1995, in addition to one previously published in June 1980 on cargo tank motor vehicle safety,90 to remind drivers about the need to review the special handling requirements for cargo tank motor vehicles with partial loads. Because the FHWA had published several On Guard bulletins since 1980 regarding the loss of stability and potential for rollover of cargo tank motor vehicles and stated it would continue to publish future bulletins if necessary, the NTSB classified Safety Recommendation H-91-33 ―Closed—Exceeds Recommended Action‖ on June 24, 1996.

85 1995 Truck and Bus Crash Fact Book, Report No. UMTRI-97-30 (Ann Arbor, Michigan: Center for National Truck Statistics, University of Michigan Transportation Research Institute, 1997). 86 Cargo Tank Roll Stability Study. 87 ―NTTC, J.J. Keller Launch Anti-Rollover Campaign,‖ Bulk Transporter, June 1, 2005. 88 Cargo Tank Roll Stability Study. 89 Overturn of a Tractor-Semitrailer (Cargo Tank) With Release of Automotive Gasoline and Fire, Carmichael, California, February 13, 1991, Hazardous Materials Accident Report NTSB/HZM-91/01 (Washington, DC: National Transportation Safety Board, 1991). 90 ―Anything Other Than Full or Empty,‖ On Guard (Washington, DC: Office of Motor Carriers, Federal Highway Administration, June 1980, August 1992, and March 1995).

NTSB Highway Accident Report 39

In late 2007, the FMCSA scheduled a series of Tank Truck Rollover Prevention Summits to discuss and review approaches for rollover reduction and develop training and management materials.91 To further address the problem, the FMCSA, in association with PHMSA and industry partners, created a Cargo Tank Driver Rollover Prevention Video, which was released on August 3, 2010, to serve as a training aid for commercial drivers of cargo tank motor vehicles transporting hazardous materials. The long-term effectiveness of traditional approaches (such as brochures and videos) for raising driver awareness of rollover prevention strategies is generally unknown. A study currently under development by the TRB, Role of Human Factors in Preventing Cargo Tank Truck Rollovers, which seeks to identify and analyze the root causes of cargo tank rollovers, may provide greater insight on increasing the awareness of drivers about actions necessary to prevent the rollover of cargo tank motor vehicles.92 A Heavy Vehicle Rollover Prevention Program introduced by VicRoads93 to approximately 5,000 commercial drivers in July 2009 was effective in reducing rollover accidents. The program used truck models to visually demonstrate the effect of CG height on heavy commercial truck rollovers and encouraged motor carriers to develop a written code of behavior on the shared role of drivers and management in developing workable solutions for preventing rollover accidents, as opposed to merely presenting driver- or management-driven objectives. The program operated with the understanding that management would reduce the risk of rollovers by purchasing trailers with as low a CG height as practical, selecting routes to avoid high risk locations, and monitoring drivers’ schedules to prevent fatigue. 1.13 Vehicle-Based Rollover Prevention Two primary vehicle-related approaches are available to prevent cargo tank motor vehicle rollovers. One approach involves equipping vehicles with stability control systems to reduce ―untripped‖ rollovers94 resulting from excessive speed in a curve, which represent approximately 10–15 percent of rollovers involving cargo tank motor vehicles. The second approach involves vehicle design strategies for improving roll stability to reduce the number of tripped and untripped rollovers. 1.13.1 Stability Control Systems The NTSB has long advocated the study and implementation of advanced crash avoidance technologies to assist drivers in maintaining control of commercial motor vehicles.

91 ―Tank Truck Rollover Prevention Summits,‖ Bulk Transporter, October 1, 2007. 92 The study was initiated in October 2010, with a final report anticipated in January 2012. 93 VicRoads is a statutory authority of the State of Victoria in the Commonwealth of Australia. For further information, see Heavy Vehicle Rollover Prevention Program, VicRoads, Australia http://www.vicroads.vic.gov.au/truckrollover, accessed May 1, 2011. 94 Untripped rollovers occur when tire/road interface friction is the only external force acting on a vehicle that rolls over. In contrast, tripped rollovers are caused when vehicles impact curbs, potholes, and guardrails or when wheel rims burrow into soft soil or pavement.

NTSB Highway Accident Report 40

For example, in its investigation of a multiple-fatality mid-size bus rollover accident that occurred in Dolan Springs, Arizona, in January 2009,95 the NTSB addressed the benefits of equipping buses with a gross vehicle weight rating (GVWR) greater than 10,000 pounds with stability control systems. As a result of that investigation, the NTSB issued the following recommendations to NHTSA: Develop stability control system performance standards applicable to newly manufactured buses with a gross vehicle weight rating above 10,000 pounds. (H-10-5) Once the performance standards from Safety Recommendation H-10-5 have been developed, require the installation of stability control systems in all newly manufactured buses in which this technology could have a safety benefit. (H-10-6) In November 2009, NHTSA announced the availability96 of its Final Vehicle Safety Rulemaking and Research Priority Plan for 2009–2011,97 which indicated test procedures would be developed to support a stability control standard for truck-tractors. The planned research involves testing rollover stability control (RSC) systems and electronic stability control (ESC) systems for heavy trucks and vehicles greater than 10,000 pounds GVWR, including truck-tractors, single-unit trucks, buses, and motorcoaches. In its initial response since Safety Recommendations H-10-5 and -6 were issued in July 2010, NHTSA indicated to the NTSB that efforts were underway to develop test procedures supporting a potential standard on ESC systems. In March 2011, NHTSA published a notice to announce the availability of its Final Vehicle Safety Rulemaking and Research Priority Plan 2011–2013,98 which was developed to apprise the public on the status of efforts delineated in the October 2009–2011 plan. The next milestone in the 2011–2013 plan for developing stability control systems to address rollover and loss-of-control accidents is a notice of proposed rulemaking in 2011, which will contain test procedures for truck-tractors and motorcoaches.99 NHTSA also plans to make a decision in 2014 about developing test procedures as part of a stability control standard for trucks, buses, and all other vehicles greater than 10,000 pounds GVWR that are not included in the truck-tractor and motorcoach rulemaking activity. Therefore, pending the completion of these recommended actions, Safety Recommendations H-10-5 and -6 were reclassified ―Open—Acceptable Response.‖

95 Bus Loss of Control and Rollover, Dolan Springs, Arizona, January 30, 2009, Highway Accident Report NTSB/HAR-10/01 (Washington, DC: National Transportation Safety Board, 2010). 96 Federal Register, vol. 74, no. 215 (November 9, 2009), p. 57623. 97 Final Notice Rulemaking and Research Priority Plan 2009–2011, National Highway Traffic Safety Administration, Document ID Number 2009-0108-0022, http://www.regulations.gov/search/Regs/home.html#documentDetail?R=0900006480a53424, accessed May 1, 2011. 98 Federal Register, vol. 76, no. 62 (March 31, 2011), p. 17808. 99 NHTSA Vehicle Safety and Fuel Economy Rulemaking and Research Priority Plan 2011–2013, March 2011.

NTSB Highway Accident Report 41

The benefits of stability control systems for passenger cars have been recognized for several years. A study using National Accident Sampling System (NASS) General Estimates System (GES) data from NHTSA to analyze different makes and models, but similar model years (MYs), of passenger vehicles found that by installing ESC systems, loss-of-control accidents could be reduced approximately 40.3 percent for cars and 71.5 percent for sport utility vehicles.100 In addition, NHTSA issued a final rule in April 2007 requiring the installation of ESC in 100 percent of light vehicles with a GVWR of 10,000 pounds or less by MY 2012 (except some vehicles manufactured in stages or by small volume manufacturers).101 ESC systems are becoming increasingly common standard equipment in passenger vehicles—an estimated 71 percent of MY 2010 light vehicles sold in the United States were equipped with ESC. Stability control systems are an emerging technology that also holds promise for reducing heavy commercial motor vehicle accidents by preventing untripped rollovers (excessive speed in a curve), mitigating severe oversteer and understeer conditions that could lead to loss of control, and providing objective feedback to assist carriers monitor and improve driver performance. NHTSA has conducted field operational tests and several studies since 1998 to examine the effectiveness and safety benefits of active safety systems for enhancing the dynamic stability of heavy truck operations. Two stability control systems, tractor- or trailer-based RSC systems and tractor-based ESC, have been developed for commercial motor vehicles. RSC systems use accelerometers to continually monitor and compare the lateral acceleration of vehicles to a known critical rollover threshold. When the threshold has been reached, a tractor-based RSC system automatically reduces delivery of fuel to the engine and applies the foundation brakes on the drive axles and trailer to slow the speed of the vehicle in a curve. A trailer-based RSC system only applies the foundation brakes on the trailer when a critical rollover threshold has been detected. RSC is designed to prevent ―untripped‖ rollovers in which the speed of a vehicle entering a curve is too fast.102 A tractor-based ESC system utilizes the same technology as RSC to prevent untripped rollovers but has the added benefits of a steer-angle sensor and yaw-rate sensor to automatically correct situations of understeer or oversteer, which can lead to loss of directional stability, and—unlike a tractor-based RSC—the capability of also applying the steer axle brakes. Sensor information (including wheel speed) is collected and analyzed by an electronic control module to determine whether a signal should be sent to automatically apply all brakes to slow the vehicle or a selective number of brakes to redirect the vehicle. To ensure wheels do not lock when brakes are applied, the ABS determines whether to maintain a constant high pressure or to modulate pressure to prevent wheel lockup. Although a trailer-based RSC system can be retrofitted as aftermarket equipment, tractor-based RSC and ESC systems must be factory installed to ensure the full integration of sensors and other equipment with the vehicle’s internal communication system. Tractor-based

100 The Effect of Stability Control on Motor Vehicle Crash Prevention, Report No. UMTRI-2006-12 (Ann Arbor, Michigan: University of Michigan Transportation Research Institute, 2006). 101 Electronic Stability Control Systems; Controls and Displays, Final Rule, Federal Motor Vehicle Safety Standards, Docket No. NHTSA-2007-27662, June 22, 2007. 102 Cargo Tank Roll Stability Study.

NTSB Highway Accident Report 42

RSC and ESC systems are offered by the three major suppliers of brake components in the North American heavy vehicle market; the estimated retail cost of outfitting a vehicle with RSC or ESC is between $620103 and $2,000.104 Such systems became commercially available for class 8 truck-tractors in 2003 and 2005, respectively.105 NHTSA estimates that 25 percent of truck-tractors will be equipped with ESC by 2012.106 Manufacturer estimates as to ESC and RSC installation vary widely: One cargo tank manufacturer stated that 26 percent of new cargo tank semitrailers were equipped with RSC;107 another indicated that although less than 5 percent of new cargo tank semitrailers were equipped with RSC between 2005 and 2008, that number increased to approximately 80 percent of cargo tank semitrailers manufactured since 2009;108 and a third manufacturer indicated that less than 5 percent of newly manufactured cargo tank semitrailers were equipped with RSC.109 A 2009 NHTSA study conducted using the National Advanced Driving Simulator (NADS) to assess the effectiveness of stability control systems in reducing the incidences of rollovers and jackknifes for heavy trucks found performance differences between tractor-based RSC and ESC systems.110 Sixty participants with a class A CDL were recruited to each complete five experimental drives on the simulator while executing an emergency maneuver, negotiating a decreasing radius curve, and traveling too fast around an exit ramp. Drivers were instructed to maintain speed for each event at the critical range necessary for RSC and ESC systems to provide a benefit. The RSC system showed strong reductions of rollovers in geometry-based situations, such as excessive speed in tight curves and exit ramps. The ESC system was effective in avoiding jackknifes but not to the same degree as the RSC system in preventing rollovers in curves.111 Neither the ESC nor RSC system was effective in responding to emergency scenarios (right and left lane incursions) due to aggressive steering inputs resulting in highly dynamic vehicle stability changes. The swing of the trailer inertia in an emergency situation on dry road proved very difficult for stability control systems to overcome. Similar conclusions were drawn after a series of maneuvers were conducted on a test track, indicating that further study is required to understand how stability control technology and other factors influence the dynamic

103 The Cargo Tank Roll Stability Study cited a cost of $619 for tractor-based RSC; factory-option costs for tractor-based, all-inclusive ESC systems are estimated to be $2,100. 104 Testimony delivered by Alan Korn, Director, Vehicle Dynamics and Control, Meritor WABCO, Vehicle Control Systems, on August 3, 2010, at the NTSB public hearing concerning the Indianapolis rollover accident. 105 Class 8 truck-tractors have a GVWR greater than 33,001 pounds. 106 ―Effectiveness of Stability Control Systems for Truck-Tractors,‖ Traffic Safety Factors, DOT-HS-811-437 (Washington, DC: U.S. Department of Transportation, National Highway Traffic Safety Administration, 2011). 107 Testimony delivered by Thomas J. Anderson, Vice-President of Product and Market Development, LBT, Inc., on August 4, 2010, at the NTSB public hearing concerning the Indianapolis rollover accident. 108 NTSB telephone call with a cargo tank manufacturer, December 28, 2010. 109 NTSB telephone call with a cargo tank manufacturer, June 1, 2011. 110 T. Brown and others, Heavy Truck ESC Effectiveness Study Using NADS, DOT-HS-811-233 (Washington, DC: U.S. Department of Transportation, National Highway Traffic Safety Administration, 2009). 111 The RSC system activated at lateral acceleration levels of approximately 0.24 g compared to approximately 0.33 g for the ESC system.

NTSB Highway Accident Report 43

response of heavy vehicles.112 The performance of ESC and RSC systems can also be compromised by the lateral displacement of sloshing liquid loads.113 1.13.2 Vehicle Design Solutions for reducing the number of rollovers should also consider measures available to improve the design and manufacture of cargo tank motor vehicles. British Petroleum realized, after 36 rollover accidents occurred in 9 months in 2005, that certain vehicle designs were less stable and prone to rollover. The company subsequently made design changes to its cargo tank motor vehicles to improve their rollover threshold.114 The static roll stability of cargo tank motor vehicles can be improved to prevent tripped and untripped rollover accidents by maximizing the track width (distance between the centerline of dual tires) and selecting several available options for lowering the center of gravity (CG) height (see figure 15).

Figure 15. Fundamental design considerations for improving the roll stability of cargo tank motor vehicles. Several factors must be considered in designing and manufacturing cargo tank motor vehicles that transport hazardous materials. These include responding to customer operational requirements; complying with Federal requirements for minimum ground clearance, maximum

112 F.S. Barickman and others, ―NHTSA’s Class 8 Truck-Tractor Stability Control Test Track Effectiveness,‖ Paper No. 09-0552, 21st Annual Conference on Enhanced Safety of Vehicles, Stuttgart, Germany, June 15–18, 2009. 113 Marco P. daSilva, Greg Ayres, and Wassim G. Najm, Crash Problem Definition and Safety Benefits Methodology for Stability Control for Single-Unit Medium and Heavy Trucks and Large-Platform Buses, DOT-HS-811-099 (Washington, DC: U.S. Department of Transportation, National Highway Traffic Safety Administration, 2009). 114 Rollover Awareness Training Pack (2005), British Petroleum, PowerPoint presentation.

NTSB Highway Accident Report 44

dimensions, and structural integrity of cargo tanks; and conforming to American Petroleum Institute (API) requirements on allowable heights for bottom-loading cargo tanks. API loading height requirements stipulate that the center of the loading pipes mounted on the side of cargo tanks be positioned 24–54 inches above the ground. Roll stability can be influenced by decisions made when cargo tank motor vehicles are designed and manufactured, such as limiting the overall length of a cargo tank motor vehicle to optimize maneuverability without revising the tank-carrying capacity or tire selections that unnecessarily raise the CG height. Despite design constraints that tend to increase the CG height considerably above the frame rails, measures can be taken to reduce the propensity of cargo tank motor vehicles to roll over. Manufacturers can voluntarily select design options to strategically and effectively improve the roll stability of cargo tank motor vehicles, such as reducing the CG height as much as possible and maximizing track width (see table 6). Table 6. Design options for improving the roll stability of cargo tank motor vehicles. Design Option Truck-Tractor Single-Unit Truck Cargo Tank Trailer Lower CG Height 1 Minimize excess frame height √ √ √ 2 Minimize suspension ride height √ √ √ 3 Install low profile tires √ √ √ 4 Minimize fifth wheel mounting bracket height √ — — 5 Minimize height of subframe that cradles cargo tank — √ √ 6 Install inserted upper coupler — — √ 7 Lower overall height of cargo tank — √ √ 8 Change geometric shape of cargo tank — √ √ Increase Track Width 9 Increase track width from 71.5–77.5 inches (dual tires) √ √ √ 10 Install wide-base tires on outset wheels* √ √ √ *An outset wheel increases the track width by extending the hub mounting surface outward from the centerline of the wheel.

Center of Gravity Height. Although each option noted in table 6 may result in a relatively small or modest drop in CG height (1–4 inches), collectively, these options can incrementally amount to a considerable reduction, contributing to a significant improvement in the roll stability of cargo tank motor vehicles. For example, the vertical distance between the ground and the top of the fifth wheel coupler on truck-tractors (regarded as the fifth wheel height) can be reduced by minimizing excess frame height above the suspension components, minimizing the suspension ride height115 within allowable limits, and minimizing the fifth wheel mounting bracket height. The typical fifth wheel height of truck-tractors ranges from 47–52 inches, with an estimated 80 percent of truck-tractors with a fifth wheel height between 49–50 inches.116 A fifth wheel height of

115 A suspension’s designed ride height is defined as the distance from the suspension mounting surface to the center of the axle. For further information, see Technical Procedure Trailer Systems, Literature Number L1388, Hendrickson, November 2008. 116 Truck-tractor fifth wheel height influences the design and effective CG height of newly manufactured DOT specification cargo tank semitrailers.

NTSB Highway Accident Report 45

1. 5 inches has been achieved on a truck-tractor equipped with 22.5-inch-diameter wheels and

low profile tires.117 Similarly, the CG height of single-unit trucks and trailers with cargo tanks can be reduced by minimizing excess frame height and suspension ride height and also by limiting the surplus height of subframes that cradle the tank. The CG height of cargo tank semitrailers can also be reduced by installing an ―inserted‖ upper coupler that is recessed at the front of the trailer between the frame rails instead of a standard upper coupler, which is mounted below the frame. Geometric Shape. The roll stability of cargo tank motor vehicles can also be enhanced by changing the geometric shape to reduce a tank’s CG height by making it wider or extending the center bottom of the shell lower than the front and rear heads. The option of modifying geometric shape to lower the CG height of DOT specification cargo tanks that transport compressed gases at high allowable working pressures, such as the tank involved in this accident, is not available because these tanks must comply with Section VIII of the ASME Boiler and Pressure Vessel Code by maintaining a circular shape with no more than a 1 percent difference between the maximum and minimum inside diameters of any cross section. Elliptically shaped cargo tanks with a dropped-center height118 to reduce CG height were introduced more than 50 years ago, when tank bottoms were straight. Initially, the base of the tank was sloped downward in one direction, which eventually evolved into the double tapered design, where the front and rear of the tank bottom slope toward the center (see figure 16). The dropped-center height of DOT specification cargo tanks for transporting bulk liquid petroleum products (DOT 406) ranges from 6–18 inches. Approximately 26–28 percent of new DOT 406 cargo tanks built are the double tapered design.119

Figure 16. Double tapered cargo tank with dropped center. The double conical design, consisting of two truncated circular cones welded together at the center, has been manufactured for about 35 years and represents approximately 20 percent of cargo tanks built since 2005 for transporting bulk liquid chemical products (DOT 407).120 A

117 P.S. Fancher and others, A Factbook of the Mechanical Properties of the Components for Single-Unit and Articulated Heavy Trucks, Report No. UMTRI-86-12 (Ann Arbor, Michigan: University of Michigan Transportation Research Institute, 1986). 118 Dropped-center height is the difference between the maximum vertical diameter at the center of the tank compared to the front and rear heads of the tank. The greater the dropped-center height, the more the CG height (as a fraction of dropped-center height) is lowered. 119 NTSB telephone calls with a cargo tank manufacturer, December 15, 2010, and July 25, 2011. 120 NTSB telephone call with a cargo tank manufacturer, December 28, 2010.

NTSB Highway Accident Report 46

typical dropped-center height for a double conical tank with the center bottom lower than the front and rear heads (which, if viewed from the side, would appear similar to figure 16) is approximately 10–12 inches, which does not necessarily result in a lower ground clearance than straight-round tanks.121 DOT specification cargo tanks for transporting bulk liquid corrosives (DOT 412) are predominantly round, but approximately 10 percent built since 2005 have a double conical design with dropped-center heights ranging from 6–20 inches. The additional cost of manufacturing a double conical/tapered cargo tank ranges from $1,500–$5,000 (depending on the extent of dropped-center height and DOT specification).122 Increased Vehicle Width. The maximum allowable overall width of commercial motor vehicles was increased from 96–102 inches by the 1982 Surface Transportation Assistance Act (STAA-82). The roll stability of cargo tank motor vehicles with dual tires can be improved substantially by increasing the track width from the 71.5 inches found on 96-inch-wide vehicles to the 77.5 inches found on 102-inch-wide vehicles (see figure 17).123

Figure 17. Roll stability improved by increased track width of 102-inch-wide vehicles.

121 Because product transported in a DOT 407 cargo tank is usually drained from the rear (and not the center) of the tank, some motor carriers cannot use a double conical tank. 122 Slight differences in the design and manufacture of individual double tapered and double conical cargo tanks may affect the actual reduction in CG height in relation to the amount of dropped-center height. 123 T.D. Gillespie and R.D. Ervin, Comparative Study of Vehicle Roll Stability, Report No. UMTRI-83-25 (Ann Arbor, Michigan: University of Michigan Transportation Research Institute, 1983).

NTSB Highway Accident Report 47

STAA-82 permitted 20,000-pound single-axle limits and designated a National Network for Large Trucks consisting of federally designated interstates and approximately 160,000 miles of other roads on which wider (102-inch) and longer tractor-semitrailers and twin trailers could travel without restriction.124 STAA-82 also required states to allow trucks with authorized dimensions to operate on the National Highway System (NHS) network and to provide ―reasonable access‖ between the network and terminals and other facilities for food, fuel, repairs, and rest.125 Currently, 41 states allow 102-inch-wide vehicles to operate throughout their states. The remaining states and the District of Columbia restrict the operation of 102-inch-wide vehicles on certain roads.126 Although the regulation allowing 102-inch-wide vehicles to operate has been in effect since 1982, motor carriers have been reluctant to voluntarily request increased track width on newly manufactured cargo tank motor vehicles. Consequently, only 10–30 percent of newly manufactured cargo tank motor vehicles feature increased track width for improving roll stability—as estimated by cargo tank manufacturers during the August 2010 NTSB public hearing and noted in published reports—which is significantly lower than for other major body types, such as enclosed van-type semitrailers.127 In contrast, more than 90 percent of cargo tank motor vehicles built by one cargo tank manufacturer and sold to Canadian fleets are equipped with the wider 102-inch axles.128 Overall Tank Height. The CG height of cargo tank motor vehicles can also be reduced by lowering the overall height of the tank, achievable by either expanding the overall width of the tank closer to the outboard edge of the vehicle129 or dropping the entire height of the tank or rear-only section lower to the ground. Lowering overall tank height is a feasible option for improving the roll stability of cargo tanks that cannot be converted from the standard geometric shape to a double conical or double tapered design. This limitation to altering tank geometry particularly applies to the straight-round profile of MC331 and MC338 specification cargo tanks, which transport compressed gases at maximum allowable working pressures as high as 500 psig. Methods for improving the roll stability of these DOT specification cargo tanks include extending the width of the frame rails to allow the tank to be positioned lower, installing

124 Title 23 CFR Part 658, Appendix A, contains a description of federally designated routes on the NHS network. 125 Report of the Subcommittee of Truck Size and Weight of the AASHTO Joint Committee on Domestic Freight Policy (Washington, DC: American Association of State Highway and Transportation Officials, 1995). Public roads that restrict the operation of 102-inch-wide vehicles may be identified by utilizing routing and mapping software (for example, PC*MILER or TomTom) or referencing the Vehicle Sizes and Weights Manual (Neenah, Wisconsin: J.J. Keller & Associates, Inc.). 126 Testimony delivered by John Nicholas, Truck Size and Weight Program Manager, Federal Highway Administration, on August 4, 2010 , at the NTSB public hearing concerning the Indianapolis rollover accident. 127 Analysis of the Vehicle Inventory and Use Survey for Trucks With Five-Axles or More (Washington, DC: Federal Highway Administration, May 2001). 128 Testimony delivered by John F. Cannon, Vice-President of Engineering, Walker Group Holdings, on August 4, 2010, at the NTSB public hearing concerning the Indianapolis rollover accident. 129 The feasibility of manufacturing a wider tank depends on whether changing the original shape of the tank by making it wider and shorter would make it necessary to increase the original shell thickness of the tank (adding weight) to maintain a minimum required level of beam strength.

NTSB Highway Accident Report 48

wide-base tires to increase the track width (see figure 18), and limiting the height of the subframe that cradles the tank.

Figure 18. Lower CG height and increased track width. Lowering tank height is still possible even when it is not practical or possible to lower both the front and rear sections of cargo tanks equally. For instance, in Australia, the rear section of a tank is lowered as much as possible, resulting in a noticeable downward slope (when viewed sideways) between the front and rear sections of the tank. Tire Selection. The CG height of cargo tank motor vehicles can also be reduced by installing low-profile tires with reduced section height (radial distance from the nominal rim diameter to the outer diameter of the tire), thus lowering the tires’ static-loaded diameter (distance from the ground to the top of tire mounted on a vehicle, calculated by adding half the overall diameter with the static-loaded radius provided by the tire manufacturer). The static-loaded diameter of the accident vehicle’s replacement tires was 40.2 inches, as compared to 30.1–35.1 inches for low-profile tires manufactured for heavy trucks and commercial trailers (see table 7). Although the installation of low-profile tires can lower the CG height of cargo tank vehicles by several inches, the proportion of newly manufactured vehicles equipped with low-profile tires is approximately 5–20 percent.130

130 NTSB telephone calls with cargo tank manufacturers, December 15, 2010, and June 1, 2011.

NTSB Highway Accident Report 49

Table 7. Difference in static-loaded diameter of standard tires and low-profile tires. Tire Type Application Tire Description Tire Size Static-Loaded Diameter (inches) Standard aspect ratio Tires on accident truck-tractor and cargo tank semitrailer Goodyear G149a 11R-22.5 40.2 Low profile Truck Michelin XDA2b 295/60R22.5 35.1 Low profile Trailer Bridgestone R184c 245/70R17.5 30.1 aSee http://www.goodyear.com/truck/pdf/gy_engdata_images.pdf, accessed July 8, 2011. bSee http://www.michelintruck.com/michelintruck/tires-retreads/tireInfo.do?tread=XDA2%2B%20ENERGY, accessed April 13, 2011. cSee, accessed April 13, 2011.

The roll stability of cargo tank motor vehicles can also be improved by installing wide-base tires on 2-inch outset wheels,131 which would effectively increase (as noted in figure 18) the track width of a cargo tank motor vehicle equipped with dual tires. 1.13.3 Performance-Based Standards Performance-based standards can be used to design and manufacture vehicles with rollover-resistant characteristics. After its investigation of a rollover and subsequent fire involving a truck-tractor and cargo tank semitrailer laden with liquefied petroleum gas,132 an accident that triggered collisions involving 29 vehicles and resulted in 6 fatalities and 3 serious injuries, the NTSB made the following recommendation to NHTSA: Set a high priority on establishing performance requirements for new buses, trucks, trailers, and combinations in regard to: (1) improved braking capabilities with balanced skid resistance, reduced ―fade,‖ and shorter stopping with maximum load; (2) the use of energy-absorbing underride and override barriers to reduce passenger-car impact decelerations through controlled yielding; and (3) minimum limits on stability factors for loaded vehicles. (H-71-18)

NHTSA stated in a May 4, 1971, letter that the NTSB report was referred to its Research Institute for review and indicated specific comments on the recommendations would be provided directly to the NTSB. Safety Recommendation H-71-18 was classified ―Closed—Acceptable Action‖ on January 1, 1980. Europe and Canada have already made progress in this area. For example, Canada has established performance-based standards to harmonize the large discrepancies in size and weight regulations among provinces that allowed the manufacture of heavy truck configurations with

131 A wheel is outset when the hub mounting surface is outboard of the centerline of the wheel. 132 Multiple-Vehicle Collisions Under Fog Conditions, Followed by Fires, New Jersey Turnpike, North of Gate 2, November 29, 1969, Highway Accident Report NTSB/HAR-71/03 (Washington, DC: National Transportation Safety Board, 1971).

NTSB Highway Accident Report 50

poor dynamic performance.133 The Vehicle Weights and Dimension Study,134 completed in 1986, produced a set of performance metrics for establishing vehicle configuration specifications that has resulted in desirable dynamic characteristics. All provinces and territories have since implemented the Canadian national memorandum of understanding on vehicle weights and dimensions,135 which defines dimensional and dynamic performance requirements for heavy vehicle configurations. The European Industrial Gases Association (EIGA) believes that rollover prevention should focus not only on the behaviors of drivers and managers but also on the design and engineering of vehicles used to transport gases. The EIGA recognizes that trailer design can be instrumental in lowering the CG height of cargo tank motor vehicles.136 Geneva Regulation UNECE (United Nations Economic Commission for Europe)137 No. R111 established a minimum rollover threshold for cargo tank motor vehicles that transport dangerous goods.138 Compliance with R111 requirements must be verified by a tilt-table test or a calculation method. The static rollover threshold of the vehicle at the point at which overturning occurs139 must be greater than 23° when tested in both directions on a tilt table140 or at least 4 meters per second/per second (m/s2) when calculated by simulation in a steady-state circular test (constant radius, speed, and lateral acceleration). UNECE regulations were also developed to provide guidance for the construction of cargo tank motor vehicles first registered on July 1, 2003.141 Further, the National Research Council of Canada conducted tilt-table tests to determine the rollover threshold and characteristics of 17 tank-truck configurations that are deployed across

133 J. Woodrooffe and others, Review of Canadian Experience With the Regulation of Large Commercial Motor Vehicles, NCHRP Report No. 671 (Washington, DC: Transportation Research Board, National Cooperative Highway Research Program, 2010). 134 Vehicle Weights and Dimensions Study, Technical Reports, vols. 1-16 (Ottawa, Canada: Roads Transportation Association of Canada, July 1986). 135 Memorandum of Understanding on Interprovincial Heavy Vehicle Weights and Dimensions, Task Force on Vehicle Weights and Dimension Policy, Council of Ministers Responsible for Transportation and Highway Safety, October 2009 http://www.comt.ca/english/programs/trucking/MOU%202009.pdf, accessed July 18, 2011. 136 ―Vehicle Rollover Incidents,‖ Safety Newsletter (Brussels, Belgium: European Industrial Gases Association, 2009). 137 UNECE is one of five regional commissions of the United Nations that brings together 56 countries located in the European Union, non-EU Western and Eastern Europe, southeastern Europe, the Commonwealth of Independent States, and North America. 138 Agreement Concerning the Approval of Tank Vehicles of Categories N and O with Regard to Rollover Stability, Regulation No.111, December 28, 2000, World Forum for Harmonization of Vehicle Regulations http://live.unece.org/fileadmin/DAM/trans/main/wp29/wp29regs/r111e.pdf, accessed April 28, 2011. 139 UNECE Regulation No. R111 considers ―rollover threshold‖ as the instant when all wheels on one side of a vehicle have lost contact with the supporting surface of a tilt-table platform. 140 A tilt table is a test device used to quantify the rollover threshold of a heavy commercial vehicle in a steady-state curve. After the vehicle is driven onto the tilt table and constrained with safety restraints, one side of the platform is very slowly lifted until the vehicle reaches the point of roll instability. This phase of the test is determined when the semitrailer tires on the unladen side of the vehicle begin to lift off the tilt-table platform. 141 Requirements Concerning the Construction and Approval of Vehicles, European Agreement concerning the International Carriage of Dangerous Goods by Road (ADR), annex B, part 9, chapter 9.7, point 9.7.5.2.

NTSB Highway Accident Report 51

Canada and travel to the United States.142 A computer simulation was used to determine the lowest rollover threshold of each vehicle configuration with tanks full and loaded to the maximum allowable gross weight. The results of the simulations and tilt-table tests were compared to the following minimum rollover thresholds: 0.35 g (acceleration of gravity)143 for all heavy vehicles, as required in New Zealand;144 0.40 g for tank trucks by tilt-table test or 0.42 g by the calculation method, as established by the UNECE; and 0.40 g for special permit vehicles, as developed by the Transportation Association of Canada. Tilt-table test results indicated that 7 of the 17 tank-truck configurations (41 percent) had a rollover threshold less than 0.35 g, and 14 of the 17 tank-truck configurations (83 percent) had a rollover threshold less than 0.40 g. The authors concluded that although a minimum rollover threshold requirement for new tank trucks would improve the roll resistance of the Canadian tank truck fleet, based on a tank truck fleet replacement rate of 3–5 percent per year and the long service life of cargo tanks, it would take 25–30 years after a performance-based standard became effective before the existing fleet of tank trucks was replaced. The study suggested that an operational requirement for all in-use tank trucks transporting hazardous materials to comply with a specific rollover threshold would decrease the time it would take to improve the rollover threshold of the tank truck fleet. 1.13.4 Partial Loads The dynamic movement of fluid within a partially filled cargo tank was suggested as an explanation for why the involvement rate of five-axle cargo tank semitrailers by rollover threshold was markedly higher than for five-axle van-type semitrailers.145 Fluid slosh generated by dynamic motions encountered under braking, acceleration, cornering, or lane-change maneuvers can yield significant transient load shifts in the roll and pitch planes and alter the directional properties of a cargo tank motor vehicle.146 Dynamic slosh motions can be readily excited on a cargo tank motor vehicle, especially when executing a lane change or an evasive maneuver with a counter-steer input.147 The maximum carrying capacity of a highway-operated cargo tank is generally decided (when the vehicle is being purchased) by the lightest density of product that will be transported. Densities of bulk liquid loads transported by cargo tank motor vehicles differ considerably, with petroleum products ranging from 6–8 pounds per gallon and common industrial acids,

142 J.R. Billing and J.D. Patten, An Assessment of Tank Truck Roll Stability, Report No. TP 14237E (Ottawa, Canada: Centre for Surface Transportation Technology, National Research Council of Canada, 2005). 143 The acceleration rate of gravity is approximately 32.2 feet (9.8 meters) per second/per second. 144 Restricted tank volumes and modest axle/gross axle weights raise the roll stability of cargo tank motor vehicles beyond the minimum rollover threshold of 0.35 g established for all heavy trucks in New Zealand. 145 P. Fancher and others, Turner Truck Handling and Stability Properties Affecting Safety, Report No. UMTRI-89-11 (Ann Arbor, Michigan: University of Michigan Transportation Research Institute, 1989). 146 G.R. Yan, S. Rakheja, and K. Siddiqui, ―Analysis of Transient Fluid Slosh in Partly-Filled Tanks With and Without Baffles; Part 1—Model Validation,‖ International Journal of Heavy Vehicle Systems, vol. 17, no. 3/4 (October 2010). 147 Future Configuration of Tank Vehicles Hauling Flammable Liquids in Michigan, Report No. UM-HSRI-80-73-1 (Ann Arbor, Michigan: University of Michigan Highway Safety Research Institute, April 1983).

NTSB Highway Accident Report 52

9–16 pounds per gallon.148 A single-compartment cargo tank transporting product with a density of 9 pounds per gallon could have limited void space above the fill level; the same trailer transporting a product with a density of 16 pounds per gallon could have significant outage.149 Factors that can lead to the sloshing (splashing lateral motion) and surging (rolling forward like a wave) of partially filled compartments include the density and viscosity of the commodity hauled; number and size of compartments; customer requirements; axle and vehicle weight restrictions; and filling level of the tank, as determined by the density of a product in relation to its total liquid carrying capacity. The fill level and geometric shape of a tank may determine how significantly the lateral sloshing and longitudinal surging of bulk liquid affect the directional stability and rollover threshold of cargo tank motor vehicles. A substantial number of partial loads are transported in smooth bore (single-compartment) cargo tanks that are not outfitted with interior bulkheads or baffles to mitigate the sloshing and surging of bulk liquid loads.150 Partial liquid loading is involved in 94 percent of cargo tank rollover accidents.151

148 L.A. Botkin, Safe Highway Transportation of Bulk Liquids, Technical Paper No. 700872 (Warrendale, Pennsylvania: SAE International, 1970). 149 Outage refers to the amount that a package (such as a cargo tank) falls short of being fully loaded, usually expressed in percent by volume (49 CFR 171.8). 150 R.D. Ervin, M. Barnes, and A. Wolfe, Liquid Cargo Shifting and the Stability of Cargo Tank Trucks, Report No. UMTRI-85-35/2 (Ann Arbor, Michigan: University of Michigan Transportation Research Institute, 1985). 151 Cargo Tank Driver Rollover Prevention Video, Federal Motor Carrier Safety Administration, August 2010.

NTSB Highway Accident Report 53

• Analysis

The analysis begins with a discussion of the factors and conditions that the NTSB has excluded as having caused or contributed to the accident, the sequence of events and speed during the combination unit’s rollover, and an evaluation of driver fatigue. Next, the analysis reviews measures for mitigating the rollover of cargo tank motor vehicles, which include a comprehensive rollover prevention program, stability control systems, vehicle design enhancements, highway design, and the effect of the lateral displacement (sloshing) of partially filled loads. The analysis then examines initiatives for reducing the release of hazardous materials when DOT specification cargo tanks are involved in motor vehicle accidents and for preventing vulnerable bridges from collapsing when bridge pier columns located near the traveled way are struck by an errant heavy commercial vehicle. 2.1 Exclusions At the time of the accident, skies were overcast, with a temperature of 58° F and winds of 4 mph. The truck driver did not report any problems with illumination or glare. The NTSB concludes that the weather did not contribute to the accident. Postaccident examination found no preexisting defects on the truck-tractor or cargo tank semitrailer. The steering gear was functionally operational, and damage to internal components was determined to have been caused by the impact loading and excessive heat generated by the postaccident fire. With the exception of the steer axle brakes, which were damaged and could not be measured, the service brakes on the truck-tractor and cargo tank semitrailer were within proper readjustment limits. The truck-tractor and semitrailer decoupled as a result of the excessive twisting of the frame rails and buckling of the cross bars during the rollover, which allowed the fifth wheel plate to separate from the slide rail bracket. The patterns of damage and fracturing of the front head of the tank indicated that the breach of the cargo tank head and shell resulted from the collision with the bridge pier column and not from preexisting damage, fatigue cracking, corrosion, or weld defects such as lack of fusion. Further, mechanical properties of the materials and cargo tank design met or exceeded all of the structural integrity requirements imposed by Federal regulations (49 CFR 178.337). Therefore, the NTSB concludes that there was no evidence of mechanical defects or preexisting damage to the combination unit and cargo tank. The truck driver was properly licensed and had the requisite endorsements to operate a truck-tractor semitrailer. He had approximately 45 years of experience driving heavy commercial vehicles and had spent the past 15 years transporting bulk liquid hazardous materials in cargo tank motor vehicles. The truck driver drove the same truck-tractor for approximately 2 years and was familiar with traveling on highways throughout Indiana, including the interchange where the accident occurred. Therefore, the NTSB concludes that the truck driver was adequately licensed and familiar with both the route and driving the combination unit. Blood samples obtained from the truck driver after the accident were negative for alcohol and a wide range of over-the-counter and illicit drugs. Atenolol, an antihypertensive medication NTSB Highway Accident Report 54

that had been prescribed to the driver, was the only drug for which the driver tested positive. The NTSB therefore concludes that the truck driver’s performance was not impaired by alcohol or any of the prescription, over-the-counter, or illicit drugs for which he was tested following the accident. Although NTSB investigators were informed by one witness that another witness allegedly observed the accident truck driver talking on a cellular telephone, a review of cellular records confirmed that the driver was not using a cellular telephone before the accident. Therefore, the NTSB concludes that there was no evidence that the truck driver was distracted by his cellular telephone immediately before the accident. Other than a speech deficit, the truck driver had no neurologic abnormalities from a stroke that occurred approximately 10 years before the accident. The truck driver indicated that he had no difficulties with the knee replacements that he received less than 6 months before the accident. Further, although the truck driver’s prescribed medications would not have been expected to directly result in impairment, one of them, glyburide, can result in hypoglycemia (low blood sugar), particularly when used in combination with other glucose-lowering medications such as metformin.152 Based on his average blood glucose, blood glucose in the emergency room, and the expected rise in blood glucose following trauma,153 it seems most probable that the truck driver’s blood glucose level was 135–200 mg/dL at the time of the accident, a level at which no significant adverse effects in performance would be expected.154 No evidence exists that the truck driver—who had made several steering inputs prior to the rollover—had an incapacitating event. Therefore, the NTSB concludes that neither the staged bilateral knee replacement surgery155 nor the general health of the truck driver caused or contributed to the accident. Emergency response from the LTFD, ISP, and other responding agencies and fire suppression units occurred as expeditiously as possible, considering the number of high-volume highway lanes that had to be rerouted and the hazards of working in a relatively confined area surrounded by flammable vapors. In addition, the unified incident command, traffic control, transport of the injured, and scene safety were well coordinated. The absence of shipping papers, which were destroyed in the fire, did not prevent first responders from identifying the product and responding to the incident in an appropriate manner. Therefore, the NTSB concludes that the emergency response was timely and adequate.

152 J.A. Davidson, A.J. Scheen, and H.C. Howlett, ―Tolerability Profile of Metformin/Glibenclamide Combination Tablets (Glucovance): A New Treatment for the Management of Type 2 Diabetes Mellitus,‖ DrugSafe, vol. 27, no. 15 (2004), pp. 1205–1216. 153 L. Li and J.L. Messina, ―Acute Insulin Resistance Following Injury,‖ Trends in Endocrinology and Metabolism, vol. 20, no. 9 (2009), pp. 429–435. 154 I. Pais and others, ―Mood and Cognitive Functions During Acute Euglycaemia and Mild Hyperglycaemia in Type 2 Diabetic Patients,‖ Experimental and Clinical Endocrinology Diabetes, vol. 115, no. 1 (2007), pp. 42–46. 155 Bilateral knee replacement surgery replaces both knees in a staged procedure on separate days that could be several days, weeks, or months apart.

NTSB Highway Accident Report 55

1. 2 Accident Discussion

When the accident occurred, the AmeriGas/PTI combination unit had just exited southbound I-69 and was on a connection ramp to travel southbound on I-465. While in the right lane of the I-465 southbound connection ramp, the combination unit, negotiating a left curve with a +8 percent cross slope (left side of lane lower than right side), began to encroach upon the left lane, occupied by a Volvo passenger car. The truck driver responded to the Volvo’s presence in the left lane by executing an excessive, rapid, evasive steering maneuver that caused the combination unit to veer right and travel onto the paved right shoulder, which had a −2 percent cross slope (left side higher than right side). The truck driver then made a rapid counterclockwise steering input to redirect the combination unit from the shoulder to the right lane (see figure 19). Therefore, the NTSB concludes that the truck driver’s excessive, rapid, evasive steering maneuver triggered the subsequent accident sequence.

Figure 19. Rollover sequence. As the combination unit advanced closer to the I-465 overpasses, the lateral displacement of the vehicle’s CG allowed weight to transfer off the inside wheels and create a rolling motion, which caused the cargo tank semitrailer to lean to the right and begin to roll over. The truck driver’s attempt to steer the combination unit away from the shoulder and into the right lane exacerbated the roll motion by reducing the curvature of the vehicle trajectory from 881 to 630 feet, as evidenced by visible weight-shift tire marks. Therefore, the NTSB concludes that the truck driver’s quickly steering the combination unit from the right shoulder to the right lane contributed to the rollover. The weight-shift marks indicated that the cargo tank semitrailer came near the edge of the pavement before it moved closer to the white painted solid line and rolled over. The combination unit struck the ground at an angle (relative to the travel lanes on the connection ramp), with the right-rear side of the semitrailer impacting the right shoulder and the right-front side of the semitrailer and truck-tractor landing diagonally across the right lane. The dark tire imprints on the right shoulder and in the right lane indicate where the sidewalls of the right outboard tires on the semitrailer and truck-tractor’s drive axles struck the ground (see figure 20).

NTSB Highway Accident Report 56

Figure 20. Tire imprints in the right lane and on the shoulder indicating where the combination unit rolled over onto its right side. (Source: Indiana State Police.) During the rollover sequence, the truck-tractor’s fifth wheel plate attached to the kingpin at the front of the cargo tank semitrailer separated from the slide rail bracket fastened to the rear of the truck-tractor. After decoupling, the trajectory of the truck-tractor and the front of the cargo tank semitrailer shifted away from the centerline toward the right shoulder, with each unit sliding independently on its right side toward the right guardrail. The truck-tractor struck and rebounded from the right guardrail before coming to rest on the connection ramp south of the I-465 overpasses. The front head of the cargo tank penetrated the W-beam guardrail at an approximately 20° angle before striking the I-465 bridge footing and completely displacing one of seven concrete bridge pier columns supporting the I-465 southbound overpass. The impact resulted in a breach of the head and shell, which provided a portal for compressed liquefied petroleum gas to escape, form a vapor cloud, ignite, and erupt into a fireball. The remaining kinetic energy and swift expulsion of liquefied petroleum gas caused the cargo tank semitrailer to advance forward and rotate counterclockwise. The cargo tank eventually came to rest on its left side, with its front head near the southbound I-465 bridge footing and the rear bumper close to the railroad tracks located west of the connection ramp (see figure 21).

NTSB Highway Accident Report 57

Figure 21. Final rest position of cargo tank semitrailer. (Source: Indiana State Police.) The lateral acceleration required to shift the CG far enough outward to create weight-shift marks, lift the inside wheels off the ground, and induce the untripped rollover was not solely caused by the speed at which the truck driver negotiated the left curve on the ramp but also by the excessive, rapid steering wheel inputs made during the evasive maneuver; the vehicle instability resulting from traveling on a −2 percent cross slope; the side-to-side displacement of the partial bulk liquid load within the cargo tank; and the truck driver’s decision to quickly return the combination unit from the right shoulder to the right lane.

NTSB Highway Accident Report 58

1. 2.1 Rollover Speed

The spot-speed study conducted by INDOT approximately 750 feet north of the westbound I-465 overpass shortly after the accident (November 2, 2009) showed that the 85th percentile speed for heavy trucks traveling on the ramp was 53 mph, slightly above the posted advisory speed of 50 mph. The Volvo driver indicated during a postaccident interview that he was not speeding on the ramp and could not estimate the combination unit’s speed. The engine’s electronic control module was destroyed in the postaccident fire, so limited objective information was available to accurately estimate the combination unit’s speed at rollover. As an alternative means of estimating the combination unit’s speed at rollover, NTSB investigators analyzed information collected during the postaccident examination of the truck-tractor and performed computer simulations. NTSB investigators used a sawtooth curve chart and data sheet obtained from Navistar International Corporation to determine the range of speeds at which the truck-tractor could travel when the transmission was engaged in ninth gear, as observed during the postaccident inspection.156 The data sheet, which provides speed calculations for the truck-tractor in each gear of the 10-speed transmission, with a Caterpillar C13 diesel engine operating at approximately 1,522–2,100 rpm, revealed that the accident truck-tractor was capable of traveling 47–65 mph with the transmission in ninth gear. Operating the engine at a lower speed of 1,200 rpm, as recommended by the engine manufacturer, would extend the speed range of the truck-tractor in ninth gear to a lower limit of 38 mph (see table 8).157 Table 8. Speed range of truck-tractor in ninth gear. Engine Operating Range Transmission Gear Engine RPM Speed (mph) Navistar 9 1522–2100 47–65 Caterpillar 9 1200–2100 38–65

The NTSB conducted a vehicle dynamics study to investigate the propensity of a truck-tractor semitrailer to roll over while traveling on a paved shoulder with a −2 percent cross slope and, moreover, to determine whether the wide speed range calculated in ninth gear (38–65 mph) could be narrowed. Using TruckSim158 software, NTSB staff performed computer simulations to determine the rollover speed of a truck-tractor semitrailer negotiating a steady-state curve with a constant radius of 700, 800, and 881 feet. The three different curve radii were selected to replicate the nominal curve radius of the connection ramp (881 feet) and the reduced instantaneous radius of trajectory curvature when the combination unit rolled over (800 and 700 feet). For each of the three curve radii selected, the simulations also considered a truck-tractor semitrailer traveling on a surface similar to the measured superelevation of the

156 The travel speed of a vehicle in each transmission gear depends upon (and can be predicted by) engine speed. 157 On-Highway Diesel Engine with ACERT Technology , accessed April 30, 2011. 158 TruckSim is a software tool used for simulating and analyzing the dynamic behavior of medium-to-heavy trucks, buses, and articulated vehicles.

NTSB Highway Accident Report 59

travel lanes on the ramp (+8 percent) and right shoulder (−2 percent) and the effective superelevation when the combination unit was partially on the right shoulder and the right lane of the connection ramp (0 percent). The nine iterations computed the combination unit’s rollover speed when optimally driven along a curve by an ideal simulated driver and the speed at which the combination unit’s inside trailer wheels would lift off the ground. In each case, the semitrailer’s inside wheels were the first to lift off the ground. The simulations indicated that the maximum speed at which a truck-tractor semitrailer combination unit could negotiate a curve with a radius of 881 feet and +8 percent superelevation without rolling over was 77 mph. The maximum speed without wheel lift was 73 mph, which was lowered to 66 mph when the effective superelevation was changed from +8 to 0 percent and to 55 mph when the nominal radius of the curve was reduced to 700 feet. The simulations did not take into account the additional lateral acceleration generated by rapid steering inputs or the resulting side-to-side displacement of the partial bulk liquid load in the cargo tank. Under those conditions, the combination unit’s maximum speed before wheel lift may have been less than 55 mph.159 Therefore, the NTSB concludes that the combination unit’s speed at the onset of rollover may have been near the posted advisory speed limit. 2.2.2 Driver Fatigue NTSB investigators examined whether fatigue played a role in the accident. The examination included reviewing the 72-hour reconstruction of the truck driver’s activities, which was developed by interpreting Qualcomm vehicle position history data, shipping documents, and information provided by the driver about when he slept. The truck driver indicated that he generally went to bed at home about 11:00 p.m. and awakened about 7:00 a.m. He stated that he did not have difficulty falling asleep but did awaken once or twice at night to use the bathroom. His self-reported sleep quality at home on a 1 to 5 scale (with ―1‖ being quite tired and ―5‖ fully alert) was 5, higher than the 4 he reported when he slept in the truck-tractor. The driver said he occasionally took a nap in the sleeper berth (usually in the afternoon) when he was away from home driving the combination unit. Investigators were able to estimate the driver’s off-duty time, which was assigned whenever the driver was not on duty loading (supported by shipping documents) or when the combination unit (according to vehicle position history data) was stationary.160 The driver’s time available for sleep, or sleep opportunity, will necessarily be less than his off-duty time due to

159 A spot-speed study of the connection ramp directly north of the I-465 westbound overpass conducted on November 2, 2009, found that the 85th percentile speed was 56 mph for passenger cars and 53 mph for heavy trucks. 160 On-duty status was assigned according to shipping documents produced when the driver loaded the combination unit at the loading terminal and estimated when the cargo tank was unloaded at a delivery location. Driving status was assigned when the combination unit traveled away from or returned to the loading terminal. The only off-duty time assigned was on October 21, when the combination unit was stationary from 5:30–9:00 a.m. in Mexico, Indiana, before traveling to the loading terminal in Lebanon.

NTSB Highway Accident Report 60

other normal daily activities such as eating, bathing, and socializing. However, investigators were not able to determine the driver’s activities and their duration during his off-duty time. Furthermore, the actual sleep obtained by the driver, a subset of the sleep opportunity, was also unknown. Investigators examined the possibility of driver fatigue using the driver’s off-duty time, which represents a maximum sleep opportunity for the driver. Two sleep schedules were analyzed because it was not known whether the driver slept during each off-duty period (schedule 1 in table 9) or just during the one off-duty period that encompassed the longer night sleep (schedule 2). The first sleep schedule assumes that the truck driver slept 0.75–3.5 hours daily when he went off duty, providing him with a maximum of 9.25–11 hours of sleep opportunity each day. The second sleep schedule provided the driver with a maximum of 6.0–8.25 hours of sleep opportunity each day. Table 9. Time available for truck driver to rest.

Date

Time Awake

Long Sleep (start)

Total Work Time* (hours) Maximum Sleep Opportunity Schedule 1 (hours) Schedule 2 (hours) October 19 7:00 a.m. 1:00 a.m. 9.75 9.5 6.0 October 20 7:00 a.m. 10:15 p.m. 15.25 11.0 6.75 October 21 5:00 a.m. 12:00 a.m. 14.5 9.25 8.25 October 22 8:15 a.m. — 2.4 — —

• Includes on-duty time spent loading, unloading, and driving.

Factors that can lead to an accident from loss of alertness due to driver fatigue include the duration of the last sleep, elapsed time awake, time of day, and known sleep disorders. Based on the first sleep schedule, the truck driver had a maximum of 9.25 hours of sleep opportunity the night before the accident and was awake the following day for approximately 2.4 hours before the accident occurred at approximately 10:38 a.m. The second sleep schedule provided the truck driver an average of 7.0 hours of sleep opportunity each day, which was an average of 2.91 hours less than the first sleep schedule and 1.25–2 hours less sleep for 2 nights than the 8 hours that he customarily received at home. Research measuring the effects of different amounts of nightly time in bed (3, 5, 7, or 9 hours) on the subsequent performance (cognitive tasks and simulated driving) of bus and truck drivers holding a valid CDL161 showed that across 7 consecutive days of testing, driver performance in the 7-hour group (averaging 6.28 hours of actual sleep, slightly less than population norms) was measurably poorer than driver performance in the 9-hour group (averaging 7.93 hours of actual sleep, within normal limits). The results of this study suggest that commercial drivers, including the AmeriGas/PTI truck driver, may not be able to adapt to, or compensate for, even mild reductions in total sleep time. Further, although the driver’s maximum sleep opportunity on the second sleep schedule the night before the accident was 8.25 hours, a

161 T. Balkin and others, Effects of Sleep Schedules on Commercial Motor Vehicle Driver Performance, DOT contract DTFH61-94-Y-00090, Report No. DOT-MC-00-133 (Silver Spring, Maryland: Walter Reed Army Institute of Research, 2000).

NTSB Highway Accident Report 61

length the driver reported that he normally slept, research has found that 2 full nights of sleep is required to obtain a near or full recovery from protracted sleep loss or sleep restriction.162 The truck driver did not comply with the sleeper berth provision and exceeded the 14-hour limit within hours-of-service regulations,163 maintained an irregular sleep/wake schedule by rising earlier one day than the next, and remained awake the day before the accident (on the second sleep schedule) for 19 hours. An arduous work schedule is one of the most highly predictive underlying factors associated with long-distance truck drivers falling asleep at the wheel.164 To summarize, because of inconsistencies with the truck driver’s reported sleep, the NTSB constructed two possible sleep schedules. Under the first sleep schedule, the driver’s performance was unlikely affected by fatigue but may have been affected by other factors, such as distraction or inattention. However, under the second sleep schedule, the driver may have been fatigued. Therefore, the NTSB concludes that there was insufficient information available to determine whether the truck driver was fatigued. The truck driver did not meet regularly with a supervisor or report to a company-operated terminal. Consequently, he worked independently, setting his own hours within the delivery schedule assigned by a dispatch office in Houston, Texas. A review of the truck driver’s work/rest schedule indicated that it differed daily and was inconsistent with sound sleep management practices. The truck driver’s decisions about when and how long to sleep may be indicative of similar choices being made by other AmeriGas/PTI drivers. In this accident, the truck driver violated Federal regulations (49 CFR Part 395) by either splitting sleep periods or not resting at least 8 consecutive hours in the sleeper berth on 2 consecutive nights before the accident. Additionally, after conducting a detailed review of the truck driver’s reported hours, comparing entries made in the driver’s handwritten logbook with shipping documents and Qualcomm vehicle position history data, NTSB investigators discovered five false log entries and hours-of-service violations on 3 separate days during the weeks before the accident. Surveys conducted for the Cargo Tank Roll Stability Study consistently identified driver fatigue and inattention as major contributors to rollover accidents. Information from the Trucks Involved in Fatal Accidents (1999–2003) and GES (2000–2004) databases revealed that

162 a) A. Smiley and R. Heslegrave, A 360 Hour Recovery Period for Truck Drivers; Synopsis of Current Scientific Knowledge, TP 13035E (Ottawa, Canada: Transport Canada, Transportation Development Centre, 1997). (b) D.F. Dinges and others, ―Cumulative Sleepiness, Mood Disturbance, and Psychomotor Vigilance Performance Decrements During a Week of Sleep Restricted to 4–5 hours Per Night,‖ Sleep, vol. 20, no. 4 (1997), pp. 267–277. (c) S. Vespa and others, ―Study of Commercial Vehicle Driver Rest Periods and Recovery of Performance in an Operational Environment,‖ Third International Conference on Fatigue and Transportation, Institute for Research in Safety and Transport, Murdoch University, February 9–13, 1998, Fremantle, Western Australia. 163 Title 49 CFR Part 395 stipulates that property-carrying commercial drivers may not drive beyond the 14th consecutive hour after coming on duty, following 10 consecutive hours off duty. Off-duty time does not extend the 14-hour limit. Drivers using the sleeper berth provision must take at least 8 consecutive hours in the sleeper berth, plus 2 consecutive hours either in the sleeper berth, off duty, or any combination of the two. 164 A.T. McCartt and others, ―Factors Associated With Falling Asleep at the Wheel Among Long-Distance Truck Drivers,‖ Accident Analysis & Prevention, vol. 32, no. 4 (2000), pp. 493–504.

NTSB Highway Accident Report 62

inattention was a factor in 12–14 percent of rollover accidents involving cargo tank motor vehicles. One countermeasure that motor carriers can implement to minimize the risk of fatigue-related accidents is a fatigue management program, the key components of which include organizational commitment; education; medical screening and treatment; scheduling; and a strategy for implementing, monitoring, and evaluating the program. The North American Fatigue Management Program, currently under development and anticipated to be completed by 2012, is a collaborative effort by the FMCSA, Canadian regulators, and industry associations to reduce fatigue-related accidents by creating the components necessary to manage commercial driver fatigue. The NTSB issued the following recommendations associated with fatigue management to the FMCSA after its investigation of a 2009 multi-vehicle rear-end accident165 resulting in 10 passenger vehicle occupant fatalities: Create educational materials that provide current information on fatigue and fatigue countermeasures and make the materials available in different formats, including updating and redistributing your truck-driver-focused driver fatigue video; make the video available electronically for quicker dissemination; and implement a plan to regularly update the educational materials and the video with the latest scientific information and to regularly distribute them. (H-10-8) Require all motor carriers to adopt a fatigue management program based on the North American Fatigue Management Program guidelines for the management of fatigue in a motor carrier operating environment. (H-10-9)

NTSB Safety Recommendations H-10-8 and -9 are currently classified ―Open—Await Response.‖ A fatigue management program should include, at a minimum, an accurate method of verifying hours-of-service records and disseminating information on sleep physiology, effect of altering sleep/wake cycles, accumulated sleep debt, sleep management, sleep disorders, and fatigue countermeasures. A recent study examining the effect of such programs on driver fatigue found that drivers experienced improvements in subjective sleep quality and in the sleep achieved during on-duty days when a fatigue management program was implemented.166 As noted earlier, when asked by NTSB investigators, AmeriGas Propane, L.P., management indicated that the company does not have a formal fatigue management program.

165 Truck-Tractor Semitrailer Rear-End Collision Into Passenger Vehicles on Interstate 44, Near Miami, Oklahoma, June 26, 2009, Highway Accident Report NTSB/HAR-10/02 (Washington, DC: National Transportation Safety Board, 2010). 166 A. Smiley and others, Effects of Fatigue Management Program on Fatigue in the Commercial Motor Carrier Industry (Ottawa, Canada: Transportation Development Centre, Transport Canada and Federal Motor Carrier Safety Administration, 2009).

NTSB Highway Accident Report 63

Such programs have been recognized by the NTSB,167 the FMCSA,168 and the motor carrier industry169 as a valuable and effective safety tool for reducing incidents from commercial driver fatigue. The NTSB concludes that AmeriGas Propane, L.P., drivers would be less likely to violate hours-of-service regulations and make better informed choices about sleep if the company implemented a fatigue management program. 2.3 Cargo Tank Rollover Prevention Cargo tank motor vehicles represent approximately 6 percent of large trucks170 yet account for 31 percent of all fatal commercial truck rollover accidents.171 The Cargo Tank Roll Stability Study examined data from the Large Truck Crash Causation Study (LTCCS)172 and found that cargo tank motor vehicles were more prone to rollover while negotiating a curve (57.1 percent) than all heavy trucks (40.1 percent). Therefore, the NTSB maintains that a holistic approach involving commercial drivers, dispatchers, carrier management, manufacturers, and highway design engineers working together to prevent cargo tank motor vehicle rollovers is an effective strategy for reducing hazardous materials releases. Measures discussed in the following sections include:  Developing and implementing a comprehensive rollover prevention program;  Equipping cargo tank motor vehicles with stability control systems;  Making design and manufacturing changes to improve the rollover threshold of cargo tank motor vehicles;  Minimizing the effect of partial loads on the rollover threshold of cargo tank motor vehicles, particularly when evasive maneuvers are executed; and  Addressing the reduced effective superelevation through changes in cross slope on curve sections of high-speed highways.

167 Truck-Tractor Semitrailer Rollover and Motorcoach Collision with Overturned Truck, Interstate Highway 94, Near Osseo, Wisconsin, October 16, 2005, Highway Accident Report NTSB/HAR-08/02 (Washington, DC: National Transportation Safety Board, 2008). 168 Pilot Test of Fatigue Management Technologies, Report Number FMCSA-RT-05-002 (Washington, DC: Federal Motor Carrier Safety Administration, 2005). 169 For further information, see ―Hours of Service Listening Session: MCSAC Briefing‖ http://mcsac.fmcsa.dot.gov/documents/HOS%20Listening%20Session%20Summary%20V1.ppt, accessed April 30, 2011. 170 Vehicle Inventory and Use Survey, 2002 Economic Census (Washington, DC: U.S. Department of Commerce, December 2004). 171 ―Tank Truck Drivers: This Sign’s for You!‖ Safety News. 172 The LTCCS contains a nationally representative sample of 967 large-truck fatal and injury crashes that were investigated in 2001–2003 at 24 sites in 17 states. For further information, see Report to Congress on the Large Truck Crash Causation Study, Report Number MC-R/MC-RRA (Washington, DC: Federal Motor Carrier Safety Administration, March 2006).

NTSB Highway Accident Report 64

1. 3.1 Rollover Prevention Programs

Rollover threshold has been defined as the maximum value of lateral acceleration required to bring a vehicle to the point of initiating roll instability.173 Rollover threshold for a five-axle articulated vehicle combination unit occurs when the inside wheels of the semitrailer begin to lift off the ground as the combination unit negotiates a curved path. The basic measure of vehicle roll stability is static rollover threshold, which is expressed as lateral acceleration in gravitational units (g).174 The typical rollover threshold of a fully loaded five-axle cargo tank motor vehicle is 0.35 g for a semitrailer carrying petroleum and 0.26 g for a semitrailer with cryogenic175 product.176 Drivers usually maneuver cars, light trucks, vans, and sport-utility vehicles below 0.2 g,177 which is well below the calculated rollover threshold of 0.8–1.2 g for passenger vehicles. The wide range of maneuvering capability that allows passenger vehicle drivers to recover when errors are made, such as traveling too fast around a curve or introducing a rapid steering input, is not available to commercial drivers because the rollover threshold of loaded heavy trucks extends occasionally into the ―normal‖ maneuvering range and well within the ―emergency‖ maneuvering capability of the vehicle,178 particularly when rapid, evasive steering maneuvers are executed. Therefore, the NTSB concludes that laden cargo tank motor vehicles provide little tolerance for operator error. Leaders from three of the largest propane retailers, including AmeriGas Propane, L.P., identified better driver training as the foremost solution for reducing the 120–150 yearly rollovers involving single-unit cargo tank trucks that transport liquefied petroleum gas.179 Training has been provided to ―program‖ drivers not to jerk the steering wheel or attempt to overcorrect when the wheels of the vehicle move off the road. The rollover segment of the Vehicle Incident Prevention Training program provided by AmeriGas Propane, L.P., to its commercial drivers primarily consisted of seven PowerPoint slides containing images and information about the basic considerations for preventing the rollover of cargo tank motor vehicles. The training, which was completed by the accident truck driver on August 15, 2008, emphasized the importance of not ―swerving‖ because it could result in the instability and untripped rollover of a cargo tank motor vehicle. In response to a question on the post-training test about what action should be avoided if an animal darts onto the road, the truck driver correctly responded ―swerve.‖ However, contrary to the training he had received to avoid ―swerving‖ to prevent rollovers, the truck driver executed an excessive, rapid, evasive

173 UMTRI-83-25. 174 C.B. Winkler and R.D. Ervin, Rollover of Heavy Commercial Vehicles, UMTRI-99-19 (Ann Arbor, Michigan: University of Michigan Transportation Research Institute, 1999). 175 Cryogenic liquids are liquefied gases such as nitrogen, natural gas, oxygen, argon, and methane that are kept in a liquid state at temperatures from -150 to -453° F. 176 UMTRI-99-19. 177 AASHTO guidelines for highway curve design result in lateral accelerations as high as 0.17 g at the posted advisory speed. 178 UMTRI-99-19. 179 ―Tipping Point: Bobtail Rollover Frequency Concerns Prompt Push for New Training Remedies,‖ LPGas magazine, June 1, 2010.

NTSB Highway Accident Report 65

steering maneuver during this accident in response to becoming aware of a passenger vehicle’s horn in an adjacent lane. The truck driver indicated during a postaccident interview with NTSB investigators that he had not received training for preventing or recognizing rollovers, although employee records showed he had attended the Vehicle Incident Prevention Training program in August 2008, just over a year before the accident. The NTSB concludes that the rollover training received by the truck driver was not effective in preventing this accident. Approximately 66 percent of cargo tank rollovers involve drivers with 10 or more years of driving experience.180 The Cargo Tank Roll Stability Study found the main training challenge facing the cargo tank industry was trying to modify human performance by motivating drivers to remain alert and not become distracted. The Cargo Tank Roll Stability Study also found that although more ―hands on‖ training using driving simulators has proven cost-effective by reducing training time, no demonstrated business model exists for incorporating simulators for small carriers; further, no long-term studies have been conducted to validate the benefits of simulator training for rollover prevention. Rollover training should not be limited to commercial drivers but also include action that can be taken by management to reduce schedule-related demands, minimize delivery of loads with partially filled compartments, and identify strategic steps that could be taken to improve the roll stability of existing and newly manufactured cargo tank motor vehicles. The Cargo Tank Roll Stability Study concluded the leading factor for increasing or decreasing cargo tank rollover risk is the dispatcher, who can control the operational demands to comply with tight delivery schedules that often pressure drivers to travel at excessive speeds or drive when drowsy. Dispatchers now more commonly have access to real-time information that can be used to monitor hours-of-service records and vehicle position history data to identify drivers who may be fatigued or driving faster than posted speed limits. Similar to the Heavy Vehicle Rollover Prevention Program initiated in Australia,181 rollover prevention programs should include, as a minimum, a detailed and informed discussion about rollover dynamics using truck models and written policies that identify the roles of—and reasonable measures to be taken collaboratively by—drivers, dispatchers, and management for preventing cargo tank motor vehicle rollovers. These policies should specifically clarify motor carrier actions to reduce the operational demands that may inadvertently be imposed on drivers and contribute to rollover accidents, and stipulate initiatives for improving the roll stability of cargo tank motor vehicles. The NTSB concludes that although a rollover prevention program will not eliminate all rollovers due to driver errors, it can be effective for identifying ways for cargo tank motor vehicle drivers and management to work collaboratively to prevent rollover accidents. The NTSB recommends that the FMCSA work with PHMSA, as appropriate, to develop and disseminate guidance that will assist hazardous materials carriers in implementing

180 ―Tank Truck Drivers: This Sign’s for You!‖ Safety News. 181 Heavy Vehicle Rollover Prevention Program, VicRoads, Australia http://www.vicroads.vic.gov.au/truckrollover, accessed May 1, 2011.

NTSB Highway Accident Report 66

comprehensive cargo tank motor vehicle rollover prevention programs, including the active participation of drivers, dispatchers, and management through training, loading practices, delivery schedules, and acquisition of equipment. 2.3.2 Stability Control Systems Simulations were conducted during the Cargo Tank Roll Stability Study using Vehicle Dynamics Analysis, Non-Linear (VDANL) software182 to compare the overall probability of a rollover crash with and without tractor-based RSC in combination with a two-axle cargo tank semitrailer. The analysis examined 126 specific events with dynamic characteristics found to precede a rollover crash, as identified during a DOT-sponsored field operational test. The simulations found that rollover crash probability was reduced with a tractor-based RSC system.183 The simulation analysis estimated that a tractor-based RSC system could prevent approximately 53 percent of untripped rollovers resulting from excessive speed in a curve. It was not possible to determine whether stability control systems could have prevented this specific accident due to the absence of information as a result of the truck-tractor’s engine electronic control module being destroyed in the fire. However, simulations conducted by the NTSB using circumstances similar to the accident indicated that an RSC system has the potential to prevent rollovers by applying the service brakes when the lateral acceleration of a simulated vehicle exceeds 0.3 g. Research has found the effectiveness of ESC and RSC in reducing rollover and loss of control accidents can vary depending on the crash scenario. The combined effectiveness rates of ESC installed on class 8 truck-tractors was found to be greater (28–36 percent) than for RSC (21–30 percent).184 A 2009 DOT study involving tractor-semitrailers found that more overall safety benefits were provided with ESC than with RSC; 106 fewer fatalities and 4,384 fewer injuries would be expected to occur if all existing five-axle tractor-semitrailers in the United States were outfitted with ESC systems.185 The NTSB concludes that a stability control system on the combination unit may have prevented this accident. The NTSB recommended, as a result of its investigation of a 2009 bus rollover in Dolan Springs, Arizona,186 that NHTSA develop performance standards and ultimately require that all newly manufactured buses with a GVWR greater than 10,000 pounds be equipped with stability control systems. Separate rulemakings may be required to equip all commercial motor vehicles

182 VANDL Systems Technology, Inc., Hawthorne, California , accessed May 10, 2011. 183 Simulations were used during the Cargo Tank Roll Stability study because (as reported in DOT-HS-811-437) statistical analysis of heavy commercial vehicles using real-world accident data has not been feasible due to ESC and RSC being relatively new technologies that were implemented primarily as optional safety features. 184 Effectiveness of Stability Control Systems for Truck Tractors, Traffic Safety Factors, DOT-HS-811-437 (Washington, DC: National Highway Traffic Safety Administration, January 2011). 185 J. Woodrooffe and others, Safety Benefits of Stability Control Systems for Tractor-Semitrailers, DOT-HS-811-205 (Washington, DC: U.S. Department of Transportation, National Highway Traffic Safety Administration, 2009). 186 NTSB/HAR-10/01.

NTSB Highway Accident Report 67

with a GVWR greater than 10,000 pounds with such systems because some vehicles have hydraulic brakes and others have pneumatic brakes, which use different components and approaches to modulate, maintain, and release the pressurized fluid or air sent to the foundation brakes to prevent wheel lockup. Therefore, the NTSB recommends that NHTSA develop stability control system performance standards for all commercial motor vehicles and buses with a GVWR greater than 10,000 pounds, regardless of whether the vehicles are equipped with a hydraulic or a pneumatic brake system; and, once the performance standards have been developed, require the installation of stability control systems on all newly manufactured commercial vehicles with a GVWR greater than 10,000 pounds. As a result of these new recommendations to NHTSA, the NTSB reclassifies Safety Recommendations H-10-5 and -6 ―Closed—Superseded.‖ The NTSB concludes that, given the long service life of cargo tanks, 25–50 years could pass before all cargo tank trailers would be equipped with stability control systems. While it is feasible to retrofit trailers with an RSC system, it is not practical to fully integrate sensors and internal communication systems on single-unit trucks and truck-tractors. Consequently, the NTSB recommends that the FMCSA require all in-use cargo tank trailers with a GVWR greater than 10,000 pounds to be retrofitted with an RSC system. 2.3.3 Vehicle Design Although several aspects of transporting hazardous materials on public roads are covered by Federal regulations, no current regulations address optimizing the roll stability of cargo tank motor vehicles. In the absence of requirements, there has been little improvement in the roll stability of cargo tank motor vehicles in the United States. Meanwhile, several countries have developed procedures, such as testing rollover propensity using a tilt table or conducting dynamic tests on a closed track, to objectively quantify and evaluate the roll stability of newly manufactured cargo tank motor vehicles. The NTSB concludes that the absence of regulatory guidance in the United States has discouraged proactive measures to improve the roll stability of cargo tank motor vehicles during the design and manufacturing process. NTSB investigators used crash data from the Cargo Tank Roll Stability Study, extracted from the GES, to determine how many rollovers could be prevented annually, on average, by equipping truck-tractors with an RSC system, lowering CG height by 3 inches, and increasing track width by 6 inches. GES crash data for 1999–2004 indicated that an average 1,265 cargo tank rollovers occurred annually, with approximately 702 (55.5 percent) of these involving a truck-tractor in combination with a cargo tank semitrailer.187 Of the 702 average annual rollovers involving cargo tank semitrailers, approximately 84 (12 percent) could be prevented by lowering the CG height 3 inches and approximately 119 (17 percent) by increasing the track width by 6 inches. An estimated one of every four cargo tank semitrailer rollovers could be prevented (27 percent) by both nominally lowering the CG height 3 inches and increasing the track width 6 inches. The relative effects and rollover prevention rate of these vehicle modifications and those that may be obtained by a tractor-based RSC, as determined by commercially available vehicle simulation software, are shown in table 10.

187 Cargo Tank Roll Stability Study, table 2-8, p. 17.

NTSB Highway Accident Report 68

Table 10. Estimated annual reduction in cargo tank semitrailer rollover accidents.

Vehicle Improvementsa Annual Rollover Reduction Rollover Prevention Rate Install tractor-based RSC system to reduce untripped rollovers (traveling too fast in a curve) 37 5% Lower CG height 3 inches to reduce tripped and untripped rollovers 84 12% Increase track widthb 6 inches to reduce tripped and untripped rollovers 119 17% Reduce CG height 3 inches and increase track width 6 inchesc to reduce tripped and untripped rollovers 189 27% aEstimates assume that all truck-tractors are equipped with an RSC system and all cargo tank semitrailers have had their CG height lowered 3 inches and/or track width increased 6 inches. Analyses to quantify the safety benefits of improving roll statiblity by lowering CG height and increasing track width were performed using DOT 406 cargo tanks. Results of similar analyses using other DOT specification cargo tanks may differ. bNo data exist to quantify the proportion of cargo tank semitrailers with increased track width, which has been estimated at 10–30 percent. Analyses performed to estimate the rollover prevention rate for increasing track width 6 inches were based on all existing cargo tanks having a standard (and not a wider) track width. Consequently, the prevention rate calculated for equipping cargo tank semitrailers with increased track width may be less than 17 percent. cThe rollover prevention rate for lowering the CG height 3 inches and increasing track width 6 inches is slightly less than the combined total because of the decreasing slope in the relationship between rollovers per million miles of travel and rollover threshold of heavy trucks, as developed from historical accident data.

The authors of the Cargo Tank Roll Stability Study emphasized that improving the roll stability of cargo tank motor vehicles, by lowering CG height and increasing track width, was the only approach that would reduce tripped and untripped rollovers because the rollover involvement of heavy trucks is strongly related to their rollover threshold. Although design improvements for increasing the roll stability of cargo tank motor vehicles have been found cost beneficial, such improvements have been slow to gain market share because of a small cost premium and thus their benefit has not been widely appreciated.188 The safety benefits of concept cargo tank semitrailers that were unveiled in the 1980s, featuring improved roll stability and an additional axle to increase the GVWR by approximately 10 percent, did not lead to widespread changes in the design and manufacture of cargo tank motor vehicles.189,190 In summary, the NTSB concludes that the roll stability of cargo tank motor vehicles can be improved significantly by two design considerations: maximizing track width and selecting several available options for lowering CG height. Both of these design improvement strategies are utilized today. Performance-Based Standards. The success of performance-based standards depends on empirically establishing a link between performance measures and accident risks.191 NHTSA has effectively linked the rollover risk of sport-utility vehicles and other high CG vehicles to their static stability factor, the measurement of a vehicle’s resistance to rollover, which led to

188 Cargo Tank Roll Stability Study. 189 L.A. Botkin, ―Proposed Tri-Axle Tank Trailer Improves Stability and Productivity,‖ Modern Bulk Transporter, September 1983. 190 B. Klingenberg, G. Rossow, and R. Jacobsen, FACT—The Freightliner/Heil Advanced Concept Truck, Technical Paper No. 892462 (Warrendale, Pennsylvania: SAE International, 1989). 191 Regulation of Weights, Lengths, and Widths of Commercial Motor Vehicles, Special Report 267 (Washington, DC: Transportation Research Board, 2002).

NTSB Highway Accident Report 69

design changes and improvements in the geometric stability and rollover resistance of those vehicles.192 In the case of cargo tank motor vehicles, no additional data are required to establish a link between the risks associated with high CG vehicles that are prone to rollover and the release of hazardous materials. A performance-based roll stability standard for all cargo tank motor vehicles transporting hazardous materials in the United States was previously recommended by UMTRI.193 The NTSB maintains that a regulation establishing minimum operational requirements for cargo tank motor vehicles may direct attention toward the efforts necessary for heavy truck and cargo tank manufacturers to build rollover-resistant cargo tank motor vehicles. The NTSB concludes that although manufacturers have the ability to improve the roll stability of cargo tank motor vehicles, little incentive exists for making improvements. Therefore, the NTSB recommends that NHTSA establish comprehensive minimum rollover performance standards, based on the least stable condition operated, for all cargo tank motor vehicles with a GVWR greater than 10,000 pounds. Further, the NTSB recommends that NHTSA, once the performance standards have been developed, require that all newly manufactured cargo tank motor vehicles with a GVWR greater than 10,000 pounds comply with the performance standards. 2.3.4 Partial Loads A partial liquid load has the potential to roll up the side of the tank and shift the CG as a vehicle negotiates a curve or if rapid steering movements are introduced. Assuming all other factors that could affect the stability of a vehicle remain constant, the rollover thresholds of cargo tank motor vehicles with fill levels of 80 and 100 percent would not differ significantly while negotiating a steady-state curve.194 However, during a transient maneuver,195 the lateral displacement of a partially filled tank introduces the added dimension of dynamic effects, which can cause bulk liquid to be displaced in one direction and then the other with an amplitude (resulting from a quick succession of steering inputs) that is twice the level of the steady-state amplitude.196 Consequently, when a rapid, evasive steering maneuver occurs, the potential for rollover of a cargo tank with a fill level of 80 percent can be greater, despite a lower CG height, than for a cargo tank with a fill level of 100 percent.197 In this accident, the fill level of the cargo tank with 9,001 gallons of liquefied petroleum gas was approximately 78 percent by volume, which resulted in approximately 23 inches of void space between the top surface of the product (fill level) and the uppermost interior surface of the tank. Evaluating the dynamic effect of the sloshing and surging of liquefied petroleum gas within the MC331 cargo tank and its contribution to the rollover of the combination unit after the rapid, evasive steering maneuver was executed is beyond the capabilities of commercially available

192 M.C. Walz, Trends in the Static Stability Factor of Passenger Cars, Light Trucks, and Vans, Report No. DOT HS 809-868 (Washington, DC: National Highway Traffic Safety Administration, 2005). 193 UMTRI-85-35/2. 194 In a steady state curve, the steering wheel is maintained in a relatively constant position. 195 In a transient maneuver, such as when a double lane change is quickly executed, the steering wheel is turned rapidly in one direction and then quickly reversed at an equal steer angle in the opposite direction. 196 C.B. Winkler and others, Rollover of Heavy Commercial Vehicles, Research Report No. RR-004 (Warrendale, Pennsylvania: SAE International, 2000). 197 Research Report No. RR-004.

NTSB Highway Accident Report 70

vehicle simulation software. Although more advanced simulations are possible, data for validating a model of fluid sloshing and surging are not available, and a more precise description of the actual vehicle motion would be required to evaluate the effect of sloshing. The NTSB has issued at least two recommendations to the Bureau of Motor Carrier Safety (BMCS, predecessor to the FMCSA) to address the instability that can result from the lateral and longitudinal displacement of bulk liquid in partially filled cargo tanks: In cooperation with affected industries, as represented by the Tank Truck Technical Council, conduct an investigation designed to resolve the overturn stability problems created by liquid surging of partially loaded tank-truck combinations. The ultimate objective of such a research program should be the promulgation of Federal regulations to limit the effects of surge to a specific degree. Such regulations might be based on acceptable liquid cargo outage and/or dampening requirements, consistent with safe tank truck operations. (H-72-45) 198 In cooperation with the Tank Truck Technical Council, investigate the overturn stability problem created by liquid cargo surging in tank-truck combinations. The ultimate objective of such an investigation should be the promulgation of Federal regulations to specifically limit the effects of surge. (H-73-24)199 The BMCS responded to Safety Recommendation H-72-45 by stating it would not issue special permits for cargo tank semitrailers pending research that was to be conducted by the National Bureau of Standards. Safety Recommendation H-72-45 was classified ―Closed—Acceptable Action‖ on January 1, 1980. The BMCS responded to Safety Recommendation H-73-24 by indicating it would determine whether to initiate rulemaking to address the surging of partial loads transported by cargo tanks after reviewing the results of a NHTSA study on the handling of trucks and buses to be completed in March 1974. In June 1980, the BMCS issued an On Guard bulletin to raise driver awareness of the instability of partial loads. Safety Recommendation H-73-24 was classified ―Closed—Acceptable Action‖ on September 26, 1980. The Truck Trailer Manufacturers Association has long expressed concern about the practice of partial loading of cargo tank motor vehicles, stating in a 1980 technical bulletin that ―a partially downloaded cargo tank will be less stable under cornering and braking conditions than an ordinary liquid tank loaded to its normal capacity.‖200 Cargo tank manufacturers have also expressed concern, as reported during the August 2010 NTSB public hearing, about the

198 Tank-Truck Combination Overturn Onto Volkswagen Microbus Followed by Fire, U.S. Route 611, Moscow, Pennsylvania, September 5, 1971, Highway Accident Report NTSB/HAR-72/06 (Washington, DC: National Transportation Safety Board, 1972). Safety Recommendation H-72-45 was reiterated in Transport Company of Texas, Tractor-Semitrailer (Tank) Collision With Bridge Column and Sudden Dispersal of Anhydrous Ammonia Cargo, I-610 at Southwest Freeway, Houston, Texas, May 11, 1976, Highway Accident Report NTSB/HAR-77/01 (Washington, DC: National Transportation Safety Board, 1977). 199 Propane Tractor Semitrailer Overturn and Fire, U.S. Route 501, Lynchburg, Virginia, March 9, 1972, Highway Accident Report NTSB/HAR-73/03 (Washington, DC: National Transportation Safety Board, 1973). 200 MC 307 Tank Vehicles, Technical Bulletin 81 (Alexandria, Virginia: Truck Trailer Manufacturers Association, June 16, 1980).

NTSB Highway Accident Report 71

practice of partially loading cargo tanks, explaining to motor carriers via letter the limitations of partially loaded cargo tank motor vehicles. The Cargo Tank Driver Rollover Prevention Video developed by the FMCSA, PHMSA, and industry partners cautions drivers that sloshing can move the liquid sideways too suddenly and too strongly, causing a cargo tank motor vehicle to roll over. Additional strategies for reducing the number of cargo tank motor vehicle rollovers that result from the sloshing and surging of bulk liquid include specifying or retrofitting vehicles with high roll stiffness suspensions, subdividing the tank into separate compartments, and installing transverse and longitudinal baffles to impede the fore/aft and lateral movement of product. Although a great deal is known about the mechanics of sloshing liquids in transportation tanks, fluid mechanics is exceedingly complex and slosh motions are difficult to generalize when wave amplitudes become severe.201 While several studies have been conducted to learn more about the stability of cargo tank motor vehicles, few, if any, have included performing dynamic tests on a closed track to quantify the effect of partial liquid loads on the roll stability of cargo tank semitrailers. The NTSB concludes that the directional stability and rollover threshold of cargo tank motor vehicles can be degraded by the sloshing and surging of partial liquid loads. Therefore, the NTSB recommends that NHTSA evaluate the effect of emergency maneuvers on the sloshing and surging of bulk liquids that have various densities over a range of partially filled levels in a DOT specification cargo tank. The NTSB further recommends that, if the results of the evaluation warrant action, NHTSA establish and implement performance standards for mitigating the sloshing and surging of bulk liquids in all newly manufactured cargo tank motor vehicles with a GVWR greater than 10,000 pounds. 2.3.5 Cross-Slope Break The most detrimental effect of cross-slope break traversals is the lateral acceleration generated when a vehicle migrates from the travel lane fully onto the shoulder. If the lateral acceleration is great enough, loss of directional control can occur directly because of the lack of available skid resistance at the tire/road interface or indirectly because of intolerable centrifugal forces that may cause a driver to become apprehensive and take inappropriate actions (hard braking or excessive steer input). An unpublished 1983 FHWA report contained the results of a study that evaluated the dynamic effects of centerline crowns when passing maneuvers were conducted on tangent roadway sections with passenger cars and loaded and empty truck-tractor combinations and single-unit trucks.202 The simulations produced vehicle dynamic responses of 0.28–0.34 g for cross slopes of 2 percent for all vehicle types. The findings indicated that cross slopes should be kept to a minimum on high-speed highways. These results were consistent with simulation-based analyses conducted by the NTSB that revealed a high CG vehicle would be significantly less stable on a shoulder with a −2 percent cross slope than on a travel lane with an 8 percent cross

201 UMTRI-85-35/2. 202 J.C. Glennon and others, HVOSM Studies of Highway Centerline Crowns, Technical Report, Contract No. DOT-FH-11-9575, unpublished, August 1983.

NTSB Highway Accident Report 72

slope. Therefore, the NTSB concludes that the transition from a positive to a negative cross slope as the combination unit moved laterally from the right lane onto the shoulder significantly decreased the speed at which the combination unit involved in this accident could negotiate the curve without rolling over. The effect of cross-slope breaks on the roll stability of heavy trucks has not been fully evaluated. The results of the limited FHWA study that examined the dynamic response of cross-slope break traversals on highway curves was based on simulations performed with a passenger car, not articulated truck-tractor semitrailers.203 NCHRP Report 505 indicated that the 2001 AASHTO Green Book criteria for cross-slope breaks and vertical clearances appeared to be appropriate for the current truck fleet; however, the report also acknowledged that no further data were found in the literature to address questions on the sensitivity of heavy trucks to cross-slope break traversals. Furthermore, the FHWA confirmed in a September 3, 2010, memorandum that it did not have adequate data to establish an appropriate cross-slope break for heavy trucks.204 The same assessment was noted during the August 2010 NTSB public hearing, when a question was asked about FHWA research regarding the effect of cross-slope breaks on the safe operation of heavy commercial vehicles. The NTSB concludes that the guidance on cross-slope break in the current AASHTO publication A Policy on Geometric Design of Highways does not take into account low-stability heavy trucks that are susceptible to rollover, such as cargo tank motor vehicles with a high CG. The NTSB believes that more information is needed on heavy truck rollover characteristics relative to cross-slope break traversals. Therefore, the NTSB recommends that AASHTO work with the FHWA to evaluate vehicle design characteristics specific to the rollover thresholds of heavy trucks, including those having cargo tanks, and use the information obtained to develop best practices in highway design that will mitigate the increased rollover risk caused by reduced effective superelevation through changes in cross slope that high CG commercial vehicles experience when they migrate onto the shoulder while negotiating curve sections of high-speed highways. The NTSB also recommends that AASHTO incorporate the findings of this evaluation in A Policy on Geometric Design of Highways and Streets. Further, if the results of the heavy vehicle design evaluation warrant such action, the NTSB recommends that the FHWA work with AASHTO to develop and implement best practices to assist state transportation agencies in identifying existing locations where cross-slope breaks pose a rollover hazard, placing an emphasis on those roadways having high volumes of heavy truck traffic, and develop appropriate strategies for mitigating the hazard. The NTSB further recommends that, until these best practices have been developed and disseminated, the FHWA provide information to state transportation agencies about the safety risks associated with cross-slope breaks and their potential for increasing the rollover propensity of commercial vehicles that have a high CG.

203 J.C. Glennon, T.R. Neuman, R.R. McHenry, and B.G. McHenry, HVOSM Studies of Cross-Slope Breaks on Highway Curves, DOT-FH-11-9575 (Washington, DC: U.S. Department of Transportation, July 1981). 204 Associate Administrator for Safety, Federal Highway Administration, memorandum (regarding design considerations for prevention of cargo tank rollovers) to Directors of Field Services, Division Administrators, and Federal Land Engineers, September 3, 2010, p. 2

NTSB Highway Accident Report 73

The NTSB addressed highway geometry in its 1994 investigation of a rollover accident involving a cargo tank semitrailer.205 The investigation determined that cargo tank motor vehicles that are susceptible to rollover should be considered when designing cross sections and horizontal curves. As such, the NTSB recommended that AASHTO: Add a cargo tank to the design vehicle in the AASHTO A Policy on Geometric Design of Highway and Streets. (H-95-39) In its response to Safety Recommendation H-95-39, AASHTO indicated the development of a cargo tank as a design vehicle would not address rollover issues because the Green Book’s design vehicles are used for assessing two-dimensional aspects of highway design using a minimum centerline turning radius, out-to-out track width (overall distance across the axle from the outboard edge of right tire to the outboard edge of left tire), wheelbase, and path of the inner-rear tire. Due to the Green Book’s limitations for evaluating rollover issues and because the NTSB believes that the new recommendations address the intent of Safety Recommendation H-95-39, this recommendation is classified ―Closed—Reconsidered.‖ The collision between the cargo tank and bridge pier column in this accident both breached the tank and displaced the outermost bridge pier column supporting the southbound I-465 overpass. In the sections that follow, the NTSB examines the availability of statistical data for evaluating the accident performance of DOT specification cargo tanks and the adequacy of bridge pier protection guidelines. 2.4 Crashworthiness of DOT Specification Cargo Tanks 2.4.1 Cargo Tank Breach In this accident, the lower half of the front tank head was deformed inward by impacting the bridge pier column, initiating a breach. The breach, which began as a fracture of the cargo tank, generally followed a fillet weld around the perimeter of the right mounting pad attaching the bottom of the tank to the upper coupler assembly. The front head of the tank then rebounded forward, as evidenced by 180° rear-facing folds at the front ends of the left and right mounting pads (see figure 22). During the forward rebound, the tank head broke free from the mounting pads, causing shell material to overlay the folds at the end of the mounting pads. The tank head rebounded approximately 3 inches forward from the left mounting pad and 8 inches forward from the right mounting pad.

205 NTSB/HAR-95/02.

NTSB Highway Accident Report 74

Figure 22. Mounting pad and rear-facing fold above upper coupler assembly. The largest breach in the tank was a vertically oriented 20- by 29-inch opening at the right side of the head/shell interface, which was formed as the crack progressed from the front of the head. Two large petal-shaped flaps of shell material were peeled outward and forward and aft of the opening; this deformation was caused by pressure loading on the interior front head of the tank. Additional damage from the force of the surging liquefied petroleum gas was seen in the forward deformation of both interior transverse baffles, in which the baffles apparently reduced some of this force. The severe deformation of the baffle panels would not be expected to occur from normal transport operations.206 The NTSB therefore concludes that the large opening at the right side of the head/shell interface was caused by internal pressure within the tank and forward surging of liquefied petroleum gas after the tank struck the bridge pier column. 2.4.2 Population of Cargo Tanks by DOT Specification A basic requirement for evaluating the accident performance of DOT specification cargo tanks (such as the MC331) is access to data that can be used to quantify both the involvement of those tanks in reportable incidents and the in-service population of those same tanks. While the approximate number of DOT specification cargo tanks involved in accidents may be obtained

206 Comments by representatives affiliated with the Mississippi Tank Company and AmeriGas/PTI.

NTSB Highway Accident Report 75

from the Hazardous Materials Information System (HMIS) or other databases, there is limited access to accurate information on the population of cargo tanks by DOT specification. For example, the most precise number of petroleum-hauling DOT 406 cargo tank semitrailers cited in the Cargo Tank Roll Stability Study appeared to be somewhere between 10,648–60,003 units. When asked at the August 2010 NTSB public hearing, a PHMSA official acknowledged that they did not know the total number of cargo tanks by DOT specification that were currently in service.207 Further, PHMSA indicated that data analyses for evaluating the performance of DOT specification cargo tanks could be enhanced if the population of cargo tanks by DOT specification were available. The NTSB concludes that the absence of a requirement for motor carriers to periodically provide the number of cargo tanks by DOT specification limits the ability to perform accurate trend analyses. The limited information currently available for PHMSA to quantify the distribution of cargo tanks by DOT specification differs considerably, for example, from information that can be accessed by the Association of American Railroads (AAR) about tank cars used for transporting bulk liquids by rail. The AAR has used the Universal Machine Language Equipment Register (UMLER) equipment management information system as the industry’s central repository for registered railroad and intermodal equipment since 1968. The UMLER system is updated in real time and capable of tracking equipment status, ownership, and inspection history and providing the particular fleet profile. The population of cargo tanks by DOT specification could be obtained by modifying the Hazardous Materials Registration Statement (DOT Form F 5800.2) administered by PHMSA or the Motor Carrier Identification Report (MCS-150) administered by the FMCSA. Although the MCS-150 requires carriers to report the classes of hazardous materials transported and the number of cargo tank single-unit trucks and trailers that are owned and leased, no obligation exists to provide the DOT specification, age, or carrying capacity of cargo tanks. Consequently, arrangements could be made to revise the MCS-150 form to regularly require all intrastate and interstate hazardous materials carriers to provide basic information about a cargo tank motor vehicle’s manufacture date, carrying capacity, DOT specification, and other pertinent information for conducting risk assessments. Therefore, the NTSB recommends that the DOT require all intrastate and interstate hazardous materials carriers to submit annually the number and types of DOT specification cargo tanks that are owned or leased in addition to data displayed on the specification plates of such tanks and, if necessary, modify the appropriate database to accept additional data fields. 2.4.3 Cargo Tank Head Protection (MC331) The NTSB determined that the heads on the accident tank were approximately 30 percent thicker than necessary to meet design and ASME code requirements. A statistical review of DOT HMIS database information by NTSB investigators indicated that the majority of releases of liquefied compressed gases from cargo tanks involve leaks from damaged hoses, valves, pipes, and fittings. Despite the inability to normalize these statistics because of uncertainty in the

207 Testimony delivered by Charles H. Hochman, Director, Office of Hazardous Materials Technology, on August 4, 2010, at NTSB public hearing concerning the Indianapolis rollover accident.

NTSB Highway Accident Report 76

distribution of DOT specification cargo tanks, the risk of catastrophic releases from breaches of MC331 heads appears relatively low compared to other DOT specification cargo tanks, with one fatality in the past 10 years. While MC330/331 cargo tanks represent approximately 15 percent of the national fleet of cargo tank semitrailers, they sustained—according to 1999–2009 HMIS data—0.5 percent of tank shell and head breaches in rollover accidents.208 PHMSA takes the position that the limited number of catastrophic releases from MC331 cargo tank head breaches provides insufficient justification for taking further measures to increase the crashworthiness of these structures. The strong negative cost-benefit analysis cited in the 2001 cargo tank crashworthiness study209 continues to discourage PHMSA from advancing any requirement for supplemental protection of the front heads of MC331 cargo tanks. There is also opposition to the additional cost of equipping cargo tanks with energy-absorbing material and to the estimated 4,376 pounds of weight needed to protect the front head, which would increase the number of individual shipments and potentially result in more accidents because of greater accident exposure for delivering an equivalent amount of hazardous materials. 2.4.4 Cargo Tank Crash Performance Federal regulations associated with the structural integrity of DOT specification cargo tanks require design calculations for the tank shell and heads to account for the load resulting from the design pressure in combination with the dynamic pressure of a longitudinal deceleration.210 The regulations, however, do not consider the magnitude of accident impact forces imposed on the external surface of DOT specification cargo tanks. Accordingly, while current regulatory requirements account for stresses imposed from a 2 g or equivalent force generated by the longitudinal surge of bulk liquid impacting the interior tank head during an abrupt stop, there is no consideration for stresses imposed when accident impact forces are applied to the tank’s external structure. PHMSA and industry panelists at the August 2010 NTSB public hearing maintain that this standard is still applicable today because a 2 g longitudinal deceleration force generated by product surge represents an extreme condition that could not be achieved by a hard brake application. However, the 2 g longitudinal deceleration does not represent all potential impact accident scenarios. For example, a cargo tank initially moving at 60 mph and decelerating at 2 g would come to a stop in 1.4 seconds after traveling a distance of 60 feet. In contrast, if a cargo tank traveling at 60 mph were to strike an immovable object and come to a stop by crushing the front head of the tank over a distance of 4 feet, the average deceleration would be 30 g, and the tank would come to a stop in less than 0.1 second. Specification MC331 cargo tanks are required to be designed to transport compressed liquefied gases under high internal tank pressures that are significantly greater than the dynamic force generated during a 2 g deceleration. Consequently, the 2 g standard does not affect the design and construction of MC331 cargo tanks but does affect other DOT specification cargo

208 Testimony delivered by cargo tank manufacturers (population estimates for DOT specification cargo tanks) and PHMSA (HMIS data) on August 4, 2010, at the NTSB public hearing concerning the Indianapolis rollover accident. 209 Further Work to Improve Crashworthiness of Front Head of MC331 Cargo Tank Motor Vehicles. 210 Title 49 CFR 178.338-3(d), Structural Integrity, and 49 CFR 178.345-8, Accident Damage Protection, Specifications for Packaging.

NTSB Highway Accident Report 77

tanks that transport hazardous materials. The NTSB concludes that performance standards for impacts to the external surfaces of all DOT specification cargo tanks, under varying accident conditions, would provide objective guidance for regulators and cargo tank manufacturers in identifying appropriate designs and protective systems for mitigating the release of hazardous materials. Statistical analysis of accident data provides a starting point for determining which DOT specification tanks are more likely to release product during rollover accidents. A review of additional information—such as the DOT specification of cargo tanks, detailed accident description, tank damage, and type of object that struck the tank—would be instrumental in identifying specific measures to protect cargo tanks and prevent the release of product after rollover accidents. For example, the higher number of shipments carried by DOT specification cargo tanks that transport petroleum may account for their greater frequency of rolling over and such tanks’ thin-wall aluminum shell construction may account for their greater risk of releasing hazardous materials than other DOT specification cargo tanks transporting bulk liquid hazardous materials. A statistical analysis of reportable incidents, for instance, may identify DOT specification tanks that were vulnerable to abrasion. Additionally, modeling impact forces and testing may identify a solution or the development of protective devices for mitigating damage that could result in the release of hazardous materials. The current 2 g longitudinal deceleration standard should be supplemented by accident impact performance standards that provide guidance about how structures could withstand significant impacts under varying accident conditions without the release of hazardous materials. Such performance standards would be more meaningful in predicting the performance and safety of DOT specification cargo tanks in accident situations than the current longitudinal 2 g deceleration standard. Therefore, the NTSB recommends that PHMSA conduct a comprehensive analysis of all available accident data on DOT specification cargo tanks to identify cargo tank designs and the associated dynamic forces that pose a higher risk of failure and release of hazardous materials in accidents; and, once such cargo tanks have been identified, study the dynamic forces acting on susceptible structures under varying accident conditions and develop performance standards to eliminate or mitigate these risks. Further, the NTSB recommends that, once the performance standards have been developed, PHMSA require that all newly manufactured cargo tanks comply with the performance standards. 2.5 Protection of Bridge Pier Columns A W-beam guardrail was installed during the connection ramp’s original construction in 1970 to prevent vehicles from colliding with the bridge pier columns that supported the westbound and southbound I-465 overpasses. Guidance at that time for selecting roadside barriers called for installing a W-beam guardrail to contain and redirect errant passenger vehicles traveling south on the ramp.211 The W-beam guardrail was not upgraded to a higher performance barrier in 1992, when the I-465 overpasses were rehabilitated and widened and the guardrail was lengthened at select locations, nor during a 1997 pavement resurfacing project.

211 Location, Selection and Maintenance of Highway Guardrails and Median Barriers, NCHRP Report No. 54 (Washington, DC: Highway Research Board, National Cooperative Highway Research Program, 1968).

NTSB Highway Accident Report 78

The 1989 AASHTO Roadside Design Guide—which may have been considered in determining whether to upgrade the W-beam guardrail—contained subjective factors but no objective warrants. Even if INDOT had believed in 1997 that the W-beam guardrail needed upgrading, no objective warrants were contained in the 1996 AASHTO Roadside Design Guide (second edition) to justify upgrading the W-beam guardrail to a higher performance barrier; further, the 1994 AASHTO LRFD Bridge Design Specifications only applied to new and replacement of existing bridges, not resurfacing projects. Essentially, the Roadside Design Guide provides guidance for protecting occupants from harm by redirecting vehicles away from bridge pier columns, which differs from the LRFD Bridge Design Specifications, which were created to protect bridge pier columns from vehicle impacts. As evidenced by the Indianapolis connection ramp, where the level of protection from a roadside barrier had not changed in 40 years, the upgrading of ―existing‖ roadside barriers is generally not high on the list of priorities competing for limited safety program funds. In contrast, if a new bridge overpass were built on I-465 today, a 42-inch concrete barrier (and not a W-beam guardrail) would be required, per the AASHTO LRFD Bridge Design Specifications, to protect the bridge pier columns, which are located approximately 14 feet from the edge of the traveled way and within the 30-foot clear zone. Therefore, the NTSB concludes that the proximity of the I-465 overpass bridge pier columns to the travel lanes on the connection ramp made them more vulnerable to damage resulting from a heavy vehicle collision. However, given the circumstances of this accident—with the combination unit vehicle not upright but on its right side, the angle of impact between the barrier and front head of the tank greater than 15°, and the spherical shape and robustness of the front of the tank—it is possible that even a 42-inch concrete continuous barrier may not have been able to redirect the combination unit back into the travel lane and protect the bridge pier column from a high-speed, heavy-vehicle impact. Under current FHWA policy, the upgrade of existing roadside barriers to protect bridge pier columns can be accomplished through planned highway improvements or a rational documented policy developed by the states for determining when upgrades are necessary. Major highway improvements include construction of new bridges and replacement of existing bridges; major reconstruction projects; and resurfacing, rehabilitation, or restoration projects. Prior to the accident, approximately 150 linear feet of W-beam guardrail on the connection ramp was replaced on October 27, 2008, and approximately 225 linear feet of damaged W-beam guardrail on the left and right sides of the ramp was replaced on October 5, 2009. INDOT’s maintenance section determines how damaged guardrail is replaced,212 which in the majority of cases will be with the same type of guardrail that was there before the damage occurred. The INDOT maintenance section consults with the INDOT design section on a case-by-case basis to determine whether a guardrail should be upgraded at high-accident locations. The INDOT design section typically evaluates guardrail replacement as part of a planned project, such as the upgrade of roadside barriers or median barriers along a stretch of interstate.

212 INDOT becomes aware of the thousands of locations in the state where guardrail is damaged through annual maintenance reviews, weekly drive inspections, damage notifications following accidents, and calls from the public.

NTSB Highway Accident Report 79

1. 5.1 Past Accident Investigations

The need to identify and assess existing bridges that could be vulnerable to impact by a heavy commercial vehicle was identified following the NTSB’s 1993 investigation of an overpass collapse in Evergreen, Alabama.213 In this accident, a tractor with a bulk-cement-tank semitrailer left the paved road, traveled along the embankment, overran a guardrail, and collided with a supporting bridge pier column of an overpass. Two spans of the overpass collapsed onto the semitrailer and the southbound lanes of the interstate. An automobile and another tractor-semitrailer, also southbound, then collided with the collapsed bridge spans. The cement-tank truck driver sustained serious injuries; the drivers of the other two vehicles were killed. The NTSB determined that the bridge collapse, which occurred after the semitrailer collided with and demolished the north column, was a combined result of nonredundant bridge design, the proximity of the column bent to the road, and the lack of protection for the column bent from a high-speed, heavy-vehicle collision. The identification and evaluation of bridges that are vulnerable to high-speed, heavy-vehicle collisions and subsequent collapse was discussed in the report, resulting in the following recommendation to the FHWA: Request States to identify and assess bridges that are vulnerable to collapse from a high-speed heavy-vehicle collision with their bridge columns and develop and implement countermeasures to protect the structures. (H-94-5) In response to Safety Recommendation H-94-5, the FHWA indicated that a program to retrofit all existing structures that may be vulnerable, or slightly vulnerable, to heavy-vehicle collisions with bridge pier columns should not be undertaken at the expense of other improvements that may be more effective and efficient in terms of reducing accidents. Furthermore, the FHWA advised the states in an April 12, 1995, memorandum to evaluate initiatives as part of a comprehensive program for improving bridge safety, noting that it would be inappropriate to bypass the bridge management processes by singling out one type of mitigation action for implementation. Because the FHWA intended to encourage the states to use the LRFD requirements pertinent to pier design and protection of structures on Federal-aid projects, which the states later began to use, and because these requirements can also be utilized to evaluate the vulnerability of existing bridges, Safety Recommendation H-94-5 was classified ―Closed—Acceptable Alternate Action‖ on October 7, 1997. One year after the Evergreen accident, a truck-tractor cargo-tank semitrailer loaded with 9,200 gallons of liquefied petroleum gas drifted across the left lane onto the left shoulder, struck a guardrail, and collided with a bridge pier column that supported an overpass.214 The tractor and the semitrailer separated and the front head of the tank fractured, releasing the liquefied petroleum gas, which vaporized and ignited. The NTSB investigation of the accident found that the design of the highway geometries and appurtenances, which did not accommodate the protection of the bridge pier columns by an errant heavy vehicle, increased the bridge’s vulnerability to collapse. As a result of its investigation, the NTSB issued two recommendations to the FHWA:

213 Tractor-Semitrailer Collision With Bridge Columns on Interstate 65, Evergreen, Alabama, May 19, 1993, Highway Accident Report NTSB/HAR-94/02 (Washington, DC: National Transportation Safety Board, 1994). 214 NTSB/HAR-95/02.

NTSB Highway Accident Report 80

Require that highway geometric design and traffic operations of the National Highway System be based on heavy-truck operating characteristics. (H-95-32) Conduct research with cargo tanks (80,000 pounds) to evaluate the safety performance of roadside barriers and highway geometrics, such as embankment sideslopes and ditches, and change the standards accordingly. (H-95-33) In response to these recommendations, the FHWA prepared and circulated a resource document entitled Supplemental on Safe Accommodation of Heavy Vehicles on U.S. Highways, dated October 8, 2004, containing references to truck characteristics in NCHRP 505,215 which was distributed to its resource centers, field offices, and Federal lands highway divisions. The supplemental document was also sent to all members of the AASHTO Technical Committee for Roadside Safety, with a suggestion to incorporate the information in the document into the next edition of the Roadside Design Guide. Because these actions met the intent of Safety Recommendation H-95-33, to raise each state’s level of awareness concerning the continuing need to weigh the likelihood and consequences of large truck crashes at selected highway locations when new construction or reconstruction projects are being considered, this recommendation was reclassified ―Closed––Acceptable Action‖ on April 1, 2005. The other recommendation issued to the FHWA, Safety Recommendation H-95-32, was reclassified ―Closed—Acceptable Alternate Action,‖ on April 1, 2005, although the NTSB emphasized that the full intent of the recommendation had not been met and that there was still concern that the protection of bridge pier columns would be an issue in future investigations. After the Indianapolis accident, on September 3, 2010, the FHWA sent a memorandum to the directors of field services, division administrators, and Federal land engineers, along with copies of the same Supplemental on Safe Accommodation of Heavy Vehicles on U.S. Highways document that was distributed in 2004. In the memorandum, the FHWA restated its position that, although crashes involving cargo tank motor vehicles can be catastrophic, they remain relatively rare and generally occur at unpredictable locations.216 The FHWA again encouraged geometric improvements at identified, predicted, or probable problem locations rather than advocating system-wide reconstruction to geometric standards above and beyond those recommended in the AASHTO Policy on Geometric Design of Highways and Streets (Green Book). The FHWA also submitted a proposal to AASHTO in October 2010 to consider funding an NCHRP research project217 for developing risk-based guidelines for designing or shielding bridge pier columns from heavy truck impacts. The 30-month project, estimated to cost $500,000, was approved by AASHTO in April 2011.

215 Review of Truck Characteristics as Factors in Roadway Design, NCHRP Report No. 505 (Washington, DC: Transportation Research Board, National Cooperative Highway Research Program, 2003). 216 FHWA memorandum regarding design considerations for prevention of cargo tank rollovers (September 3, 2010), p. 1. 217 NCHRP Research Problem Statement, Guidelines for Design and Shielding of Bridge Piers, Project Number 2012-C-03.

NTSB Highway Accident Report 81

1. 5.2 Risk Assessment

Bridges without two specific attributes—redundancy and continuity—are at higher risk of failure due to pier column impacts.218 Redundancy means that alternate load paths are available when a portion of a structure fails. In this accident, one of the outside columns collapsed. However, the I-465 southbound bridge structure was supported by seven columns, so even though the accident removed the outside column, the structure remained standing because six columns were still carrying the load. Continuity means that the bridge beams are continuous over the top of the pier columns, allowing the redistribution of loads in the superstructure from one beam to another. In some older bridge structures, the joints are placed over the pier columns, resulting in a superstructure that is not continuous. With such bridge structures, if the bridge pier columns deflect (move in a different direction) as a result of an impact, the beams will also deflect and be more likely to collapse. The bridge in this accident had continuous beams that did not deflect when the outside pier column was removed by the cargo tank semitrailer. Thus, although the right guardrail failed to redirect or prevent the combination unit from impacting the bridge pier column, the ability of the I-465 overpass to remain standing after impact indicates that consideration was taken when the bridge was designed to ensure that the integrity of the structure would be maintained and not compromised when struck by a heavy commercial vehicle. The NTSB therefore concludes that the bridge structure’s existing redundancy and continuity prevented the southbound I-465 overpass from collapsing after the cargo tank semitrailer collided with and displaced the outside bridge pier column. It is not feasible to expect that all inadequate roadside barriers will be replaced or upgraded through planned highway improvements. Accordingly, a risk assessment should be performed to identify high-risk interchanges and prioritize bridges in terms of vulnerability to collapse if struck. The risk assessment would examine key pier protection factors such as the bridge’s redundancy, continuity, and distance of bridge pier columns from the edge of the traveled way. It would also take a tiered approach, first looking at locations with no redundancy, no continuity, and bridge pier columns close to the edge of the traveled way. Targeting the most unsafe locations would be more focused and strategic than attempting to retrofit all existing structures that may be vulnerable, or slightly vulnerable, to heavy-vehicle impacts. The NTSB therefore recommends that the FHWA work with AASHTO to develop guidance for a bridge pier protection program that will allow state transportation agencies to conduct risk-based assessments of bridges located within highway interchanges. At a minimum, the program should consider each structure’s redundancy, continuity, and the distance of bridge pier columns from the edge of traveled ways. Additionally, consider traffic volumes, traffic type, and the percentage of commercial vehicles transporting bulk liquid hazardous materials in identifying and prioritizing initiatives for preventing vulnerable bridges at high-risk interchanges from collapsing if struck or otherwise damaged by a heavy vehicle. Once the guidance for a bridge pier protection program has been developed, the NTSB recommends that the FHWA require that it be applied to bridges that are vulnerable to collapse if struck by a heavy vehicle.

218 Testimony delivered by the AASHTO Chair of the Technical Committee for Guardrail and Bridge Rail on August 4, 2010, at the NTSB public hearing concerning the Indianapolis rollover accident.

NTSB Highway Accident Report 82

Conclusions 3.1 Findings

The weather did not contribute to the accident.

There was no evidence of mechanical defects or preexisting damage to the combination unit and cargo tank.

The truck driver was adequately licensed and familiar with both the route and driving the combination unit.

The truck driver’s performance was not impaired by alcohol or any of the prescription, over-the-counter, or illicit drugs for which he was tested following the accident.

There was no evidence that the truck driver was distracted by his cellular telephone immediately before the accident.

Neither the staged bilateral knee replacement surgery nor the general health of the truck driver caused or contributed to the accident.

The emergency response was timely and adequate.

The truck driver’s excessive, rapid, evasive steering maneuver triggered the subsequent accident sequence.

The truck driver’s quickly steering the combination unit from the right shoulder to the right lane contributed to the rollover.

The combination unit’s speed at the onset of rollover may have been near the posted advisory speed limit.

There was insufficient information available to determine whether the truck driver was fatigued.

AmeriGas Propane, L.P., drivers would be less likely to violate hours-of-service regulations and make better informed choices about sleep if the company implemented a fatigue management program.

Laden cargo tank motor vehicles provide little tolerance for operator error.

The rollover training received by the truck driver was not effective in preventing this accident.

Although a rollover prevention program will not eliminate all rollovers due to driver errors, it can be effective for identifying ways for cargo tank motor vehicle drivers and management to work collaboratively to prevent rollover accidents.

NTSB Highway Accident Report 83

• A stability control system on the combination unit may have prevented this accident.
• Given the long service life of cargo tanks, 25–50 years could pass before all cargo tank

trailers would be equipped with stability control systems.

• The absence of regulatory guidance in the United States has discouraged proactive measures

to improve the roll stability of cargo tank motor vehicles during the design and manufacturing process.

• The roll stability of cargo tank motor vehicles can be improved significantly by two design

considerations: maximizing track width and selecting several available options for lowering center of gravity height.

• Although manufacturers have the ability to improve the roll stability of cargo tank motor

vehicles, little incentive exists for making improvements.

• The directional stability and rollover threshold of cargo tank motor vehicles can be

degraded by the sloshing and surging of partial liquid loads.

• The transition from a positive to a negative cross slope as the combination unit moved

laterally from the right lane onto the shoulder significantly decreased the speed at which the combination unit could negotiate the curve without rolling over.

• The guidance on cross-slope break in the current American Association of State Highway

and Transportation Officials publication A Policy on Geometric Design of Highways does not take into account low-stability heavy trucks that are susceptible to rollover, such as cargo tank motor vehicles with a high center of gravity.

• The large opening at the right side of the head/shell interface was caused by internal

pressure within the tank and forward surging of liquefied petroleum gas after the tank struck the bridge pier column.

• The absence of a requirement for motor carriers to periodically provide the number of cargo

tanks by U.S. Department of Transportation specification limits the ability to perform accurate trend analyses.

• Performance standards for impacts to the external surfaces of all U.S. Department of

Transportation specification cargo tanks, under varying accident conditions, would provide objective guidance for regulators and cargo tank manufacturers in identifying appropriate designs and protective systems for mitigating the release of hazardous materials.

• The proximity of the Interstate 465 overpass bridge pier columns to the travel lanes on the

connection ramp made them more vulnerable to damage resulting from a heavy vehicle collision.

• The bridge structure’s existing redundancy and continuity prevented the southbound

Interstate 465 overpass from collapsing after the cargo tank semitrailer collided with and displaced the outside bridge pier column. NTSB Highway Accident Report 84

1. 2 Probable Cause

The National Transportation Safety Board determines that the probable cause of this accident was the excessive, rapid, evasive steering maneuver that the truck driver executed after the combination unit began to encroach upon the occupied left lane. Contributing to the rollover was the driver’s quickly steering the combination unit from the right shoulder to the right lane, the reduced cross slope of the paved right shoulder, and the susceptibility of the combination unit to rollover because of its high center of gravity. Mitigating the severity of the accident was the bridge design, including the elements of continuity and redundancy, which prevented the structure from collapsing.

NTSB Highway Accident Report 85

• Recommendations

As a result of its investigation of this accident, the National Transportation Safety Board makes the following recommendations: 4.1 New Recommendations To the U.S. Department of Transportation: Require all intrastate and interstate hazardous materials carriers to submit annually the number and types of U.S. Department of Transportation specification cargo tanks that are owned or leased in addition to data displayed on the specification plates of such tanks and, if necessary, modify the appropriate database to accept additional data fields. (H-11-1) To the Federal Motor Carrier Safety Administration: Work with the Pipeline and Hazardous Materials Safety Administration, as appropriate, to develop and disseminate guidance that will assist hazardous materials carriers in implementing comprehensive cargo tank motor vehicle rollover prevention programs, including the active participation of drivers, dispatchers, and management through training, loading practices, delivery schedules, and acquisition of equipment. (H-11-2) Require all in-use cargo tank trailers with a gross vehicle weight rating greater than 10,000 pounds to be retrofitted with a rollover stability control system. (H-11-3) To the Pipeline and Hazardous Materials Safety Administration: Work with the Federal Motor Carrier Safety Administration, as appropriate, to develop and disseminate guidance to assist hazardous materials carriers in implementing comprehensive cargo tank motor vehicle rollover prevention programs, including the active participation of drivers, dispatchers, and management through training, loading practices, delivery schedules, and acquisition of equipment. (H-11-4) Conduct a comprehensive analysis of all available accident data on U.S. Department of Transportation specification cargo tanks to identify cargo tank designs and the associated dynamic forces that pose a higher risk of failure and release of hazardous materials in accidents. Once such cargo tanks have been identified, study the dynamic forces acting on susceptible structures under varying accident conditions and develop performance standards to eliminate or mitigate these risks. (H-11-5) NTSB Highway Accident Report 86

Once the performance standards in Safety Recommendation H-11-5 have been developed, require that all newly manufactured cargo tanks comply with the performance standards. (H-11-6) To the National Highway Traffic Safety Administration: Develop stability control system performance standards for all commercial motor vehicles and buses with a gross vehicle weight rating greater than 10,000 pounds, regardless of whether the vehicles are equipped with a hydraulic or a pneumatic brake system. (H-11-7) This safety recommendation supersedes H-10-5. Once the performance standards from Safety Recommendation H-11-7 have been developed, require the installation of stability control systems on all newly manufactured commercial vehicles with a gross vehicle weight rating greater than 10,000 pounds. (H-11-8). This safety recommendation supersedes H-10-6. Establish comprehensive minimum rollover performance standards, based on the least stable condition operated, for all newly manufactured cargo tank motor vehicles with a gross vehicle weight rating greater than 10,000 pounds. (H-11-9) Once the performance standards in Safety Recommendation H-11-9 have been developed, require that all newly manufactured cargo tank motor vehicles with a gross vehicle weight rating greater than 10,000 pounds comply with the performance standards. (H-11-10) Evaluate the effect of emergency maneuvers on the sloshing and surging of bulk liquids that have various densities over a range of partially filled levels in a U.S. Department of Transportation specification cargo tank. (H-11-11) If the results of Safety Recommendation H-11-11 warrant action, establish and implement performance standards for mitigating the sloshing and surging of bulk liquids in all newly manufactured cargo tank motor vehicles with a gross vehicle weight rating greater than 10,000 pounds. (H-11-12) To the Federal Highway Administration: Work with the American Association of State Highway and Transportation Officials to evaluate vehicle design characteristics specific to the rollover thresholds of heavy trucks, including those having cargo tanks. Use the information obtained to develop best practices in highway design that will mitigate the increased rollover risk caused by reduced effective superelevation through changes in cross slope that high center of gravity commercial vehicles experience when they migrate onto the shoulder while negotiating curve sections of high-speed highways. (H-11-13) If the results of the evaluation in Safety Recommendation H-11-13 warrant such action, work with the American Association of State Highway and Transportation Officials to develop and implement best practices to assist state transportation

NTSB Highway Accident Report 87

agencies in identifying existing locations where cross-slope breaks pose a rollover hazard, placing an emphasis on those roadways having high volumes of heavy truck traffic, and develop appropriate strategies for mitigating the hazard. (H-11-14) Until the best practices in Safety Recommendations H-11-13 and -14 have been developed and disseminated, provide information to state transportation agencies about the safety risks associated with cross-slope breaks and their potential for increasing the rollover propensity of commercial vehicles that have a high center of gravity. (H-11-15) Work with the American Association of State Highway and Transportation Officials to develop guidance for a bridge pier protection program that will allow state transportation agencies to conduct risk-based assessments of bridges located within highway interchanges. At a minimum, the program should consider each structure’s redundancy, continuity, and the distance of bridge pier columns from the edge of traveled ways. Additionally, consider traffic volumes, traffic type, and the percentage of commercial vehicles transporting bulk liquid hazardous materials in identifying and prioritizing initiatives for preventing vulnerable bridges at high-risk interchanges from collapsing if struck or otherwise damaged by a heavy vehicle. (H-11-16) Once the guidance for a bridge pier protection program as described in Safety Recommendation H-11-16 has been developed, require that it be applied to bridges that are vulnerable to collapse if struck by a heavy vehicle. (H-11-17) To American Association of State Highway and Transportation Officials: Work with the Federal Highway Administration to evaluate vehicle design characteristics specific to the rollover thresholds of heavy trucks, including those having cargo tanks. Use the information obtained to develop best practices in highway design that will mitigate the increased rollover risk caused by reduced effective superelevation through changes in cross slope that high center of gravity commercial vehicles experience when they migrate onto the shoulder while negotiating curve sections of high-speed highways. Also, incorporate the findings in the American Association of State Highway and Transportation Officials publication A Policy on Geometric Design of Highways and Streets. (H-11-18) If the results of the evaluation in Safety Recommendation H-11-18 warrant such action, work with the Federal Highway Administration to develop and implement best practices to assist state transportation agencies in identifying existing locations where cross-slope breaks pose a rollover hazard, placing an emphasis on those roadways having high volumes of heavy truck traffic, and develop appropriate strategies for mitigating the hazard. (H-11-19) Work with the Federal Highway Administration to develop guidance for a bridge pier protection program that will allow state transportation agencies to conduct

NTSB Highway Accident Report 88

risk-based assessments of bridges located within highway interchanges. At a minimum, the program should consider each structure’s redundancy, continuity, and distance of bridge pier columns from the edge of traveled ways. Additionally, consider traffic volumes, traffic type, and the percentage of commercial vehicles transporting bulk liquid hazardous materials in identifying and prioritizing initiatives for preventing vulnerable bridges at high-risk interchanges from collapsing if struck or otherwise damaged by a heavy vehicle. (H-11-20) 4.2 Previously Issued Recommendations Reclassified in This Report The National Transportation Safety Board classifies the following previously issued recommendations:  Safety Recommendation H-95-39 to the American Association of State Highway and Transportation Officials is classified ―Closed—Reconsidered‖ in the ―Cross-Slope Break‖ section of this report’s Analysis.  Safety Recommendations H-10-5 and -6 to the National Highway Traffic Safety Administration are classified ―Closed—Superseded‖ in the ―Stability Control Systems‖ section of this report’s Analysis.

NTSB Highway Accident Report 89

BY THE NATIONAL TRANSPORTATION SAFETY BOARD DEBORAH A.P. HERSMAN ROBERT L. SUMWALT Chairman Member

CHRISTOPHER A. HART MARK R. ROSEKIND Vice Chairman Member

EARL F. WEENER

Member

Adopted: July 26, 2011

NTSB Highway Accident Report 90

• Appendixes

Appendix A Investigation and Public Hearing Investigation The National Transportation Safety Board was notified of the Indianapolis, Indiana, accident on October 22, 2009. An investigative team responded from the Washington, D.C.; Gardena, California; and Arlington, Texas, offices. Groups were established to investigate human performance; motor carrier operations; hazardous materials; structural integrity of cargo tanks; and highway, vehicle, and survival factors. No Board Member traveled to the accident scene. Parties to the investigation were the Federal Highway Administration (FHWA), Indiana Department of Transportation (INDOT), Lawrence Township Fire Department, Indiana State Police, Mississippi Tank Company, and AmeriGas Propane, L.P. Public Hearing The NTSB held a public hearing on this accident August 3–4, 2010, in Washington, D.C. NTSB Chairman Deborah A.P. Hersman presided over the hearing, and NTSB staff participated as members of a Board of Inquiry. Six technical panels composed of subject matter experts participated. Three panels explored the capability and limitations of electronic stability control systems, role of driver training and testing, and feasibility of vehicle design improvements for reducing cargo tank motor vehicle rollovers. Three other panels examined the prevalence and cause-effect relationship between excessive cross-slope break and roll stability of heavy commercial vehicles with a high center of gravity, guidelines for protecting the bridge pier columns of vulnerable bridges at high-speed interchanges, and measures to improve the crashworthiness of cargo tanks for mitigating the unintentional release of hazardous materials. NTSB investigators were members of a technical panel that asked questions of the subject matter experts. Additional questions were asked by the parties to the public hearing and the Board of Inquiry. Parties to the hearing included the U.S. Department of Transportation (DOT), the Federal Highway Administration (FHWA), the Federal Motor Carrier Safety Administration (FMCSA), the National Highway Traffic Safety Administration (NHTSA), and the Pipeline and Hazardous Materials Safety Administration (PHMSA); INDOT; and National Tank Truck Carriers (NTTC), AmeriGas Propane, L.P., Mississippi Tank Company, and Truck Trailer Manufacturers Association. NTSB Highway Accident Report 91

Witnesses who participated at the hearing included representatives of the following organizations: the DOT, FHWA, FMCSA, NHTSA, and PHMSA; Connecticut Department of Motor Vehicles, INDOT, and the Ohio and Texas Departments of Transportation; and Battelle, Meritor WABCO Vehicle Control Systems, Bendix Commercial Vehicle Systems LLC, Haldex Commercial Vehicle Systems, Inc., Trimac Transportation System, All State Career School, Commercial Vehicle Training Association, Praxair, Inc., Groendyke Transport, Inc., Vanasse Hangen Brustlin, Inc., Walker Group Holdings, LBT, Inc., Mississippi Tank Company, and RLT, Inc.

NTSB Highway Accident Report 92

Appendix B Improvements to Connection Ramp Before Accident Measurements of the connection ramp obtained after the accident revealed that the cross-slope break between the right southbound lane and right shoulder varied from 8.08–10.75 percent. The concrete bridge pier column impacted by the semitrailer was offset from the W-beam guardrail by approximately 6 feet (see figure B-1).

Figure B-1. Cross-slope break and bridge pier column protection (before improvements). After Accident Following the accident, the Indiana Department of Transportation installed a 32-inch-high temporary barrier before improvements were made to the Interstate 465 (I-465) connection ramp to modify the cross-slope break and enhance the protection of the bridge pier columns supporting the I-465 overpasses. As shown in figure B-2, the right shoulder was reconstructed after the accident to change the superelevation from a −2 percent cross slope that sloped downward from left to right (in the direction of travel) to a +4 percent cross slope that sloped upward from left to right (in the direction of travel). This alteration allowed the right shoulder to slope upward in the same direction as the travel lanes and changed the cross-slope break from 10 percent (at the time of the accident) to 4 percent. A slotted drain pipe was constructed on the right shoulder to drain stormwater runoff from the travel lanes. In addition, a permanent 45-inch-high concrete barrier and moment slab was constructed approximately 4 feet1

1 The actual distance varied from 3.7–4.8 feet depending on the location of the bridge pier columns.

NTSB Highway Accident Report 93

from the bridge pier columns that support the southbound I-465 overpasses, extending approximately 290 feet along the right shoulder. The barrier construction began on August 5, 2010, and was completed October 21, 2010, at a cost of $277,343.

Figure B-2. Cross-slope break and bridge pier column protection (after improvements). Planned Improvements

The twin bridges that carry the westbound and southbound lanes of I-465 over the connection ramp will be replaced as part of a new I-69 and I-465 interchange project planned to begin within 5 years. The new ramp will carry three lanes instead of two lanes, with a ramp-to-ramp merge area located immediately north of the overpass. If bridge pier columns are part of the new design and located within the 30-foot clear zone, bridge pier protection will conform to current American Association of State Highway and Transportation Officials guidance in the AASHTO LRFD [Load and Resistance Factor Design] Bridge Design Specifications.

NTSB Highway Accident Report 94

Appendix C Outdoor Advertising Signs Federal law requires that all real property, including air space, within right-of-way boundaries be devoted exclusively to public highway purposes (23 Code of Federal Regulations [CFR] 1.23). State highway departments are responsible for ensuring that the right-of-way is free of all public and private installations, facilities, or encroachments. Although exceptions exist, any agreement for outdoor advertising signs entered into by a state must conform to Federal advertising policy and standards (Federal-Aid Highway Act of 1958, section 12). Further, the Manual on Uniform Traffic Control Devices (MUTCD) forbids the use of signs on the right-of-way as an advertising medium; guide and information signs are intended solely for traffic control and navigation (section 1A-1, 1988 edition). One notable exception is signage covered by the Highway Beautification Act, which allows advertising on the right-of-way using logo signs and, to a limited degree, in rest areas. Two high-rise outdoor advertising signs are located near the accident location, with one sign approximately 60 feet north of Interstate 465 (I-465) and the other approximately 60 feet south of I-465. The signs were damaged by the postaccident fire but later restored. Current plans for future reconstruction of the I-69/I-465 interchange, expected to occur within the next 5 years, will require the removal or relocation of the sign on the south side of I-465 but not the sign on the north side. The sign north of I-465 was directly in the line of sight of vehicles entering the curved portion of the ramp. The accident truck driver indicated during a postaccident interview with NTSB investigators that there were no external distractions and he did not notice the outdoor advertising sign. The two signs are located on a railroad right-of-way owned by the Hoosier Heritage Port Authority, a nonprofit organization established to preserve Indiana railroad history. The Indiana Department of Transportation (INDOT) approved permits for the signs on October 5, 2005. INDOT indicated that because the outdoor advertising signs are not on INDOT right-of-way, but on a right-of-way owned by the railroad that traverses through the interchange, the agency did not believe it had a legal basis to deny the permits.1 The Federal Highway Administration (FHWA) is investigating the circumstances surrounding the permit approvals. The FHWA’s Indiana Division Office is working with INDOT to trace the information provided on the permit application.2 The FHWA is also attempting to determine (a) why the outdoor advertising signs were installed in 1999 before the permits were approved, and (b) why the current multifamily residential zoning surrounding this area does not allow outdoor advertising signs. INDOT is also attempting to determine whether the information

1 INDOT e-mail to the NTSB (August 19, 2010). 2 FHWA Office of Real Estate Services e-mail to the NTSB (October 18, 2010).

NTSB Highway Accident Report 95

contained on the permit application is correct, to include determining whether the zoning within the vicinity of the signs in 1999 was commercial, as stipulated on the permit application. False statements on a permit are grounds for permit revocation and removal of the billboard.

FD07366 ｜ 2009_美国_NTSB_HZB0901_Collision_of_Cargo_Tank_Truck_and_Automobile_and_Subsequent.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2009 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

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

Hazardous Materials Accident Brief

Accident No.: DCA-09-FZ-001 Transportation Mode: Highway Location: Upper Pittsgrove Township, New Jersey Date: July 1, 2009 Time: 1:46 a.m., eastern daylight time1

Carrier: Ross Fogg Gas Company Shipper: Ross Fogg Fuel Oil Company Vehicles: 2002 Kenworth tractor; 1989 Fruehauf MC-306 cargo tank semitrailer

2002 Mitsubishi Diamante Fatalities: 1 Injuries: None Property Damage: About $27,000 Materials Involved: Gasoline, a flammable liquid Type of Accident: Vehicle collision and fire

The Accident On July 1, 2009, about 1:46 a.m., a 2002 Kenworth tractor pulling a 1989 Fruehauf MC-306 cargo tank semitrailer (the cargo tank truck) was traveling eastbound on U.S. Route 40 in Upper Pittsgrove Township, New Jersey, when it was struck by a 2002 Mitsubishi Diamante (the automobile) traveling northbound on Commissioners Pike. The automobile driver failed to obey a stop sign equipped with flashing red lights and collided with the external loading lines2 on the passenger side of the cargo tank truck. Loading line 4 was ruptured and about 13 gallons of gasoline were released as the automobile became wedged beneath the cargo tank truck and was dragged about 500 feet. (See figure 1.) A postcrash fire consumed the automobile, killing the driver; the cargo tank truck also was damaged. The Daretown Volunteer Fire Department arrived within 15 minutes and extinguished the fire. Property damage was about $27,000. At the time of the accident, it was dark, and the temperature was 67° F. There were light winds and clear skies. Rain had been observed in the hour before the collision; however, it was not a factor in the accident.

1 All times in this brief are eastern daylight time. 2 Loading lines are used to both load and unload product. For the purposes of this brief, the term loading lines will be used in lieu of loading/unloading lines. NTSB/HZB-09/01

Figure 1. Schematic of accident scene. Events Preceding the Accident About 12:08 a.m. on the day of the accident, the cargo tank truck was loaded with 8,999 gallons of gasoline. The driver delivered 6,000 gallons of the gasoline about 1:00 a.m. and was en route to deliver the remaining 2,999 gallons when the collision occurred. During the same work shift (which began about 1:00 p.m. on June 30), the driver had delivered three other similar loads of fuel. Hazardous Materials Information The U.S. Department of Transportation (DOT) classifies gasoline as a class 3 flammable liquid. Gasoline has a flash point of -40° F, an auto ignition temperature of 500° F, and a flammable range of 1.3 to 7.1 percent in air. It is extremely flammable and explosive in the presence of open flames, sparks, or static discharge. NTSB/HZB-09/01 2

Cargo Tank Information The accident cargo tank, serial number 4LK023501, was a DOT specification MC-306 cargo tank built in 1989 by the Fruehauf Corporation in Detroit, Michigan. The tank was made of aluminum and was elliptical in shape, measuring 80 inches in height by 96 inches in width by 533 inches in length. It had a total water capacity of 10,000 gallons distributed among four internal compartments. The first compartment had a capacity of 3,000 gallons; the second compartment, 2,000 gallons; the third compartment, 2,000 gallons; and the fourth compartment, 3,000 gallons. The maximum allowable working pressure of the cargo tank was 1 pound per square inch, gauge, at 150° F. The cargo tank was equipped with four 4-inch-diameter aluminum pressure relief devices, one on each compartment, manufactured by Betts Industries in Warren, Pennsylvania. An external loading line constructed of 4-inch-diameter aluminum piping connected an inlet valve on the loading rack to the external bottom outlet valve of each compartment. The total length of the loading lines for all of the compartments was about 49 feet; the length of loading line 4 was about 18 feet. Each compartment was equipped with an internal self-closing stop valve that prevented product from releasing from the cargo compartment in the event that the loading lines and the bottom of the cargo tank were damaged in an accident. The cargo tank was owned and operated by the Ross Fogg Gas Company (the motor carrier). Ross Fogg Gas Company was registered with both the Federal Motor Carrier Safety Administration and the Pipeline and Hazardous Materials Safety Administration (PHMSA) as a private carrier of liquids and gases. Ross Fogg Gas Company handles the delivery of gasoline and diesel fuel to various retail dealers in New Jersey, Delaware, and Pennsylvania. About 85 percent of the company’s business involves operating as a transporter for the Ross Fogg Fuel Oil Company (the shipper), as was the case in this accident. The remaining 15 percent involves transporting petroleum products shipped by other companies to their respective retail outlets. Postaccident Examination Cargo Tank Truck Postaccident examination of the cargo tank truck revealed that the cargo tank did not sustain any mechanical damage. Black soot was visible toward the rear of the tank on both sides and underneath it, where the automobile had been lodged and the fire occurred. Various components external to the cargo tank, including the aluminum fenders, hose shelf, storage containers, and tires on the rear passenger side were destroyed as a result of the impact and fire. Additionally, the loading rack on the passenger side at the bottom center of the tank was twisted and bent. The rear section of the rack nearest to loading line 4 was pushed inward and shifted forward, and the aluminum angle mount connecting the rack to the tank was sheared off the tank at this point. Loading lines 1, 2, and 3 were not visibly damaged as a result of the impact, and each of these lines remained connected to the tank. However, lines 1 and 3 had separated from the couplings, just behind the loading rack, as a result of the rack’s shifting. Loading line 4 and the vapor recovery line were destroyed as a result of both the impact and fire. The impact of the collision ruptured loading line 4 and also sheared the rear vapor recovery line and valve from the loading rack. (See figure 2.) As a result, the estimated NTSB/HZB-09/01 3

13 gallons of gasoline contained inside loading line 4 were released onto the automobile below. The gasoline was ignited, most likely by an unknown ignition source from the automobile, and a fire engulfed the automobile, loading line 4, and the vapor recovery line. The self-closing stop valve on the fourth compartment of the cargo tank functioned properly, and the 2,999 gallons of fuel contained in the compartment prior to the accident were safely offloaded after the fire was extinguished. Consequently, the release of gasoline and the subsequent fire likely would not have occurred if the cargo tank’s loading lines had been empty.

Figure 2. Rear passenger side of accident cargo tank truck showing external damage from collision and fire. Automobile The automobile was destroyed by the impact and fire. (See figure 3.) Postaccident examination revealed that the most severe fire damage was concentrated toward the rear of the automobile. With the exception of some foam from the passenger seat behind the driver, all of the combustibles in the back seat area were consumed. Large portions of foam from the driver seat and the adjacent passenger seat remained. Heavy char was present on all of the remaining combustible materials. NTSB/HZB-09/01 4

Figure 3. Left side view of automobile showing damage from collision and fire. Several samples were collected from the remaining combustible materials3 and sent to the Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) to determine whether petroleum products were present. ATF positively identified gasoline in a sample taken from the rear seat cushion, confirming that gasoline entered the automobile.

Injuries The driver of the automobile was killed. The Gloucester County Medical Examiner’s Office postmortem report indicated that the cause of death was smoke and soot inhalation and severe thermal burns. The medical examination did not reveal any evidence of blunt trauma or fractures.

3 The remaining combustible materials included the driver seat, passenger seat, and rear seat cushions; the driver and passenger floor mats; dashboard foam; and clothing scraps from the automobile driver. NTSB/HZB-09/01 5

Safety of Loading Lines Previous Accidents On October 9, 1997, a cargo tank truck loaded with 8,800 gallons of gasoline was traveling south on Central Park Avenue under an overpass in Yonkers, New York, when it was struck by a southbound automobile. A subsequent fire destroyed both vehicles and a thruway overpass; the automobile driver died from burns and smoke inhalation. The National Transportation Safety Board (NTSB) concluded that the automobile struck and fractured one or more of the loading lines of the cargo tank, thus releasing up to 28 gallons of gasoline, and that had the loading lines been empty, the fire would likely not have occurred.4 On February 15, 1998, a cargo tank truck carrying 8,900 gallons of gasoline was traveling across a bridge on Interstate 495 in Wilmington, Delaware, when it struck a parked automobile on the shoulder of the road. A fire ensued after the collision that destroyed the automobile and moderately damaged the cargo tank truck; the driver of the automobile was killed. Recommendations and Regulations In its report on the Yonkers, New York, accident,5 the NTSB expressed concern about the potential loss of life and possible injuries associated with transporting flammable liquids in cargo tank loading lines. In 1997, when the accident occurred, federal regulations did not prohibit the transportation of flammable liquids in the external piping of cargo tanks. As a result of the Yonkers investigation, the NTSB issued the following recommendation to the U.S. Secretary of Transportation (DOT): Prohibit the carrying of hazardous materials in external piping of cargo tanks, such as loading lines, that may be vulnerable to failure in an accident. (H-98-27) On December 30, 2004, the Research and Special Programs Administration (RSPA) published a notice of proposed rulemaking (NPRM) titled “Safety Requirements for External Product Piping on Cargo Tanks Transporting Flammable Liquids.”6 The NPRM proposed to amend the Hazardous Materials Regulations (Title 49 Code of Federal Regulations 173.33) to prohibit flammable liquids from being transported in unprotected external piping on all newly constructed and existing DOT specification cargo tank trucks. However, on June 7, 2006, PHMSA7 published a notice withdrawing the NPRM and terminating the rulemaking proceeding.

In July 2007, PHMSA informed the NTSB that it was working with the cargo tank industry and major emergency response organizations to develop a comprehensive national wet

4 For more information, see Collision of Tractor/Cargo Tank Semitrailer and Passenger Vehicle and Subsequent Fire, Yonkers, New York, October 9, 1997, Highway/Hazardous Materials Accident Summary Report NTSB/HAR-98/02/SUM (Washington, DC: National Transportation Safety Board, 1998). 5 NTSB/HAR-98/02/SUM. 6 Federal Register, vol. 69, no. 250 (December 30, 2004), p. 78375. 7 As part of a DOT reorganization, PHMSA was established in 2005 and assumed regulatory responsibility for RSPA’s hazardous materials safety program. NTSB/HZB-09/01 6

NTSB/HZB-09/01 7 and other safety data to determine whether rulemaking action regarding wet lines is necessary. unsafe practice of transporting flammable materials in the external loading lines of cargo tanks. Probable Cause rom the release of gasoline from a cargo tank loading line that was ruptured during the collision. Adopted: November 12, 2009 lines (loading lines) outreach awareness program to enhance public safety and assist those who respond to transportation emergencies. The NTSB responded by clarifying to PHMSA that the intent of Safety Recommendation H-98-27 was to prohibit the unsafe practice of transporting flammable liquids in loading lines, and that these actions did not address or satisfy the intent of the recommendation. In a letter dated October 16, 2009, PHMSA stated that it was completing an in-depth, comprehensive review of incident reports The NTSB remains concerned about this safety issue. This accident illustrates once again why the NTSB strongly believes that PHMSA should prohibit the The National Transportation Safety Board determines that the probable cause of the July 1, 2009, vehicle collision and fire in Upper Pittsgrove Township, New Jersey, was the failure of the automobile driver to obey a stop sign equipped with flashing red lights. Contributing to the severity of the accident was a fire that resulted f

FD07367 ｜ 2009_美国_NTSB_MAB1002_Fire_On_Board_US_Small_Passenger_Vessel_Fire_Island_Belle.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2009 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

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-09-LM-021 Vessel Fire Island Belle Accident Type Engineroom fire Location: Fair Harbor, New York Date: September 20, 2009 Time: 1010 eastern daylight time1 Owner/Operator: Fire Island Ferries Property Damage: $490,000 Injuries: None Summary On September 20, 2009, at 1010 eastern daylight time, the passenger ferry Fire Island Belle (figure 1), with 100 passengers, the vessel master, and two deckhands on board, experienced an engineroom fire in the Great South Bay between Long Island and Fire Island, New York (figure 2). The vessel had departed Ocean Beach, Fire Island, 10 minutes earlier, and was approximately 300 yards from the dock at Fair Harbor, Fire Island, when the fire broke out. No passengers or crewmembers were injured, and no pollution resulted. The cost of repairing the vessel was $490,000. The U.S. Coast Guard was the lead investigative agency in the accident. The National Transportation Safety Board (NTSB) provided assistance with fire investigation and metallurgical analysis. Accident Narrative At 0925 on September 20, the Fire Island Belle departed Bay Shore, Long Island, on its regularly scheduled route, which included stops on Fire Island at Ocean Beach, Fair Harbor, and Saltaire before returning to Bay Shore. About 0950, the vessel reached Ocean Beach, where arriving passengers and cargo were offloaded and departing passengers and cargo were loaded. According to their statements to the Coast Guard, the vessel master and one of the deckhands reported smelling fuel while the cargo was being loaded. They checked the passenger baggage to determine if that was the source of the odor but found nothing.

1 Times are given according to the 24-hour clock. NTSB/MAB-10/02

Figure 1. Fire Island Belle before the fire.

Figure 2. Accident location.

2 NTSB/MAB-10/02

The master then entered the engineroom through the forward port access hatch. The engineroom contained three engines, port, center, and starboard, and four access hatches, two forward and two aft (figure 3). The master discovered fuel leaking from the pipe nipple connection to a T-fitting on top of the secondary fuel filter on the center engine. All thre e engines had experienced fuel leaks at that connection. As a result, the pipe nipples had been replaced on all three engines, most recently on the center engine, about 30 days before the fire.

e engineroom and went to the pilothouse to shut down the center engine because of the fuel leak at the pipe nipple. (The engines had been at idle while t About the same time, the alarm from the engineroom heat detectors sounded in the pilothouse. Figure 3. Schematic of engineroom layout on Fire Island Belle (not to scale). The master stated that he did not see any fuel around the area of the filter on the center engine or on the surface below it. He left th he ferry was docked at Ocean Beach.) About 0959, after the master had shut down the center engine and loading was complete, the vessel left Ocean Beach. As the vessel rounded the channel marker into Fair Harbor, passengers reported thick black smoke coming from the port and starboard engineroom vents.

3 NTSB/MAB-10/02

The deck crew was directed to inform the passengers that they would all disembark at Fair Harbor. The master directed the ferry into the mooring slip at Fair Harbor, where it was secured by a springline to the dock. ystem activated and the sound of pressurization in the lines, which confirmed system activation.

FHFD assistant chief assumed command of the firefighting effort until the FHFD chief arrived. from going farther than the bottom of the ladder to avoid becoming lost in the confined space. s. Firefighters sprayed those areas with foam for several minutes to ensure that the fire was out. The master saw that the ferry was still too far from the dock to disembark passengers and tried to start the port engine to move it closer. The engine had shut down because of the fire and would not restart. The master and a few passengers then manually pulled the vessel to the dock. After securing the vessel, the master and crew safely disembarked all passengers. The master then pulled the emergency fuel shut-off valve and activated the engineroom’s fixed carbon dioxide (CO2) fire suppression system. The master heard the alarm that sounded 30 seconds before the s At the master’s request, a member of the Fair Harbor Fire Department (FHFD) who was on the dock notified the nearby fire department of the fire. (The dock was about 100 feet from the FHFD headquarters.) According to the FHFD incident report, two firefighters from the FHFD had noticed the Fire Island Belle exhausting a large volume of dense black smoke as it neared Fair Harbor. One of the firefighters dialed 911 to report the fire and began helping the passengers evacuate the ferry. At 1015, Suffolk County Fire Rescue and Emergency Services began dispatching vehicles to the scene. The FHFD had two 1-3/4-inch hose lines, one supplied with foam, on the dock within minutes of the Fire Island Belle disembarking its passengers. An The first firefighters on scene noticed thick black smoke pouring from the engineroom vents, the heaviest smoke coming from the starboard vent. The master notified the fire chief that the vessel’s CO2 fire suppression system had been activated. The master also told him that approximately 700 gallons of diesel fuel were on board. Firefighting began with an inspection of the aft deck hatches that allowed access to the engineroom. According to firefighters, the area around the aft port hatch was extremely hot and painful to the touch, even with gloves. The deck paint around the hatch was burned, and the decking around the hatch was warped from the heat. When the firefighters opened the hatch, fire and heavy gray-and-black smoke poured out. One foam line was sprayed down the rear port hatch into the engineroom for 15 to 20 minutes to suppress the fire. Firefighters entered the engineroom from the forward starboard access hatch, but according to the FHFD incident report, thick smoke kept them After the foam line was shut off, a high-power fan was installed to vent the engineroom. After 20 minutes of venting, firefighters entered the engineroom through the forward starboard hatch. Smoke had abated and visibility was good. Firefighters noted that foam had coated the bottom 12 inches of the engineroom and that fire damage was limited to the top of the space. Conditions at floor level were cool. Smoke was still coming off wiring on the ceiling, as well as from the top of the port engine and from the insulation, also known as lagging, around the exhaust duct from the port engine. Some of the lagging around the port engine exhaust was removed while firefighters checked for hot spot

4 NTSB/MAB-10/02

About 1045, Coast Guard Sector Long Island Sound was notified of the fire. At that point, the FHFD vacated the engineroom and turned it over to an assistant chief from the Kismet Fire Department. The assistant chief oversaw members of his department and the Saltaire Fire Company while they performed a secondary examination and assessment of the engineroom using a thermal imaging camera (Kismet and Saltaire are both on Fire Island; refer to figure 2). The fire was reported extinguished and ground operations were terminated at 1110. Ground operations were witnessed by members of the Suffolk County Police Department, the Ocean Beach Police Department, the Town of Islip Harbor Police, and the Fire Island National Seashore rangers d boat crew conducted drug and alcohol tests, as required by 46 Code of Federal Regulations (CFR) 4.06.2 The Fire Island Belle moored at the Fire Island Ferry terminal Vess rs—one master and two deckhands. The number of deckhands varied with the number of passengers. The vessel had a passenger capacity of 382, hatches provided access through doors and stairs that led to the engineroom. The rear hatches had floor- level co . By the time firefighting operations ended, the owners of Fire Island Ferries had arrived to take possession of the vessel. At 1221, the vessel departed Fair Harbor under tow to Bay Shore by the vessel Eagle. At 1243, Coast Guard investigating officers boarded the Fire Island Belle while it was under way. Within 10 minutes of arriving on board, a qualified member of the Coast Guard Station Fire Islan in Bay Shore at 1415. el Information The Fire Island Belle was an 85-foot, double-deck, single-hull aluminum vessel built in 2009 by Blount Boats, Inc., of Warren, Rhode Island. The vessel was delivered to Fire Island Ferries on June 18, 2009. According to its certificate of inspection, the vessel was inspected under 46 CFR, subchapter K (applicable to small passenger vessels carrying more than 150 passengers or with overnight accommodations for more than 49 passengers), and operated in ferry service on rivers including Great South Bay on runs not to exceed 30 minutes. On the day of the fire, the vessel operated with three crewmembe of whom 178 were allowed on the upper deck. The enclosed pilothouse was forward on the upper deck. The engineroom was directly below the main passenger deck, with access hatches in each corner. The forward vers that, when lifted, provided access to the aft engineroom by way of ladders.

2 Regulations at 46 CFR 4.06 require that after a serious marine incident, “each individual engaged or employed on board the vessel who is directly involved in the incident” be tested for alcohol within 2 hours and for illicit drug use within 32 hours “unless precluded by safety concerns directly related to the incident.” Regulations at 46 CFR 16.113 specify testing for marijuana, cocaine, opiates, phencyclidine, and amphetamines. Alcohol testing is not required more than 8 hours after a serious marine incident. 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 nvironment of the United States. 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 e

5 NTSB/MAB-10/02

The vessel was powered by three Detroit Diesel Series 60 Tier II engines.3 Alternators were located forward of each engine. The fuel tank, immediately forward of the engineroom, was stocked with ultralow sulfur No. 2 diesel fuel.4 Fuel went from the tank to each engine through a primary fuel filter, then through a fuel pump and a secondary fuel filter to the back of the cylinde tor and the Puradyn system were attached to the secondary fuel filters. The fuel pressure going into the secondary fuel filter was quare inch, depending on engine speed. Fire . The cover did not interfere with the ventilation damper because the dampers had closed automatically when the fire suppression system was activated (see “F the center and starboard engines had fractured. The lenses for the overhead lighting in the aft portion of the engineroom had melted away from the lights a elted. Part of the wiring to the ignition box for the center engine was heavily fire-damaged. Most of the insulation had melted, but the wires were intact and did not exhibit signs of arcing.

r head, and from there to the engine injector ports (fuel gallery). A second fuel gallery captured returned fuel. Unused, heated fuel was first cooled in the heat exchanger, then returned to the tank. Each engine was equipped with a Puradyn® filtration system for the lubricating oil.5 Sensors serving the alterna 82 to 90 pounds per s Damage Smoke and other fire damage was limited to the engineroom and adjacent structures such as ventilation ducts and the aft access hatches. The only exterior damage was around the engineroom vent openings. Soot was visible on the outside of the hull above the dampers, with more soot on the starboard side than on the port side (figure 4). The Coast Guard–approved polyvinyl chloride (PVC) weather covers over the vents had melted. The starboard cover, which exhibited more melting than the cover on the port side, fell out of position and came to rest on top of the ventilation damper (figure 5) ire Protection System,” below). The engineroom showed varying degrees of fire damage. Damage in the forward section was limited to heavy sooting and some light thermal damage, particularly to plastic components, in the overhead forward of the engines. Damage was more severe near the engines, especially on the overhead between the center and port engines (figure 6). Thermal damage patterns extended 2 to 3 feet down from the overhead. One of the aluminum hangers for the fire suppression system piping had melted, and the hanger between nd dripped onto the surfaces below. Almost all exposed surfaces on the engines exhibited heavy sooting. The air filters for all the engines were covered with soot, and the port and starboard filters had partially collapsed from the heat. Plastic components on the rear of the port and center engines were m

3 The Series 60 is an inline, 6-cylinder, water-jacketed engine. According to the manufacturer, the engine’s maximum exhaust gas temperature at full power is 671° F. 4 This fuel is recommended by the engine manufacturer to avoid fouling the exhaust after-treatment system. According to the material safety data sheet, the fuel’s autoignition temperature is 489° F. Autoignition temperature is the lowest temperature at which a combustible material ignites in air without a spark or flame. The temperature of a heated surface required to ignite a combustible material is usually lower than the autoignition temperature. 5 According to the Puradyn manufacturer, a bypass filtration system is required to remove the wear-producing soot deposited in lubrication oil by modern, low-emission diesel engines.

6 NTSB/MAB-10/02

Figure 4. Soot damage to vent opening on starboard side of vessel.

Figure 5. Closeup of damaged starboard vent cover (viewed from inside vent).

7 NTSB/MAB-10/02

Figure 6. Damage to overhead wiring in engineroom. A Detroit Diesel engine technician downloaded data from each engine’s computer. The data showed that the center engine had not been running at the time of the fire. According to the computer data, the port and starboard engines, both running at full power at the time of the fire, showed elevated air intake temperatures about the same time as the engineroom alarm sounded in the pilothouse. The only mechanical engine damage was a fractured pipe nipple connection on the center engine’s secondary fuel filter (figure 7). The fractured nipple and adjoining fittings were removed and retained by the NTSB for further examination. The insulation on the wiring to the sensors attached to the T-fitting had melted, but the sensors were otherwise intact. The lagging for the port engine exhaust duct, which was about 19 inches above the center engine’s secondary fuel filter, was charred (figure 8). As noted earlier, parts of the lagging were removed by firefighters while searching for hot spots. Another section of lagging was removed to assess the condition of the duct underneath. The surface of the duct showed evidence of resolidified plastic, most likely from the lens of the overhead light. The duct hanger was not lagged.

8 NTSB/MAB-10/02

Figure 7. Fractured nipple (above) and associated fittings (below) on secondary fuel filter of center engine.

Figure 8. Charred lagging on port engine exhaust duct.

9 NTSB/MAB-10/02

Fire Protection System Title 46 CFR, Part 118, §400 requires a space that contains propulsion machinery to be equipped with an automatic fire detection system unless (1) the vessel was built before March 10, 1996, and (2) does not have a hull, machinery space boundary bulkhead, or deck that is composed of wood or fiber-reinforced plastic, sheathed on the interior with fiber-reinforced plastic, or is continuously manned. The space is also required by 46 CFR, Part 118, §400 to be equipped with a fixed gas fire-extinguishing system unless (1) it was built before March 10, 1996, and (2) does not have a hull, machinery space boundary bulkhead, or deck composed of wood or fiber-reinforced plastic or sheathed on the interior with fiber-reinforced plastic. Because the Fire Island Belle was built after 1996, it was required to have both an automatic fire detection system and a fixed fire suppression system (figure 9) The engineroom contained five heat detectors manufactured by Notifier®. The remains of two detectors were found in the debris after the fire. The other three detectors were still in place in the engineroom overhead. Smoke detectors, also manufactured by Notifier, were located on the main passenger deck and forward engineroom access stairwells. A Notifier NFS2-640 fire alarm control panel was located on the bridge. The fire suppression system was equipped with two 75-pound CO2 cylinders, installed in a separate compartment forward of the engineroom. Galvanized piping connected the cylinders to the engineroom, where two discharge nozzles were installed (one in the forward portion of the engineroom and one in the aft portion near the center engine). A discharge alarm and a 30- second delay device allowed for evacuation of the engineroom if necessary. The system was remotely activated by a pull cable on the main deck near the forward port engineroom access hatch. The fire suppression system was configured so that the engineroom vents closed when the remote cable was pulled. The cylinders, pipes, and nozzles were found intact during the postaccident examination. The servicing company for the fire suppression system reported that the cylinders were empty after the fire. The master said that the system actuated properly because he heard both the discharge alarm and the lines being pressurized.

10 NTSB/MAB-10/02

Figure 9. Diagram of engineroom fire detection and suppression system on Fire Island Belle.

11 NTSB/MAB-10/02

Metallurgical Examination The NTSB materials laboratory in Washington, DC, examined the fractured pipe nipple from the secondary fuel filter on the center engine (figure 13). The nipple was constructed of 3/8-inch seamless steel pipe (1/8 American Standard pipe), commonly referred to as black steel. Examination by stereomicroscope and scanning electron microscope revealed a fatigue fracture (crack) that went through the wall of the pipe and part-way around it. The dimensions, chemistry, and hardness of the pipe nipple were measured and compared with appropriate standards for seamless steel pipe. The measurements were within specifications.

Figure 13. Pipe nipple and T-fitting from center engine. Origin and Cause of Fire Fire damage, including damage from smoke, was limited to the engineroom and adjacent structures such as the ventilation ducts for the engineroom and aft access hatches. Damage was more severe between the center and port engines, particularly overhead, where wiring bundles were melted and charred. Based on the location of the damage, investigators determined that the fire had originated in the aft portions of the port and center engines. Shortly before the fire broke out, the crew had smelled fuel and the master had found fuel leaking from the nipple connection to the secondary fuel filter on the center engine (which was idling at the time). The postaccident laboratory examination found a fractured connection (pipe nipple) on the fuel filter. All three engines had experienced leaking at that connection. It is

12 NTSB/MAB-10/02

reasonable to conclude that during the voyage across the bay from Long Island to Ocean Beach, with all three engines running, pressurized fuel had sprayed from the crack in the pipe nipple up onto the exhaust duct for the port engine (refer to figure 3). Based on the fracture analysis, the master’s discovery before the fire, and the history of issues with the nipple connection, investigators determined that diesel fuel coming from the fractured fitting on the center engine was the source of fuel for the fire. The exhaust ducts from the vessel’s engines, as the only exposed hot components in the engineroom, were covered with insulation (lagging). After the fire, the lagging on the port exhaust duct was removed. The lagging was charred both inside and outside, and molten plastic was observed on the surface of the duct, suggesting the presence of a gap in the stitching that held the lagging together. Therefore, the fuel from the center engine that had sprayed onto the port engine’s exhaust duct could have leaked through the gap onto the hot surface of the duct, even after the center engine was shut down at Ocean Beach. The engines were at idle while at the Ocean Beach dock, but the temperature of the exhaust from the port engine would have increased once the vessel got under way toward Fair Harbor. The autoignition temperature of the ultralow sulfur No. 2 diesel fuel used in the engines is 489° F. That temperature is below the temperature of the exhaust gas at full engine power (671° F). The apparent gap in the lagging demonstrates that despite the presence of insulation, the port exhaust duct was exposed, and fuel could therefore have contacted the hot duct. The gap in the lagging and the damage to the lagging itself suggest that the hot surface of the port engine’s exhaust duct was the ignition source for the fire. Postaccident Actions by Owner Fire Island Ferries made several changes to the Fire Island Belle after the fire: • Altered the lubricating oil filtration system to activate by the ignition system rather than by the secondary fuel filter. • Eliminated the pipe nipple and T-connector from the secondary fuel filter configuration. • Added two-part insulation/lagging wrap to the exhaust ducting and duct hangers. • Installed aluminum frames on the engineroom vent covers and aluminum mesh backing on the vents to keep the PVC part of the covers from falling inside the vents. • Added another nozzle to the fire suppression system, making three nozzles in the engineroom—two over the engines and one forward. • Updated the vessel’s fire control plan.

13 NTSB/MAB-10/02

14 NTSB/MAB-10/02 Probable Cause The National Transportation Safety Board determines that the probable cause of the engineroom fire on the Fire Island Belle was the ignition of fuel that had leaked from a fatigue- fractured fitting on the center engine’s secondary fuel filter, sprayed onto the lagging around the port engine exhaust duct, and seeped through a gap in the lagging onto the hot duct, where it caught fire. Adopted: July 2, 2010

FD07368 ｜ 2009_美国_NTSB_MAR1103_Collision_Between_US_Coast_Guard_Vessel_CG_33118_and_Sea_Ray.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2009 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

Collision Between U.S. Coast Guard Vessel CG 33118 and  Sea Ray Recreational Vessel CF 2607 PZ  San Diego Bay, California  December 20, 2009  Accident Report NTSB/MAR-11/03 PB2011-916403 National Transportation Safety Board

(This page intentionally left blank)

NTSB/MAR-11/03 PB2011-916403 Notation 8193A Adopted July 12, 2011

Marine Accident Report Collision Between U.S. Coast Guard Vessel CG 33118 and Sea Ray Recreational Vessel CF 2607 PZ San Diego Bay, California December 20, 2009

National Transportation Safety Board

490 L’Enfant Plaza, SW Washington, DC 20594

National Transportation Safety Board. 2011. Collision Between U.S. Coast Guard Vessel CG 33118 and Sea Ray Recreational Vessel CF 2607 PZ, San Diego Bay, California, December 20, 2009. Marine Accident Report NTSB/MAR-11/03. Washington, DC. Abstract: This report discusses the December 20, 2009, collision on San Diego Bay, California, between the 33- foot-long U.S. Coast Guard special purpose craft – law enforcement (SPC-LE) CG 33118 and an unnamed 24-foot-long Sea Ray recreational boat with California registration CF 2607 PZ. As a result of the accident, an 8-year-old passenger on board the Sea Ray died. Safety issues identified in this accident include the speed of the CG 33118, Coast Guard oversight of small boat operations, SPC-LE forward visibility, Coast Guard monitoring of small boat operational data, and Coast Guard use of personal cell phones while under way. On the basis of its findings, the NTSB made recommendations to the Coast Guard. NOTE: This report was reissued on April 29, 2026, with corrections to the Safety Recommendation text and numbers on pages 39 and 40. The National Transportation Safety Board (NTSB) 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 NTSB 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 Internet at http://www.ntsb.gov. Other information about available publications also may be obtained from the website or by contacting: National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, SW Washington, DC 20594 (800) 877-6799 or (202) 314-6551 NTSB publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2011-916403 from: National Technical Information Service 5301 Shawnee Road Alexandria, Virginia 22312 (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 NTSB reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

NTSB Marine Safety Report ERRATA SHEET Pages 39–40, the numbers for Safety Recommendations M-11-1 through -4 were corrected (previously M-11-002 through -005). Additionally, the text of Safety Recommendation M-11-4 (previously M-11-005) was updated as follows to reflect the final text as issued to the Coast Guard: • Previous: Develop regulations governing nonoperational use of cell phones and other wireless electronic devices by on-duty crewmembers in safety-critical positions, and should continue its outreach program of information and education to the maritime industry on this issue. • Revised: Until you can develop regulations governing nonoperational use of cell phones and other wireless electronic devices by on-duty crewmembers in safety- critical positions, continue your outreach program of information and education to the maritime industry on this issue.

NTSB Marine Safety Report Contents Figures............................................................................................................................................. v Acronyms and Abbreviations ........................................................................................................ vi Executive Summary ..................................................................................................................... viii 1 Factual Information ...................................................................................................................... 1 1.1 Parade of Lights .................................................................................................................... 1 1.2 Accident Narrative ................................................................................................................ 2 1.2.1 Sea Ray .......................................................................................................................... 2 1.2.2 CG 33118 ....................................................................................................................... 4 1.2.3 Witness Reports ............................................................................................................. 7 1.3 Injuries .................................................................................................................................. 8 1.4 Damage ................................................................................................................................. 9 1.4.1 CG 33118 ....................................................................................................................... 9 1.4.2 Sea Ray .......................................................................................................................... 9 1.5 Personnel Information ........................................................................................................... 9 1.5.1 CG 33118 ....................................................................................................................... 9 1.5.2 Sea Ray ........................................................................................................................ 11 1.6 Vessel Information .............................................................................................................. 11 1.6.1 CG 33118 ..................................................................................................................... 11 1.6.2 Sea Ray ........................................................................................................................ 14 1.7 Wreckage ............................................................................................................................ 15 1.7.1 CG 33118 ..................................................................................................................... 15 1.7.2 Sea Ray ........................................................................................................................ 16 1.7.3 Strike Angle ................................................................................................................. 17 1.8 Waterway Information ........................................................................................................ 18 1.8.1 General ......................................................................................................................... 18 1.8.2 Vessel Traffic Density ................................................................................................. 18 1.8.3 San Diego Bay Background Lighting .......................................................................... 19 1.9 Meteorological Information ................................................................................................ 19 1.10 Medical and Pathological Information .............................................................................. 20 1.11 Survival Aspects ............................................................................................................... 20 1.12 Management/Coast Guard Operational Information ........................................................ 22 1.12.1 Guidance on Parade of Lights Operations ................................................................. 22 1.12.2 Small Boat Speed Guidance ....................................................................................... 23 1.12.3 Crew Brief .................................................................................................................. 25 1.12.4 Coxswain and Crew Training .................................................................................... 25 1.12.5 Lookout Procedures ................................................................................................... 26 1.12.6 Coast Guard Boat Forces Oversight .......................................................................... 26 1.12.7 The Bayside Blaster Accident .................................................................................... 27 1.12.8 Nondistress Search-and-Rescue Assist Policy ........................................................... 29 1.12.9 Coast Guard Postaccident Activity ............................................................................ 29 1.13 Vessel Forward Visibility ................................................................................................. 31 1.13.1 General ....................................................................................................................... 31 1.13.2 Design Standards ....................................................................................................... 32 iii

NTSB Marine Safety Report 1.14 Tests and Research ............................................................................................................ 32 1.14.1 ABYC Visibility Testing ........................................................................................... 32 1.14.2 Forward Line of Sight—NTSB Comparison Study ................................................... 33 1.14.3 SPC-LE Engine rpm/Speed Determinations .............................................................. 34 1.14.4 Video Study ............................................................................................................... 35 1.14.5 Audio Study of CG 33118 Speed .............................................................................. 35 1.15 Other Information ............................................................................................................. 36 1.15.1 Nighttime Visual Perception ...................................................................................... 36 1.15.2 Coast Guard AIS Policy ............................................................................................. 37 1.15.3 AIS Operation on the CG 33118 ................................................................................ 37 1.15.4 Thriller 09 and CG 25689 Collision .......................................................................... 38 1.15.5 Cell Phone Use ........................................................................................................... 38 1.15.6 Previous Safety Recommendations ............................................................................ 39 2 Analysis...................................................................................................................................... 41 2.1 General ................................................................................................................................ 41 2.2 Exclusions ........................................................................................................................... 41 2.3 The Accident ....................................................................................................................... 42 2.3.1 CG 33118 Operating Speed ......................................................................................... 42 2.3.2 Marine Assistance Radio Broadcast ............................................................................ 43 2.3.3 Traffic Density ............................................................................................................. 43 2.3.4 Safe Speed .................................................................................................................... 43 2.3.5 Visual Perception and Conspicuity .............................................................................. 44 2.4 SPC-LE Forward Visibility................................................................................................. 45 2.5 Sea Ray ............................................................................................................................... 47 2.6 Training and Oversight ....................................................................................................... 47 2.6.1 SPC-LE Coxswain Training ........................................................................................ 48 2.6.2 Oversight ...................................................................................................................... 48 2.6.3 SPC-LE Speed Policies ................................................................................................ 51 2.7 AIS Use ............................................................................................................................... 51 2.8 Vessel Operations Monitoring ............................................................................................ 52 2.9 Cell Phone Use .................................................................................................................... 52 2.10 Emergency Response ........................................................................................................ 53 3 Conclusions ................................................................................................................................ 54 3.1 Findings............................................................................................................................... 54 3.2 Probable Cause.................................................................................................................... 55 4 Recommendations ...................................................................................................................... 56 Appendixes ................................................................................................................................... 57 iv

NTSB Marine Safety Report Figures Figure 1. Aerial photo of San Diego Bay.. ..................................................................................... 2 Figure 2. A 24-foot-long Sea Ray recreational boat similar to the one involved in the accident ... 3 Figure 3. SPC-LE CG 33118 .......................................................................................................... 4 Figure 4. The path of the CG 33118 from Station San Diego. ....................................................... 6 Figure 5. Interior of the CG 33118 cabin ...................................................................................... 13 Figure 6. Damage to the CG 33118 .............................................................................................. 16 Figure 7. Damage to the Sea Ray .................................................................................................. 17 Figure 8. Fractured fiberglass on the Sea Ray, viewed looking aft and port from cockpit .......... 17 Figure 9. Depiction of the CG 33118 colliding with the Sea Ray at an angle of about 11 degrees ........................................................................................................................... 18 Figure 10. View of San Diego Bay ............................................................................................... 19 Figure 11. Layout of the Sea Ray and locations and injuries of the 13 people on board. ............ 22 Figure 12. Stages of generic vessel planing and corresponding trim angles ................................ 31 v

NTSB Marine Safety Report Acronyms and Abbreviations ABYC American Boat and Yacht Council AIS automatic identification system AOR area of responsibility BCEB boat crew examination board CBL cutter boat large CPR cardiopulmonary resuscitation DGPS differential global positioning system DHS U.S. Department of Homeland Security FAA Federal Aviation Administration GAR green-amber-red (risk assessment) HF-SSB high frequency-single sideband IAP incident action plan ISO International Organization for Standardization JHOC Joint Harbor Operations Center MAIT Multidisciplinary Accident Investigation Team MARB marine assistance radio broadcast MISLE Marine Information for Safety and Law Enforcement nm nautical mile OIC/OINC officer-in-charge RBS response boat small RFO Ready for Operations SINS scalable integrated navigation system SDHP San Diego Harbor Police SPC-LE special purpose craft – law enforcement STAN Coast Guard Standardization TCT team coordination training UCSD University of California San Diego USCG U.S. Coast Guard UHF ultra high frequency vi

NTSB Marine Safety Report UTB utility boat big UTL utility boat light VHF very high frequency vii

NTSB Marine Safety Report viii Executive Summary On Sunday, December 20, 2009, about 1744 Pacific standard time,1 the 33-foot-long Coast Guard vessel CG 33118, designated by the Coast Guard as a “special purpose craft – law enforcement” or SPC-LE, with five crewmembers on board, collided with a 24-foot-long Sea Ray recreational vessel with state registration number CF 2607 PZ, carrying 13 people, on San Diego Bay, California. The collision occurred during the city’s annual holiday boat parade, the Parade of Lights. The Sea Ray was headed west near the main shipping channel2 to enable the occupants to watch the boat parade. The CG 33118, on patrol in the bay, was also headed west, its crew responding to a reported grounding. The CG 33118 struck and overran the Sea Ray’s stern near the west end of Harbor Island. As a result of the collision, an 8-year-old boy on board the Sea Ray was fatally injured and four other people on board sustained serious injuries. No CG 33118 crewmembers were injured in the accident. Following the collision, drug and alcohol testing was performed on CG 33118 crewmembers, and all results were negative. The Sea Ray operator voluntarily submitted to drug and alcohol testing, and the results of his tests were negative as well. The National Transportation Safety Board determines that the probable cause of the collision between the CG 33118 and the Sea Ray was the failure of the CG 33118 crew to see and avoid the Sea Ray because of the excessive speed at which the coxswain operated the CG 33118, given the prevailing darkness, background lighting, and high vessel density, and the U.S. Coast Guard’s lack of effective oversight of its small boat operations both nationally and at Coast Guard Station San Diego. Safety issues in this accident include the speed of the CG 33118, Coast Guard oversight of small boat operations, Coast Guard monitoring of small boat operational data, SPC-LE forward visibility, and Coast Guard use of personal cell phones while under way. As a result of this investigation, the NTSB makes recommendations to the Coast Guard. 1 Unless noted otherwise, all times in this report are Pacific standard time (universal time coordinated –8 [UTC-8]) based on the 24-hour clock. 2 The main shipping channel runs roughly east-west and is marked by lighted red and green buoys.

NTSB Marine Safety Report 1 1 Factual Information 1.1 Parade of Lights Each December, the on-water holiday event Parade of Lights takes place on San Diego Bay. The event attracts hundreds of boaters who watch the festivities from their vessels, ranging from small dinghies, kayaks, and canoes to large yachts and commercial vessels. Vessel traffic during the Parade of Lights is typically higher than on almost any other night on San Diego Bay, except perhaps July 4th. The Parade of Lights is held on successive Sunday nights, and the 38th annual event was scheduled for December 13 and 20, 2009. Both days’ events featured a fireworks display at 1730 followed by a parade of more than 80 decorated boats on San Diego Bay. The event organizer had obtained a marine event permit, issued by the U.S. Coast Guard Sector San Diego, which authorized the festivities.3 In addition to the boats participating in the parade, organizers estimated an additional 100 spectator vessels. The Coast Guard’s captain of the port for San Diego issued a notice of enforcement for a “special local regulation”4 for the Parade of Lights. The parade was to begin at the south end of Shelter Island on the west side of the bay, then turn northeast and east and run parallel to Harbor Island to the east side of the bay and then south along the downtown waterfront. The trackline was about 5 miles long and ran along the shores of Shelter, Harbor, and North islands (figure 1). A Coast Guard Local Notice to Mariners5 warned boaters to use “due caution” when transiting near the designated parade area. 3 Sector San Diego has authority, including captain of the port authority, for safety within the southern California coast that includes San Diego Bay (33 Code of Federal Regulations [CFR] 3.55-15). Several Coast Guard stations, including Station San Diego, are responsible to Sector San Diego for certain duties, including operation of small boats. Coast Guard small boats are vessels less than 65 feet in length. 4 The special local regulation area for the parade included most of San Diego Bay. The notice contained no spectator craft viewing areas or operating restrictions other than to not impede the parade. 5 A Local Notice to Mariners may be issued to specify a temporary safety zone for marine events and other on-water operations for safety or environmental purposes.

NTSB Marine Safety Report

2

Figure 1. Aerial photo of San Diego Bay. The yellow line shows the Parade of Lights trackline. The Coast Guard established an incident action plan (IAP) for the Parade of Lights, which stated in part that Coast Guard vessels assigned to the event would “provide for an overt and aggressive waterborne presence” between 1730 and 2000 on both days of the parade. This was to keep boaters clear of the fireworks barge and to avoid their interfering with the lighted boats in the parade. Several Coast Guard Auxiliary6 vessels also were assigned to assist in the event. The 87-foot-long Coast Guard cutter Haddock was the first vessel in the parade. San Diego Harbor Police (SDHP), which normally had two vessels patrolling the bay at all times, had four boats on patrol that night. The SDHP and the Coast Guard shared law enforcement activities on San Diego Bay. The IAP also stated that any injuries were to be reported to the Joint Harbor Operations Center (JHOC).7 1.2 Accident Narrative 1.2.1 Sea Ray About 1715, the 24-foot-long Sea Ray recreational boat (figure 2) left its berth at the Harbor West Marina located at the west end of Harbor Island. On board were three families: the operator, his wife, and three children; and two other couples with two children each. In total, 13 people were on board. After departing the marina, the Sea Ray operator proceeded along Harbor

6 The Coast Guard Auxiliary is an incorporated civilian volunteer component of the U.S. Coast Guard. 7 The JHOC is a command and control facility staffed by contingents of the Coast Guard, U.S. Navy, San Diego Harbor Police, and, on occasion, other Federal, state, and local government agencies. The JHOC communicates with and coordinates government vessel operations on San Diego Bay. H HHaaarrrbbbooorrr IIIssslllaaannnddd SSShhheeelllttteeerrr IIIssslllaaannnddd SSSaaannn D DDiiieeegggooo B BBaaayyy N NNooorrrttthhh IIIssslllaaannnddd C CCoooaaasssttt G GGuuuaaarrrddd SSStttaaatttiiiooonnn Parade Start D DDooow wwnnntttooow wwnnn H HHiiillltttooonnn H HHooottteeelll H HHaaarrrbbbooorrr IIIssslllaaannnddd FFFuuueeelll D DDoooccckkk B BBaaallliii H HHaaaiii R RReeessstttaaauuurrraaannnttt Accident Site

N

NTSB Marine Safety Report

3

Island’s south shore toward the east end of the island. There, he stopped the boat to watch the fireworks, which were scheduled to begin at 1730.

Figure 2. A 24-foot-long Sea Ray recreational boat similar to the one involved in the accident. Photo by Sea Ray, Inc. After the fireworks display ended, the Sea Ray operator headed west in the bay at idle speed (about 2–4 knots) toward the west end of Harbor Island to position the vessel for viewing the boat parade. According to a passenger, the families decided that, because several young children were on board and because it was a Sunday night with school the next day, they would position themselves close to the Harbor West Marina, thus shortening the time needed to return and dock the boat after the parade. Both the Sea Ray operator and a passenger told NTSB investigators that the boat’s navigation lights, including the port and starboard running lights and the all-around light, were illuminated. The operator, SDHP officers, and other witnesses confirmed that all the children on board were wearing lifejackets.8 The Sea Ray operator said that when he was about three-quarters of the way to the west end of Harbor Island he heard what sounded like an engine running at high speed behind him. He estimated that about 20 other boats were within 50 yards of his location, primarily to the north, and that the other boats were drifting, idling, or at anchor. On hearing the engine sound, he looked back over his shoulder and noted that the engine sound seemed to be coming closer and that the vessel that was producing the sound had not appreciably changed course. The Sea Ray operator told investigators that, shortly before the collision, he saw the approaching vessel with red and green running lights illuminated and three people silhouetted in the pilothouse. The

8 California state boating law requires that all children 11 years of age or younger wear a Type I, II, III, or V Coast Guard-approved lifejacket while on board a vessel that is 26 feet or less in length while the vessel is under way (http://www.dbw.ca.gov/Pubs/Pfd/PFDs.pdf accessed January 4, 2011). According to San Diego Harbor Police, the Sea Ray also carried lifejackets for all persons on board, as required by law.

NTSB Marine Safety Report

4

Sea Ray operator told investigators that he saw that the approaching vessel’s hull was “on the plane,”9 and that the vessel was “dead center” off his stern. He said that he thought he needed to move his boat out of the way to avoid being struck by the oncoming vessel. He “slammed” the throttle forward and turned to starboard, but as he was starting to make the starboard turn, the oncoming vessel struck the Sea Ray’s stern. The Sea Ray operator told investigators that there was no time for his boat to reach any kind of speed between the time that he accelerated and the collision. He said that his boat “did not move more than five feet, if that,” and that the other vessel was closing in “very rapidly, like almost at us and then maybe a second passed and then it hit us. It was just very fast.” The Sea Ray operator said that the colliding vessel had “such high speed … it literally [shot] right over the top of us.” 1.2.2 CG 33118 The CG 33118 (figure 3), which the Coast Guard designates a “special purpose craft – law enforcement” or SPC-LE, and its crew were not assigned to the Parade of Lights. The IAP for the event stated that the patrol commander could call on a station asset (such as the CG 33118) to support law enforcement activity; however, one was not requested.

Figure 3. SPC-LE CG 33118. Photo by the Coast Guard.

9 Planing occurs when a boat’s speed and hull shape generate sufficient lift to support a portion of the craft above the water. See section “Vessel Forward Visibility” for more detail.

NTSB Marine Safety Report

5

Although Sector San Diego did not request a station asset to assist in the event, Station San Diego’s operations petty officer scheduled a patrol that evening. About 1645, the five CG 33118 crewmembers met for a briefing before their anticipated 1700 departure and patrol. The boat crew included the coxswain,10 a second qualified boat crewmember, the boat’s engineer, a crewmember-in-training, and Station San Diego’s officer of the day (OOD),11 who had elected to join the patrol. (For more information on the crew, see section “Personnel Information.”) The crewmember-in-training told NTSB investigators that the coxswain led the meeting and informed the crewmembers that they might be on patrol for 3 or 4 hours. He said that although they were not officially assigned to the Parade of Lights, their stated purpose was “just going out, making sure everything’s good, making sure there’s no DUIs, making sure—just having an asset in the area for…general safety overall.” The boat engineer told NTSB investigators that the station’s “boat assignment board” assigned the CG 33118 a patrol mission to assist the Haddock that night. The boat engineer told NTSB investigators that a crew meeting was held before getting under way and that it included a green-amber-red (GAR) risk assessment12 for that mission. He said that the results of the GAR were “green” (also see section on Management/Coast Guard Operational Information, Crew Brief). At 1723, the CG 33118 crew notified the JHOC of its departure from Station San Diego. When the fireworks display began at 1730, the crew stopped the vessel to watch. When the display ended about 5 minutes later, the CG 33118 proceeded toward Shelter Island on the west side of the bay where the boat parade was to start. When the CG 33118 reached that location, the crewmembers radioed the Haddock’s crew, stating that they had no specific assignment related to the parade but would be nearby and could provide assistance if requested. Figure 4 shows the approximate route of the CG 33118 across San Diego Bay.

10 The Coast Guard assigned coxswains the responsibility for, in order of priority, the safety and conduct of passengers and crew, safe operations and navigation of the boat, and completion of the mission. Coxswains were also to respond to hazards to life and property, violations of laws or regulations, and discrepancies to aids to navigation. 11 At Coast Guard stations, the OOD is the direct representative of the station’s officer in charge, and ensures compliance with the station’s regulations and policies. Except for the executive petty officer and the engineering petty officer, all personnel at the station are subordinate to the OOD. Normally, the officer in charge assigns the senior coxswain in the duty section as OOD to oversee security, order, and supervision of personnel. Nonetheless, while underway the OOD’s status is no different than that of the other crewmembers in being subordinate to the coxswain. 12 The GAR safety risk assessment determines whether a mission should be deemed green (0–22 points, low risk), amber (23–43, medium risk, caution), or red (44–60 points, high risk).

NTSB Marine Safety Report

6

Figure 4. The path of the CG 33118 from Station San Diego to the Haddock, then northeast and east across the bay, and then returning west to the accident site. Also indicated are the locations of the Coast Guard cutter Haddock at the time of the accident, the sailboat from which a witness filmed a video that the NTSB later used for video and sound analysis, and the Hilton Hotel from which witness photographs were taken of the accident scene. According to the crewmember-in-training, a few minutes after communicating with the Haddock, the CG 33118 crew heard a marine assistance radio broadcast (MARB),13 transmitted by the JHOC,14 that stated that a 25-foot Catalina sailboat was aground. The Catalina operator advised the JHOC that he and his passengers were not in distress and that he was going to wait for high tide to refloat his vessel. The MARB provided the sailboat’s estimated coordinates, and added that the vessel was located “within view” of the Sheraton Hotel on Harbor Island. The MARB included a request for other boaters or a private towing company to assist. On hearing the MARB, the CG 33118 crew radioed the JHOC and asked for permission to respond to the call.15 The JHOC watchstander told NTSB investigators that he granted the permission, and that he informed the CG 33118 crew that the grounded vessel, “wasn’t in any immediate danger, wasn’t

13 According to Commandant Instruction M16130.2E, National Search and Rescue Supplement, a MARB is made to solicit voluntary response from anyone who can assist the mariner. If the Coast Guard does not receive a response to the MARB within a reasonable period of time, typically 10 minutes, Coast Guard resources and/or auxiliary vessels may be directed to respond. 14 The JHOC transmitted the MARB at 1738. However, because the Catalina was not equipped with a GPS, JHOC personnel had to estimate its position coordinates for the MARB. 15 According to Coast Guard search-and-rescue operating procedures, a small boat such as the CG 33118 must have the sector’s permission to respond to a search-and-rescue situation.

NTSB Marine Safety Report

7

taking on water, and that we weren’t asking them or tasking them to go there.” The CG 33118 crew then headed east to look for the sailboat along the south shore of Harbor Island. However, the sailboat was actually on the north side of Harbor Island, in the West Basin.16 When the CG 33118 crewmembers could not locate the sailboat, they radioed the JHOC for clarification. The information was corrected, and, according to the crewmember-in-training, the coxswain turned the CG 33118 around and headed west toward the West Basin inlet. The crewmember-in-training told NTSB investigators that, leading up to the collision, he was not paying attention to the speed of the vessel. He said that the engine sound seemed commensurate with traveling about 20–25 knots. Neither the crewmember-in-training nor the boat engineer recalled hearing any crewmember voice concern about the speed of the CG 33118. Both of them told investigators that the radar on board the CG 33118 was operating. The boat engineer told investigators that, just before the CG 33118 impacted the Sea Ray, he heard one of the crewmembers shout “oh god.” Following the accident, the CG 33118 coxswain told SDHP that, at the time of the collision, he was proceeding at about 3000 rpm17 about 200–300 yards south of Harbor Island, close to the main shipping channel. He stated that, as the CG 33118 was en route, it suddenly “shot straight up in the air.” He told police, “I knew I hit a boat,” and that he had not seen it. The coxswain stated that when he “landed” he turned the CG 33118 around and came alongside the boat. He then handed the controls to the OOD. The coxswain declined to be interviewed by NTSB investigators. 1.2.3 Witness Reports

Witnesses interviewed after the accident indicated that the CG 33118 was moving at a higher speed than other vessels in the area that night, and that the speed was about the same on both the eastbound and westbound legs. They also indicated that the vessel was on a plane both before and during the accident leg. The witnesses stated that the CG 33118 approached the slower-moving boat from astern. Witnesses (including boat crew) reported that the sound of the engine pitch did not decrease before the collision. A recreational boater witnessed the sequence of events from an estimated 70-yard distance. He told investigators that he saw blue flashing lights on top of a fast-moving vessel (he estimated a speed of about 25 knots) headed west toward his location. As the vessel approached, he could see that it had an orange hull with a high aluminum cab. He did not hear a siren nor see the vessel slow down before it collided with the stern of a smaller boat, which had its running lights on and was also traveling to the west. When the faster vessel struck the smaller boat, the stern of the smaller boat moved down and the bow of the faster vessel was projected up and momentarily into the air above the other boat. The witness said that he could see some of the occupants on the smaller boat and that they seemed to be ducking as the faster vessel came over the top of their boat. The faster vessel landed on the smaller boat, rolled off its port side onto the

16 The West Basin is a protected area north of Harbor Island, primarily containing marinas and recreational boat slips. 17 About 19 knots on SPC-LE vessels.

NTSB Marine Safety Report

8

water, and then continued to “coast” toward the west. The smaller boat righted itself and remained afloat but was rotating in a clockwise rotation. The noise of the collision alerted boaters in the immediate area, and some began directing their spotlights in that direction. Another witness, a guest at the Hilton hotel located on the south shore of Harbor Island, observed the events from the sixth floor of the hotel, about 240 yards from the accident site. He told investigators that he saw what appeared to be a law enforcement vessel with its blue lights activated. The witness stated that the vessel first passed his location in an eastbound direction. It then stopped and was motionless for about a minute before turning and traveling back. He estimated the vessel’s speed at 25–30 knots. A second witness on the south shore of Harbor Island told investigators that he saw a Coast Guard vessel traveling to the east and then back again to the west at high speed until it struck a boat on the starboard quarter, about 300 yards off the island. He described the Coast Guard vessel as “running flat” (that is, planing), with its bow fairly level with the water and not high in the air. A witness on Shelter Island said that the CG 33118 was traveling at “a high rate of speed.” Another witness said that after the CG 33118 turned around, it appeared to be traveling at a “higher rate of speed, dangerously close to the anchorage.” According to automatic identification system18 (AIS) data obtained from Sector San Diego, the Haddock was southwest of the west end of Harbor Island when the accident occurred. The Haddock’s officer of the deck19 told NTSB investigators that he saw the CG 33118 approach the Sea Ray and wondered if the Coast Guard vessel would avoid the Sea Ray. He estimated the CG 33118’s speed as 25 knots, the same speed he estimated the vessel had been traveling when it departed the Haddock and headed east in the bay. The Haddock’s commanding officer reported that the collision occurred about 100 yards off the Haddock’s bow. NTSB investigators determined the approximate position to be latitude 32o43’18.8” N and longitude 117o12’38.2” W. 1.3 Injuries The injuries sustained in this accident are categorized in the table below according to the injury criteria of the International Civil Aviation Organization. The NTSB uses these injury criteria in all its accident reports, regardless of transportation mode.

18 An AIS is a maritime communications system that automatically transmits vessel information, including a vessel’s name, type, position, course, speed, navigational status, and other safety-related information, to appropriately equipped shore stations, other vessels, and aircraft. The AIS also automatically receives such information from similarly fitted vessels. Also see sections 1.15.3, Other Information, Automatic Identification System, and 2.7, AIS Use. 19 On Navy and Coast Guard vessels, the officer of the deck is the direct representative of the commanding officer and is responsible for the safe operation of the vessel.

NTSB Marine Safety Report

Type of Injury CG 33118 Sea Ray Total Fatal 0 1 1 Serious 0 4 4 Minor 0 6 6 None 5 2 7 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 burn affecting more than 5 percent of the body surface. 1.4 Damage 1.4.1 CG 33118 The CG 33118 sustained minor damage. As of the date of this report, the cost of the damage to the CG 33118 had not been determined. 1.4.2 Sea Ray The Sea Ray was destroyed in the accident. Its value was estimated at $30,000. 1.5 Personnel Information 1.5.1 CG 33118 Coxswain. The coxswain, age 21, was seated in the forward starboard seat, and was operating the CG 33118 at the time of the accident. According to Coast Guard records, he obtained his qualifications as follows: • Utility boat big (UTB) boat crewmember, October 2007 • UTB tactical crewmember, September 2008 • SPC-LE pursuit crewmember, November 2008 • SPC-LE boat crewmember, December 2008 • UTB coxswain, January 2009 • SPC-LE coxswain, February 2009 • UTB and SPC-LE tactical coxswain, June 2009 • SPC-LE pursuit coxswain, July 2009 From April to June 2007, the coxswain attended and satisfactorily completed the Coast Guard’s Boatswain’s mate “A” School, which included testing on navigation rules. He also completed a search-and-rescue coordination and execution course in January 2009. 9

NTSB Marine Safety Report

10

The coxswain was involved in an incident about 2 months before the accident. He was on board another SPC-LE close to a concrete pier at a maintenance facility in San Diego Bay and was trying to hold the vessel’s position. However, the SPC-LE and its outboard engines made contact with the pier, causing damage to the lower portion of the engines. The incident was considered minor and no action was taken against the coxswain. Boatswain’s mate third class. The boatswain’s mate third class, age 24, was seated in the forward port seat at the time of the accident. According to Coast Guard training records, she obtained the following qualifications: • Cutter boat large (CBL) crewmember, March 2009 • Utility boat light (UTL) crewmember, March 2009 • UTB and SPC-LE crewmember, October 2009 Boatswain’s mate second class. The boatswain’s mate second class, age 27, was Station San Diego’s OOD on the day of the accident and the highest-ranked crewmember on board the CG 33118. He was seated in the aft port seat at the time of the accident. According to Coast Guard training records, he obtained the following qualifications: • Response boat small (RBS) 20 crewmember, May 2007 • SPC-LE crewmember, October 2007 • SPC-LE pursuit crewmember, December 2007 • UTB crewmember, November 2007 • UTB and SPC-LE coxswain, July 2008 • UTB and SPC-LE tactical crewmember, December 2008 • UTB and SPC-LE tactical coxswain, March 2009 • SPC-LE pursuit coxswain, July 2009 Boat engineer. The boat engineer, a machinery technician third class, age 29, was seated in the aft starboard seat at the time of the accident. According to Coast Guard training records, he obtained the following qualifications: • UTB crewmember, May 2007 • UTB engineer, October 2007 • SPC-LE pursuit crewmember, October 2007 • SPC-LE tactical crewmember, December 2007 Crewmember-in-training. The crewmember-in-training, a machinery technician third class, age 20, was standing next to the starboard bench seat at the rear of the cabin at the time of the accident. He attained the rank of machinery technician third class in April 2009 and had served on board the Coast Guard cutter Chase before his assignment to Station San Diego.

20 A response boat small, or RBS, is similar in design to the 33-foot-long SPC-LE; however, the RBS is 25 feet long.

NTSB Marine Safety Report

11

According to Coast Guard training records, he had not yet obtained any boat-related qualifications. Work/rest history. Only the two CG 33118 crewmembers who agreed to be interviewed by NTSB investigators provided their work-rest schedules. However, the work record of the crew indicates that all five crewmembers maintained the same work schedule in the 72 hours preceding the accident. Crewmembers reported for duty at 0700 on Friday, December 18, 2009, and remained at the station in duty status until 0700 Saturday, December 19. They then entered day-worker status until 1600 on Saturday, December 19. On weekends they would ordinarily be relieved an hour later and as a result, the crew reported for duty at 0800 on Sunday, December 20, the day of the accident. During the duty periods, the crew was expected to be readily available to respond to Coast Guard situational needs. When not responding to these needs, sleep facilities were available to crewmembers and they were expected to use these facilities as needed. The facilities were three-person bedrooms, each with its own bathroom. The boat engineer told investigators that the night before the accident he had stayed out late. He estimated that he fell asleep about 0300 and woke about 0630 on the morning of the accident. He worked a 12-hour shift that day, beginning at 0700. He told investigators that he took an afternoon nap that day. About 1630, a station petty officer told him to report to the armory to prepare for patrol. The boat engineer told investigators that, the day before the accident, Saturday, December 19, he worked from 0600 to 1600. The day before that, Friday, December 18, he worked from 0700 to 1600. He stated that he had a good night’s rest Thursday night into Friday, but his amount of sleep that night was not known, nor was his amount of sleep Friday night into Saturday. The crewmember-in-training told investigators that on the day of the accident he arrived at work at 0800 and began preparing for patrol in the bay about 1645. His work schedule in the days prior was not known. He told investigators that, during the weekend of the accident, he went to sleep about 2130 or 2200 and woke about 0630. 1.5.2 Sea Ray The Sea Ray operator, age 44, had more than 100 hours of experience as a boat operator. He had no formal operating training and had not taken a boating safety course, nor was he required to do so under California boating law. 1.6 Vessel Information 1.6.1 CG 33118 The CG 33118 was manufactured in February 2007 by SAFE Boats International in Port Orchard, Washington,21 and ultimately delivered to Station San Diego later that same year. The

21 The vessel is a configuration of the 33-foot-long “Defender Class” SAFE Boat.

NTSB Marine Safety Report

12

SPC-LE is a multimission22 boat, purchased by the U.S. Department of Homeland Security (DHS) for use by both the Coast Guard and U.S. Customs and Border Protection with minor equipment differences.23 As of 2010, the Coast Guard operated 58 SPC-LE vessels. Several other agencies and municipalities also operate 33-foot SAFE Boats. The admiral in charge of the Eleventh Coast Guard District, which includes San Diego, told NTSB investigators that the CG 33118 was assigned to national border units for border-related missions24 and that the vessel had very good seakeeping and far-off-shore capability. The SPC-LE Boat Operator’s Handbook stated that the vessel’s cruise speed was 35 knots at 4200 engine rpm, and its range at this speed was 250 nautical miles (nm) on one tank of fuel.25 The handbook also stated that the vessel could operate up to 50 nm offshore, in wind up to 30 knots, and in rolling seas of up to 8 feet.26 In reply to the contract solicitation, SAFE Boats asserted that the vessel would be able to have a zero-to-plane time under 3 seconds, turn in a radius of less than one boat length, and stop in less than 13 seconds, all while vessel controllability was being maintained. The CG 33118, like all SPC-LEs, had a deep-vee rigid monohull constructed of welded marine grade aluminum with a watertight, self-bailing deck and a blended polyurethane membrane collar reinforced with a woven polyester base cloth. The vessel had an enclosed cabin with shock-absorbing seating for four crewmembers (figure 5) and a small bench seat aft on each side. The vessel’s operating controls were contained within the cabin. A cuddy cabin27 was located forward of the main cabin area and provided additional bench seating. The CG 33118 was fitted with two blue law enforcement lights mounted at the base of the radar pod, and a siren.

22 The Coast Guard has 11 stated missions: ports, waterways, and coastal security; drug interdiction; aids to navigation; search and rescue; living marine resources; marine safety; defense readiness; migrant interdiction; marine environmental protection; ice operations; and other law enforcement. According to the SPC-LE Boat Operator’s Handbook, the vessel is suitable for all of those missions, except ice operations. The Coast Guard intends its vessels to be used for more than one mission. 23 Department of Homeland Security, SPC-LE specifications, August 18, 2006, noted that typical SPC-LE missions include locating, tracking, and intercepting suspicious vessels entering U.S. waters as well as maintaining port security. 24 The district commander also stated that he expected Coast Guard personnel to be able to shift missions as quickly as needs dictated. He stated that a station boat could be under way on a law enforcement mission, be diverted to a search-and-rescue mission, and then be diverted back to a law enforcement case, all in the course of the same patrol. 25 All SPC-LE Boat Operator’s Handbook performance parameters were based on triple 275-hp outboard engines. 26 The Coast Guard magazine Proceedings stated in its fall 2007 edition, page 13, that the SPC-LE “with top speeds in excess of 50 knots, a range of more than 200 miles, and over-the-horizon command, control, and communications is an extraordinarily capable shore-based response asset.” 27 A cuddy cabin is a small cabin on a vessel, usually not high enough to stand up in.

NTSB Marine Safety Report

13

Figure 5. Interior of the CG 33118 cabin. SPC-LEs are equipped with a scalable integrated navigation system (SINS) built around a radar chart plotter. The SINS includes a radar antenna,28 a 10.4-inch color LCD surface radar– chart plotter display (with range scales from 0.125 to 24 nautical miles), a differential global positioning system29 (DGPS) receiver and navigator display, a multidisplay repeater, a heading sensor, and a depth sensor. The vessel’s communication system consists of a loudhailer,30 an ultrahigh frequency31 (UHF) marine radio, two VHF-FM marine radios, and a high-frequency– single-sideband32 (HF-SSB) marine radio.

28 The crewmembers who could have verified whether the radar was used declined to speak with NTSB investigators. 29 DGPS is an enhancement to GPS. In addition to receiving satellite-based information, DGPS also receives and computes data from known, ground-based reference stations, which enhances position accuracy. 30 A loudhailer is a multipurpose device for audio amplification. 31 A UHF radio uses frequencies between 300 and 3,000 megahertz. 32 Single sideband modulation uses all available transmitter power to convey information using voice or digital means for long-range communications.

NTSB Marine Safety Report

Personnel at the NTSB’s vehicle recorder laboratory examined the CG 33118’s radar and DGPS display units to determine if the components had recorded the vessel’s trackline, speed, and locations leading up to the collision. However, no usable information was available on either unit because the units were not configured to record the information nor were they required to be. In addition, the CG 33118 was equipped with an L-3 ProTec AIS that could transmit both standard and restricted signals; however, no AIS data from the vessel registered at any receiving stations on the night of the accident. (For more information, see section 1.15.3 on AIS operation on the CG 33118.) The CG 33118 was originally outfitted with three 275-hp engines, which were replaced at Station San Diego with three 300-hp gasoline-powered Mercury Verado engines. Coast Guard personnel responsible for maintenance of the station’s SPC-LEs told NTSB investigators that the reliability of the 300-hp engines was better than that of the 275-hp engines and that the CG 33118 was as reliable as the other two SPC-LEs at the station. He further stated that he knew of no outstanding problems with the CG 33118 either before or after the accident. The CG 33118 had accrued a total of 2,340 operating hours up to the date of the accident. The last logbook maintenance issue for the vessel involved an engine overheating at idle on December 5, 2009; no other discrepancies were noted from that time until the accident. The SPC-LE was last operated twice on December 18, 2009, two days before the accident. Neither of the coxswains who operated the CG 33118 on that date, one of whom was the accident coxswain, noted any operating anomalies in the vessel’s logbook. Available engine data from the CG 33118’s three engines was downloaded at Sector San Diego on December 22, 2009, under NTSB supervision. The downloaded information was limited to engine alarm codes. The SPC-LE Boat Operator’s Handbook does not include information about the vessel’s forward visibility. (For more information, see section on Tests and Research.) 1.6.2 Sea Ray The 24-foot-long recreational boat was manufactured by Sea Ray Boats Incorporated in Knoxville, Tennessee. The boat was a model year 2003 Sea Ray Sundeck® Sports Boat, designated by the manufacturer as a model 240SD. It had a fiberglass reinforced plastic hull with stainless steel outfitting and trim. The boat was styled as a bow rider, allowing for seating forward of the operator. The engine was a gasoline-powered Mercury Marine Mercruiser 350 Mag MPI Inboard/Outboard rated at 300 hp. The boat’s stated capacity was 12 persons or 2,000 pounds, and up to 2,100 pounds total including gear for the boat and passenger weight. At the time of the accident, 13 people (6 adults and 7 children), were on board. NTSB investigators did not obtain the individual weights of the Sea Ray occupants. To estimate the weight of the occupants at the time of the accident, NTSB investigators used current Federal Aviation Administration (FAA) standard weights for adults and children. Based on FAA weight assumptions, the Sea Ray passengers weighed about 1,490 14

NTSB Marine Safety Report

15

pounds, or about 600 pounds less than the vessel’s rated maximum 2,100-pound passenger-plus-gear load. No substantial equipment or provisions were on board. The navigation lights on the Sea Ray consisted of a red port and green starboard sidelight and a removable all-around white light, which 33 CFR 83.21(e) defines as “a light showing an unbroken light over an arc of the horizon of 360 degrees.” The all-around white light may also function as a stern light on vessels less than 12 meters (39.4 feet) in length, as specified in the inland navigation rules. The all-around light was mounted on the centerline of the transom at the stern of the Sea Ray. Vessel lighting was required to meet the inland navigation rules for vessels the size of the Sea Ray: Annex 1 of 33 CFR Part 84 states that, for inland navigation, an all-round light on vessels less than 12 meters in length should be positioned at least 1 meter (3.28 feet) higher than the sidelights and be visible at a minimum range of 2 miles. The 5.1-foot-high post that supported the light allowed the light to be located above a Bimini top on the Sea Ray (which was lowered on the night of the accident), allowing for 360-degree visibility. The Sea Ray operator stated that he replaced the light bulb about 2 months before the accident with a clear wedge-base bulb found to be rated at 9 watts and 0.69 amps. NTSB investigators determined that the replacement bulb had a light output of 6 candela, or candlepower, the same as the original manufacturer’s bulb. (Also see section 1.7.2 on Sea Ray wreckage.) 1.7 Wreckage 1.7.1 CG 33118 The CG 33118 sustained surface scratches and paint transfer starting at the beaching plate33 at the stem and continuing aft along the keel for about three-quarters of the length of the hull (figure 6). The crewmembers indicated that they did not notice any major postaccident problems with the vessel’s performance on the way to impoundment at Coast Guard San Diego’s helicopter hanger.

33 A beaching plate is a keel guard that protects the hull from abrasion during beach landings.

NTSB Marine Safety Report

16

Figure 6. Damage to the CG 33118. 1.7.2 Sea Ray Most of the Sea Ray’s damage was located above its water line, from the starboard side of the transom and extending forward of the port windshield (figures 7 and 8). The port window was torn off and the remaining frame bent outward. The fiberglass at the sheer below the missing port window had failed and cracked down the length of the remaining window frame. The door to the head,34 located just below the port window, was knocked off and pushed inward. The swim platform in the stern had a sharp gouge on the starboard side. The structural fiberglass damage to the Sea Ray rendered the vessel beyond repair. The Sea Ray’s all-around light pole was bent and found lying in the vessel, separated from its transom mounting socket. Following the accident, the California Highway Patrol’s Multidisciplinary Accident Investigation Team (MAIT) analyzed the Sea Ray’s all-around light to determine if it had been illuminated at the time of the collision.35 MAIT investigators determined that material transfer from the light bulb’s filament to the light’s envelope as well as blue and green discoloration of the bulb’s filament indicated that the bulb was hot and the light illuminated at the time of the collision.

34 The head is the onboard bathroom. 35 Supplemental MAIT Case No. BL-003-10, Vessel Collision Report No. 09-8157A, San Diego Harbor Police.

NTSB Marine Safety Report

Figure 7. Damage to the Sea Ray.

Figure 8. Fractured fiberglass on the Sea Ray, viewed looking aft and port from inside the boat’s cockpit. 1.7.3 Strike Angle NTSB investigators calculated the strike angle by taking location measurements of the damage to both vessels. The strike angle to the Sea Ray was estimated to be about 11 degrees to starboard (figure 9). 17

NTSB Marine Safety Report

Figure 9. Depiction of the CG 33118 colliding with the Sea Ray at an angle of about 11 degrees. 1.8 Waterway Information 1.8.1 General The distance from Harbor Island to the main shipping channel is about 800 yards. The width of the bay in the accident area, between Harbor Island and North Island, is about 1,350 yards. The water depth in the accident area is about 28 feet. According to the Coast Pilot, San Diego Bay does not have excessive tidal current movements. 1.8.2 Vessel Traffic Density Vessel density in San Diego Bay was considered heavy at the time of the accident. SDHP officers stated that on the night of December 20, 2009, the bay was congested with hundreds of boaters because of the Parade of Lights. One officer characterized the Parade of Lights as bringing “one of the highest amounts of boat traffic on any given date in San Diego Bay.” In its accident report, SDHP noted that its vessel therefore responded to the collision “at a slow rate of speed due to the very heavy vessel traffic.” Witnesses also characterized heavy traffic density from the north end of Shelter Island to the Hilton Hotel on Harbor Island, along the parade route. As noted earlier, the Sea Ray operator estimated that about 20 vessels were within 50 yards of his boat at the time of the accident. Many spectator vessels were located near the West Basin inlet. As the parade moved northeast along Shelter Island and turned east to parallel Harbor Island, spectator vessels located near the West Basin inlet would have been primarily to the left of the parade route. Other than the spectator vessels near the West Basin inlet, vessels were also located along the shore of Harbor Island. Figure 10 shows conditions near the accident site. 18

NTSB Marine Safety Report

Figure 10. View of San Diego Bay looking southwest from the sixth floor of the Hilton Hotel near the western end of Harbor Island before and after the collision. The two combined photos illustrate the waterway traffic before the accident (right) and the location of the accident site (left). The CG 33118’s approximate path to the West Basin would have been from the left to the right through the combined photos. (These two photos were the best available, and were taken as close as possible to the time of the accident.) Photo courtesy of T. Beckman. 17:49:07 About 5 ½ minutes after collision Accident Photo Stitch Line 17:34:41 About 9 minutes prior to collision A crewmember on board the Silver Fox III, a Coast Guard Auxiliary vessel positioned near the west end of Harbor Island to keep spectator vessels south of a perimeter line off the island, said that 30 to 40 spectator vessels were in the area, including kayaks and some vessels with no navigation lights. He said that his vessel was 200 feet from the Sea Ray when the accident occurred. The Silver Fox III crewmember said that the Sea Ray was struck just outside the area where the spectator vessels were concentrated. Figure 4 in section 1.2.2, Accident Narrative, CG 33118, depicts the approximate path that the CG 33118 took leading up to the accident. 1.8.3 San Diego Bay Background Lighting Coast Guard coxswains who regularly operated on San Diego Bay told NTSB investigators that background lighting from the city at night makes it difficult to differentiate between vessel navigational lights and lights on the shore. SDHP also stated that navigating in the bay at night was “challenging” due to the background lights making it “difficult to distinguish lighting on shore from lighting by navigational aids or other vessels.” The police further stated that experience was required to recognize navigation lights and boats on the water because of the conditions in certain parts of the bay. 1.9 Meteorological Information The sun set at 1646 on the day of the accident. The moon was a waxing crescent, with 19 percent of its disk illuminated. Observations at San Diego International Airport, less than 1 mile from the accident location, noted an unrestricted visibility of about 10 miles, a few clouds at 19

NTSB Marine Safety Report

20

12,000 feet above ground level, and a broken ceiling at 22,000 feet. According to an NTSB weather study, the broken to overcast cloud cover reduced the illumination from the moon at the time of the accident.36 The wind was from the south-southeast at about 3 miles per hour. The air temperature was 63° F, and the water temperature was 60° F. The bay was calm. 1.10 Medical and Pathological Information About 5 hours after the accident, the five crewmembers on the CG 33118 were tested for the presence of illegal drugs and alcohol at Naval Hospital Balboa.37 All results were negative. The Sea Ray operator was tested about 6 hours after the accident and those results were negative as well. The fatality was an 8-year-old boy who was a passenger on board the Sea Ray and was the son of the operator. The cause of his death was determined to be multiple blunt force trauma. Four other passengers on board the Sea Ray received serious injuries: a 37-year-old male suffered a scalp laceration and skull fracture; his son, age 3, suffered a concussion and lip laceration; a 39-year-old male passenger sustained a scalp laceration; his son, age 4, suffered a skull fracture, a concussion, and a deep laceration. No one on board the CG 33118 was injured. 1.11 Survival Aspects The Sea Ray passengers were evacuated from the damaged boat and taken to shore on three vessels. The CG 33118 was the first vessel to assist the passengers. The crew turned around immediately after the collision and brought the vessel alongside the Sea Ray. The 8-year-old boy, who was the most severely injured, was removed from the boat, placed on board the CG 33118 with a physician who had been on a nearby vessel. They were taken to the Harbor Island fuel dock on the west end of Harbor Island, where San Diego Fire and Rescue had dispatched an ambulance and a fire engine to meet the vessel. The ambulance transported the 8-year-old boy and the physician to University of California, San Diego (UCSD) Medical Center, where the boy later died from his injuries. The occupants of a nearby 26-foot-long Bayliner also assisted in the evacuation after hearing about the accident on VHF radio channel 16. Its operator and a passenger, both Navy surgeons, offered medical assistance. When they arrived at the Sea Ray, CG 33118 already had departed with the injured 8-year-old, and no other response assets had yet arrived. The two physicians boarded the Sea Ray and began helping the injured.

36 Weather Study, NTSB Office of Aviation Safety, December 22, 2009. 37 Federal regulations at 46 CFR Part 4.06 did not apply in this accident. 46 CFR Part 4.06 requires postaccident drug and alcohol testing on all individuals engaged in or employed on board a commercial vessel who are directly involved in any accident meeting the criteria of a serious marine incident as defined at 46 CFR 4.03-2. On June 20, 2006, new Coast Guard regulations (46 CFR 4.06-3) took effect requiring alcohol testing within 2 to 8 hours of a serious marine incident and the collection of drug-test specimens within 32 hours. The five drugs for which tests are conducted are amphetamines, cocaine, marijuana, opiates, and phencyclidine.

NTSB Marine Safety Report

Sea Tow, a local vessel assistance company, dispatched a vessel after hearing about the collision on VHF radio. The Sea Tow vessel arrived at the scene shortly after the two Navy surgeons. Though not typically used as a rescue vessel, the Sea Tow vessel took the injured on board at the request of the Sea Ray passengers. Eight people from the Sea Ray (two men, two women, two boys, and two girls), including the four seriously injured passengers, were transported by the Sea Tow vessel to the Bali Hai Restaurant dock on the north end of Shelter Island, which the Sea Tow operator believed to be closest to the accident location. He estimated that it took 10 minutes to reach the dock. The remaining four passengers on the Sea Ray (the operator, one woman, and two boys) were taken to the Bali Hai dock by one of the two physicians on the Bayliner. The other physician stayed on board the damaged Sea Ray to assist in towing it to shore. Vessel Assist, another marine assistance company operating on the bay, towed the boat. Because of the Parade of Lights, several Coast Guard and SDHP vessels were operating on the bay at the time of the accident. The Haddock’s commanding officer told investigators that about 1745, after hearing VHF radio communication about the collision, he diverted from the parade to assist. Four crewmembers from the Haddock, one trained as an emergency medical technician, assisted the injured passengers at the Bali Hai dock. Alerted to the collision via radio communications, SDHP responded by sending four vessels, two to assist at the Bali Hai dock, one at the Harbor Island fuel dock, and one remaining on standby near Harbor Island. A responding officer indicated that he and another SDHP crewmember approached the accident slowly because of the heavy vessel traffic density in the area from the ongoing Parade of Lights event. Three ambulances transported the four seriously injured passengers from Shelter Island to hospitals. Two of the ambulances transported the two injured men to UCSD Medical Center. The third ambulance transported the two injured children to Rady’s Children’s Hospital. The remaining eight passengers were taken either to UCSD Medical Center or Rady’s Children’s Hospital, depending on where their injured family members were. Figure 11 details the approximate location of each passenger on board the Sea Ray at the time of the accident and the severity of their injuries, based on medical records and interviews with surviving passengers. The four seriously injured passengers and the fatally injured boy were all seated in the rear half of the vessel. Those sitting or standing forward of the operating station received either minor injuries or none at all. 21

NTSB Marine Safety Report

Figure 11. Layout of the Sea Ray and locations and injuries of the 13 people on board. 1.12 Management/Coast Guard Operational Information 1.12.1 Guidance on Parade of Lights Operations NTSB investigators interviewed six coxswains assigned to Station San Diego, none of whom had served as coxswain during a Parade of Lights. Only one coxswain had participated in any other large event in San Diego, a marine event in Mission Bay north of San Diego Bay. All of the interviewed coxswains stated that no speed limits for Coast Guard or other vessels had 22

NTSB Marine Safety Report

been established in connection with the Parade of Lights, and that they were not aware of any risks or modifications to Coast Guard operating procedures specific to the event. 1.12.2 Small Boat Speed Guidance The Coast Guard Boat Operations and Training Manual, Volume I, stated, “All personnel operating Coast Guard boats are obligated to abide by Inland and International Navigational Rules.” Rule 6 of the navigation rules stated in part, “Every vessel shall at all times proceed at a safe speed so that she can take proper and effective action to avoid collision and be stopped within a distance appropriate to the prevailing circumstances and conditions.” Rule 6 further specified factors to be considered in determining safe speed, including visibility, traffic density, maneuverability, and background light” (see Appendix B). In addition, the Coast Guard’s Boat Crew Seamanship Manual provided crewmembers with “approved methods and procedures for the conduct of Coast Guard boat operations.” Under “appropriate speed,” the manual stated, “Running at full speed all of the time should be avoided” and “finding a speed that offers a comfortable ride as well as allows mission completion is advised.” The manual listed factors that should be considered to determine safe speed, including high seas, traffic density, visibility and shoal waters. With regard to traffic density and visibility, the manual stated: Do not use high speed in high traffic density areas. A safe speed allows response to developing situations and minimizes risk of collision, not only with the nearest approaching vessel, but with others around it. … If conditions make it difficult to see, slow down. … Darkness and steering directly into the sun lessens ability to see objects or judge distances. The manual also required coxswains to be aware of and responsible for the wake that their vessels create when in enclosed waters or near other vessels, and for injuries or damage that may result from excessive vessel wake. Under “wake awareness” the manual said, “Only an unaware coxswain trails a large wake through a mooring area or shallows, tossing vessels and straining moorings. ‘Get-home-itis’ and a false sense of urgency are two reasons coxswains forget to watch their wake.” The Boat Crew Seamanship Manual also stated that the coxswain should “choose a boat speed that enables lookouts to effectively and safely perform duties” and to “position lookouts so they can effectively and safely perform their duties under the operating conditions (e.g., restricted visibility, boat speed, sea state, weather).” The Coast Guard Navigation Standards Manual (Commandant Instruction M3530.2c) directed officers in charge (OICs) of local stations to establish navigation standards for small boats as appropriate to their respective operating areas. Station navigation standards were required to include certain navigation criteria. With regard to speed, OICs were instructed to “describe areas where boats must adhere to no wake zones or speed limits during operations.” Pursuant to this requirement, Station San Diego established piloting and navigation standards that prohibited coxswains from exceeding the vessel’s operational cruising speed unless operational necessity or law enforcement missions so required. Station San Diego navigation 23

NTSB Marine Safety Report

24

standards listed the SPC-LE cruising speed as 4200 rpm38 (about 35 knots) and the UTB cruising speed as 2430 rpm.39 No other speed restrictions were established for San Diego Bay. Station San Diego navigation standards identified four geographic areas—all outside San Diego Bay—in which “slow speed” was to be used: Imperial Beach, Point Loma, the entrance to Mission Bay, and the entrance to Oceanside Harbor. Station San Diego also required coxswains to operate their vessels “with extreme caution” when close to known hazards or shoals during times of restricted visibility or darkness. In addition, Station San Diego navigation standards informed coxswains to consider operating conditions in choosing particular speeds of their vessels: “Reduced ability to see vessel traffic, hazards, or navigation reference points in low visibility or at night add extra risk factors while navigating. Reduced visibility, either from night or weather conditions, usually dictates the need for reduced speed, even when responding to a potential life threatening case.” The San Diego-based Coast Guard coxswains that NTSB investigators interviewed confirmed that, with regard to speed, they were taught Rule 6 of the navigation rules of the road. The coxswains added that when considering operating speeds, they were directed to use their best judgment and experience. They told investigators that they considered their “comfort level with” the number and proximity of boats in their vicinity when determining vessel operating speeds. They also said that they considered Rule 6 in determining safe speed, but that they routinely operated the SPC-LEs at 4200 rpm, both day and night, on San Diego Bay. The coxswains stated that, in general, they discussed safe speed with coxswain trainees. They reinforced safe speed considerations while under way by reviewing Rule 6 elements for determining a safe speed based on prevailing circumstances and conditions. They told coxswain trainees to evaluate the conditions in judging what speed was safe. The CG 33118 crewmember-in-training told NTSB investigators that he had been on SPC-LEs operating at “full throttle”40 at night on San Diego Bay. The former Station San Diego OIC, the station executive petty officer, and the station training officer told NTSB investigators that coxswains had the authority to exceed the cruising speed if they determined that the situation called for it, such as during search-and-rescue or law enforcement. The former station OIC told NTSB investigators that he would have expected coxswains to request his permission to use higher speed, but Station San Diego had no established procedures to that effect.

38 The former Station San Diego OIC, who issued the navigation standards in place at the time of the accident, told NTSB investigators the 4200-rpm limit in the navigation standards applied to day and night operations. 39 Coast Guard small boats have different cruising speeds. According to Coast Guard Boat Forces personnel, small boat cruising speeds are typically based on the most economical speed a boat can travel. 40 5300 rpm, or about 44 knots.

NTSB Marine Safety Report

1. 12.3 Crew Brief

Coast Guard Navigation Standards called for crewmembers to hold an informal brief for the entire boat crew before getting under way or entering restricted waters. The brief was to include a risk assessment associated with the mission, referred to as a green-amber-red (GAR) model. The GAR considered supervision, planning, crew selection, crew fitness, environment, and event complexity. Station San Diego navigation standards required crews to notify the OIC if the GAR scored amber or higher. The CG 33118 boat engineer told NTSB investigators that the crew performed a GAR before getting under way on the evening of the accident, and that it scored ”green.” The crewmember-in-training did not remember whether a GAR was conducted. 1.12.4 Coxswain and Crew Training Coast Guard personnel did not apply to become coxswains; they qualified by completing the boat crewmember and coxswain qualification program. The qualification program established minimum standards of “knowledge, performance, and currency” for all personnel (regular, reserve, and auxiliary) serving as crewmembers on Coast Guard vessels. To qualify for either boat crewmember or coxswain, Coast Guard personnel had to complete required classroom and underway training and demonstrate proficiency in the particular qualification. Coast Guard boat crews would vary through the qualification process; that is, they would serve under, and work with, different crewmembers. Before coxswains could qualify for their positions, they had to qualify as boat crewmembers. Boat crewmembers needed to complete 92 tasks to qualify for that position, and coxswains an additional 82 tasks, including crew efficiency and team coordination, boat handling, rules of the road, piloting and navigation, search-and-rescue, and towing and salvage. Trainees were apprenticed to instructors who guided them through the qualification phase and provided them with hands-on training and assistance with the program of study. Both boat crewmembers and coxswains needed to complete an oral exam, which tested the applicant’s knowledge of Coast Guard policies and procedures, the local area, navigation and seamanship, pertinent technical data for the boat type for which the trainee was being certified, team coordination and risk assessment standards and concepts. Applicants were assessed on their maturity, judgment, attitude, and professionalism; willingness to accept the duties and responsibilities of a coxswain; detailed knowledge of the unit’s operational area including knowledge of the unit’s boat piloting; and navigation instruction. Once qualified, coxswains and boat crewmembers had to meet currency requirements, either through normal operating performance or through dedicated training. This included a minimum of 40 hours under way (including 10 nighttime hours) every 6 months. No mission-specific performance was required, and all underway hours sufficed. The CG 33118 coxswain attended boatswain’s mate “A” school, a 12-week training program. Students were exposed to the many facets of boatswain’s mate rating, including 25

NTSB Marine Safety Report

26

navigation, rules of the road, and team coordination training (TCT).41 Students also received first-aid and CPR certification and conducted practical underway exercises on 41-foot-long UTB vessels. Station San Diego coxswains told NTSB investigators that the Coast Guard’s TCT instructed even the most junior persons on a Coast Guard boat to speak up should they feel “uncomfortable” or see what “they think is a violation of rules.” 1.12.5 Lookout Procedures The Boat Crew Seamanship Manual describes watchstanding responsibilities, including performing the lookout watch. On Coast Guard small boats, “although not specifically assigned the duty of lookout, the entire crew must perform lookout duties unless directed otherwise. … Lookouts must report to the coxswain everything seen, smelled, or heard as well as everything they think they see, smell, or hear. If in doubt, report it!” The manual also provides guidelines such as remaining alert; speaking loudly when making a report; repeating a report until acknowledged by coxswain; when in doubt, report it; report floating objects; and make certain duties are understood. These guidelines also included that if conditions impaired the lookout’s ability to see, smell or hear, the lookout should report the condition to the coxswain. 1.12.6 Coast Guard Boat Forces Oversight Station San Diego coxswains were commanded by a Coast Guard station commanding officer, who was overseen by an operational commander at Sector San Diego.42 The Coast Guard regularly evaluated the readiness and proficiency of boat forces personnel through Ready for Operations (RFO) and Standardization (STAN) team evaluations. RFO evaluations, which were conducted annually at the station level, assessed boat crew training, survival systems, and personal protective equipment programs to evaluate compliance with Coast Guard policies and procedures. RFO evaluations also included material inspections and underway exercises. RFO evaluations were conducted by the station’s operational command, in this case, Sector San Diego. Station San Diego’s most recent RFO evaluation before the accident was conducted December 2–3, 2009. In this evaluation, the RFO team concluded that “all boat crews operated safely and competently” during the drills. The RFO team also reviewed Station San Diego’s training program and did not note any discrepancies. Station San Diego’s coxswains averaged a score of 90.3 percent on the RFO knowledge-based written tests. The unit

41 The Coast Guard established TCT requirements through Commandant Instruction 1541.1 to increase team effectiveness in cutter, boat, and command/control operations and activities. TCT addressed seven critical skills that reduce the risk of mishaps: leadership, mission analysis, adaptability and flexibility, situational awareness, decision making, communication, and assertiveness. The skills were meant to control safety risks and improve team performance by way of risk management, crew briefing, and crew debriefing. Coast Guard boat crews were expected to apply these TCT skills to prevent mishaps. The CG 33118 crewmembers had completed and were current with their annual TCT requirements. 42 Oversight of Station San Diego coxswains was generally provided by a senior enlisted OIC. About 2 weeks before the accident, the OIC was relieved of command for inappropriate behavior and was replaced by a lieutenant, the Sector San Diego Enforcement Division Chief.

NTSB Marine Safety Report

27

received an overall score of 37/50 and was deemed ready for operations. The minimum score that a unit could achieve to maintain its RFO status was 33. The RFO coordinator noted, in reference to Station San Diego personnel, that “the crew continues to impress me with their professionalism and team work.” The RFO evaluation mirrored the biennial STAN assessments. The STAN assessments, conducted at the national level, evaluated the performance of individual stations at least every 2 years. The nationwide STAN mean assessment score for FY10 was 38/50 for the 145 completed assessments. Station San Diego’s most recent STAN assessment before the accident was in early

1. After the accident, a STAN assessment, which had been scheduled before the accident,

was conducted January 11–14, 2010. Station San Diego SPC-LE crewmembers, with the exception of the CG 33118 crew, participated in the STAN evaluation. The station’s overall score in the January 2010 STAN evaluation was a 40/50, and it was deemed ready for operations. Station San Diego received perfect scores in the underway exercises and training program assessment. The station received 3 points of a possible 5 on the knowledge-based written test.43 The average score for Station San Diego’s SPC-LE coxswains was 81.1 percent. They scored lower than 81.1 percent on two of the five sections of the test, with scores of 58.6 percent on navigation rules testing and 71.4 percent on piloting and navigation testing. In the station underway exercises, only one drill failure was noted out of 24 total drills. Drills were conducted on both SPC-LE and 41-foot vessels. 1.12.7 The Bayside Blaster Accident About 2013 eastern standard time on January 12, 2002, a 24-foot-long Coast Guard nonstandard44 patrol boat from Coast Guard Station Miami Beach with two crewmembers on board was on a routine nighttime recreational boating safety patrol in Biscayne Bay, Florida, when it collided with the small passenger vessel Bayside Blaster, carrying 2 crewmembers and 53 passengers.45 The patrol boat was operating at the Coast Guard Station limit of 4000 rpm (equivalent to 32 knots) in a no-wake zone. The local station had set the 4000-rpm limit for normal, nonemergency operations. The NTSB determined that the probable cause of the accident was the failure of the Coast Guard coxswain to operate the vessel at a safe speed in a restricted-speed area frequented by small passenger vessels and in conditions of limited visibility due to darkness and background lighting. Contributing to the cause of the accident was the lack of adequate Coast Guard

43 Written test results accounted for 10 percent of a team’s overall performance in both the RFO and STAN team assessments. The written assessments were not treated as pass or fail, rather, as a portion of the overall performance in the assessment. 44 At the time, several Coast Guard stations operated a variety of station-specific small boats purchased locally by each Coast Guard district to suit a station’s operational requirements. Because the purchase and management of these boats was not coordinated nationally, the Coast Guard identified these vessels as “nonstandard” boats. 45 Collision Between the U.S. Coast Guard Patrol Boat CG242513 and the U.S. Small Passenger Vessel Bayside Blaster, Biscayne Bay, Florida, January 12, 2002. Marine Accident Report NTSB/MAR-02/05 (Washington, DC: National Transportation Safety Board, 2002).

NTSB Marine Safety Report

oversight of nonstandard boat operations. The NTSB found no safety or law enforcement reason to employ excessive speed while conducting a routine patrol at night, in restricted waters, and close to shore. The NTSB noted that high speeds should be reserved for emergency responses, and it concluded that, even without the speed restriction, the speed the Coast Guard vessel used in the accident was imprudent for the prevailing conditions of darkness, background lighting, and potential for encountering passenger and recreational vessels in the area. The NTSB noted that several Coast Guard small boat accidents had prompted the Coast Guard to issue nonstandard boat operator’s handbooks that cautioned against operating vessels at excessive speed. The NTSB report noted that, “The Commandant issued a directive for area and district commanders to publish operating limits for their nonstandard boats and reexamine each boat’s suitability for its purpose.” The NTSB also concluded that the lack of Coast Guard policies and procedures regarding operating speeds for nonstandard boats at the time of the accident afforded coxswains too much latitude in determining speed and that Coast Guard oversight was inadequate at the time of the accident. Without some means of oversight, the NTSB noted, Coast Guard commanding officers cannot know that the speed limits are followed or that other safety requirements are met. Further, the NTSB said that oversight could be improved by direct observation of coxswain performance and solicitation of feedback from waterway users as well as greater formality in conducting routine patrols. As a result of its investigation of this accident, the NTSB issued the following recommendations to the Coast Guard: Establish oversight procedures for use by the commanding officers or officers-in- charge of Coast Guard stations to improve the safety of Coast Guard routine small boat operations, including the institution of in-depth predeparture briefings, thorough predeparture checks of boats, monitoring of coxswain performance, and thorough postpatrol debriefings. (Safety Recommendation M-02-25) Evaluate on an annual basis your program for reducing nonstandard boat accidents and for ensuring compliance with Coast Guard policies and procedures related to those vessels; publish the results annually for use by Coast Guard stations. (Safety Recommendation M-02-26) In response to these recommendations, the Coast Guard reported that it published a revised Boat Readiness and Standardization Program Manual (COMDTINST MI6114.24B) that required continuous evaluation of readiness of boats and crews. The manual recommended that self-audited evaluations of material readiness and standardization also assess performance in team coordination, risk management, and crew briefings and debriefings as part of standard boat operations. The Coast Guard also tasked operational commanders to conduct annual RFO evaluations to determine unit compliance with Coast Guard policies and procedures, and to assess a unit’s crew training program and underway exercise evaluation. As a result of the Coast Guard actions, on November 21, 2003, the NTSB classified both recommendations “Closed—Acceptable Action.” After the Biscayne Bay accident, Coast Guard headquarters issued the following directive to small boat force leaders: “Impress upon all hands that throttles have more than two [stop and 28

NTSB Marine Safety Report

29

full] operational positions. … Normal operating speeds must be something less than maximum speeds, and coxswains must have time to see, react, and avoid obstacle. … The image of the young Coastie zipping along at max throttle is becoming a stereotype, reflects poorly upon our professionalism, and encourages reckless behavior in our developing boat crews.” After the accident the Coast Guard also stated the following in its Non-standard Boat Operator’s Handbook: A high number of small boat mishaps can be attributed to excessive speed. … As a crewmember, never hesitate to ask the coxswain to SLOW DOWN or take up a more forgiving heading. Safe operating speed is an element of prudent seamanship.46 As a result of another Coast Guard small boat accident in 2001,47 the Coast Guard required each area and district commander to publish operating limits for each boat type and reexamine each boat’s suitability for its purpose. Commanding officers were also required by the newly issued Navigation Standards Manual to impose specific operating restrictions (speed, distance from hazards, and frequency of fixes) on locations within the area of responsibility (AOR) identified as posing significant navigational or environmental risk to boats. 1.12.8 Nondistress Search-and-Rescue Assist Policy At the time of the accident, the Coast Guard’s policies and procedures in search-and-rescue operations were included in an addendum to the United States National Search and Rescue Supplement, which in turn was a section of the International Aeronautical and Maritime Search and Rescue Manual. Part of the Coast Guard’s search-and-rescue addendum addressed instances in which a boater requested assistance but was not in distress. Under those circumstances, the Coast Guard policy was to offer to issue a MARB on behalf of the boater to request that other boaters or a private towing company in the vicinity come to the boater’s assistance. If no one responded within a “reasonable” period of time, the Coast Guard would send one of its boats to assist. Representatives of the Coast Guard’s Office of Search and Rescue told NTSB investigators that all Coast Guard personnel, including coxswains, received training in the nondistress policy. Although there were no written procedures, Sector San Diego personnel told NTSB investigators that a coxswain could decide to check on a nondistress vessel and was allowed to do so. 1.12.9 Coast Guard Postaccident Activity The commanding officer of Station San Diego told NTSB investigators that, shortly after the accident, he issued verbal guidance limiting the speed of SPC-LEs to minimum speed48 outside the main shipping channel. This new speed restriction was not incorporated into Station San Diego’s navigation standards, which were revised on July 29, 2010, and, as of the date of

46 It was noted in the NTSB of the investigation of the Bayside Blaster accident that a recent DOT IG audit reported a 225% increase in accidents in FY 2000 over FY 1998 and that 56% of the accidents were caused by poor judgment or navigation and operational errors and hence were preventable. 47 Because this accident did not involve a nonpublic vessel, the NTSB did not investigate it. 48 Minimum speed is generally understood to mean idle speed, or 2–4 knots.

NTSB Marine Safety Report

30

this report, were still current. The commanding officer stated that slower speeds would reduce the risk of collision but he did not think that Coast Guard boat operators were going too fast or operating unsafely during normal operations. Appendix C contains a letter from the commander of Sector San Diego concerning this verbal guidance on safe speed. Also in the July 29, 2010, revision to the navigation standards, Station San Diego added the following: The SPC-LE represents a unique challenge in safe speed determination. At lower rpm’s the stern of the SPC-LE will squat, causing the bow to rise and limit the forward visibility of the crew (lookouts). Due to this design restriction, the SPC-LE shall not be consistently (more than a few seconds) operated at between 2000-3500 rpm’s unless absolutely necessary to the assigned mission. For missions where slower speeds are extensively needed, the 41 [-foot-long] UTB should be considered the primary resource. Following the December 20, 2009, collision of the CG 33118 and a December 5, 2009, collision in Charleston Harbor, South Carolina, involving a 25-foot-long Coast Guard boat,49 the Coast Guard commandant issued a message titled, “Leadership for Safe and Effective Boat Operations,”50 to all Coast Guard units. In this message, the commandant discussed the need to ensure that all Coast Guard boat operators “have the time and focus to develop and maintain the skills needed to safely accomplish their very demanding missions.” The message also announced that the Coast Guard vice commandant had directed the Coast Guard’s force readiness command to conduct a systematic review of small boat operational doctrine, tactics, techniques, and procedures, which was to be completed by August 1, 2010. As of the date of this report, the review (“Boat Operations Safety Review”) had not yet been completed. The vice commandant also called for the establishment of a boat forces advisory council “to provide a communications conduit between the field and headquarters” and to make recommendations on policy, doctrine, training, support, and acquisition issues affecting Coast Guard boat forces. The advisory council participated in the Boat Operations Safety Review, and is assessing whether to create a navigator position on Coast Guard high-speed boats. The admiral in charge of the Eleventh Coast Guard District told NTSB investigators that the Coast Guard would not issue safety alerts targeted to its own operators before its investigations were completed because doing so could communicate information different from the findings of the completed investigations.

49 A 25-foot Coast Guard vessel collided with a small passenger vessel outfitted with holiday lights in Charleston Harbor, South Carolina. On December 18, 2009, the Coast Guard issued a safety alert 09-09 for informational purposes, addressing how holiday lights can impair navigation lights on vessels. Also see section “Other Information, Thriller 09 and CG 25689 Collision.” 50 U.S. Coast Guard, ALCOAST 064/10, COMDTNOTE 16010, February 4, 2010.

NTSB Marine Safety Report

31

1. 13 Vessel Forward Visibility
2. 13.1 General

The SPC-LE is considered a high-speed planing boat. The hull of such a vessel will rise, that is, be on plane, as the vessel attains higher speeds. As a vessel’s speed increases, it passes from displacement to semidisplacement (transition) mode, to planing mode. Once a vessel is in planing mode, planing can be maintained with a slight reduction in engine power. Vessels typically reach their highest trim angle51 in the transition zone (figure 12). In general, planing boat operators avoid traveling in the transition zone because of the obstructive effects of the high trim angles on their forward visibility, and because of poor fuel economy. In addition, operating in the transition zone causes large wakes.

Figure 12. Stages of generic vessel planing and corresponding trim angles. Visibility from the helm of the SPC-LE is therefore affected by the hull trim angle, which is itself affected by several factors: the weight and distribution of fuel, persons, and gear on board the vessel; vessel speed; sea conditions; trim position of the outboard engines; and the horsepower and rpm of the outboard engines. As on many planing boats, as the vessel transitions between displacement mode and planing mode, the hull is subject to its largest operating trim angle. A high trim angle reduces forward visibility because the height of the bow above the water line obstructs the operator’s forward view of the water. Once the vessel reaches planing speed and the bow begins to trim downward, forward visibility improves. An SPC-LE coxswain at Station San Diego stated that for her to have good visibility in the planing mode, the boat would need to be traveling at 3500 to 4000 rpm. She stated that if she traveled at an rpm below that, she could not see. She further indicated that if she did not want to travel at speeds higher than that rpm range, then she would travel in the displacement mode, at slow speed. SDHP officers, who operate a 31-foot-long SAFE Boat,52 stated that while operating in the transition zone, the bow of the vessel can obstruct forward vision. The SDHP officers stated that they accounted for the reduced visibility zone by avoiding traveling in the zone’s associated

51 Trim angle is the change in a vessel’s inclination from the boat’s design horizontal deck, or reference line, to the surface of the water. 52 The 31-foot-long SAFE Boat operated by the SDHP is also a planing vessel, but has different engine configuration, performance characteristics, and range of visibility than the SPC-LE.

NTSB Marine Safety Report

32

speed range, that is, by traveling above and below this range as circumstances and conditions warranted. 1.13.2 Design Standards The American Boat and Yacht Council (ABYC) has published ABYC Standards for Small Craft since 1954. Compliance with these standards is not required by regulation, but the standards are widely used by small craft manufacturers. DHS, in its contract with SAFE Boat, required that the SPC-LE meet applicable ABYC standards. The Coast Guard’s contract with SAFE Boat said “unless otherwise specified, construction of the SPC-LE and installation of all equipment and systems shall be in accordance with … ABYC standards.” One of the standards ABYC established was visibility standard, H-1 – Field of Vision from the Helm Position, a design standard for vessels less than 79 feet in length.53 The purpose of this standard was to “minimize obstructions in the field of vision from the helm station(s).” The H-1 standard required visibility to be determined in a range of eye heights, from seated and standing positions. (See Appendix D for more information on the H-1 visibility standard.) The H-1 standard consists of horizontal and vertical components that comprise the range of visibility across the unobstructed vertical and horizontal fields of view. NTSB investigators requested Coast Guard assistance in verifying that the SPC-LEs met the ABYC H-1 visibility standard. The Coast Guard responded that it had not conducted any first article testing54 of the SPC-LEs because the vessel “was a proven capability which had been in use by Customs and Border Protection” and did not confirm whether the vessel complied with the H-1 standard. NTSB investigators also requested that SAFE Boat confirm that the SPC-LE met the ABYC H-1 visibility standard. SAFE Boat responded that the vessel complied with the standard and produced documentation to that effect. 1.14 Tests and Research 1.14.1 ABYC Visibility Testing The NTSB contracted with ABYC to test whether the SPC-LE met the H-1 visibility standard. Because the CG 33118 was impounded, another SPC-LE was used in the testing on San Diego Bay under NTSB supervision. ABYC conducted underway testing to determine the vessel’s highest trim angle. This was done by recording trim angles, engine rpm, and speed throughout the vessel’s operating range. The highest trim angle, outside of the transition zone,55

53 This report refers to the ABYC H-1 visibility standard dated July 2000. 54 First article testing includes inspection and testing to ensure that a product’s characteristics conform to drawings or specifications. 55 The H-1 standard specifically excludes the high trim angles that occur during the transition zone, that is, between the displacement and planing modes.

NTSB Marine Safety Report

33

occurred at about 3000 rpm, corresponding to a speed of about 19 knots. This trim angle corresponded to the end of the transition zone and the start of the planing mode.56 ABYC subsequently tested the vessel on shore by positioning a trailered SPC-LE at the various trim angles that had been recorded while under way, and noting if a target point located four boat lengths from the bow57 (135 feet) could be seen from specific eye positions. ABYC determined that the SPC-LE failed to meet the H-1 visibility standard for the following reasons:

1. The horizontal 15-degree clear sector to port is obstructed by the center cabin

structure at the standing low eye height position.

1. The horizontal 15-degree clear sector in the standing high eye position is obstructed

from port to starboard.

1. The standing low eye (3.5 degrees maximum) and standing high eye (5.5 degrees

maximum) positions cannot view the target at the maximum running angle of 6.5 degrees.

1. The port forward corner of the cabin structure does not allow normal movements of

the operator’s head to permit unobstructed visibility.

1. Controls for steering, shift, throttle, and trim were not positioned so that operator

hand contact can be maintained during use in the seated position.58 1.14.2 Forward Line of Sight—NTSB Comparison Study NTSB investigators examined the vertical forward field of view from the two front-seat positions of the SPC-LE using input from the ABYC testing, Coast Guard Investigative Service underway testing video, and SPC-LE drawings. Investigators chose these positions because the starboard forward seat is manned by the coxswain, and the port forward seat is required to be manned another crewmember. The assessment considered both front-seat positions to be similar in configuration. Investigators used the approximate eye heights of the CG 33118 coxswain, who

56 The following table summarizes the recorded data from the on-water testing, correlating the approximate outboard engine rpm, boat speed, and boat trim angle to the SPC-LE’s travel mode: Mode Displacement Semi-Displacement Planing Outboard Engine (rpm) 0–2000 2000–3000 3000–5250+ Speed (knots) 0–8.4 8.4–19.2 19.2–43.7+ Boat Trim (degrees) 1.2–5.0 5.0–unknown 6.5–2.0

57 Established in the H-1 design standard. 58 The outboard engine throttle control levers on the tested SPC-LE were similar in dimension and location to the levers on the CG 33118; however, they were not the same type of control levers as on the CG 33118. The crew of the tested SPC-LE stated that the lever style on the tested vessel was the latest model fitted to SPC-LEs.

NTSB Marine Safety Report

was 6’1” tall, and the boatswain’s mate, who was 5’5” tall, to determine their sight lines to the surface of the water and the Sea Ray’s all-around light and its hull, at different speeds. At a vessel speed of 5 to 7 knots, crewmembers with eye heights of either the coxswain or the boatswain’s mate would have had unobstructed sight lines to the Sea Ray’s all-around light, and these sight lines would have met H-1 criteria. At eye heights similar to that of the coxswain, the Sea Ray’s hull would be completely visible until it was 58 feet or less from the bow. At eye heights similar to that of the boatswain’s mate, the Sea Ray’s hull would have been completely visible until it was 77 feet or less from the bow. At the speed that produced the greatest trim angle (about 19 knots), SPC-LE operators with eye heights similar to the coxswain’s would not have a sight line to the surface of the water that met H-1 criteria, but would still have an unobstructed view to the Sea Ray’s all-around light. The Sea Ray’s hull would be obstructed from 0 to 135 feet from the bow, partially obstructed from 135 to 432 feet from the bow, and completely visible at distances greater than 432 feet from the bow. At the same speed, the sight line of crewmembers with eye heights similar to that of the boatswain’s mate would not meet H-1 criteria, as those crewmembers would have had an obstructed sight line to the water the entire time; that is, the horizon would never be in view. This eye height would have an obstructed sight line to the Sea Ray’s all-around light until the light came within 160 feet of the bow, at which point it would gradually become visible. However, the Sea Ray’s hull would not be visible at any time to crewmembers with this eye height. The forward sight lines from both front-seat positions would improve at speeds above 19 knots. Near the SPC-LE’s cruising speed of 35 knots, crewmembers with eye heights similar to either the coxswain or the boatswain’s mate would have an unobstructed sight line to the Sea Ray’s all-around light, and this sight line would have met the H-1 criteria. At this speed, the Sea Ray’s hull would be completely visible to crewmembers with eye heights of the coxswain until the hull was less than 85 feet from the bow, and completely visible to crewmembers with eye heights similar to the boatswain’s mate’s until the hull was less than 121 feet from the bow. 1.14.3 SPC-LE Engine rpm/Speed Determinations NTSB investigators were unable to obtain documentation of SPC-LE boat speeds at various outboard engine rpms with triple 300-hp engines. The data existed only for the SPC-LE as originally configured with triple 275-hp engines. To obtain the data, after completion of ABYC visibility testing, NTSB investigators recorded vessel speeds at particular engine rpms. The engine speeds recorded for engine rpms above the transition zone (i.e., in planing mode) are as follows: 34

NTSB Marine Safety Report

35

SPC-LE with Triple 300-hp Engines Engine rpm Speed in Knots 3000 19.2 3250 22.0 3500 25.9 3750 29.0 4100 33.0 4500 34.5 5000 39.2 5250 43.7 1.14.4 Video Study NTSB investigators obtained witness video of the CG 33118 operating in San Diego Bay prior to the accident. One video showed the vessel traveling southbound in the bay prior to meeting the cutter Haddock, and another showed the CG 33118 on the leg prior to the accident, traveling from the northern end of Shelter Island eastward along Harbor Island. The latter eastbound video consisted of 12 seconds of footage of the CG 33118, filmed by a witness on board a sailboat a few minutes before the collision. The sailboat was positioned about 460 yards south of the west end of Harbor Island and was estimated at one point to be about 66 yards from the passing CG 33118. The witness filmed in a sweeping motion from southwest to northeast. The footage captured the CG 33118 during the vessel’s eastbound transit on the bay when crewmembers were searching for the grounded Catalina along the south shore of Harbor Island. Shortly after this portion of the video was recorded, the CG 33118 reversed its course to a west-northwesterly heading before the collision occurred. None of the west-northwesterly leg was captured by the video; however, the camera did capture the sound of the collision and filmed the area of the accident immediately after the collision. The video was filmed about 190 yards from the collision site. Using fixed reference points in the background of the video, NTSB investigators calculated the speed at which the CG 33118 was traveling during the earlier eastbound transit. Investigators determined that the CG 33118 was traveling at about 42 knots59 during a portion of the eastbound transit. 1.14.5 Audio Study of CG 33118 Speed NTSB investigators used audio tracks of the recording described in the previous section to conduct a sound spectrum study as an additional determinant of the speed of the CG 33118. The results indicated that, during the eastbound leg of the CG 33118, its engine rpm reached 5450 to 5550. This rpm corresponds to an estimated speed of 44–45 knots in accordance with the speed-versus-rpm graphs NTSB investigators developed during underway testing of an SPC-LE.

59 The calculated average speed on a portion of the leg was 41.74 knots, with a +/–3.4 knot range of uncertainty.

NTSB Marine Safety Report

36

1. 15 Other Information
2. 15.1 Nighttime Visual Perception

Because of statements from CG 33118 crewmembers that they did not see the Sea Ray leading up to the accident, CG 33118 investigators considered nighttime visual factors including the contrast of the Sea Ray’s hull with the surface of the bay, the visibility and conspicuity of the Sea Ray’s navigation lights, and the effect of the lights with regard to the visual angle to determine what effect, if any, these factors may have had on the crew’s ability to see the Sea Ray. During the day, people can visually distinguish objects that differ in brightness, color, pattern, and shading, but at night they rely on contrast to differentiate an object from its background. An object must be sufficiently brighter or darker than its background to be visible at night. Visibility of a lighted object, one researcher notes, normally refers to its intensity and depends on properties such as its luminance or brightness, color, size, and shape.60 By comparison, an object’s conspicuity also depends on these properties, but is relative to those of objects in the perceiver’s field of vision. At night, a bright object that may be visible if viewed against a dark background will be inconspicuous or invisible if viewed against a background containing other, similar lights in the visual field. Therefore, at night, a lit object can be visible but not conspicuous if other lit objects are nearby. The Sea Ray had three navigation lights, red port and green starboard lights mounted forward on its hull and an all-round white light mounted about 7 feet above the waterline at the centerline of the stern. The port and starboard lights faced forward in accordance with regulations and were shrouded from an astern view. Further, from an astern view, the Sea Ray’s hull was unlit. Figure 9, shown earlier, depicts the waterway and background near the Sea Ray around the time of the collision. Both photos in Figure 9 indicate that lights with colors similar to the Sea Ray trio of navigation lights were present along the shore from the west to the north and on the water from other vessels, including some with extraneous holiday lighting. San Diego-based coxswains described San Diego Bay as a challenging nighttime visual environment because of background lighting. Research also indicates that, at night, vehicle drivers use two additional cues, changes in the visual angle and changes in the size of the vehicle, to detect a vehicle ahead. The visual angle, which is formed by the angle of the paths of the two vehicles, will change as the angle of the paths changes. The perceived size of an object will change as a vehicle approaches another. The rate of changes in the visual angle, and the rate of change of the size of a stopped vehicle, provide operators with indications of the distance to an object and its speed relative to the speed of the operator’s vehicle. An increasing visual angle indicates that the distance to the object ahead is decreasing. The smaller and more distant an object, the more diminished the ability of an operator to judge its distance and speed. Because the angle of the CG 33118 and the Sea Ray was relatively constant, it did not change from the perspective of the CG 33118 crew. Only the

60 Wertheim, A. H. (2010). Visual conspicuity: A new simple standard, its reliability, validity, and applicability. Ergonomics 53, 421–442.

NTSB Marine Safety Report

37

size of the Sea Ray’s all-around light would have changed as the CG 33118 approached the vessel. 1.15.2 Coast Guard AIS Policy The CG 33118 was outfitted with AIS, and the transponder was located above the helm console. In standard mode, AIS units on SPC-LEs broadcast a vessel’s name, course, speed, latitudinal and longitudinal position, AIS identification number, and the vessel’s dimensions. The unit provides AIS capabilities through three modes of operation. Coast Guard AIS policy guidance, issued in August 2008 by the admiral in charge of the Eleventh Coast Guard District, stated the following with respect to the three AIS modes: • Standard mode—The unit will perform similarly to standard commercial shipboard AIS units, broadcasting the vessel’s position and information to all other AIS receivers within VHF range. This mode is recommended for increased navigation safety and overt operations. • Disabled mode—The unit will not transmit data at all. This mode is recommended for increased operations security and covert operations. • Restricted mode—The unit will transmit encrypted AIS data that will be available only for friendly or blue force61 units with similar encryption capabilities. This mode is recommended as the default setting for boats with AIS units. In all modes, the unit is able to receive, monitor, and display both encrypted and unencrypted AIS data from other AIS-equipped vessels. The August 2008 AIS policy guidance also sought to “standardize the District-wide use of … AIS and to enhance command centers’ common operating picture.” The policy guidance also stated that coxswains were allowed to switch modes at their discretion. 1.15.3 AIS Operation on the CG 33118 The CG 33118 boat engineer told NTSB investigators that coxswains usually activated the AIS, and he believed that the AIS on board the CG 33118 was operating on the evening of the collision. He also stated that the JHOC often notified Coast Guard vessels on departure that their AIS signals were displayed on the JHOC screens, but he was unsure if this occurred that evening. After the accident, NTSB investigators reviewed the AIS history plots for San Diego Bay that were recorded around the time of the collision. Although the JHOC AIS recording showed the Haddock and several large commercial vessels, it did not display any CG 33118 AIS data. After the accident NTSB investigators oversaw the testing of the CG 33118’s AIS. The tests were conducted in the enclosed Station San Diego helicopter hanger. The results revealed

61 Blue force tracking is used by law enforcement and military organizations to denote a GPS-enabled system that allows blue force command centers to locate and monitor AIS-equipped military assets, both friendly and hostile, and general AIS-equipped traffic in the area.

NTSB Marine Safety Report

38

that latitude and longitude coordinates were not displayed on the AIS data screen, nor did the vessel’s position register in the JHOC in either restricted or standard modes. The JHOC watchstander at the time of the accident told NTSB investigators that he normally monitors the AIS of the small boats, but he said that when the CG 33118 was under way, he did not notice that the CG 33118 was not transmitting its AIS data. He said that after the accident occurred, he did not have a chance to follow up on whether the CG 33118 had been transmitting AIS data. He would routinely note vessels not transmitting AIS data and then call their coxswains to tell them to activate their AIS units. He also noted that on some occasions when an AIS was not transmitting data, the JHOC would allow the vessel to continue its patrol. 1.15.4 Thriller 09 and CG 25689 Collision On the night of December 5, 2009, at 2028 eastern standard time, the 25-foot Coast Guard small boat CG 25689 and the small passenger vessel Thriller 09 collided in Charleston Harbor, South Carolina.62 Before the accident, the CG 25689 had been providing security escort service to a commercial ship that was outbound to sea. At the time of the accident, the CG 25689 had completed its escort and was returning to its station. The Thriller 09 was on a 1-hour sightseeing cruise in Charleston Harbor. On board the CG 25689 were three crewmembers; on board the Thriller 09 were two crewmembers and 22 passengers. As a result of the accident, six passengers on the Thriller 09 sought and received medical treatment for injuries. No crewmembers on the CG 25689 or the Thriller 09 were injured. 1.15.5 Cell Phone Use Following the accident, the NTSB obtained records for the five CG 33118 crewmembers’ personal cellular telephones to determine what cell phone activity, if any, took place after the time the CG 33118 got under way about 1723. The records indicated that the coxswain made a 2-minute call at 1724, but neither received nor sent text messages. The boatswain’s mate in the forward port seat received a text message at 1742 (about 2 minutes before the collision) but did not send any herself, and she did not place or receive calls. The OOD, seated in the aft port seat, made a 9-second call at 1726 and a 7-second call at 1726. He sent a text message at 1727. The boat engineer, seated in the starboard aft seat, did not receive or make phone calls while under way. His text message activity could not be determined.63

62 Collision between USGC boat CG 25689 and passenger vessel Thriller 09, 12/5/2009, Charleston, SC, Marine Accident Brief NTSB/MAB-11/02 (Washington, DC: National Transportation Safety Board, 2011). 63 The boat engineer’s wireless provider’s information regarding text message activity did not allow investigators to determine the times at which the activity occurred.

NTSB Marine Safety Report 1.15.6 Previous Safety Recommendations In August 2010, the NTSB issued two safety recommendations to the Coast Guard with respect to cellular phone use: Develop and implement national and local policies that address the use of cellular telephones and other wireless devices aboard U.S. Coast Guard vessels. (M-10-2) Issue a safety advisory to the maritime industry that (1) promotes awareness of the risk posed by the use of cellular telephones and other wireless devices while operating vessels and (2) encourages the voluntary development of operational policies to address the risk. (M-10-3) The recommendations were based in part on the CG 33118 accident but primarily on the December 5, 2009, collision in Charleston. Cellular telephone records revealed that crewmembers on both Coast Guard vessels had been using cellular telephones to engage in text messaging or personal conversations near the time of the accident. In November 2010, the Coast Guard responded to the NTSB and indicated it concurred with both recommendations. In response to M-10-2, the Coast Guard stated that in July 2010 it established a policy mandating that crewmembers may use cellular telephones or texting devices on Coast Guard small boats, but only when authorized by the coxswain. The Coast Guard further stated that at no time was a Coast Guard vessel operator to use a cellular telephone or texting device for nonoperational purposes. The new policy was to be added to the Coast Guard’s Boat Operations and Training Manual in the subsequent revision of the manual in 2011. In response to Safety Recommendation M-10-3, the Coast Guard issued a safety advisory (01-10) in October 2010 that addressed distractions due to the use of cellular telephones and wireless devices. The Coast Guard added that it would work with the National Boating Safety Advisory Council to raise awareness of this issue with the recreational boating community. As a result of the Coast Guard’s response and action, the NTSB in November 2010 classified Safety Recommendation M-10-2 as “Open—Acceptable Response” and M-10-3 as “Closed—Acceptable Action.” On June 21, 2011, the NTSB adopted further recommendations concerning cell phone use following its investigation of the 2010 collision of the tugboat/barge Caribbean Sea/The Resource with the amphibious passenger vehicle DUKW 34, in Philadelphia, Pennsylvania. The NTSB recommended that the Coast Guard • Develop and implement an investigative protocol that directs your investigation officers to routinely check for nonoperational use of cell phones and other wireless electronic devices by on-duty crewmembers in safety-critical positions involved in marine accidents. (M-11-1) • Revise your commercial vessel accident database (MISLE) to maintain a record of nonoperational use of cell phones and other wireless electronic devices by 39 CORRECTED COPY

NTSB Marine Safety Report on-duty crewmembers in safety-critical positions when such use is causal or contributory to marine accidents. (M-11-2) • Regulate and enforce the restriction on nonoperational use of cell phones and other wireless electronic devices by on-duty crewmembers in safety-critical positions so that such use does not adversely affect vessel operational safety. (M-11-3) • Until you can develop regulations governing nonoperational use of cell phones and other wireless electronic devices by on-duty crewmembers in safety-critical positions, continue your outreach program of information and education to the maritime industry on this issue. (M-11-4) 40 CORRECTED COPY

NTSB Marine Safety Report

41

2 Analysis 2.1 General The analysis first identifies factors that can be readily eliminated as causal or contributory to the accident, followed by a summary of the accident sequence. It then discusses safety issues identified in the accident investigation: • Speed of the CG 33118 • Coast Guard oversight of small boat operations • SPC-LE forward visibility • Coast Guard monitoring of small boat operational data • Coast Guard use of personal cell phones under way 2.2 Exclusions At the time of the accident, the winds and sea were calm and visibility was good. The CG 33118 crew and the Sea Ray operator were tested after the accident for the presence of alcohol and illegal drugs, and all results were negative. Both vessels were examined after the accident and found to have been free of preexisting issues that would have compromised their seaworthiness or operational capabilities. The Sea Ray’s all-around light bulb was examined after the accident and found to have shown damage consistent with its being illuminated at the time of impact. The NTSB therefore concludes that weather, illegal drugs and alcohol, and the mechanical condition of both vessels were not factors in this accident. Three of the five CG 33118 crewmembers declined requests of NTSB investigators to be interviewed. Neither of the two crewmembers NTSB investigators interviewed—the boat engineer and the crewmember-in-training—was directly involved in navigating the CG 33118, and they did not sit in the front of the vessel where they could have played a substantial role in its operation. The boat engineer did not recall his sleep schedule in the days preceding the accident, but he reported going to sleep at 0300 and arising at 0630 on the day of the accident, for a total of 3.5 hours of sleep. This amount would, at best, lead to an acute sleep loss, which has been found to degrade performance.64 The boat engineer reported taking a nap of unknown duration in the afternoon on the day of the accident; however, even if he slept well during the nap, the amount and quality of sleep would have been unlikely to compensate for the night’s sleep loss because of the effects of his circadian sleep cycle. In any event, his role in the operation of the vessel was, as noted, minor. The crewmember-in-training estimated that, based on his typical rest schedule, he slept about 8.5 hours per day in the days before the accident. However, because the majority of CG 33118 crew members declined to be interviewed by the NTSB, insufficient information was available to evaluate the role of fatigue in this accident.

64 Mallis, M. M., Banks, S., and Dinges, D. D. (2010). Aircrew fatigue, sleep need, and circadian rhythmicity. In E. Salas and D. Maurino (Eds.) Human Factors in Aviation (2nd Ed. pp. 401-436). Burlington, MA: Academic Press.

NTSB Marine Safety Report

1. 3 The Accident

The Coast Guard SPC-LE vessel CG 33118 departed Coast Guard Station San Diego at 1723 on December 20, 2009. The five crewmembers had no specific assignment except to patrol San Diego Bay during the Parade of Lights and assist other Coast Guard vessels as necessary. After departing the station, the crew coordinated with the crew of the Coast Guard cutter Haddock, the lead vessel in the Parade of Lights, and informed its commanding officer that the CG 33118 crewmembers were available to provide assistance as needed. After hearing a MARB about a grounded sailboat, the CG 33118 crew obtained permission from the JHOC to respond. The crew initially searched for the sailboat along the south shore of Harbor Island. When the crewmembers could not locate it, they communicated with JHOC personnel and were redirected to the vessel’s correct location, Harbor Island’s West Basin. About three-quarters of a mile after the CG 33118 crew turned the SPC-LE to travel to the second location, it collided with the Sea Ray recreational boat. Witnesses described the CG 33118’s course as constant and at the same approximate west to northwest heading as the Sea Ray ahead of it. The physical evidence of the collision shows that the bow of the CG 33118 struck the stern of the Sea Ray at an angle of about 11 degrees to starboard, an angle consistent with the Sea Ray operator’s stated attempt, immediately before impact, to accelerate and turn his boat to the right to avoid being struck by the CG 33118. 2.3.1 CG 33118 Operating Speed The speed of the CG 33118 directly affected the amount of time in which the crewmembers could have taken action to avoid the accident once they detected the Sea Ray; specifically, the time available for the coxswain and the crew to detect, perceive, and then avoid the Sea Ray. At the same time, vessel speed has a direct relationship to any vessel damage or personal injury that would be sustained in a collision with another vessel. NTSB investigators sought to determine why the CG 33118 crew operated the vessel at the speed they did, given the prevailing circumstances and conditions. The coxswain told SDHP that the CG 33118 was traveling at 3000 rpm or about 19 knots at the time of the collision. Another crewmember estimated that the vessel was traveling 20 to 25 knots. Witnesses stated that the CG 33118 was planing, corresponding to a minimum speed of 19 knots at the time of the accident, and estimated its speed as 20–30 knots. They also said that the vessel’s speed on the accident leg was about that of the previous eastbound leg. The NTSB analysis of witness video of the CG 33118 determined the vessel’s speed to be about 42 knots while it was traveling east to the first reported location of the grounded sailboat, nearly full throttle, about 5000 rpm, a speed that audio analysis corroborated. If the accident leg speed was as high as the eastbound leg speed, as witnesses consistently attested, the speed on the collision leg could have been as high as 42 knots. Because of the absence of data on the accident leg, a precise determination of the speed and track of the CG 33118 at the moment of collision could not be obtained. Nevertheless, operating the CG 33118 at any speed above 8 knots (the vessel’s approximate maximum displacement speed) was unsafe for the prevailing conditions. NTSB concludes that the CG 33118 was planing, that is, traveling at least 19 knots, at the time of the 42

NTSB Marine Safety Report

collision, considerably faster than a safe speed of 8 knots or lower under the prevailing conditions. 2.3.2 Marine Assistance Radio Broadcast Coxswains must evaluate and determine the commensurate response for any assistance or distress call. The accident occurred while the CG 33118 was actively responding to a MARB for a grounded sailboat. In accordance with its policy the Coast Guard issues MARBs on behalf of boaters that are requesting assistance, but are not in distress. Although the grounding location was originally conveyed incorrectly to the CG 33118, both the original and corrected grounding locations were in a protected harbor environment with fair weather conditions. Further, the JHOC watchstander clearly conveyed to the CG 33118 that the sailboat was not in distress and there was no indication that the grounded boater was in any danger. Therefore the NTSB concludes that the vessel grounding to which the CG 33118 responded was not an emergency, and did not necessitate a high-speed response that reached 42 knots at one point. 2.3.3 Traffic Density Because of the Parade of Lights, considerably more vessels were on the bay that night than virtually any other night. The route of the CG 33118 in response to the MARB was documented by witness and crew statements and by witness video. The CG 33118 left station San Diego and met the Haddock near the north end of Shelter Island. In response to the MARB, the CG 33118 initially headed to the northeast in an arc congruent to but south of the parade route. The eastbound leg passed close to the eventual accident site. This track allowed the crew to see the vessels in the vicinity of the parade route near the West Basin inlet, which would have made them cognizant of the heavy vessel density in the area. Further, the two crewmembers that the NTSB interviewed both commented on the greater than usual number of boats on the Bay that night. The NTSB therefore concludes that the CG 33118 coxswain and crew were aware of the heavy vessel density in the area. 2.3.4 Safe Speed Inland navigation rules obligate all mariners to operate their vessels at safe speeds “so they can take proper and effective action to avoid collision.” The rules assign mariners the responsibility to correctly interpret and apply navigational principles and practices, given the conditions and circumstances. The NTSB examined the prevailing conditions and circumstances to determine how the coxswain should have considered them in operating the CG 33118. These included darkness, background lights, the lights of the vessels in the area, the vessel traffic density, and the effects of the CG 33118’s wake. Station San Diego Boat Piloting and Navigation Standards state that “special consideration must be given to the fact that background lights on shore will make the identification of vessel traffic more difficult.” Station San Diego coxswains told NTSB investigators that they were aware of the effects of the bay’s background lighting on their ability to detect vessels at night. Investigators examined the approximate route of the CG 33118 on the 43

NTSB Marine Safety Report

accident leg and noted that extensive background lighting spanned across the field of view of the CG 33118 crew as they overtook the Sea Ray. In addition to the effects of background lighting, the coxswain also needed to consider the effects of the density of vessels in the area. Over 80 boats participated in the parade, and there were hundreds of spectator boats, ranging from small dinghies, kayaks, and canoes (some unlighted) to large yachts and commercial vessels, congregated along the parade route, creating higher than normal vessel traffic, particularly in the area near the West Basin inlet. The wake created by the CG 33118 needed to be considered as well. A boat’s wake can be hazardous, especially to smaller vessels. It can rock and potentially swamp or capsize other boats, and passengers may be thrown off balance or overboard. Where local conditions warrant, “no wake” areas are designated in many waterways as a means to protect other vessels. The CG 33118 would have produced a wake at the speeds at which it was estimated to have been operated, endangering smaller vessels present at the event. On the accident leg, the coxswain was operating the CG 33118 at planing speed, which was at least 19 knots and possibly as high as 42 knots. He operated the vessel at 42 knots just minutes earlier on the preceding leg. Station San Diego instructions specified that SPC-LE cruising speed should not exceed 4200 rpm, which is equivalent to a speed of about 35 knots. The CG 33118 crew was responding to a soft grounding, a nonemergency that did not warrant operating at such speeds. Given the inland navigation rules and Station San Diego speed guidance, the CG 33118 coxswain and crew should have considered nighttime visibility limitations, San Diego Bay background lighting, and traffic density in determining safe vessel operating speed. In addition, crews should have considered wake effects of vessel speed. As noted previously, operating the CG 33118 at any speed above 8 knots (the vessel’s approximate maximum displacement speed) was unsafe for the prevailing conditions. Therefore, the NTSB concludes that the coxswain’s operating the CG 33118 at any planing speed was unsafe for the prevailing conditions and circumstances of darkness, background lighting, and high vessel density in the parade area. 2.3.5 Visual Perception and Conspicuity Although the NTSB could not determine the precise point at which CG 33118 crewmembers could have detected the Sea Ray immediately in front of them, investigators attempted to determine why the crew did not avoid striking the Sea Ray. The vessel was equipped with a functioning radar; however, the only crewmembers consenting to be interviewed were not involved in navigating the vessel and were unable to verify whether the radar was used on the night of the accident. For the crew to visually “see” the Sea Ray, they would need to detect it, perceive it as a boat, and then accurately interpret the boat’s distance and relative speed. In addition, given the cloud layer, the ambient level of illumination was relatively low. As a result, the Sea Ray’s hull lacked contrast with the surface of the bay. The Sea Ray’s navigation lights were determined to be illuminated in accordance with applicable regulations. However, the considerable background lights around San Diego Bay 44

NTSB Marine Safety Report

would have lessened the visual cues available to the CG 33118 crew by limiting the visibility and the conspicuity of the Sea Ray’s all-around light against the background. This phenomenon was well known to Station San Diego personnel. Further exacerbating the effects of the background lighting were the brightly lit parade vessels along the eastern shore of Shelter Island that were moving northward into the CG 33118 field of view. Compounding the difficulties of nighttime visual perception, the CG 33118 and Sea Ray maintained similar headings for some distance before the accident. Given the CG 33118’s course—directly approaching the Sea Ray’s stern—the boat’s all-around light would have appeared fixed, with no lateral relative motion in the CG 33118 crew’s visual field. This lack of relative motion deprived the crew of another visual cue which would have assisted in differentiating the all-around light from the background lighting because people more readily detect changes in the visual field, that is, motion or flashing, than they do constancy. Because of the constant-heading, dead-astern approach path of the CG 33118 to the Sea Ray, the crew’s ability to detect the Sea Ray’s all-around light was limited. Assuming that the crewmembers detected the all-around light, their ability to perceive that they were rapidly closing on the slow-moving boat in front of them would be limited because of the single-point nature, or small size, of the all-around light and its lack of contrast with the surroundings. In sum, an operator must detect and identify an object, perceive the associated hazard, and then take effective action to avoid striking that object. Operating at a slower speed would have increased the amount of time available to the CG 33118 crew to detect, perceive, and take action to avoid the collision. Therefore, the NTSB concludes that the continuous illumination of the Sea Ray’s all-around light, the effects of the background lights that limited the conspicuity of the all-around light, and the similar headings of the two vessels coupled with the dead-astern approach by the CG 33118 made it difficult for the crew to visually detect and perceive the Sea Ray; however, traveling at a slow speed would have compensated for these visual difficulties. 2.4 SPC-LE Forward Visibility Vessel design standards, while fundamental, play but one role in vessel safety. Regardless of design standards, operator skill and judgment, as well as system safety factors, are all basic elements in overall safety. The NTSB did not investigate contractual matters between SAFE Boat and the Coast Guard, which accepted delivery of the vessels under its contract with SAFE Boat. The NTSB also did not investigate the suitability of the specifications, or adequacy of the standards, that the Coast Guard specified for the SPC-LEs. The NTSB examined the forward visibility of the SPC-LE to determine if, absent nighttime visual perception factors, the boat’s design had any impact on the ability of the crew to detect targets ahead. The purpose of the visibility study was to identify obstructions to forward visibility for the two CG 33118 crewmembers in the forward seats, the operating conditions under which these obstructions were present, and the effects of these obstructions on the ability of the two crewmembers to see the Sea Ray. One of the ABYC small craft standards (ABYC H-1, Field of Vision from the Helm Position) pertains to forward visibility, which for the SPC-LE applied only to the coxswain’s position. At the request of and under observation by NTSB investigators, ABYC tested the SPC-LE’s compliance with the H-1 standard. This standard 45

NTSB Marine Safety Report

divides forward visibility into horizontal and vertical fields of view. The SPC-LE did not meet all the horizontal visibility criteria of the H-1 standard. However, considering the dead-astern approach of the CG 33118 to the Sea Ray, investigators determined that the horizontal range of visibility was likely not a factor in the crew’s ability to see the Sea Ray immediately preceding the accident. The NTSB examined the effects, if any, of the SPC-LE’s failure to meet vertical visibility criteria on the coxswain’s ability to detect the Sea Ray from the helm position. However, the NTSB encountered several difficulties in attempting to determine what the coxswain could have seen. The vessel’s exact speed, and therefore trim angle, before striking the Sea Ray is unknown. Further, the coxswain’s position during this period could not be precisely determined. Nonetheless, the NTSB attempted to determine, within a range of vessel speeds, the point at which the coxswain may first have seen the Sea Ray. Assuming a known static coxswain position and the highest vessel running trim angle, that is, a speed at 3000 rpm or 19 knots, the results of the NTSB comparison study indicate that the coxswain’s unobstructed sight line to the water did not meet the vertical distance criteria specified in the H-1 standard. At this speed, the coxswain would have seen a portion of the Sea Ray, including the all-around white light, until that vessel was about 135 feet forward of the CG 33118’s bow, at which point only the all-around white light would still have been visible. These circumstances illustrate a worst-case visibility scenario. The vessel’s vertical forward visibility is most limited at its highest running trim angle. In addition, the evidence indicates that at least one CG 33118 crewmember reacted to the Sea Ray just before the collision, and the operator of the Sea Ray said he saw crewmembers in the cabin of the CG 33118 just before impact. Thus, regardless of the H-1 visibility standards, the CG 33118 coxswain should have been able to see at least a portion of the Sea Ray at some point before the collision. Further, boat speed and nighttime visual perception factors may have played a larger role than vessel obstructions in limiting the ability of the coxswain to detect and perceive the Sea Ray in time to avoid the collision. Operators can reduce the extent to which obstructions impair visibility by changing speed (for instance, slowing below 8 knots), changing their eye positions, or both to suit operational circumstances. Forward sight lines progressively improve with higher speeds which decrease the trim angles. Slower speeds, specifically below the transition zone (or about 8 knots), also improve forward sight lines due to lower trim angles. Several SPC-LE coxswains stated they were aware that the bow obstructed forward visibility, at speeds in, and just above, the transition zone. They therefore avoided traveling in this range. Although not required by the visibility standard, the Coast Guard requires that the forward port position be manned. Along with the coxswain’s position, the forward port position affords the best forward visibility on the vessel. Therefore, NTSB investigators examined the sight line of the boatswain’s mate, who was seated in that position on the night of the accident. The results of the NTSB study indicate that at the boat’s highest running trim angle, the boatswain’s mate, who was of average female height, would not have been able to see the surface of the water over the CG 33118 bow or any part of the Sea Ray. In addition, she would 46

NTSB Marine Safety Report

not have seen the Sea Ray’s all-around light until the CG 33118 bow was within 160 feet of it. At speeds below 8 knots, the crewmember would have had an unobstructed sight line to the Sea Ray until it was about 77 feet forward of the bow. The importance of adequate visibility for coxswains and crew is self-evident. Without it, the safety of SPC-LE operations is compromised and the risk of collisions and allisions increases. The Coast Guard expects its boats to be operated by crewmembers of a wide range of heights. However, the evidence indicates that shorter operators may not be able to see the surface of the water directly forward of the SPC-LE while in its lower planing range. Therefore, the NTSB concludes that SPC-LEs have obstructions to forward visibility from the helm and the forward port positions, which increase risks if not properly addressed. Investigators were unable to find evidence indicating that the Coast Guard was aware at the time of the accident that SPC-LEs had obstructions to forward vertical visibility at certain speeds. In July 2010, Station San Diego modified its navigation standards, stating that its SPC-LEs should not be operated “between 2000-3500 rpm’s unless absolutely necessary” because of the bow rise in that rpm range. However, investigators found no evidence that any other Coast Guard stations with SPC-LEs have similarly revised their navigation standards. As a result, the Coast Guard may not be adequately mitigating the risks associated with SPC-LE operation. Unless crewmembers are aware of the vessel’s forward visibility limitations, they may not take adequate steps to compensate for them. Therefore, the NTSB recommends that the Coast Guard develop and implement procedures for its SPC-LEs that allow crewmembers to compensate for obstructions affecting forward visibility from the helm and the forward port positions. 2.5 Sea Ray The Sea Ray operator stated he was traveling at idle speed, and witness statements supported this. NTSB investigators determined that the Sea Ray’s navigation lights were illuminated at the time of the accident and configured in accordance with applicable inland navigation rules. Therefore, the NTSB concludes that the Sea Ray operator was driving his vessel at a safe speed and manner for the prevailing conditions and circumstances. Further, with the estimated speed of the CG 33118 and its reported path, the Sea Ray operator could have done little to avoid being struck by the Coast Guard vessel. Although he attempted to steer his boat out of the path of the oncoming CG 33118, the time available to him to maneuver the boat was insufficient to avoid being struck. Therefore, the NTSB concludes that the CG 33118’s high speed and its astern path relative to the Sea Ray precluded the Sea Ray operator from taking effective action to avoid the collision. 2.6 Training and Oversight Investigators examined Coast Guard training and oversight of its small boats and SPC-LE crews in San Diego to determine why the coxswain and the crew operated the CG 33118 at high speed in the crowded conditions of the Parade of Lights on San Diego Bay. 47

NTSB Marine Safety Report

1. 6.1 SPC-LE Coxswain Training

Coast Guard coxswains at all stations were trained through standardized instructional methods. The candidate must complete numerous qualification tasks, demonstrate proficiency during a comprehensive check ride with an instructor, and pass an oral examination before a board comprising senior Coast Guard station command and operations personnel. Examination topics included situational judgment, rules of the road, piloting and navigation, and risk assessment. The Coast Guard emphasized successful completion of each requirement more than the time required to attain proficiency. 2.6.2 Oversight The CG 33118’s speed exceeded Station San Diego’s maximum recommended operating speed for SPC-LEs in San Diego Bay on the evening of the accident. While coxswains were permitted to exceed the 4200 rpm limit, or 35 knots, for operational necessity or hot pursuit, no operational need called for speeds as high as 42 knots on the night of the accident, especially given the crowded, dark conditions that prevailed. Coast Guard managers told investigators that its oversight provided sufficient information to determine whether crews followed policies and rules. However, the speed of the vessel on the night of the accident and the lack of objections by other CG 33118 crewmembers, including the officer of the day, regarding its speed, raises questions about Coast Guard oversight. The disparity in the evidence and testimony suggest that Coast Guard management is unaware of or possibly tolerates such speeds. Station navigation standards specifically call for reduced speed at night, “even when responding to a potential life threatening case.” However, interviews with coxswains and crew indicated that they considered 4200 rpm to be a normal transit speed for the SPC-LE in the bay during the day and night. Station command appears to have accepted this speed as normal. Further, following the accident witnesses stated that Coast Guard boats often operated vessels at high speeds in the bay. While some Coast Guard high-speed operations observed may have been for valid reasons, the evidence suggests that high-speed operations were routine rather than isolated events. The NTSB would expect an effective oversight system to identify unsafe practices, including excessive speed, and take steps to address them. There is no evidence that this occurred. Coast Guard crewmembers were trained to voice safety concerns to coxswains about how boats were operated. However, neither of the two crewmembers NTSB investigators interviewed after the accident reported that anyone on the CG 33118 voiced objections about the speed at which the coxswain operated the vessel. The NTSB cannot determine the reasons why none of the crewmembers objected to the speed even though they were expected to speak up if they were concerned about the way the vessel was being operated. Further, Coast Guard personnel on board the Haddock who witnessed the CG 33118 depart from alongside the cutter at high speed also did not indicate a concern with the vessel’s speed. Moreover, a more senior coxswain was on board the CG 33118; he was higher in rank than the coxswain and functioning as officer of the day and therefore directly represented the station’s senior management. The senior coxswain declined an NTSB request to be interviewed; therefore, investigators could not ask him whether he recognized the speed of the CG 33118 as excessive. Regardless, based on 48

NTSB Marine Safety Report

conditions in the bay that night, he should have recognized that the speed of the CG 33118 was excessive, and he was responsible and obligated to inform the coxswain to maintain a safe speed. His not speaking up regarding the vessel’s speed indicates that the senior coxswain was deficient in exercising his oversight role and may have regarded the speed as acceptable. In 2002, the NTSB investigated a collision in Biscayne Bay, Florida, between a Coast Guard Station Miami Beach patrol boat and a small passenger vessel, the Bayside Blaster. In that case, a Coast Guard coxswain was determined to have been operating at an excessive speed, at night, and in an area subject to background lighting. In both the Biscayne Bay and the San Diego accidents, Coast Guard station management was unaware of coxswains’ excessive speeds for existing circumstances and conditions. In the Bayside Blaster accident report, the NTSB commented, “Without some means of oversight, commanding officers cannot know that the speed limits are being followed or that other safety requirements are being met.” Additionally, the NTSB concluded, the Coast Guard should “establish oversight procedures for use by commanding officers or officers-in-charge of Coast Guard stations to improve the safety of Coast Guard routine small boat operations.” The NTSB added that oversight could be improved by regular direct observation of coxswain performance, and it issued Recommendations M-02-25 and M-02-26 to address the shortcomings it identified. The following year, NTSB classified both recommendations as “Closed—Acceptable Action.” Maximum authorized speed was apparently regarded as normal operating speed at Coast Guard Station Miami Beach during that time, prompting a 2002 Coast Guard Commandant statement to urge small boat force leaders to “impress upon all hands that throttles have more than two [stop and full] operational positions. The image of a young coastie zipping along at max throttle is becoming a stereotype, reflects poorly upon our professionalism, and encourages reckless behavior in our developing boat crews. This is a safety issue, an equipment issue and a leadership issue.” The Coast Guard concurred with the NTSB recommendations. It revised its Boat Readiness and Standardization Program Manual requiring continuous evaluation of the readiness of boats and crews. It recommended that readiness and standardization evaluations include assessment of performance in team coordination, risk management, and crew briefing and debriefing as part of standard boat operations. It used STAN and RFO evaluations to assess a unit’s crew training program and underway exercise evaluation. NTSB investigators examined the results of the January 2010 STAN assessment conducted shortly after the accident. Station San Diego SPC-LE coxswains performed poorly on portions of the written test, averaging a score of 58.6% on navigation rules. Coxswains on the station’s other small boat also performed poorly on this section, averaging 62.5%. According to the STAN program manager, the station’s command is responsible for addressing such shortcomings. Investigators requested documentation of actions taken in response to these findings. There were none. Lack of any remedial actions taken is not indicative of responsible oversight. 49

NTSB Marine Safety Report

Although RFO and STAN team evaluations provided the Coast Guard with information about SPC-LE crew knowledge, techniques, and skills, they did not provide Station San Diego information about how coxswains and crewmembers were operating the vessels outside these controlled circumstances. RFO and STAN team evaluations provide snapshots in time of performance in controlled, predicted, and structured environments with oversight personnel constantly present, but provide no information to managers about how SPC-LE vessels were being operated day-to-day. Therefore, RFO and STAN team assessments provide an incomplete picture of how vessels are routinely being operated. In sum, the investigation uncovered several areas in which Coast Guard Station San Diego oversight was deficient: the speed at which the CG 33118 was operated on the night of the accident; the speeds at which SPC-LE vessels were routinely being operated at night; the silence of the CG 33118 crewmembers regarding the speed; the limitations of RFO and STAN team evaluations; the lack of follow-up on STAN assessments; and, as is discussed below, the failure to ensure transmission of AIS data. Without effective oversight, management cannot determine if policies and procedures are followed or other safety requirements are being met. Oversight of Station San Diego Coast Guard small boat operations could be improved by direct observation of coxswain performance and monitoring of AIS and other recordable operating data, among other means. Therefore the NTSB concludes that Station San Diego oversight of small boat operations was ineffective in ensuring compliance with established policies for safe operations. Effective oversight requires an organization to maintain an ongoing awareness of how its personnel operate its equipment, so that rules are being adhered to and best practices followed. This involves problem recognition and implementation or modification of policies and procedures as needed. Without the necessary data and procedures needed to review and analyze operations, managers are limited in their ability to assess those policies, procedures, and risks. Current Station San Diego practices do not afford comprehensive oversight of small boat operations. Changes in oversight procedures should effectively address risks that small boat crews face. These risks include nighttime operations in areas where background light can interfere with visibility and in congested waterways. The circumstances of this accident call for the Coast Guard to implement oversight procedures that provide it with information about day-to-day small boat operations. Moreover, given the shortcomings identified in Station San Diego oversight, the NTSB is concerned that other Coast Guard small boat stations may also be unaware of the manner in which small boats are being operated. Therefore, the NTSB recommends that the Coast Guard examine its oversight of small boat operations to determine where local procedures are inadequate, implement procedures nationally and at each station (including Station San Diego) to provide continual, systematic, and thorough oversight information, and require action on information obtained to ensure that crewmembers are operating their vessels safely in all conditions and circumstances. 50

NTSB Marine Safety Report

51

1. 6.3 SPC-LE Speed Policies

Shortly after the Bayside Blaster accident, the Coast Guard updated its safety policies65 to require commanding officers of Coast Guard stations to establish speed limits in specific areas of their AORs “that pose significant or environmental risk to boats.” In hindsight, the evidence suggests that the actions the Coast Guard took after that accident did not establish the policies it needed to ensure the safety of its vessel operations. Station San Diego afforded coxswains broad authority to determine the speed at which to operate their vessels, although coxswains were expected to proceed at a safe speed at all times and were not to exceed 4200 rpm (about 35 knots) unless dictated by operational necessity, hot pursuit, or an emergency. The rpm limit appears to be related to fuel efficiency rather than to safe operation. San Diego coxswains told NTSB investigators this was the only parameter that restricted their boat speed and that it was not unusual to operate at night, in the bay, at 4200 rpm. After the accident, Station San Diego’s commanding officer issued verbal guidance restricting speeds in the bay, outside of the main shipping channel, to a “minimal” or idle speed. The NTSB concludes that at the time of the accident, the absence of Station San Diego speed restrictions for routine patrols at night allowed coxswains too much latitude in selecting patrol boat speed. Furthermore, the NTSB is concerned that other Coast Guard stations may lack speed restrictions for routine patrols in their areas of responsibility. Although the NTSB supports Station San Diego’s attempt to improve safety by providing verbal speed guidance to its SPC-LE coxswains, such guidance can, over time, lose effectiveness. Providing written policy to small boat operators, on the other hand, serves as an official Coast Guard procedure for coxswains to follow. Over time, written policy retains its effectiveness to a greater extent than verbal guidance. Therefore, the NTSB recommends that the Coast Guard require each small boat station, including Station San Diego, to establish specific operating procedures governing small boat speeds that account for prevailing conditions and circumstances affecting the safety of small boat operations. 2.7 AIS Use This investigation was hampered by the absence of exact speed, heading, and position data on the CG 33118 at critical points during the transit. Although the CG 33118 was equipped with AIS, which would have provided this information, no AIS data were available. Investigators determined possible reasons why the data were not recorded: crewmembers did not activate the unit; they activated the unit in a mode that did not transmit; or the AIS unit was not functioning properly at the time of the accident. However, the reason why AIS data were not recorded at the JHOC could not be determined. Regardless of the reason, Coast Guard policy calls for small boats to operate their AIS in a transmitting mode when under way unless operational security needs dictate otherwise. Both Coast Guard headquarters and the Eleventh Coast Guard District’s AIS transmission policy identified “restricted mode” as the default setting for standard (small) boats. The fact that the

65 Commandant Instruction (COMDTINST) 3530.2C, Coast Guard Navigation Standards Manual.

NTSB Marine Safety Report

CG 33118 was operating on the night of the accident without its AIS transmitting, and that JHOC personnel did not address this omission, indicates that deficiencies exist in the application and enforcement of the Coast Guard’s AIS policy. Therefore, the NTSB concludes that the Coast Guard failed to effectively ensure that its AIS policy was enforced in San Diego. Coast Guard policy relied on coxswains to activate the AIS, and set it to the appropriate mode. However, no procedures were in place to ensure that the coxswain activated the AIS or that, if on, the AIS was actually transmitting. In San Diego, JHOC personnel were in the best position to carry out this function. On the night of the accident, the CG 33118 crew checked in with the JHOC, as required, on getting under way. JHOC personnel should have noticed that the CG 33118’s AIS was not transmitting at that time. However, this verification did not take place, nor was it required to by any written policy or procedure. As a result, important vessel data from the CG 33118 was not transmitted or recorded. The NTSB therefore recommends that the Coast Guard develop and implement procedures to ensure that its coxswains follow established AIS transmission policies. 2.8 Vessel Operations Monitoring In addition to AIS, a wide array of technologies is used to navigate and operate vessels, including electronic chart displays and Global Positioning System (GPS) units. The NTSB recognizes the benefits of using all available data for operational and crew monitoring and oversight in addition to navigation. An operational monitoring program might have helped to prevent this collision by enabling supervisors to track coxswains’ underway practices that may have fallen outside established guidelines. However, no formal monitoring program was developed or used by the Coast Guard. The Coast Guard would benefit from the review and monitoring of all these sources of available operational recorded data on its vessels. The NTSB recognized this in its investigation of the collision of the CG 242513 and the Bayside Blaster when it commented, “Technological advances in transponder technology may provide an additional oversight tool if applied to station operations.” Therefore, the NTSB concludes that systematic monitoring of all available operating data could assist Coast Guard small boat supervisors in objectively assessing how their vessels are operated, and periodic review of this information could enhance operational safety and oversight by aiding supervisors in detecting and correcting deviations from standard operating guidance and procedures. The NTSB therefore recommends that the Coast Guard establish a structured data monitoring program for its small boats that reviews all available data sources to identify deviation from established guidance and procedures. 2.9 Cell Phone Use At the time of the accident the Coast Guard had no policy governing the use of cell phones and similar portable electronic devices by its crewmembers during vessel operations. However, all crew were responsible for performing lookout duties during small boat operations, 52

NTSB Marine Safety Report

53

according to the Coast Guard’s Boat Crew Seamanship Manual.66 Coast Guard crewmembers also were trained to voice safety concerns or “speak up” if they noted an unsafe condition, such as operating at an unsafe speed or in an area of high boat traffic density. Yet, if crewmembers were engaged in using personal electronic devices during the trip, this distraction would have prevented them from executing these duties. As noted, the NTSB obtained records from the CG 33118 crewmembers’ personal cell phone service providers and determined that activity was recorded for the coxswain, the boatswain, and the OOD (activity could not be determined for the engineer). The NTSB was troubled to learn that this activity included sending text messages approximately 15 minutes before the collision. The NTSB concludes from these records that CG 33118 crewmembers used their personal cell phones for voice calls and text messaging while under way, distracting them from effectively performing their duties as lookouts. Based on this accident, along with the Thriller 09 accident in Charleston, South Carolina, the NTSB issued recommendation M-10-2 to the Coast Guard urging it to develop and implement policy to address the use of cell phones and other wireless devices by its crewmembers during vessel operations, as previously noted. The Coast Guard responded positively by issuing a policy restricting crew cell phone use during operation of its vessels to purposes related to those operations. 2.10 Emergency Response Following the collision, the CG 33118 crew quickly responded to the accident and cared for the most seriously injured passenger on the Sea Ray, the 8-year-old boy who had been seated near the center of the rear bench of the boat. The crew immediately removed him from the vessel and transported him to the nearby Harbor Island fuel dock, where he was taken to a nearby hospital. Other seriously injured passengers were transferred to local hospitals for treatment as a result of the prompt actions of the Sea Tow, good Samaritans on nearby recreational vessels, and shore side responders from San Diego Fire and Rescue. The NTSB therefore concludes that actions of the emergency response personnel following the collision were timely and effective.

66 See section 1.12.5, Lookout Procedures.

NTSB Marine Safety Report

3 Conclusions 3.1 Findings

1. Weather, illegal drugs and alcohol, and the mechanical condition of both vessels were

not factors in this accident.

The vessel grounding to which the CG 33118 responded was not an emergency and did not necessitate a high-speed response that reached 42 knots at one point.

The CG 33118 was planing, that is, traveling at least 19 knots, at the time of the collision, considerably faster than a safe speed of 8 knots or lower under the prevailing conditions.

The CG 33118 coxswain and crew were aware of the heavy vessel density in the area.

The coxswain’s operating the CG 33118 at any planing speed was unsafe for the prevailing conditions and circumstances of darkness, background lighting, and high vessel density in the parade area.

The continuous illumination of the Sea Ray’s all-around light, the effects of the background lights that limited the conspicuity of the all-around light, and the similar headings of the two vessels coupled with the dead-astern approach by the CG 33118 made it difficult for the crew to visually detect and perceive the Sea Ray; however, traveling at a slow speed would have compensated for these visual difficulties.

Special purpose craft – law enforcement (SPC-LE) vessels have obstructions to forward visibility from the helm and the forward port positions, which increase risks if not properly addressed.

The Sea Ray operator was driving his vessel at a safe speed and manner for the prevailing conditions and circumstances.

The CG 33118’s high speed and its astern path relative to the Sea Ray precluded the Sea Ray operator from taking effective action to avoid the collision.

Station San Diego oversight of small boat operations was ineffective in ensuring compliance with established policies for safe operations.

At the time of the accident, the absence of Station San Diego speed restrictions for routine patrols at night allowed coxswains too much latitude in selecting patrol boat speed.

The Coast Guard failed to effectively ensure that its automatic identification system policy was enforced in San Diego. 54

NTSB Marine Safety Report

Systematic monitoring of all available operating data could assist Coast Guard small boat supervisors in objectively assessing how their vessels are operated, and periodic review of this information could enhance operational safety and oversight by aiding supervisors in detecting and correcting deviations from standard operating guidance and procedures.

CG 33118 crewmembers used their personal cell phones for voice calls and text messaging while under way, distracting them from effectively performing their duties as lookouts.

Actions of the emergency response personnel following the collision were timely and effective. 3.2 Probable Cause The National Transportation Safety Board determines the probable cause of the collision between the CG 33118 and the Sea Ray was the failure of the CG 33118 crew to see and avoid the Sea Ray because of the excessive speed at which the coxswain operated the CG 33118, given the prevailing darkness, background lighting, and high vessel density, and the U.S. Coast Guard’s lack of effective oversight of its small boat operations both nationally and at Coast Guard Station San Diego.

55

NTSB Marine Safety Report

4 Recommendations To the U.S. Coast Guard: Develop and implement procedures for your special purpose craft – law enforcement that allow crewmembers to compensate for obstructions affecting forward visibility from the helm and the forward port positions. (M-11-8)

Examine your oversight of small boat operations to determine where local procedures are inadequate, implement procedures nationally and at each station (including Station San Diego) to provide continual, systematic, and thorough oversight information, and require action on information obtained to ensure that crewmembers are operating their vessels safely in all conditions and circumstances. (M-11-9)

Require each small boat station, including Station San Diego, to establish specific operating procedures governing small boat speeds that account for prevailing conditions and circumstances affecting the safety of small boat operations. (M-11-10)

Develop and implement procedures to ensure that your coxswains follow established automatic identification system transmission policies. (M-11-11)

Establish a structured data monitoring program for your small boats that reviews all available data sources to identify deviation from established guidance and procedures. (M-11-12)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

DEBORAH A.P. HERSMAN ROBERT L. SUMWALT Chairman Member

CHRISTOPHER A. HART MARK R. ROSEKIND Vice Chairman Member

EARL F. WEENER Member

Adopted: July 12, 2011

56

NTSB Marine Safety Report

Appendixes Appendix A Investigation The National Transportation Safety Board was notified of the accident by the Coast Guard National Command Center at 2157 eastern standard time on December 20, 2009. A four-member go-team launched at 1200 the following day and arrived on scene in San Diego at 1500 Pacific standard time. The launch team consisted of specialists in engineering, deck operations, and survival factors. On December 22, the team was joined by a representative from the NTSB’s Transportation Disaster Assistance Division. Also joining the team was a Coast Guard investigator from Coast Guard headquarters’ Office of Investigations and Analysis. The investigators interviewed two crewmembers from the CG 33118, the operator and the passengers on the Sea Ray, and Coast Guard Sector San Diego supervisory personnel. After completing the interviews, documenting the vessel damage, and collecting documentation, the investigators concluded the on-scene investigation on December 25. The NTSB investigated the accident under the authority of the Independent Safety Board Act of 1974, according to the Board’s rules. The sole party to the investigation was the Coast Guard. 57

NTSB Marine Safety Report

Appendix B U.S. Coast Guard Inland Navigation, Steering and Sailing Rules, Rule 6, Safe Speed Every vessel shall at all times proceed at a safe speed so that she can take proper and effective action to avoid collision and be stopped within a distance appropriate to the prevailing circumstances and conditions.

In determining a safe speed the following factors shall be among those taken into account:

(a) By all vessels:

(i) the state of visibility;

(ii) the traffic density including concentration of fishing vessels or any other vessels;

(iii) the maneuverability of the vessel with special reference to stopping distance and turning ability in the prevailing conditions;

(iv) at night, the presence of background light such as from shore lights or from back scatter of her own lights;

(v) the state of wind, sea, and current, and the proximity of navigational hazards;

(vi) the draft in relation to the available depth of water.

(b) Additionally, by vessels with operational radar:

(i) the characteristics, efficiency and limitations of the radar equipment;

(i) any constraints imposed by the radar range scale in use;

(ii) the effect on radar detection of the sea state, weather, and other sources of interference;

(iii) the possibility that small vessels, ice and other floating objects may not be detected by radar at an adequate range;

(iv) the number, location, and movement of vessels detected by radar; and

(v) the more exact assessment of the visibility that may be possible when radar is used to determine the range of vessels or other objects in the vicinity.

58

NTSB Marine Safety Report

Appendix C Letter from Commander, U.S. Coast Guard Sector San Diego, Concerning Verbal Speed Guidance

59

NTSB Marine Safety Report

Appendix D ABYC H-1 Visibility Standard

The purpose of the ABYC H-1 visibility standard is to provide guidance to minimize obstructions in the field of vision from the helm position. In part, the standard includes the following visibility criteria: • Horizontal range looking forward: Shall have a 30-degree clear sector (15 degrees to port and starboard). Outside the clear sector, from 90 degrees to port and 112.5 degrees to starboard, obstructions shall be kept to a minimum so normal head movements will permit unobstructed visibility. • Horizontal range looking aft: Must keep obstructions to a minimum. • Vertical range looking forward, within the 30-degree clear horizontal section: Shall extend from a horizontal line from the high eye position to a line established between a point on the water four boat lengths or 164 feet, whichever is less, ahead of the boat and measured from the bow, through the highest point of lower obstructed visibility to the low eye position. [An NTSB-developed diagrammatic representation of the vertical range requirement is shown on the following page.] • Vertical range outside the forward 30-degree clear sector (remaining 330 degrees): Similar to within the 30-degree clear sector forward, but measured from the gunwale. The standard also states:

1. In order for this standard to be effective the boat must be operated in a reasonable and

prudent manner.

1. Boats can be operated in a manner and at certain speeds causing trim and/or roll angles

such that vision is obscured. This standard cannot assure that a boat can be operated without some loss of vision from the helm position while operating at high trim angles during the transition between displacement and planing mode.

1. This standard does not relieve the operator of the requirement to comply with the Rules

of the Road.

60

NTSB Marine Safety Report

61

NTSB Marine Safety Report

62

Appendix E USCG Shore-Based Boat Accident Data Each year the Coast Guard publishes an Annual Afloat Safety Report containing data on mishaps for that year, and historical data from previous years. The report examines cutter mishaps and small boat mishaps separately. The Coast Guard provided investigators with the annual reports from FY01-FY10. There was no report created for FY06. Overall small boat mishap rates (Class A-D combined)* increased each year from 1999 to 2007. Since 2007, mishaps rates have declined steadily, from about 118 per 100,000 operating hours to just fewer than 80 per 100,000 operating hours in FY10. Mishap rates for Class A and B mishaps have remained steady for the last 10+ years. There was only one Class A mishap in FY10, the San Diego CG3318 accident. There were no Class B mishaps in FY10. In FY09 there were two Class B mishaps and no Class A. In FY08 there were no Class A or B mishaps. There was one of each in FY2007. Overall, the Class A and B mishap rates per 100,000 small boat operating hours are each less than 1 since 1999. The SPC-LE’s mishap rate per 100,000 hours has decreased each year since FY07, the first year data was available for the platform. In FY07 its mishap rate was around 120 per 100,000 hours. In FY10 its mishap rate was around 75 per 100,000 hours. In FY10, the SPC-LE had the 7th lowest rate of mishaps per 100,000 operating hours out of 17 small boat platforms. The most common types of mishaps were collisions, followed by groundings. The mishaps most often occurred during training, followed by search and rescue missions.

FD07369 ｜ 2009_美国_RAB0902.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2009 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

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-08-FR-001 Location: Painesville, Ohio Date: October 10, 2007 Time: 12:02 p.m., eastern daylight time1 Railroad: CSX Transportation Property Damage: $1.4 million Environmental Cleanup: $7.08 million Fatalities: None Injuries: None Type of Accident: Derailment

The Accident On Wednesday, October 10, 2007, about 12:02 p.m., eastbound CSX Transportation (CSX) freight train Q380-09 derailed 31 cars in Painesville, Ohio, while being operated on main track 1. The train was traveling 48 mph at the time of the derailment. The crew’s last train operation had been made about 1 1/2 miles before the derailment. The train consisted of 2 locomotives and 112 cars (106 loaded and 6 empty). The 31st through 61st cars in the train derailed. The derailed cars included seven tank cars carrying ethanol, one tank car carrying liquefied petroleum gas, and one tank car carrying phthalic anhydride. Also among the 31 cars that derailed were covered hoppers carrying corn, wheat, feed, plastic, and lumber. The ethanol tank cars and many of the other freight cars caught on fire. Twenty-six of the derailed cars were destroyed. (See figure 1.) As a precaution, about 1,400 area residents were evacuated from an area of approximately 3 square miles. There were no reported injuries. The temperature at the time of derailment was 51° F, and it was daylight. Estimated damages and environmental cleanup costs were $8.48 million. At 10:00 a.m., about 2 hours before the accident, the engineer and conductor had gone on duty at CSX’s Collinwood Yard in Cleveland, Ohio, to relieve the inbound crew of the train. The crew received new train documentation and the current dispatcher bulletin. The engineer performed the required air brake test, contacted the train dispatcher for permission to depart, and departed at 11:28 a.m.

1 All times in this brief are eastern daylight time. NTSB/RAB-09/02

Figure 1. Accident site.

About 6 1/2 miles before the accident, at control point (CP) 162, the train passed a limited clear signal. The train crossed over to main track 1 and proceeded east. The train’s speed increased to 48 mph. After the train’s locomotive passed a clear signal at CP 155, the engineer said he felt “a nudge, like a jerk” in the train. The nudge was followed by an emergency application of the train’s air brakes, caused by a train line separating during the derailment. The engineer said that after he saw a large fireball in the middle of the train reflected in the side mirror, the train came to a stop. (See figure 2.) He immediately used the radio to broadcast an emergency notification three times, and he asked officials to come to the scene. The train crew provided the emergency responders with the train consist and information about the hazardous materials on the train. NTSB/RAB-09/02 2

Figure 2. Derailment.

Investigation The derailment occurred at milepost 155.62 on main track 1, which was made of 132- pound continuous welded rail (CWR). At the point of derailment, a plug rail2 had been installed in the south rail on December 15, 2006. The plug rail was 136-pound rail and was 20 feet 5 inches long. To install the plug rail, two pairs of 132- to 136-pound rail compromise joint bars3 and eight bolts were used. No rail certification4 was visible on the plug rail. The west end of the plug rail had evidence of multiple fractures and rail end batter.5 Rail fragments from this joint area were found at the point of derailment, about 125 feet west of the point of derailment, and about 200 feet east of the point of derailment. The bottom side of the side frames of the leading end of the 32nd car showed signs of rail burns, indicating that it was first car to derail. Its trailing end also had rail burns on both side frames, and the track was damaged as the train continued to move. A piece of rail was imbedded in the south side frame of the 33rd car, as a result of damage to track ahead of it.

2 Plug rails are used to replace and span a rail defect in CWR. The plug rail is normally temporarily fastened in place by joint bar connections until the plug rail can be welded in place. 3 Compromise joint bars connect and align rail of unequal size or weight. 4 A rail certification is used to show that a plug rail is free of internal defects. 5 Batter is the deformation of the surface of the railhead, usually close to or at the end of the rail. NTSB/RAB-09/02 3

About 4 1/2 hours before the train derailed, a westbound train (Q377-09) had traveled over the same track. Its lead locomotive had a forward facing image recorder.6 The National Transportation Safety Board’s Vehicle Recorder Division reviewed the recorder’s video and audio of the derailment area. The rail at the point at which the accident train later derailed appeared on the recording to be shaded, which suggests that a rail segment was missing. The track ballast appeared to be darker than usual, consistent with the vertical movement of the rail joint and mud pumped onto the ballast. As the westbound locomotive passed over the dark spot, the locomotive deflected noticeably downward, and the wheels made a squealing and banging sound. The engineer of the westbound train said that the track at the dark spot had felt a little rough and that it had been that way for some time. The CSX track inspector for the area said that during his normal twice-a-week track inspections he had conducted maintenance three times on this rail joint, which had initially been installed as a temporary fix on December 15, 2006. In early September 2007, he removed a compromise joint bar that had cracked and replaced it with a straight joint bar. On the Friday before the accident, he had had to raise, tamp, and re-spike the supporting rail joint crossties. During this effort, he noted that the rail ends exhibited rail end batter. During his last track inspection, 2 days before the accident, he had replaced one joint bar bolt. His statements regarding the three maintenance activities correlated with the information in the CSX’s joint inspection records. When the CSX installed the plug, it drilled 1 1/4-inch holes into the rail ends and fastened the joint bars to the ends with 1-inch-diameter bolts. For a 1 1/4-inch hole, the American Railway Engineering and Maintenance-of-Way Association recommends a 1 1/8-inch-diameter bolt. A bolt with a smaller diameter is more likely to allow longitudinal movement of the rail, which can result in a larger gap between the rail ends. As the gap between the rail ends widens, more impact force is transferred to the rail ends, which in turn creates additional rail end batter. The CSX division engineer responsible for the overall track maintenance of the division said that the rail joint involved in the accident—the temporary joint7—had been installed about 10 months before the accident. However, he was not able to provide a date when the temporary rail joints would have been welded and the joint bars removed. The Safety Board’s Materials Laboratory examined the joint bars at the west end of the plug and found that one was a compromise bar and the other was a straight bar. (See figures 3 and 4.) When the track inspector changed the broken compromise joint bar in September, he incorrectly replaced it with a straight bar. The two types of bars have similar marks. The Materials Laboratory found that the straight bar had “132-136” in raised letters on its side, which means it could be used with either 132-pound rail or 136-pound rail. The compromise bar also had “132-136” in raised letters on its side. In addition, the compromise bar had one end that was stamped “132,” and the other end was stamped “136.”

6 A forward facing recorder can digitally record views of tracks, crossings, and signals in front of a train. This recorder also recorded sounds. 7 A temporary joint uses four bolts, instead of six bolts, to join a plug rail and the continuous welded rail ends. Also, the rail ends are suspended above the ballast and between the ties to allow for future welding.

NTSB/RAB-09/02 4

Figure 3. Broken rail and joint bars from the west end rail plug joint at accident site.

Figure 4. Reconfiguration of plug rail pieces from accident site.

In the Safety Board’s Materials Laboratory, the 132-pound rail and the 136-pound rail were joined using a straight bar and a compromise bar similar to the accident joint. During the examination, the rail end of the 136-pound rail was found to be about 1/4 inch higher on the tread of the rail end than the tread end of the 132-pound rail. When tread rail ends are mismatched by 1/4 inch, Federal track safety standards require the track to be designated class 2 NTSB/RAB-09/02 5

track, which reduces the maximum authorized speed of a freight train from 60 mph to 25 mph. Reducing a train’s speed reduces wheel impact forces on uneven rail ends. Operations Information Train movements were governed by the signal indications of a traffic control system. The CSX’s operating rules and timetable instructions provided specific instructions for train movements over the CSX’s Great Lakes Division, Erie West Subdivision, where the accident occurred. Both train crewmembers had passed the CSX operating rules test in 2007. The train was operated in accordance with signal indications. The CSX’s operating rules require train crews to report any unusual condition that may affect the safe, efficient operation of the railroad. The CSX’s records of reported rough riding track conditions from March 8, 2007, through February 13, 2008, do not include any reports about the area of the derailment. Emergency Response The initial call for emergency assistance came from a local resident about 12:02 p.m., immediately after the accident. The first responders—2 chief officers and 17 firefighters— arrived at 12:09 p.m. The on-scene commander was the chief of the Painesville City Fire Department. He implemented an incident command system, which he located at Cherrywood, Ohio. Command, operations, hazardous materials personnel, and the police used different radio channels. After the initial response, most of the responders communicated via cellular telephone. The derailment was not accessible from a public road. The emergency responders accessed the derailment from the south; they used ladders to cross the ditches. The closest hydrant was approximately 1,500 feet south of the derailment. The chief of the Painesville City Fire Department officially declared the fire under control on October 12, 2007, at 6:00 p.m. Event Recorders The accident train had a lead locomotive and a trailing locomotive; each locomotive had an onboard event recorder. The data from the two event recorders were downloaded at the accident scene. On October 17, 2007, the Safety Board’s Vehicle Recorder Division analyzed the data and found that at the time of the derailment, the train had been traveling 48 mph and that there had been no unusual operating activities. (The maximum operating speed for freight trains over the accident area was designated by CSX as 50 mph.) CSX Track Inspector The CSX track inspector responsible for the track maintenance in the accident area began working for CSX on September 3, 1976, as a trackman. In 1979, he became a class II machine operator. In 1986, he was promoted to track foreman, and he also did various types of track maintenance. For about 13 years, he worked as a welder. During his CSX employment, he worked various track jobs. About 6 years before the accident, he became a track inspector on the accident territory. NTSB/RAB-09/02 6

The track inspector said that Mondays were his main track inspection days. On Mondays, he typically started his track inspection at CP 167 and inspected eastward. He usually traveled on main track 2 and inspected both main tracks simultaneously. He said that he usually worked about 3 hours of overtime each Monday. On Tuesdays, he inspected siding tracks. On Wednesdays, he inspected track switches. On Thursdays, he inspected main track again, but to the west, starting at CP 97 and usually traveling on main track 1. On Fridays, he inspected siding tracks and, sometimes, track switches. At the time of accident, he was responsible for inspecting and maintaining 928 rail joints. Wayside Equipment Detectors The train had passed five wayside equipment detectors before the accident. None had recorded an alarm. Probable Cause The National Transportation Safety Board determines that the probable cause of the October 10, 2007, derailment of CSX Transportation freight train Q380-09 in Painesville, Ohio, was a broken rail due to a track inspector’s installation of an incorrect type of rail joint bar. Contributing to the derailment was CSX Transportation’s failure to weld the rail and, thereby, remove the temporary joint before the accident.

Adopted: June 1. 2009

NTSB/RAB-09/02 7

FD07370 ｜ 2009_美国_RAR0901.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2009 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

Collision of Amtrak Passenger Train 371 and Norfolk  Southern Railway Company Freight Train 23M  Chicago, Illinois  November 30, 2007        Accident Report NTSB/RAR-09/01 PB2009-916301

National Transportation Safety Board

NTSB/RAR-09/01 PB2009-916301 Notation 7989A Adopted March 31, 2009

Railroad Accident Report Collision of Amtrak Passenger Train 371 and Norfolk Southern Railway Company Freight Train 23M Chicago, Illinois November 30, 2007 

National Transportation Safety Board

490 L’Enfant Plaza, S.W. Washington, D.C. 20594

National Transportation Safety Board. Year. Collision of Amtrak Passenger Train 371 and Norfolk Southern Railway Company Freight Train 23M, Chicago, Illinois, November 30, 2007. Railroad Accident Report NTSB/RAR-09/01. Washington, DC.

Abstract: On Friday, November 30, 2007, Amtrak (National Railroad Passenger Corporation) passenger train 371, consisting of one locomotive and three passenger cars, struck the rear of a standing Norfolk Southern Railway Company freight train near Chicago, Illinois. The forward portion of the Amtrak locomotive came to rest on top of a container on the rear car of the freight train. Sixty-six passengers and five crewmembers were transported to hospitals; two passengers and one crewmember were subsequently admitted. The weather was clear, and the temperature was 30º F. Estimated damage was $1,299,000

As a result of its investigation of this accident, the Safety Board identified the following safety issues: wayside signal indication training and proficiency programs, crewmember communication and action in response to operating concerns, and inadequate locomotive cab emergency egress and rescue access.

As a result of its investigation of this accident, the National Transportation Safety Board makes recommendations to the Federal Railroad Administration, Amtrak, the Association of American Railroads, the American Short Line and Regional Railroad Association, the Brotherhood of Locomotive Engineers and Trainmen, the United Transportation Union, and the American Public Transportation 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 Internet at http://www.ntsb.gov. Other information about available publications also may be obtained from the website or by contacting:

National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, SW Washington, DC 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 PB2009-916301 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.

Railroad Accident Report Contents Figures........................................................................................................................................... iii Acronyms and Abbreviations ..................................................................................................... iv Executive Summary.......................................................................................................................v Factual Information.......................................................................................................................1 Accident Synopsis............................................................................................................................1 Accident Narrative...........................................................................................................................1 Injuries .............................................................................................................................................5 Damage ............................................................................................................................................5 Amtrak Car 35008 ....................................................................................................................6 Amtrak Car 34054 ....................................................................................................................7 Amtrak Car 34002 ....................................................................................................................7 Personnel Information......................................................................................................................8 Engineer....................................................................................................................................8 Relief Engineer.......................................................................................................................10 Equipment Information..................................................................................................................11 Preaccident Inspections and Maintenance..............................................................................12 Postaccident Inspections.........................................................................................................12 Signal Information .........................................................................................................................12 Operations Information..................................................................................................................13 CSX Transportation................................................................................................................13 Norfolk Southern ....................................................................................................................13 Amtrak Yard...........................................................................................................................13 Management Oversight..................................................................................................................13 Engineer Training...................................................................................................................14 Crew Resource Management Training ...................................................................................15 Meteorological Information...........................................................................................................17 Toxicological Information .............................................................................................................17 Emergency Response.....................................................................................................................17 Local Emergency Response....................................................................................................17 Crew Extrication.....................................................................................................................20 Disaster Preparedness ....................................................................................................................20 Crew Training.........................................................................................................................20 Emergency Responder Training .............................................................................................21 Testing and Examination of Seat Mount Studs..............................................................................21 Event Recorder Information ..........................................................................................................21 Analysis.........................................................................................................................................23 Exclusions......................................................................................................................................23 Train Crew’s Actions.....................................................................................................................23

National Transportation Safety Board i

Railroad Accident Report Amtrak Crew Training and Qualifications .............................................................................26 Train Signals..................................................................................................................................27 Positive Train Control....................................................................................................................28 Survival Factors .............................................................................................................................29 Emergency Response..............................................................................................................29 Extrication of Locomotive Crew ............................................................................................30 Appliance Securement............................................................................................................31 Seat Pedestal Securement .......................................................................................................31 Conclusions...................................................................................................................................32 Findings..........................................................................................................................................32 Probable Cause.............................................................................................................................32 Recommendations........................................................................................................................34 Appendix A...................................................................................................................................36 Investigation...................................................................................................................................36

National Transportation Safety Board ii

Railroad Accident Report Figures Figure 1. Map of Amtrak Train 371’s route and stops. (“X” indicates location of accident.)........2 Figure 2. Path of accident train.......................................................................................................4 Figure 3. Amtrak locomotive resting on top of container on rear car of Norfolk Southern freight train. ........................................................................................................6 Figure 4. Seat pair 19-20.................................................................................................................8 Figure 5. Emergency response locations.......................................................................................19

National Transportation Safety Board iii

Railroad Accident Report Acronyms and Abbreviations AAR Association of American Railroads Amtrak National Railroad Passenger Corporation CFR Code of Federal Regulations CRM crew resource management CSX CSX Transportation EMS Emergency Medical Services FRA Federal Railroad Administration METRA Northeast Illinois Regional Commuter Rail Corporation MP milepost NORAC Northeast Operating Rules Advisory Committee psi pounds per square inch PTC positive train control

National Transportation Safety Board iv

Railroad Accident Report Executive Summary On Friday, November 30, 2007, about 11:23 a.m., Amtrak (National Railroad Passenger Corporation) passenger train 371, consisting of one locomotive and three passenger cars, struck the rear of standing Norfolk Southern Railway Company freight train 23M near Chicago, Illinois. The forward portion of the Amtrak locomotive came to rest on top of a container on the rear car of the freight train. Sixty-six passengers and five crewmembers were transported to hospitals; two passengers and one crewmember were subsequently admitted. The weather was clear, and the temperature was 30º F. Estimated damage was $1,299,000. The National Transportation Safety Board determines that the probable cause of the November 30, 2007, collision of Amtrak train 371 with the rear of Norfolk Southern Railway Company train 23M near Chicago, Illinois, was the failure of the Amtrak engineer to correctly interpret the signal at Englewood interlocking and Amtrak’s failure to ensure that the engineer had the competency to correctly interpret signals across the different territories over which he operated. Contributing to the accident was the relief engineer’s failure to immediately communicate to the engineer that he had miscalled the signal at Englewood and to stop the train when he did not respond to her expressed concern. Also contributing to the accident was an absence of effective crew resource management between the relief engineer and the operating engineer which led to their failure to resolve the miscalled signal prior to the collision. Further contributing to the accident was the absence of a positive train control system that would have stopped the Amtrak train when it exceeded restricted speed. As a result of its investigation of this accident, the Safety Board identified the following safety issues: • Wayside signal indication training and proficiency programs. • Crewmember communication and action in response to operating concerns. • Inadequate locomotive cab emergency egress and rescue access. As a result of its investigation of this accident, the National Transportation Safety Board makes recommendations to the Federal Railroad Administration, Amtrak, the Association of American Railroads, the American Short Line and Regional Railroad Association, the Brotherhood of Locomotive Engineers and Trainmen, the United Transportation Union, and the American Public Transportation Association.

National Transportation Safety Board v

Railroad Accident Report Factual Information Accident Synopsis On Friday, November 30, 2007, about 11:23 a.m.,1 Amtrak (National Railroad Passenger Corporation) passenger train 371, consisting of one locomotive and three passenger cars, struck the rear end of standing Norfolk Southern Railway Company freight train 23M near Chicago, Illinois. The forward portion of the Amtrak locomotive came to rest on top of a container on the rear car of the freight train. Sixty-six passengers and five crewmembers were transported to hospitals; two passengers and one crewmember were subsequently admitted. The weather was clear, and the temperature was 30º F. Estimated damage was $1,299,000. Accident Narrative The engineer and conductor initially went on duty at Chicago on November 29, 2007, at 4:35 p.m. They were assigned to operate Amtrak train 370 from Chicago to Grand Rapids, Michigan. The crew arrived at Grand Rapids with the train and went off duty at 10:28 p.m. The following morning, November 30, the crew reported for duty at 5:50 a.m. and was assigned to Amtrak train 371, which was destined for Chicago. On the previous day, the crew had been on duty 5 hours 53 minutes; they had a rest period of 7 hours 22 minutes. Although 49 Code of Federal Regulations (CFR) Part 228 allows for an interim rest period, a rest period greater than 4 hours but less than 8 hours requires that the hours of the original trip be counted toward the total of 12 hours of limited service. The crew had 6 hours 7 minutes until they would reach their 12- hour limit at 11:57 a.m. Train 371 was scheduled to depart Grand Rapids at 6:35 a.m.; however, it departed 27 minutes late because the cold weather had hampered the operation of a switch. The train departed New Buffalo, Michigan, the last scheduled passenger stop, at 10:37 a.m., and was an hour behind schedule due to in-transit delays. Concerned that the original crew of train 371 would not have enough duty time to reach Chicago, Amtrak called a relief engineer and a relief conductor to report for duty. This relief crew was transported to Hammond, Indiana, where the train made an unscheduled stop about 10:45 a.m. to pick up the relief crew. (See figure 1.) The relief conductor boarded a passenger car, and the relief engineer rode in the cab of the locomotive. The original engineer was permitted to work until 11:57 a.m. and opted to continue operating the train after the relief engineer came on board. The relief engineer sat in a seat on the left side of the locomotive cab. The relief engineer said that she did not specifically ask whether the engineer wanted her to operate the train. However, she did recall that the engineer had said he was going to be able to “run all the way into the terminal” and had added, “let’s hurry up and get on” and “let’s go.”

1 All times are central standard time unless otherwise noted.

National Transportation Safety Board 1

Railroad Accident Report

Figure 1. Map of Amtrak Train 371’s route and stops. (“X” indicates location of accident.) As the Amtrak train approached Chicago, it entered an area that had a large number of freight trains. Approaching Englewood interlocking, which is milepost (MP) 516 and 7 miles from Union Station in Chicago, the Amtrak train was operating on track 1 when it passed another westbound train (Norfolk Southern freight train 667) that was stopped on track 2 east of Englewood interlocking. At Englewood interlocking, there was a red over yellow wayside signal aspect for Amtrak train 371, and the crossover switch was lined for the train to cross from track 1 to track 2. Beyond the interlocking, the engineer and relief engineer saw that an approaching freight train was stopped on track 1.

National Transportation Safety Board 2

Railroad Accident Report The track was owned by Norfolk Southern, and according to the Norfolk Southern operating rules, the red over yellow aspect was a restricting signal that required the Amtrak train to be operated at restricted speed. A Norfolk Southern freight train that was stopped ahead on the track was the reason for the restricting signal. Norfolk Southern’s operating rules for restricted speed required, in part, that the train not exceed 15 mph and that the train be operated so that it could be stopped within one-half the range of vision short of either a stop signal or a train that might be encountered on the track beyond the signal. The engineer said that when he saw the red over yellow signal, he called out slow approach2 in the cab and announced slow approach on the radio3 to the conductor riding in one of the passenger cars. A slow approach signal would have required the engineer to not exceed 30 mph and to be prepared to stop short of the next signal; a slow approach signal also would have conveyed that the section of track beyond the signal was not occupied. The relief engineer told investigators that after the engineer had miscalled the signal at Englewood, she had thought to herself, “… maybe [the engineer] just called it wrong but he knew it was a restricting.” She said that she had “wanted to see what he was going to do.” She also said, … when the vision came clearer, I could see it was a red over yellow which is a restricting, and when the engineer called slow approach, I started questioning what I knew of signals, and I started going through my head what all the signals are in the NS [Norfolk Southern] and what their aspects are. In the postaccident interview, the Amtrak relief engineer also said, “… [the] speed was still low while I was going through signals in my head.” The locomotive’s event recorder indicated that the engineer had slowed the train to 10 mph while traveling through the crossover switches from track 1 to track 2. When the train cleared on track 2, it accelerated to 25 mph until it cleared a permanent speed restriction (due to curved track) at MP 516.3. (See figure 2.) During the postaccident interviews, the crew noted that when the train was traveling through the crossovers, they had started a conversation about the job assignments they had received while working the extra board.4 Once the train cleared the curved track at MP 516.3, the engineer accelerated the train to more than 40 mph. The relief engineer said that she had become uneasy about the speed of the train and that she had challenged the engineer. She said that she had asked the engineer what signal he had called at the Englewood interlocking. She said that he responded that it was a slow clear. (A slow clear signal would have allowed the engineer to accelerate to a maximum authorized speed of 40 mph after clearing the crossovers and the curve restrictions.) During postaccident interviews, the relief engineer said that she told the engineer,

2 Postaccident signal testing determined that this signal had displayed a red over yellow aspect, which was a restricting signal, not a slow approach signal. 3 During postaccident interviews, the conductor on the train confirmed that he had heard the engineer’s announcement but, having not seen the signal, had no reason to doubt its accuracy. 4 The extra board is a group of employees, usually with low seniority, that fill open work assignments when needed.

National Transportation Safety Board 3

Railroad Accident Report “You called a slow approach at Englewood, right? … Even if it’s a slow approach, you have to be down to 30.”5

Figure 2. Path of accident train. Based on the event recorder data and the postaccident crew interviews, the rear of the standing Norfolk Southern freight train on track 2 came into view about a minute after the train was accelerated to 40 mph and while the crew was debating the last signal indication. The engineer reacted and started applying the brakes 8 seconds before the collision. The event

5 In the Northeast Operating Rules Advisory Committee’s (NORAC’s) Rules, Terminology, Definitions, and Authorized Abbreviations, medium speed means not exceeding 30 mph.

National Transportation Safety Board 4

Railroad Accident Report recorder showed that the brakes were quickly applied at several stages until the emergency application, which was made about 1 second before the Amtrak train struck the stopped Norfolk Southern train. The Amtrak train had slowed to 36 mph at impact. Almost 2 miles and about 3 1/2 minutes after crossing from track 1 to track 2, the Amtrak train struck the rear car of the stopped Norfolk Southern train at MP 517.34. Injuries The Chicago Fire Department transported 66 passengers and 5 crewmembers to hospitals; 111 passengers on the scene declined treatment. Of the 71 people transported, two passengers and one crewmember were admitted. The two admitted passengers sustained serious injuries as a result of the collision. The day after the accident, the crewmember was released from the hospital. According to Emergency Medical Services (EMS) records, 10 hospitals received the injured passengers and crewmembers. (See table 1.)

Table 1. Injuries. Injury Typea Train Crew Passengers Others Total Fatal 0 0 0 0 Serious 0 2 0 2 Minor 5 64 0 69 Total 5 66 0 71 aTitle 49 CFR 840.2 defines fatality as the death of a person either at the time an accident occurs or within 24 hours thereafter. Title 49 CFR 830.2 defines 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.” Damage When the Amtrak train struck the rear of the Norfolk Southern freight train, the Amtrak locomotive lifted off its leading truck and rode up onto the rear car, sliding over and crushing the rear corner of a container on the car. The locomotive came to rest on top of the container. (See figure 3.) The derailment did not damage the signals or track structure, except for two crossties that were marked by the wheels during the re-railing process; however, these crossties did not require replacement. The Amtrak locomotive was the only derailed piece of equipment. The leading truck assembly6 ruptured the left front section of the fuel tank, and about 300 gallons of diesel fuel

6 A locomotive truck assembly includes the wheels, the axles, the side frames, and the traction motors.

National Transportation Safety Board 5

Railroad Accident Report spilled from the tank. Both front windows of the cab were dislodged during the collision. The rear window on the right side of the cab was shattered but still in its frame.

Figure 3. Amtrak locomotive resting on top of container on rear car of Norfolk Southern freight train. Just inside the rear door to the cab from the engine room, the floor was lifted 7 inches and was arched upward in the cab. The engineer’s seatback was about 5 1/2 inches from the roof of the cab, the center seatback was about 2 1/2 inches from the roof, and the left seatback was touching the roof. Normally, the seatbacks are 23 inches from the roof. The three trailing Amtrak passenger cars—35008, 34054, and 34002, in order after the locomotive—remained on the rail, and the exteriors and undersides of the coaches were undamaged. The batteries, battery boxes, power cables, and side and end doors were intact and operable. The emergency lighting remained on in Amtrak car 35008 about 3 1/2 hours after the collision. The public address system was tested after the accident and determined to be functioning in all of the Amtrak cars. Amtrak Car 35008 On the upper level of the car, two emergency windows on the right side had been removed. The snack area of the lower level of Amtrak car 35008 had both a microwave oven and

National Transportation Safety Board 6

Railroad Accident Report an empty coffee pot that were found out of their holders and on the floor. The coffee pot’s dimensions matched its bracket; however, the microwave’s did not. The microwave oven was 13 inches tall. Its bracket was 15 7/8 inches tall, and its holder was 14 1/4 inches tall. Amtrak Car 34054 The upper level of Amtrak car 34054 had two emergency windows on the right side that had been removed. A seat pair is attached to the car via a wall mount and a pedestal, which is on the aisle side. The pedestal is attached to the floor track with two mount studs. The frame of seat pair 7-8 was not secured to the floor track; the two mount studs on the pedestal securing the seat frame to the track had been fractured. The seat frame was still secured to the wall mount. The frame of seat pair 19-20 was not secured to either the floor track or the wall mount. (See figure 4.) One mount stud on the pedestal securing the seat frame to the track had been fractured. Fractured mount studs were examined in the Safety Board’s Materials Laboratory as described later in this report. The rear connection from the wall mount was sheared. The forward connection had been pulled intact from the wall bracket. Amtrak Car 34002 On the upper level of the car, two emergency windows (one on either side of the car) were open. The mirror in the dressing room of Amtrak car 34002 had shattered, and pieces were lying on the floor. The Americans with Disabilities Act ramp was stored and secured. In the seating portion of the lower level, one light cover was on the floor. The frame of seat pair 41-42 was not secured to the floor track. The forward mount stud stayed intact with the pedestal, but the rear mount stud had been fractured. The wall mount was still intact. The damage was approximately $1,299,000. (See table 2.)

National Transportation Safety Board 7

Railroad Accident Report

Pedestal Wall Mount Figure 4. Seat pair 19-20. Table 2. Damage Estimates. Item Damage Amtrak Equipment $1,200,000 Lading 80,000 Container 12,000 Freight Car 7,000 Total $1,299,000 Personnel Information Engineer Training/Experience. The Amtrak engineer began his railroad career with the Norfolk Southern as a brakeman in October 2002. He was promoted to conductor on February 28, 2003. He left the Norfolk Southern on November 13, 2003, to pursue his own business. He never worked as an engineer while with the Norfolk Southern.

National Transportation Safety Board 8

Railroad Accident Report On September 8, 2006, Amtrak hired him. He began an 8-week locomotive engineer training program at the Amtrak training facility in Wilmington, Delaware. He completed the training with an average score of 91 percent. He then took the on-the-job training, which consisted of operating trains under the supervision of a certified engineer. This on-the-job training typically lasts about 10 months. His supervisors noted on different occasions that he needed to make smoother station stops and that “[he] needs to stay focused on blowing the whistle for crossings even when other things are going on (radio).” On his final evaluation ride, a supervisor noted that he “exhibits good train handling skills.” He became a certified locomotive engineer on September 6, 2007. The engineer was qualified to operate between Grand Rapids and Chicago on June 15, 2007.7 He estimated that during his on-the-job training period he had taken 20 to 30 trips to Grand Rapids. From September 25, 2007, through November 30, 2007, he primarily worked railroad yard jobs in Chicago. On November 10 and 11, 2007, he made a round trip from Chicago to Grand Rapids. Then he returned to work on yard jobs. On November 27 and 28, 2007, he completed a round trip to Grand Rapids. After completing his on-the-job training and prior to receiving his certification as a locomotive engineer, the engineer attended Amtrak’s annual refresher training in early September 2007. During this training, he was examined several times on railroad rules and signals. On September 4, 2007, he passed the rules examinations related to the General Code of Operating Rules, the Canadian National Railway, and CSX Transportation (CSX). However, he failed his examination on Northeast Operating Rules Advisory Committee (NORAC)8 rules. The examination was a 15-question multiple-choice examination on the operating rules. He answered correctly 8 of the 15 questions. The next day, he retook the examination and passed with a score of 93 percent (that is, 14 out of 15). The engineer was also given his annual refresher signal examinations on September 4,

1. All operating employees must obtain a perfect score (100 percent) on the annual signal

examination before operating or continuing to operate on that railroad. He failed both the Norfolk Southern and the Amtrak terminal signal tests. On the 10-question multiple-choice examination that covered Norfolk Southern signals, the engineer failed to correctly identify two signals. He gave the same incorrect response for a signal as he did on the day of the accident. In both instances, he misinterpreted a restricting signal as a slow approach signal. After his examination, the instructor reviewed the questions with the engineer and verified that he understood the correct answers. The engineer was not allowed to work on the Norfolk Southern until he passed the signal examination. The following day, September 5, he retook and passed the Norfolk Southern signal examination.

7 “Certification” and “qualification” have different meanings. Certified locomotive engineers are in compliance with 49 CFR Part 240 and have displayed the skills and knowledge necessary to operate a train. “Qualified” is a term used to signify that an individual has the skills and knowledge about a specific territory and has the necessary knowledge of that specific route to operate without assistance. Engineers even when certified are not allowed to operate on specific routes until qualified. 8 Norfolk Southern used NORAC for its operating rules in the Chicago area.

National Transportation Safety Board 9

Railroad Accident Report On the Amtrak signal examination for the Chicago Terminal, the engineer missed 4 of the 10 questions on his first attempt. He incorrectly identified an approach indication, a stop indication, a medium approach indication, and a medium approach medium indication. The following day, he took the Amtrak signal examination for the second time. On this examination, he missed 2 of the 10 questions. He incorrectly identified an approach slow indication and a stop indication. Later that same day, the engineer retook the signal exam and passed. The Safety Board notes that the engineer’s incorrect answers on the examinations typically identified signal aspects as less restrictive than what the signal indicated. For example, during the engineer’s examinations, he had misinterpreted a stop indication as a stop and proceed. Work/Rest. The engineer’s activities during the 72 hours that led to the accident were reconstructed through interviews, company records, and information provided by the engineer following the on-scene investigation. The engineer had gone on duty the previous Tuesday, November 27, 2007, at 4:35 p.m. in Chicago. He had been assigned to operate a train to Grand Rapids. He arrived at Grand Rapids on Tuesday evening about 10:29 p.m. and then went off duty. He said that he went to bed soon after 11:00 p.m. and awoke the next morning, Wednesday, November 28, 2007, around 5:00 a.m. He went on duty at 5:50 a.m., and his train departed Grand Rapids for Chicago about 6:00 a.m. The train arrived in Chicago about 11:30 a.m., at which time he went off duty. He said that he performed some chores in the afternoon and took a 90-minute nap. He went to bed about 11:30 p.m. He awoke on Thursday, November 29, 2007, at 5:00 a.m., exercised, and did chores. Between 10:00 a.m. and noon, he took a nap. He said that when he awoke, he ate lunch. He left for work at 2:00 p.m. He went on duty in Chicago at 4:35 p.m. and was again assigned to a train that was headed for Grand Rapids. He went off duty in Grand Rapids at 10:28 p.m., and he went to bed about 11:00 p.m. On the day of the accident, he awoke about 5:00 a.m. and went on duty at 5:50 a.m. When he was asked about his alertness level at the time of the accident, he said that his alertness had been about 4 1/2 on a scale from 1 to 5.9 Health. The 50-year-old engineer told investigators that before the accident he was in good health. A review of his medical records indicated that his last medical examination with Amtrak had been on September 7, 2007. He was found to be medically fit for duty without restriction. However, he had been taking prescription drugs to control his high blood pressure. Workload. He told investigators that his trip from Grand Rapids to Chicago had been mostly typical. He indicated that his workload had been somewhat more demanding than usual because he had about 23 temporary speed restrictions during the trip. He said that he had taken his cellular telephone with him but had used it only after the collision. The cellular telephone records confirmed his statement. Relief Engineer Training/Experience. In 1987, Amtrak hired the relief engineer as a clerk. In October 2003, she became a yardmaster. In October 2005, she left Amtrak and entered the dispatcher training program at CSX. In February 2006, she returned to Amtrak as a yardmaster.

9 The scale was explained to the engineer as follows: 1 is a low level of alertness, and 5 is a high level of alertness.

National Transportation Safety Board 10

Railroad Accident Report In June 2006, she entered Amtrak’s locomotive engineer training program in Wilmington, Delaware; she completed the training with an average score of 97 percent. During her on-the-job training, she spent about 3 months operating trains out of St. Louis, Missouri. The remainder of the time, she worked out of Chicago. She said that as a student she had made 12 round trips through the area where the accident occurred. On June 12, 2007, she became a certified locomotive engineer. She was qualified to operate trains between Chicago and Grand Rapids and between Chicago and Battle Creek, Michigan. She also worked in the Amtrak rail yard at Chicago. On October 23, 2007, she passed her last operating rules examination. In the 2 months before the accident, the majority of her time was spent operating in the Amtrak rail yard at Chicago; she also made an occasional trip from Chicago to Butler, Indiana. Work/Rest. At 10:00 p.m. on the Tuesday before the accident, the relief engineer had gone on duty when she was assigned to a yard job in Chicago. On Wednesday morning at 6:00 a.m., she went off duty. When she had checked with Amtrak, she was told that it was unlikely she would be called for work until at least the next day. She said that she had stayed up on Wednesday. During the day, she did routine chores and activities. About 8:00 p.m. on Wednesday evening, she went to bed. On Thursday about 7:00 a.m., she awoke and did chores; Amtrak did not call. On Thursday evening between 9:00 and 10:00 p.m., she went to bed. On Friday about 6:30 a.m., she awoke. During interviews, she said that she had felt “very alert” when Amtrak called at 8:30 a.m. and told her to report to work at 10:31 a.m. Health. The 43-year-old relief engineer told investigators that her overall health was good. On May 10, 2007, she had her last medical examination with Amtrak. At that time, she was found to be medically fit for duty without restriction. She said that she wore prescription lenses when operating trains. At the time of the accident, she was wearing prescription contact lenses. Workload. When first boarding the train, she read the applicable operating instructions issued for the train on this specific trip. Since the engineer did not leave the engineer’s seat, she understood that he would operate the train until either reaching his time limit or reaching Union Station, whichever occurred first. During the postaccident interview, she said that she had been a working crewmember of the locomotive cab. She said that one of her duties was to call aloud the wayside signals together with the engineer; however, at Englewood interlocking, she did not call out this signal. She said that she had taken her cellular telephone with her but had used it only after the collision. Equipment Information Amtrak train 371 consisted of one locomotive and three Amtrak Superliner I passenger cars (35008, 34054, and 34002). The standing Norfolk Southern freight train 23M consisted of two locomotives and 20 multi-platform intermodal cars. The Norfolk Southern train was 5,055

National Transportation Safety Board 11

Railroad Accident Report feet long and, excluding the locomotives, weighed 4,062 tons. The Amtrak train, including the locomotive, was 338 feet long and weighed 358 tons. Preaccident Inspections and Maintenance Amtrak train 371 was mechanically inspected and the air brakes were tested before the train’s departure from Grand Rapids. The records on the locomotive indicated that the predeparture air brake test and mechanical inspection were completed successfully. No exceptions were noted in the records concerning the predeparture condition of the train. All periodic inspections were within the prescribed limits for each car and the locomotive. Postaccident Inspections Because of the damage to the Amtrak locomotive in the accident, the air brake system could not be tested. While operating the train, the engineer had not reported a defective condition. The air brake system of the three Amtrak cars was tested using a Norfolk Southern locomotive. The air brake system was charged, and the brakes were applied and released in both service and emergency applications. During the tests, no binding or fouling was observed in the foundation rigging; the brakes performed as designed. Signal Information The Englewood interlocking had interlocking signals and power-operated switches, which were controlled by the Consolidated Control Facility in downtown Chicago. The facility was owned and operated by Northeast Illinois Regional Commuter Rail Corporation (METRA). The Amtrak train was traveling on Norfolk Southern tracks, but the Norfolk Southern tracks crossed two METRA main tracks at the Englewood interlocking. Typically, when railroads cross each other at an interlocking, one of the two railroads will control the crossing location. In this case, a METRA control operator controlled the train movements from track 1 and track 2 on the Norfolk Southern track. On the day of the accident, a data log was recorded at the METRA facility that captured the signal events and train movements at Englewood interlocking. The control operator had requested that the power-operated switches line for a movement from track 1 to track 2 at 11:08:54 a.m. Five seconds later, the data showed, the switch reversed and the signal cleared10 for the approaching Amtrak train 371. At 11:19:09, the interlocking track circuit was occupied. At 11:20:32, the interlocking track circuit showed the interlocking was unoccupied. These times matched the times of Amtrak train 371’s event recorder, which had recorded the train’s westbound movement through Englewood interlocking.

10 The dispatching system will not indicate the specific aspect given in the field. It can only display if the signal has cleared for a movement or the signal is a stop signal.

National Transportation Safety Board 12

Railroad Accident Report The signal maintenance records were examined. Postaccident testing of the applicable signals was performed. No condition was identified that would have prevented the signal system from functioning as designed. A test was performed to simulate the movement of Amtrak train 371. Operations Information CSX Transportation Between Grand Rapids, Michigan, and Michigan City, Indiana, Amtrak train 371 operated on the CSX’s Chicago Division, Grand Rapids subdivision. The operations were governed by the NORAC rulebook. The signal aspects and indications are described in CSX Signal Aspects and Indications Rules. Norfolk Southern Between Michigan City and 21st Street in Chicago, Amtrak train 371 operated on Norfolk Southern track. The operations were governed by the same NORAC rulebook. For specific instructions, information was available in the Norfolk Southern’s Dearborn Division, Northern Region Timetable No. 4. The red over yellow aspect at Englewood interlocking had a restricting indication. According to Norfolk Southern’s signal rules, this signal indication required the train to be operated at a restricted speed into the next block. The restricted speed meant that the train must not exceed 15 mph and that it must be prepared to stop within one-half the range of vision of another train. Amtrak Yard In Chicago, between 21st Street and Union Station, the Amtrak rules for the Central Division, Chicago Terminal, governed Amtrak train 371. The signal aspects and indications were in Amtrak’s Timetable No. 3. The Central Division, Chicago Terminal General Order No. 3-S16, added a rule governing a red over yellow signal. The red over yellow aspect between 21st Street Chicago to the Chicago Terminal Union Station had a slow approach indication, which meant the following: the engineer should proceed but be prepared to stop at the next signal and, when the entire train clears the interlocking or control point limits, proceed at a speed not exceeding 30 mph and be prepared to stop at next signal. Unlike the Norfolk Southern red over yellow signal aspect, there would be no expectation of a train on the track beyond the signal. Management Oversight Amtrak has to prepare its employees to operate on many different railroads throughout the United States. The railroads use different rulebooks and different signal systems. Because a

National Transportation Safety Board 13

Railroad Accident Report particular Amtrak train can operate on several different railroads, the instructions covering a single trip can be scattered among multiple operating rulebooks. An Amtrak official told investigators that one of the greatest challenges in engineer training is dealing with the signals of two different railroads that have similar aspects but different indications. For example, identical signal aspects for different railroads may specify different speeds. Managers are responsible for signal training and tests. An employee must obtain a perfect score (100 percent) on the annual signal examination before he or she is allowed to operate or continue to operate on that railroad. Engineer Training All prospective Amtrak engineers begin their formal locomotive engineer training at Amtrak’s training center in Wilmington, Delaware. This portion of the training, which is primarily classroom instruction, lasts 8 weeks. Student engineers are taught the duties and responsibilities of being an engineer. Training includes operating rules (including signals), equipment (locomotives and troubleshooting equipment problems), airbrakes, train handling, and emergency procedures. The Amtrak system general road foreman said that the railroad uses train simulators to expose students to the basics of train handling and the application of the operating rules. The student engineers take written examinations during this part of their training. Most of the tests are multiple choice. In signal examinations, students select the indication that matches a corresponding color drawing of the signal aspect. A passing percentage for the operating rules examination is 85 percent, but 100 percent is required for the signal section. To achieve a passing score during the engineer training, students are allowed to take the tests twice. If they fail on their second attempt, they are terminated from the training program.11 Upon successful completion of the training at the training center, prospective engineers are sent to different regions and assigned to local engineer instructors. This on-the-job-training phase generally lasts about 10 months, depending on the routes on which the engineer will be qualified. The purpose of this training is to provide student engineers with direct supervision as they learn the physical characteristics, signals, and operating rules particular to territories and railroads. The engineer trainees and certified engineers also take annual refresher training, in which they spend 2 or 3 days in a classroom reviewing policies, procedures, regulations, operating rules, physical characteristics, customer service, and emergency procedures. The training includes case studies involving operating rules violations and previous incidents or accidents involving Amtrak trains.12 The training ends with a 15-question multiple-choice examination on operating rules and a 10-question examination on signals. If the participant fails to answer any of the signal questions correctly, the instructor hands the examination back without any notations

11 To pass the annual signal examination in the field, an engineer must score 100 percent; however, an unlimited number of attempts are allowed. 12 Amtrak officials said that most of the operating violations committed by its locomotive engineers cited in the case studies are not due to confusion over a rule (that is, misinterpretation of a signal aspect) but to other factors, including operator distraction and inattention.

National Transportation Safety Board 14

Railroad Accident Report and asks whether the engineer would like to change any answers.13 If the participant cannot correct the examination, the instructor marks the incorrect answers, and the employee will not be in service until completing the exam with a perfect score. An Amtrak supervisor said that most employees who fail the test wait at least 1 day before retaking the test. Crew Resource Management Training Amtrak based its crew resource management (CRM) program on the CRM principles that are applied in the aviation industry, as well as on those principles that are already used in the railroad industry. Amtrak’s CRM training, which was developed in 2002, was initially a separate program that was given to engineers during their initial classroom training in Wilmington and was reinforced during their annual refresher training. A few years after its development, Amtrak’s CRM training was integrated with a review of operating rules violations and a discussion of how CRM tools could have been used to avoid incidents and operating violations. Similar to other CRM programs in the transportation industry, Amtrak’s CRM program addressed such principles as situation awareness, workload distribution, and effective communication. Crewmembers are instructed to assert themselves when they determine that proper procedures or safe practices are not being exercised. When questioned on how to intercede when an employee is not following the procedures properly, an Amtrak system general road foreman whose duties include CRM training told investigators that “appropriate assertiveness” should be exercised. The official said, If somebody is not willing to accept your direction or you[r] input sometimes you have to take action… if you have to pull the air, you pull the air….[14] Part of the thing about speaking up is just questioning. You don’t have to be alarmed and say, ‘Hey, shouldn’t we be stopping?’ but you could say, ‘Hey, wasn’t that signal this or shouldn’t we be doing 15 [mph] …’ the action may be simply to speak up. If that doesn’t trigger the appropriate reaction or the engineer says, ‘Oh, no, I’m pretty sure it was a green’ and then the appropriate assertiveness, you may have [to] say, ‘No, listen, I’m directing you to stop and sort this out’ or whatever it takes. And, you know, it’s an easy thing to say. It’s hard to put into practice, but we encourage appropriate action…. I mean my mantra in class is, if in doubt, use the air, slow down. I bring up stories and relate incidents that I’ve been involved in and that prove that’s the way to go and that can save the day. During the training, the instructors may intentionally communicate a wrong signal to an engineer trainee while operating a train to observe whether the trainee uses the appropriate assertiveness in responding.

13 Amtrak’s senior director, System Operating Practices, said that this “second look” on an examination was discontinued in 2008. 14 Pulling the air means placing the train into emergency braking. A brake handle that is accessible to the employee in the locomotive cab is on the fireman’s side.

National Transportation Safety Board 15

Railroad Accident Report At the time of the accident, the employees in the cab of the locomotive were governed by four NORAC rules that pertain to observing signals. The first rule is the following:

1. Responsibilities of Employees: Signals and Restrictions

a. General Requirements Employees qualified on the operating rules and located on the leading engine or car must be on the lookout for signal affecting the movement of their train. They must communicate to each other in a clear manner the name of each signal as soon as it becomes clearly visible. After the name of a signal has been communicated, employees must observe it until passed. Any change in the signal must be communicated in the required manner. If a train is not operated in accordance with the requirements of a signal indication or restriction, qualified employees located in the leading engine or car must communicate with the Engineer immediately. If necessary, they must stop the train. The second applicable rule is the following:

1. Observing Signals; Moving Engine

Engine Service Employees will be responsible for the observance of all signals and for controlling movements accordingly. To prevent injury to persons, to prevent damage to property and lading, and to avoid collisions and derailments they must:

1. Regulate the speed of their train,

AND

1. Exercise discretion, care and vigilance in moving their train.

The third applicable rule is the following:

1. Visibility Compromised: Regulation Speed

If anything distracts attention from a constant lookout ahead or if weather conditions make observation of signals in any way doubtful, Engine Service Employees must at once regulate the speed of their train to ensure safety. The fourth applicable rule explains how to resolve a situation in which more than one speed is authorized. The fourth rule, Rule 40, is the following: Train speeds may be authorized by the rules, special instructions, signal indications, dispatcher messages or other means. When there is a difference in the speeds, the lowest speed will govern.

National Transportation Safety Board 16

Railroad Accident Report Amtrak’s operating crews are required to adhere to the rules that govern the territory on which they are operating trains. Amtrak does not have written rules that specifically require an engineer to either make an immediate brake application or slow the train when another crewmember raises concerns about the train’s operation. Meteorological Information At 10:51 a.m., at the Midway Airport, which is approximately 6 miles west of the accident site, the winds were from the northwest at 17 mph with gusts of up to 25 mph. The visibility was 10 miles with partly cloudy skies. The temperature was 30º F, and the dew point was near 9º F. Toxicological Information The Amtrak crewmembers (engineer, relief engineer, conductor, relief conductor, and assistant conductor) provided postaccident toxicological specimens that were tested for the presence of alcohol and drugs.15 Results for all crewmembers were negative for alcohol and drugs. Emergency Response Local Emergency Response A passenger aboard the Amtrak train placed the first 911 call at 11:23 a.m. The passenger reported the collision but was unsure of the train’s location. After discussions with the passenger, the 911 dispatcher determined the location and assured the passenger that ambulances were responding. At 11:27 a.m., the Amtrak conductor called 911. The initial dispatch, at 11:32 a.m., included four engine companies, four truck companies, one heavy rescue squad, four battalion chiefs, one deputy district chief, one mobile command and communications vehicle, seven ambulances, two EMS chief officers, one EMS assistant deputy chief paramedic, and an advanced life support engine. The conductor reported that the first fire department official arrived at 11:37 a.m. The first of the engine companies arrived at 11:38 a.m. The commissioner of the Chicago Fire Department was the incident commander. The operations command post for the fire department was established at 312 West 52nd Street, the EMS treatment and triage area was established at 5200 South Princeton Avenue, and the EMS transport area was established in the 5200 to 5300 block of South Princeton Avenue. The nearby

15 Substances tested for included cannabinoids, cocaine, opiates, amphetamines, methamphetamines, phencyclidine, barbiturates, and benzodiazepines.

National Transportation Safety Board 17

Railroad Accident Report Parkman Elementary School was used as a shelter and as an additional treatment and transport area for passengers. A unified command post was established at 5220 South Shields Avenue. Representatives of the Chicago Fire Department, the Office of Emergency Management and Communications, Amtrak, the Red Cross, and the Chicago Police Department were at this location. The Chicago Police Department assisted with the evacuation of the passengers and provided security at the accident site and school. Norfolk Southern police and personnel also responded. (See figure 5.) Hose lines were run as a precaution because the locomotive’s fuel tank had been breached. However, the leaking diesel never ignited. Triage was started immediately on the train. Passengers were evacuated from the train to an area near a fence between the rail yard and a street east of the accident site. After firefighters had cut down parts of the fence, passengers were led down an embankment to a secondary triage and treatment area. Firefighters placed ladders along the embankment to help the passengers walk down the embankment. At 11:48 a.m., four additional ambulances, another advanced life support engine, and a mass casualty unit16 were dispatched. At 11:50 a.m., a heavy rescue unit and a collapse unit were requested. At 11:51 a.m., five advanced life support engines were dispatched to assist with triaging the patients. At 11:52 a.m., six ambulances and two additional mass casualty units were dispatched. At 11:53 a.m., four additional truck companies were requested. At this time, 182 firefighters were on scene. At noon, two additional battalion chiefs and one EMS chief officer were requested. The transportation of patients to hospitals began at 12:05 p.m. At 12:13 p.m., the final search of the train was complete, and all passengers were off the train. At 12:19 p.m., two additional advanced life support engine companies were dispatched. One of these engines responded to Parkman School. Four additional ambulances were sent to Parkman School at 12:28 p.m.

16 A mass casualty unit is capable of treating 50 critical patients.

National Transportation Safety Board 18

Railroad Accident Report

Figure 5. Emergency response locations. Passengers who were not taken by ambulance to hospitals were taken to Parkman School. After additional triage and treatment at this location, 24 passengers were transported by bus, accompanied by an advanced life support engine company, to Stroger Hospital at about 1:25 p.m. They were the last to be transported to hospitals. Additional buses were used to take uninjured passengers to the train’s final destination, Chicago’s Union Station. The scene was secured and released to the railroad at 1:30 p.m., a little more than 2 hours after the collision. At one time during the response, Chicago Fire Department personnel at the scene numbered 250. At the scene, the following were present: 23 companies (engines, trucks, and squads), 6 battalion chiefs, 4 EMS chief officers, 3 mass casualty units, 2 heavy rescue squads, 2

National Transportation Safety Board 19

Railroad Accident Report collapse rescue units, a command and communication unit, a support logistics division vehicle with 100 stairchairs, a helicopter, and additional chief officers. Crew Extrication Because of the damage to the Amtrak locomotive, the two Amtrak engineers were trapped in the cab compartment. The locomotive cab had three doors. Each side of the cab had a door with a ladder on the outside. The third door was behind the engineer’s seat and led to the engine room toward the rear of the locomotive. The crew was not pinned within the cab but could not exit through the doors. Firefighters tried to force open the cab door on the right, but they were unsuccessful. Instead, they broke a window on the right rear door for access. There were no roof access panels or structural weak point to provide additional quick access for emergency personnel; nor were they required.17 Once inside the locomotive, they found that the door from the engine compartment leading into the cab was jammed closed by the raised floor. This door had to be forced open. To reach the trapped engineers, the firefighters also removed a panel of the right-side cab window.18 The relief engineer exited the locomotive through the right- side cab window and climbed down the ladder to the ground. The operating engineer walked back through the engine to the rear door, was placed in a rescue basket,19 and was lowered to the ground. A review of a rail yard video shows that the relief engineer was extricated about 12:05 p.m. and the operating engineer was extricated about 12:16 p.m.20 Disaster Preparedness Crew Training Amtrak has an emergency preparedness training program for its crewmembers. This training is required by 49 CFR Part 239. A refresher course is required every 2 years. Amtrak’s training program is called PREPARE (Passenger Railroad Emergency Preparedness and Response Education). The purpose of the course is to prepare operating and on-board crews for managing train emergencies. The course includes topics such as rail equipment familiarization, passenger evacuation, and emergency care. All of the crewmembers were current with their training.

17 For passenger train operations with speeds in excess of 125 mph, 49 CFR 238.441 requires roof access panels or a structural weak point to provide quick access for emergency personnel. This accident train operated at less than 125 mph. 18 The side cab windows were approximately 45 inches wide with one 22-inch panel and one 23-inch panel. 19 A rescue basket is a rigid body-sized platform on which a stretcher can be secured for transporting patients. 20 These times were adjusted from the video time stamp to match the accurate time provided by the 911 call-in emergency system.

National Transportation Safety Board 20

Railroad Accident Report Emergency Responder Training Title 49 CFR Part 239 also requires passenger railroads to maintain liaison with local emergency responders. Amtrak provides a training program for emergency responders called Passenger Train Emergency Response. This training includes railroad operations, equipment familiarization, and types of train service emergencies. In August 2007, Amtrak had held an emergency incident management meeting, which included the emergency response training, with the Chicago Fire Department, the Chicago Police Department, and the Office of Emergency Management and Communications at Union Station in Chicago. The purpose of the meeting was to identify areas that emergency responders could use for command posts, treatment and triage areas, and field hospitals. Testing and Examination of Seat Mount Studs Two different types of mount studs were discovered during the postaccident examination of the Superliner cars. All the mount studs that fractured were of the same type; Amtrak searched its inventory of replacement mount studs and reported that it could find no evidence of this type in its inventory. Amtrak also reported the presence of lead in the type of mount studs that fractured; however, no lead was found in the type of mount studs that did not fracture. The two fractured mount studs from seats 7-8 and the fractured mount stud from seats 19- 20 from car 34054 were sent to the Safety Board’s Materials Laboratory. The Materials Laboratory compared the accident mount studs that failed with an exemplar mount stud of the type that did not fail. The head profile of each mount stud was measured and the material was tested for hardness. Minor differences in head profiles and average hardness values were noted. The fractures on two of the mount studs contained crack arrest marks that are typical of fatigue cracking emanating from the relief radius between the shank and head portion of the mount stud. The fractures on the head of the third mount stud had fine-grained features that are typical of overstress separation with no evidence of fatigue cracking. The exposed fracture faces showed metal flow that is consistent with the mount stud pulling up relative to the floor- mounting track. The upper side portion21 of the heads in areas that corresponded to a fatigue crack had fretting22 damage. Event Recorder Information The event recorder captured data through the trip up to the collision. According to the recorder, the train had decelerated to 10 mph near the crossover at the railroad crossing at Englewood interlocking, the train started to accelerate to 25 mph while within the curve restrictions, and finally the train reached a speed of 43 mph. The data showed several brake

21 This was the portion of the head that was in contact with the floor-mounting track. 22 Fretting is damage that is induced under load and in the presence of repeated relative surface motion.

National Transportation Safety Board 21

Railroad Accident Report applications just before the collision, including an engineer-initiated emergency application. The last recorded train speed was 36 mph.

National Transportation Safety Board 22

Railroad Accident Report Analysis Exclusions Safety Board investigators reviewed the signal system data logs and performed postaccident signal testing. The logs and tests indicated that the signals were functioning properly at the time of the accident. Investigators examined the Amtrak train equipment and recovered the maintenance records. The equipment that was tested, including the braking systems, had worked as intended. The track and structures had been maintained within tolerances and Federal regulations. Both Amtrak operating crewmembers (engineer and relief engineer) indicated that until the Englewood interlocking nothing about the accident trip was abnormal or created an unmanageable workload. There is no evidence that their performance was affected by the use of prescription or non-prescription medication. Postaccident toxicological testing for all the crewmembers was negative for drugs and alcohol. Their work/rest schedules were regular; it does not appear that operator fatigue was a factor in this accident. Neither crewmember was using a cellular telephone or radio before the accident. Nothing in the environment (that is, rain, fog, or direct sunlight) affected the visibility of the signals. Therefore, the Safety Board concludes that the following were not factors in this accident: the functioning of the signal system, the condition of the equipment and the track, drug and alcohol use, fatigue, cellular telephone or radio use, and the visibility of signals. Train Crew’s Actions As westbound Amtrak train 371 approached Englewood interlocking on track 1, the operating crew observed two stopped Norfolk Southern freight trains. Both trains were stopped to give the Amtrak train priority on the track. Train crews understand that Amtrak trains are often given a higher priority than the host railroad's freight traffic. It would have been normal for the train dispatcher to route the Amtrak train around the freight trains by changing tracks and threading the passenger train through the congestion caused by a large number of freight trains. Because of its delayed departure from Grand Rapids, the Amtrak train was running about 1 hour behind schedule when it reached Englewood. From Englewood, the Chicago passenger terminal was about 15 minutes away. It would have been reasonable for the Amtrak engineer, who had just seen two freight trains yield to him, to believe that he would continue to receive priority over other trains ahead of him, thereby preventing additional delays. He was interested in not being delayed, which was evident when he said, “let’s hurry up and get on” and “let’s go” to the relief engineer when she boarded the train. The engineer was likely trying to reach the Chicago Terminal before he ran out of work time at 11:57 a.m. As the train traveled closer to the first signal at Englewood interlocking, the engineer made a significant error when he misinterpreted the meaning of the red over yellow signal

National Transportation Safety Board 23

Railroad Accident Report aspect. The red over yellow aspect was a restricting indication, requiring the crew to operate the train at a maximum speed of 15 mph and to be prepared to stop for any trains or obstructions ahead. The aspect should have alerted the crew to the possibility of a train on the track ahead of them. However, the engineer misinterpreted the signal as a slow approach, which would have allowed him to operate through the interlocking at a maximum speed of 30 mph while being prepared to stop at the next signal. Of even more importance, a slow approach signal indication would have meant that there was no train within the next block. As the westbound Amtrak train approached Englewood, the engineer slowed his train and then crossed over from track 1 to track 2. This action routed his train around the eastbound freight train that was directly ahead of him on track 1. Once the Amtrak train was on track 2, the eastbound freight train was neither a concern nor a source of additional delay. From that point, based on his misinterpretation of the meaning of the signal, the engineer may have had no expectation of operating the train at a reduced speed, at least until the train reached the next signal. The Amtrak engineer, believing he had just received a slow approach indication, operated his train at 25 mph around the curves and at 30 mph on tangent track, which is consistent with the timetable speed for this territory. The crew observed nothing in front of them at that time to suggest that slowing the train below track speed was necessary. Consequently, the engineer likely felt comfortable about increasing the train’s speed to the next timetable speed of 40 mph. Moments later, when questioned by the relief engineer about the signal they had passed, he stated that it was a slow clear indication, which would have permitted him to operate at the higher speed (40 mph). This second misinterpretation was different from his first misinterpretation and, in fact, was even less restrictive. The engineer and relief engineer continued to discuss the signal while the engineer maintained the train speed at 40 mph. When the engineer saw the stopped Norfolk Southern freight train on the track in front of him, the speed and distance did not allow enough time for him to stop his train short of the Norfolk Southern train. The relief engineer told investigators that she had immediate concerns about the engineer’s misinterpretation of the signal indication at Englewood. However, because of their conflicting interpretations of the signal, she began doubting her own knowledge of that signal and, she said, she thought that initially the engineer had understood the signal but had misspoken. Consequently, she delayed voicing her concerns until she gave it additional thought and felt more confident with her position.23 She communicated her concerns about 3/4 mile before the collision and as the Amtrak train’s speed reached 40 mph, which exceeded both the maximum authorized speed (30 mph) of the signal indication that the engineer had erroneously called and the maximum authorized speed (15 mph) that she correctly believed the signal indication allowed. The relief engineer said that she asked the engineer, “You called a slow approach at Englewood, right? ... Even if it’s a slow approach, you have to be down to 30.” The discussion about the previous signal between the engineer and the relief engineer lasted for

23 Lack of confidence is one of several barriers to communication identified in CRM research. Other factors, some of which might have been present in this accident, include gender differences, lack of credibility, rapport, or authority, experience, rank, and fear of reprisal. R. Baron, “Barriers to Effective Communication: Implications for the Cockpit,” 2005, http://www.airlinesafety.com/editorials/BarriersToCommunication.htm.

National Transportation Safety Board 24

Railroad Accident Report several moments, and the engineer, believing that he was operating the train appropriately, maintained the train’s speed. Although the relief engineer voiced her concerns in time for the engineer to make a brake application and safely stop the train, her actions were not immediate and were not adequate. She asserted herself after the engineer accelerated the train to 40 mph rather than asserting herself immediately after she first believed that the engineer had miscalled the signal, and she never asserted to the engineer that she believed that the Englewood signal was a restricting signal that limited their speed to 15 mph. After the relief engineer first voiced her concern, the process by which the two crewmembers attempted to resolve their differences was to discuss the indication of the previous signal: the engineer did not immediately slow the train, and the relief engineer, seeing that the engineer did not immediately slow the train, did not herself apply the brakes to stop the train. The engineer applied the brakes only after he saw the stopped Norfolk Southern train in front of them. Therefore, the Safety Board concludes that the engineer misinterpreted and miscalled the signal at Englewood which resulted in the operation of the Amtrak train at a speed greater than authorized, and when challenged by the relief engineer, the engineer failed to slow or stop the train while he and the relief engineer discussed their differences in understanding the signal displayed at Englewood. The Safety Board also concludes that the relief engineer failed to communicate effectively and in a timely manner to the engineer that he had miscalled the restricting signal at Englewood interlocking and failed to then take action herself to stop the train after the engineer did not slow or stop the train when challenged. The process by which train crews should identify and strategically respond to unsafe situations is addressed in Amtrak’s Crew Resource Management (CRM) program. Modern railroads emphasize both the application of CRM principles and crewmember proficiency to establish and maintain safe train operations. The purpose of CRM is to help operating crews use all of the available resources (information, personnel, and equipment) at their disposal effectively. The role for crewmembers is to perform their assigned tasks responsibly, to know about or participate in determining the plans for movement of the vehicle, to be alert to departures from plans or from the expected performance of others, and to make those departures known in time to avert an operational error. If properly applied, CRM will increase the likelihood that human operation errors will be detected in time for action to be taken to prevent an accident. Although Amtrak’s CRM program emphasizes the importance of crewmembers immediately voicing their concerns after recognizing potentially unsafe situations, this accident clearly demonstrates the importance of crewmembers implementing the principles of CRM to prevent accidents. Therefore, the Safety Board believes that Amtrak, the Association of American Railroads, the American Short Line and Regional Railroad Association, the Brotherhood of Locomotive Engineers and Trainmen, the United Transportation Union, and the American Public Transportation Association should use the circumstances of the November 30, 2007, accident in Chicago, Illinois, during crew resource management training to reemphasize the necessity of any qualified person on the leading locomotive or car to immediately communicate any disagreement on a called signal and to immediately take action necessary to ensure that the train is operated safely.

National Transportation Safety Board 25

Railroad Accident Report Amtrak Crew Training and Qualifications Amtrak operating crews are often assigned to operate over multiple railroads, sometimes during a single trip, as was the case in this accident. This type of operation requires the crew to be competent in multiple signal systems. Generally, Amtrak has been successful in preparing its crewmembers for these challenges. However, on the accident trip, the engineer appeared to have misinterpreted the meaning of a signal aspect found on different railroad properties. The signal displayed a red over yellow aspect, yet it had different meanings on different railroads. At Englewood interlocking on Norfolk Southern territory, a red over yellow aspect is a restricting indication. During his on-the- job training, the engineer had operated on this territory several times under the supervision of an on-board foreman. It is unknown, however, whether the engineer had been exposed to a restricting indication during his training.24 In contrast, a red over yellow aspect in the Amtrak yard indicates a slow approach. Since receiving his certification, the engineer had spent most of his time working yard jobs. His experience with this Amtrak signal aspect and its associated indication would have been more recent and frequent and, as a result, more likely committed to his memory. In the December 27, 2007, proceedings of Amtrak’s internal investigation of this accident, the engineer stated, “I looked at the signal [the Norfolk Southern signal at Englewood], and I saw our signal, Amtrak’s signal. And I called that signal a slow approach.” Certain fallibilities of human memory may have contributed to his misinterpreting or forgetting the meaning of the signal at Englewood. His forgetting may have been related to retroactive interference,25 which happens when new information affects the recall of somewhat similar material that had been previously learned. In this case, the engineer could have easily confused the red over yellow (slow approach indication) signal in the train yard, which was a signal indication that currently was more salient to him, with the red over yellow (restricting indication) signal at Englewood, which had been more relevant to him months earlier. Furthermore, his last experience of the red over yellow restricting signal indication may have been during his written examination, which occurred a few months before the accident. He had operated infrequently over the accident territory since then, and this lack of exposure to and rehearsal of the signals in their true context may have made it more difficult for him to accurately retrieve from his memory the meaning of signal aspects while he was operating in this territory. The Safety Board also is concerned about the Amtrak engineer’s proficiency with signal identification when he received his engineer certification. Specifically, after completing several months of training on the accident territory, he nonetheless misinterpreted the meaning of several signals on the examinations just before his certification on the Norfolk Southern territories. During his signal examination, he made the same misinterpretation of a restricting signal as he

24 His certification was 3 months before the accident, and the engineer had operated only twice on the route from Chicago to Grand Rapids. 25 This type of interference is retroactive in the sense that current tasks are interfering with the retrieval of memories of learning that took place earlier in time.

National Transportation Safety Board 26

Railroad Accident Report did on the day of the accident. He took this exam only several days before he received his engineer certification. On the same testing day, he also missed 4 of the 10 questions related to the signals that are found on the Amtrak territories on which he had been qualified to operate. He made a significant mistake when he misinterpreted a stop indication for a stop and proceed indication. Further, he not only missed this question on his first attempt but also on his second attempt. Amtrak reported that engineers with limited operating experience may not be exposed to all signal aspects for a significant period, but stated that most of its operating violations are due to factors unrelated to the crew’s knowledge of the signal indications.26 Although the Safety Board understands this, the Board also recognizes that newly certified engineers, whose knowledge and skills related to their craft are still being developed, are most vulnerable to errors that might be attributed to a lack of rehearsal or experience. The Amtrak engineer struggled on his last signal examinations immediately before he received his engineer certification. While engineer trainees occasionally miss some signal exam questions, the accident engineer’s multiple mistakes during the latter part of his training demonstrate a lack of mastery of this essential skill. His failure to correctly interpret critical signal indications of territories on which he had been qualified to operate should have raised concerns about his readiness to operate a locomotive independently and may have warranted additional preparation. Signal interpretation is a skill that should be overlearned (that is, practiced beyond the point of mastery). Information that is overlearned is more resistant to disruption and is retained longer in memory. Since his last signal examination, it is unlikely the engineer had engaged in this type of learning for those signals that he had difficulty remembering. Because his work assignments had been predominantly yard jobs since his certification, his experience with the signals that he had mistaken would have been extremely limited and would have provided few opportunities to reinforce his signal interpretation memories. The Safety Board concludes that the engineer did not show the signal recognition proficiency level necessary to operate on the territories where the accident occurred. Consequently, the Safety Board believes that Amtrak should identify engineers and engineer trainees who have not consistently demonstrated competency in interpreting signals and provide them with enhanced training, supervision, testing, and evaluation necessary to determine that signal proficiency has been achieved and maintained. Train Signals Over the years, privately owned railroads have designed and installed signal systems on their properties to control their train movements. As previously noted, in this accident the red over yellow signal aspect on Norfolk Southern’s signal system had a different meaning from the red over yellow signal aspect on Amtrak’s signal system within the Chicago Terminal. Currently, there are various railroad signal system configurations across the United States. Hence, the same signal aspect may have different meanings or indications, depending on which railroad a train is operating.

26 A review of Amtrak employee operating violations over the last few years indicates that unfamiliarity with the signal system does not appear to be a common problem.

National Transportation Safety Board 27

Railroad Accident Report The Federal Railroad Administration (FRA) issued regulations in 49 CFR 236.23 that provide some standards for signal systems. The FRA regulations allow signal aspects to be displayed by the color of lights, the position of lights, and the flashing of lights.27 Signal aspects may also be qualified by a marker plate, a number plate, a letter plate, and a marker light. Each aspect displayed by a signal must be identified by a name and must indicate the action to be taken; however, only one name and one indication can apply to each aspect, and the same aspect cannot be used with any other name and indication on the same railroad. While these regulations apply to each railroad individually, two adjoining railroads may have signals with the same aspects and different indications, as in this accident. A signal with the same aspect and two different indications or requirements can be confusing. Although railroads may use the same aspect to communicate a different meaning, some fundamental conditions must apply across all railroads. These regulations address the use of four colors of lights (that is, red, green, yellow, and lunar) and their meanings. A red light or a series of horizontal lights must be used to indicate stop; a yellow light or a lunar light must be used to indicate that speed is to be restricted and a stop may be required; and a green light or a series of vertical lights must be used to indicate proceed. The railroads combine colors in numerous arrangements to create signal aspects, such as a red light over a yellow light. Even though the FRA requires each railroad to define each signal aspect used on its property and to provide a meaning for that aspect, the regulations do not prohibit different railroads from having different meanings for the same aspect. As seen in this accident, a red over yellow signal aspect on the Norfolk Southern’s signal system was restricting; hence another train may be occupying the block of track beyond the signal. A red over yellow signal aspect on Amtrak’s signal system within the Chicago Terminal was a slow approach; hence the block of track beyond the signal was not occupied. While engineers and conductors operated predominately on the same railroad territories in the past, today’s train crews may operate over several territories in a single day, and train crews must be proficient on more than one signal system. The Safety Board concludes that the lack of uniform meanings of signal aspects can lead to misinterpretation, as demonstrated in this accident. Therefore, the Safety Board believes that the FRA should establish uniform signal aspects that railroads must use to authorize a train to enter an occupied block and prohibit the use of these aspects for any other signal indication. The Safety Board also believes that the FRA should study the different signal systems for trains, identify ways to communicate more uniformly the meaning of signal aspects across all railroad territories, and require the railroads to implement as many uniform signal meanings as possible. Positive Train Control Over the last 4 decades, the Safety Board has investigated many railroad accidents in which crewmembers failed to operate their trains effectively and in accordance with operating

27 These regulations also allow the signal aspect to be displayed by the position of semaphore blades, which are signals equipped with a large mechanical arm that raises and lowers to provide different aspects. The use of semaphore blades has been discontinued by most railroads.

National Transportation Safety Board 28

Railroad Accident Report rules for a variety of reasons, including fatigue, sleeping disorders, use of medications, or distractions within the operating cab. The Board has advocated the implementation of positive train control (PTC) systems that compensate for human error and that incorporate collision avoidance to prevent train collisions. The Board believes that PTC is particularly important in places where passenger trains and freight trains both operate. Because of the Board’s longstanding interest in this issue, PTC remained on the Board’s Most Wanted Transportation Safety Improvements list from 1990 to 2008. Following a head-on collision between a passenger train and a freight train in Chatsworth, California, on September 12, 2008, which resulted in 25 fatalities and more than 130 injuries, the Rail Safety Improvement Act of 2008 was enacted. In addition to other safety improvements, this law mandates the installation of PTC systems by December 31, 2015, on all main-line tracks where intercity passenger and commuter railroads operate and where toxic-by- inhalation hazardous materials are transported. This includes the territory where this accident occurred. After the enactment of the Rail Safety Improvement Act of 2008, the Safety Board’s Safety Recommendation R-01-06, which called for PTC to be installed on railroads, was classified “Closed—No Longer Applicable”28 and was removed from the Board’s Most Wanted list in October 2008. Had a PTC system been in place at Chicago, it would have intervened by stopping the Amtrak train when the engineer failed to comply with the restricted speed. The Safety Board concludes that had a PTC system been in place at the time of this accident, the collision would not have occurred. Survival Factors Emergency Response The first call to 911 was placed by a passenger at 11:23 a.m. The 911 communications center spoke with this passenger until 11:35 a.m. During this time, the 911 communications center identified a street location for the accident using the computer-aided dispatch system. The Chicago Fire Department was dispatched at 11:32 a.m. Fire department units began arriving on scene at 11:37 a.m., which was 14 minutes after the first 911 call was initiated. The commissioner of the fire department assumed incident command. A command post was established. Representatives from the railroads, the Red Cross, the Office of Emergency Management, and the Chicago Police Department assisted at the command post. Staging, triage and treatment, and transportation operations were established. Specialty equipment, including three mass casualty units, two heavy rescue squads, and two collapse rescue units responded. In total, 250 members of the Chicago Fire Department operated at the scene of the derailment.

28 Closed—No Longer Applicable means the Safety Board’s recommended action has been overtaken by events.

National Transportation Safety Board 29

Railroad Accident Report Firefighters began triage on the train. Passengers were then led from the rail yard to the treatment area. Transportation of people to hospitals began 28 minutes after the fire department’s arrival. All passengers were off the train 35 minutes after the fire departments arrived. The emergency response was rapid and included enough resources to address the size of the emergency. Once on scene, the responders evacuated the injured individuals from the train and appropriately selected those needing immediate attention and transport. Therefore, the Safety Board concludes that the emergency response was timely and effective. Extrication of Locomotive Crew The Amtrak locomotive’s fuel tank was breached during the accident, and although no postaccident fire occurred, about 300 gallons of diesel fuel spilled from the tank. Due to the collision forces and structural damage, the cab compartment doors were inoperative. Additionally, because the windows were not designed to be removed by the crewmembers, the two engineers in the cab could not exit the locomotive without assistance. The relief engineer exited the cab through a window that was removed by firefighters, about 28 minutes after the fire department’s arrival. The delay occurred because the windows also were not designed to be rapidly removed by the emergency responders.29 The engineer was extricated from the cab about 39 minutes after the fire department’s arrival. This extended delay occurred because the firefighters had to force open a door into the structurally damaged cab. The Safety Board concludes that because all cab compartment doors were inoperable and the windows were not designed to be easily removable from either the inside or the outside, the engineers could not exit the locomotive nor could the emergency responders enter the locomotive in a timely manner. In 49 CFR 229.206, the FRA’s locomotive design requirements state, Each locomotive used in occupied service must meet the minimum … emergency egress … design requirements set forth in AAR [Association of American Railroads] S-580” for locomotives manufactured or remanufactured after January 1, 2009. The AAR sets forth in its S-580 Locomotive Crashworthiness Requirements, subsection 6.3, Emergency Egress that the locomotive cab “must allow for exit through at least one opening (for example, the engineer’s side door, nose door, windows) in any locomotive orientation. After an accident, a train crew may need to quickly exit a locomotive cab, particularly in the event of a fire or a hazardous materials release, and a train crew may require assistance from emergency responders when injured or incapacitated. The need for passengers to quickly exit passenger cars and for emergency responders to be able to enter passenger cars has been previously addressed in 49 CFR Part 238. The FRA’s regulations for emergency windows in passenger cars have an “ease of operability” requirement. Title 49 CFR 238.113 states that emergency window exits in passenger cars “shall be designed to permit rapid and easy removal

29 This engineer was smaller, had minor injuries, and was more agile than the other engineer.

National Transportation Safety Board 30

Railroad Accident Report from the inside of the car during an emergency situation without requiring the use of a tool or other implement.” Title 49 CFR 238.114 states that rescue access windows in passenger cars “must be capable of being removed without unreasonable delay by an emergency responder.” While the regulations for emergency egress and access in passenger cars clearly address the need for the rapid evacuation of the cars, the requirements for the emergency evacuation of locomotives do not incorporate similar “rapid and easy removal” systems. Therefore, the Safety Board believes that the FRA should require that emergency exits on new and remanufactured locomotive cabs provide for rapid egress by cab occupants and rapid entry by emergency responders. Appliance Securement The microwave oven and the coffee pot in the café car were thrown to the floor during the collision. No injuries were attributed to the microwave or the empty coffee pot in this accident. The restraining bracket was larger than the microwave and could not have secured the microwave to the counter. Since the accident, Amtrak has changed to a new style of microwave on Superliner café cars. The new microwaves match their mounting brackets and are properly secured. Seat Pedestal Securement As a result of the collision, three seat pairs were detached from the guides on the floor of the car. The Safety Board’s Materials Laboratory examined the mount studs that attached the seat pedestals to the mounting guides on the floor. The head portions of two mount studs contained preexisting fatigue cracks that contributed to the detachment of each seat pedestal during the accident. The fatigue cracks were a stress riser that reduced the impact resistance of the mount studs. The Safety Board concludes that some of the seat mount studs experienced fatigue cracking that resulted in seat pedestals detaching from the floor. Amtrak reviewed its existing inventory and found no seat mount studs of the type that fractured in this accident. All mount studs on the seats involved in this accident were replaced before the passenger cars were returned to service. During Amtrak’s ongoing overhaul program, replacement mount studs of the type that did not fracture are being installed in all seat pedestals on Superliner passenger cars. This replacement program will be completed within 4 years.

National Transportation Safety Board 31

Railroad Accident Report Conclusions Findings

1. The following were not factors in this accident: the functioning of the signal system, the

condition of the equipment and the track, drug and alcohol use, fatigue, cellular telephone or radio use, and the visibility of signals.

1. The engineer misinterpreted and miscalled the signal at Englewood which resulted in the

operation of the Amtrak train at a speed greater than authorized, and when challenged by the relief engineer, the engineer failed to slow or stop the train while he and the relief engineer discussed their differences in understanding the signal displayed at Englewood.

1. The relief engineer failed to communicate effectively and in a timely manner to the engineer

that he had miscalled the restricting signal at Englewood interlocking and failed to then take action herself to stop the train after the engineer did not slow or stop the train when challenged.

1. The engineer did not show the signal recognition proficiency level necessary to operate on

the territories where the accident occurred.

1. The lack of uniform meanings of signal aspects can lead to misinterpretation, as

demonstrated in this accident.

1. Had a positive train control system been in place at the time of this accident, the collision

would not have occurred.

1. Because all cab compartment doors were inoperable and the windows were not designed to

be easily removable from either the inside or the outside, the engineers could not exit the locomotive nor could the emergency responders enter the locomotive in a timely manner.

1. The emergency response was timely and effective.
2. Some of the seat mount studs experienced fatigue cracking that resulted in seat pedestals

detaching from the floor. Probable Cause The National Transportation Safety Board determines that the probable cause of the November 30, 2007, collision of Amtrak train 371 with the rear of Norfolk Southern Railway Company train 23M near Chicago, Illinois, was the failure of the Amtrak engineer to correctly interpret the signal at Englewood interlocking and Amtrak’s failure to ensure that the engineer had the competency to correctly interpret signals across the different territories over which he operated. Contributing to the accident was the relief engineer’s failure to immediately

National Transportation Safety Board 32

Railroad Accident Report communicate to the engineer that he had miscalled the signal at Englewood and to stop the train when he did not respond to her expressed concern. Also contributing to the accident was an absence of effective crew resource management between the relief engineer and the operating engineer which led to their failure to resolve the miscalled signal prior to the collision. Further contributing to the accident was the absence of a positive train control system that would have stopped the Amtrak train when it exceeded restricted speed.

National Transportation Safety Board 33

Railroad Accident Report Recommendations As a result of its investigation of the November 30, 2007, collision of Amtrak train 371 with the rear of standing Norfolk Southern Railway Company train 23M near Chicago, Illinois, the National Transportation Safety Board makes the following recommendations: To the Federal Railroad Administration: Establish uniform signal aspects that railroads must use to authorize a train to enter an occupied block, and prohibit the use of these aspects for any other signal indication. (R-09-1) Study the different signal systems for trains, identify ways to communicate more uniformly the meaning of signal aspects across all railroad territories, and require the railroads to implement as many uniform signal meanings as possible. (R-09-2) Require that emergency exits on new and remanufactured locomotive cabs provide for rapid egress by cab occupants and rapid entry by emergency responders. (R-09-3) To Amtrak: Identify engineers and engineer trainees who have not consistently demonstrated competency in interpreting signals, and provide them with enhanced training, supervision, testing, and evaluation necessary to determine that signal proficiency has been achieved and maintained. (R-09-4) Use the circumstances of the November 30, 2007, accident in Chicago, Illinois, during crew resource management training to reemphasize the necessity of any qualified person on the leading locomotive or car to immediately communicate any disagreement on a called signal and to immediately take action necessary to ensure that the train is operated safely. (R-09-5) To the Association of American Railroads, the American Short Line and Regional Railroad Association, the Brotherhood of Locomotive Engineers and Trainmen, the United Transportation Union, and the American Public Transportation Association: Use the circumstances of the November 30, 2007, accident in Chicago, Illinois, during crew resource management training to reemphasize the necessity of any qualified person on the leading locomotive or car to immediately communicate any disagreement on a called signal and to immediately take action necessary to ensure that the train is operated safely. (R-09-5)

National Transportation Safety Board 34

Railroad Accident Report BY THE NATIONAL TRANSPORTATION SAFETY BOARD MARK V. ROSENKER KATHRYN O’LEARY HIGGINS Acting Chairman Member DEBORAH A. P. HERSMAN ROBERT L. SUMWALT Member Member

Adopted: March 31, 2009

National Transportation Safety Board 35

Railroad Accident Report Appendix A Investigation The National Transportation Safety Board was notified of Amtrak passenger train 371’s collision with Norfolk Southern freight train 23M, near Chicago, Illinois, about 1:30 p.m., on November 30, 2007. The investigator-in-charge and the mechanical group chairman were launched from the Safety Board’s Los Angeles Regional Office. The track group chairman was launched from the Safety Board’s Chicago Regional Office. The operations, human factors, survival factors, and signal/event recorder group chairmen were launched from Safety Board Headquarters in Washington, D.C. Then-Vice Chairman Robert L. Sumwalt accompanied the team to the accident site. Parties to the investigation included Amtrak, the Norfolk Southern Railway Company, the Federal Railroad Administration, the Illinois Commerce Commission, the Brotherhood of Locomotive Engineers and Trainmen, and the United Transportation Union.

National Transportation Safety Board 36

FD07371 ｜ 2009_美国_RAR0902.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2009 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

Collision Between Two Massachusetts Bay  Transportation Authority Green Line Trains  Newton, Massachusetts  May 28, 2008          Accident Report NTSB/RAR-09/02 PB2009-916302

National Transportation Safety Board

NTSB/RAR-09/02 PB2009-916302 Notation 8126A Adopted July 14, 2009

Railroad Accident Report Collision Between Two Massachusetts Bay Transportation Authority Green Line Trains Newton, Massachusetts May 28, 2008

National Transportation Safety Board

490 L’Enfant Plaza, S.W. Washington, D.C. 20594

National Transportation Safety Board. 2009. Collision Between Two Massachusetts Bay Transportation Authority Green Line Trains, Newton, Massachusetts, May 28, 2008. Railroad Accident Report NTSB/RAR-09/02. Washington, DC.

Abstract: On May 28, 2008, about 5:51 p.m., eastern daylight time, westbound Massachusetts Bay Transportation Authority Green Line train 3667, traveling about 38 mph, struck the rear of westbound Green Line train 3681, which had stopped for a red signal. The accident occurred in Newton, Massachusetts, a suburb of Boston. Each train consisted of two light rail trolley cars and carried two crewmembers—a train operator at the front of the lead car and a trail operator in the second car. The operator of the striking train was killed; the other three crewmembers sustained minor injuries. An estimated 185 to 200 passengers were on the two trains at the time of the collision. Of these, four sustained minor injuries, and one was seriously injured. Total damage was estimated to be about $8.6 million. In the course of its investigation of this accident, the NTSB identified the following safety issues: lack of a positive train control system on the Massachusetts Bay Transportation Authority light rail system, lack of coordination between crewmembers on Massachusetts Bay Transportation Authority light rail trains with regard to signal indications, inadequate requirements for Massachusetts Bay Transportation Authority train operators to report possible signal malfunctions, and lack of screening of rail transit operators for possible obstructive sleep apnea. As a result of its investigation of this accident, the NTSB makes recommendations to the Federal Transit Administration, all U.S. rail transit agencies, and the Massachusetts Bay Transportation Authority. The National Transportation Safety Board also reiterates one safety recommendation to the Massachusetts Bay Transportation 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 NTSB 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 Internet at http://www.ntsb.gov. Other information about available publications also may be obtained from the website or by contacting:

National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, SW Washington, DC 20594 (800) 877-6799 or (202) 314-6551

NTSB publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2009-916302 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 NTSB reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

NTSB Railroad Accident Report iii Contents Figures .............................................................................................................................................v  Acronyms and Abbreviations ..................................................................................................... vi  Executive Summary .................................................................................................................... vii  Factual Information .......................................................................................................................1  Synopsis ...........................................................................................................................................1  The Accident ....................................................................................................................................2  Emergency Response .......................................................................................................................5  Newton Fire Department ..........................................................................................................5  MBTA .......................................................................................................................................5  Injuries .............................................................................................................................................6  Damage ............................................................................................................................................6  Train 3667—Striking Train ......................................................................................................7  Train 3681—Struck Train .........................................................................................................7  Personnel Information ......................................................................................................................9  Train 3667—Striking Train ......................................................................................................9  Train 3681—Struck Train .......................................................................................................10  Medical and Toxicological Information ........................................................................................10  Meteorological Information ...........................................................................................................11  Site Description ..............................................................................................................................11  Operations Information ..................................................................................................................12  General ....................................................................................................................................12  Operating Rules Relevant to Accident ...................................................................................13  Mechanical Information .................................................................................................................14  Pre-Departure Tests ................................................................................................................14  Postaccident Inspection of Striking Train ...............................................................................15  Track Information ..........................................................................................................................15  General ....................................................................................................................................15  Track Inspections ....................................................................................................................15  Permanent Speed Restriction ..................................................................................................16  Signal Information .........................................................................................................................16  General ....................................................................................................................................16  Postaccident Inspection/Testing of Signal System .................................................................17  Signal Maintenance Records ..................................................................................................17  MBTA Rules Regarding Anomalous Signal Displays ...........................................................18  Governmental Oversight of MBTA ...............................................................................................19  Federal Transit Administration ...............................................................................................19  Massachusetts Department of Public Utilities ........................................................................19  MBTA Employee Performance Monitoring ..................................................................................20  Sight-Distance Tests ......................................................................................................................21  Other Information ..........................................................................................................................22  MBTA Actions Taken Since Accident ...................................................................................22 

NTSB Railroad Accident Report iv Emergency Preparedness ........................................................................................................23  Fault Loggers ..........................................................................................................................23  Analysis .........................................................................................................................................24  Exclusions ......................................................................................................................................24  The Accident ..................................................................................................................................24  Performance of Operator of Striking Train ....................................................................................25  MBTA Signal Rules .......................................................................................................................29  Reporting of Anomalous Signal Aspects ................................................................................29  Notification of Restrictive Signals ..........................................................................................29  Positive Train Control ....................................................................................................................30  Trolley Car Crashworthiness .........................................................................................................31  Conclusions ...................................................................................................................................32  Findings..........................................................................................................................................32  Probable Cause...............................................................................................................................33  Recommendations ........................................................................................................................34  New Recommendations .................................................................................................................34  Recommendation Reiterated in Report ..........................................................................................35  Recommendation Reclassified in Report .......................................................................................35  Appendix A ...................................................................................................................................36 

NTSB Railroad Accident Report v Figures Figure 1. Accident location. .....................................................................................................1  Figure 2. Two-car MBTA Green Line train similar to the two trains involved in this accident. ....................................................................................................................................2  Figure 3. Signal layout between Waban and Woodland stations on D Branch of MBTA Green Line. ...............................................................................................................................3  Figure 4. Crushed lead car of striking train. ............................................................................7  Figure 5. Each train involved in accident consisted of two permanently coupled cars, as shown in drawing. Car 3667 was A-end and lead car of striking train; car 3681 was B-end and lead car of struck train. .......................................................................................................8  Figure 6. Partial diagram of MBTA commuter rail system. Inset arrow indicates accident location on D Branch of the Green Line. ................................................................................12 

NTSB Railroad Accident Report vi Acronyms and Abbreviations BMI

body mass index DOT U.S. Department of Transportation FMCSA Federal Motor Carrier Safety Administration FTA

Federal Transit Administration MBTA Massachusetts Bay Transportation Authority NTSB National Transportation Safety Board US&S Union Switch & Signal

NTSB Railroad Accident Report vii Executive Summary On May 28, 2008, about 5:51 p.m., eastern daylight time, westbound Massachusetts Bay Transportation Authority Green Line train 3667, traveling about 38 mph, struck the rear of westbound Green Line train 3681, which had stopped for a red signal. The accident occurred in Newton, Massachusetts, a suburb of Boston. Each train consisted of two light rail trolley cars and carried two crewmembers—a train operator at the front of the lead car and a trail operator in the second car. The operator of the striking train was killed; the other three crewmembers sustained minor injuries. An estimated 185 to 200 passengers were on the two trains at the time of the collision. Of these, four sustained minor injuries, and one was seriously injured. Total damage was estimated to be about $8.6 million. The National Transportation Safety Board determines that the probable cause of the May 28, 2008, collision of two Massachusetts Bay Transportation Authority Green Line trains in Newton, Massachusetts, was the failure of the operator of the striking train to comply with the controlling signal indication, likely as a result of becoming disengaged from her environment consistent with experiencing an episode of micro-sleep. Contributing to the accident was the lack of a positive train control system that would have intervened to stop the train and prevent the collision. The safety issues identified during this accident investigation are as follows:

1. Lack of a positive train control system on the Massachusetts Bay Transportation

Authority light rail system,

1. Lack of coordination between crewmembers on Massachusetts Bay Transportation

Authority light rail trains with regard to signal indications,

1. Inadequate requirements for Massachusetts Bay Transportation Authority train

operators to report possible signal malfunctions, and

1. Lack of screening of rail transit operators for possible obstructive sleep apnea.

As a result of its investigation of this accident, the National Transportation Safety Board makes recommendations to the Federal Transit Administration, all U.S. rail transit agencies, and the Massachusetts Bay Transportation Authority. The National Transportation Safety Board also reiterates one safety recommendation to the Massachusetts Bay Transportation Authority.

(This page intentionally left blank)

NTSB Railroad Accident Report Factual Information Synopsis On May 28, 2008, about 5:51 p.m., eastern daylight time,1 westbound Massachusetts Bay Transportation Authority (MBTA) Green Line train 3667, traveling about 38 mph, struck the rear of westbound MBTA Green Line train 3681, which had stopped for a red signal. The accident occurred in Newton, Massachusetts, a suburb of Boston. (See figure 1.) Each train consisted of two light rail trolley cars2 and carried two crewmembers—a train operator at the front of the lead car and a trail operator in the second car. The operator of the striking train was killed; the other three crewmembers sustained minor injuries. An estimated 185 to 200 passengers were on the two trains at the time of the collision. Of these, four sustained minor injuries, and one was seriously injured. Total damage was estimated to be about $8.6 million.

Figure 1. Accident location.

1 All times referred to in this report are eastern daylight time. 2 The two cars, which were permanently coupled and traveled as a unit, actually constituted a single No. 7 surface railcar. For the purposes of this report, each such unit involved in this accident will be referred to as a “train” consisting of two cars with individual car numbers. 1

NTSB Railroad Accident Report The Accident On May 28, 2008, the two crewmembers (the operator and the trail operator3) of train 3681 (the struck train) reported for their second tour of duty of the day4 at 2:52 p.m. and 2:50 p.m., respectively, in Riverside, Massachusetts. The operator and the trail operator of train 36675 (the striking train) reported for their afternoon tours of duty at 4:35 p.m., also at Riverside. Both crews operated on the D Branch of the MBTA Green Line from Riverside eastward to Government Center in Boston, where the trains moved around a loop track then returned westward to Riverside. Both trains consisted of two light rail trolley cars. (See figure 2.)

Figure 2. Two-car MBTA Green Line train similar to the two trains involved in this accident. (Photo copyright Richard Panse http://world.nycsubway.org/us/boston/index.html)

3 The operator in the lead car runs the train while the trail operator in the last car operates the doors and makes announcements over the public address system. 4 All of the train operators involved in this accident worked split shifts. They operated trains during the morning-to-noontime rush periods then returned for the evening rush. 5 Train numbers are derived from the number of the lead car. 2

NTSB Railroad Accident Report The trail operator of the striking train said that when he and the operator reported for work, an inspector certified them as fit for duty. He said he had noticed nothing unusual about the operator’s demeanor, behavior, appearance, or attitude. He said that when he and the operator took charge of their train, they performed a cursory visual inspection before departing. During the first several miles of the run, they conducted a successful brake test. The trail operator said that he had noted a problem with the public address system in that he was unable to override the automatic prerecorded announcements to make modifications regarding station stops or to provide other information. He stated that he had attempted to call both the train operator and the operations center on the radio to notify them of the problem with the public address system but that he could not reach either party. This suggested to him that the radio might be malfunctioning. Crewmembers of the struck train reported nothing out of the ordinary during their afternoon run until about 5:50 p.m., when the train operator observed that signal H-66, about 1,666 feet west of Waban station, was displaying a single red aspect. (See figure 3.) MBTA rules state that a train encountering such a signal must stop and hold short of the signal for 1 minute before proceeding at restricted speed not to exceed 10 mph while being prepared to stop short of a car, train, or other obstruction. The operator of the struck train stated that he held his train for the specified time even though the track ahead was clear and he saw no reason for the red signal. The operator told National Transportation Safety Board (NTSB) investigators that he had encountered a red aspect at signal H-66 with the track ahead clear on one of his morning runs on the day of the accident. He stated that at that time he reported the red signal to the Operations Control Center and was told that it had been previously reported; however, there was no MBTA record of a trouble report being filed for the signal at this location.

Figure 3. Signal layout between Waban and Woodland stations on D Branch of MBTA Green Line. Meanwhile, train 3667, which was travelling behind train 3681, arrived at Waban station, where it stopped to discharge and pick up passengers. The trail operator of train 3667 said that his tour of duty up until that time had been uneventful except for the problems with the public address system and possibly the radio. 3

NTSB Railroad Accident Report 4 The presence of stopped train 3681 at signal H-66 just ahead caused signal H-64, at the west end of Waban station, to also show a single red aspect. The trail operator of train 3667 stated that he remained on the train while it served Waban station and that, from his position in the operator’s compartment of the rear car, he could not see the aspect of signal H-64. The red signal indication at H-64 required that the operator of train 3667 hold for 1 minute before proceeding at no more than 10 mph. However, according to the trail operator, the train instead departed Waban as usual (after a stop of 20 to 30 seconds) and accelerated normally. Because the trail operator could not see the red aspect being displayed by signal H-64 and because MBTA rules did not require that the operator call out signal indications over the radio, the trail operator was not aware that his train should have remained stopped briefly before proceeding at reduced speed. He said he therefore had no reason to think anything was wrong when the train began to move westward after the station stop. He said he assumed the train was operating under a clear signal and was accelerating to the maximum authorized track speed of 40 mph for that location. Just ahead of train 3667, train 3681 was beginning to move after being stopped at signal H-66 as required by MBTA rules. The operator said that shortly after his train began to accelerate, he heard a loud noise like an explosion from the rear of the train but felt no significant movement. Thinking that a car had derailed, he stopped his train, then noticed smoke coming from the rear of the train. He said he left the cab and walked back to the rear, where he saw that his train had been struck by a following train. He said he noticed that his trail operator was on a cell phone attempting to contact the control center. Based on data retrieved from the fault loggers6 aboard each of the four cars involved in the accident, the striking train was travelling about 38 mph at the time of impact, and the struck train, which was just beginning to accelerate, was travelling about 3.4 mph. The trail operator of the struck train stated that she had been unaware of the approach of a train from the rear when she heard an explosion and was knocked out of her seat. When she recovered from the impact, she became aware of passengers screaming and yelling. She said that she assisted some of her passengers from her car and then went back to see what had happened. She stated that she had seen fire and lots of smoke and heard screaming coming from the striking car. She also noted that the front of the striking train had collapsed and folded down so that the front of the car was unrecognizable. The trail operator of the striking train said that his train had continued to accelerate normally until it suddenly decelerated, throwing him against his operating console. (The investigation determined that impact occurred less than 40 seconds after the train departed Waban station.) He said that at the same time he heard a loud noise and noticed smoke coming from outside the car. He stated that he had not felt any uneven motion and did not discern any brake application before the impact. Postaccident inspection of the rails did not identify any streak marks consistent with an emergency brake application. The trail operator had not heard

6 A fault logger is a maintenance and troubleshooting device that provides a snapshot of selected parameters. It does not provide a continuous recording of parameters as event recorders do.

NTSB Railroad Accident Report 5 anything from the train operator, but, he said, that was not unusual, and he still believed his radio to be malfunctioning. He was, however, able to contact the operations center by radio to report the accident. (The investigation determined that the intercom between the two operating compartments on the train had been inoperative at the time of the accident.) The trail operator of the striking train said he initially assisted passengers in detraining, then went forward to assess the situation. He said he observed extensive damage to the front of the lead car and found the operator wedged in the crushed cab. He said he attempted to assess her condition but she was unresponsive. He then continued to assist passengers attempting to exit the train. Emergency Response Newton Fire Department At 5:54 p.m., a resident of a home adjacent to the right-of-way called 911 and reported that two Green Line trains had collided and that there was fire.7 Elements of the Newton Fire Department and Newton Police Department were dispatched at 5:57 p.m. and began arriving at the accident scene at 5:59 p.m. Fire companies first gained access to the accident site from an adjacent roadway. A neighboring golf course was used for a second access point and a landing zone. A triage area was also established at the golf course. Firefighters found the striking train operator trapped in the crushed cab compartment. They checked for signs of life but could not feel a pulse. Firefighters first attempted, unsuccessfully, to gain access to the crushed cab by cutting through the railcar floor. They continued to work on the front and on the side of the cab area while they made a second attempt to access the cab by placing a steel beam under and across the width of the damaged car then lifting the beam with jacks. After additional lifting and cutting of the cab structure, the operator was removed from the train about 12:51 a.m. on May 29. MBTA An MBTA superintendent of maintenance coordinated with emergency responders at the accident scene during the response. After checking in with emergency responders, he walked around the accident site to assess the situation. He called for extra MBTA personnel and maintenance trucks to respond. He also requested that the Braintree rescue unit respond.8 While efforts were ongoing to extricate the striking train operator, the superintendent suggested to a firefighter that MBTA personnel could further lift and reposition the train to help give responders better access to the crushed cab area. The offer was at first declined. Later in the

7 The reported fire, which the Newton Fire Department extinguished quickly, was a small grass fire caused by electrical arcing. 8 This rescue unit was funded by the MBTA and was staged at the Braintree Fire Department.

NTSB Railroad Accident Report 6 evening, after further extrication efforts proved unsuccessful, MBTA personnel were allowed to lift the train as the superintendent had suggested. Injuries The operator of train 3667, the striking train, was killed in the collision. The cause of death was determined to be multiple blunt force injuries to the head, chest, neck, torso, and pelvis. The operator and trail operator of train 3681, the struck train, and the trail operator of train 3667 sustained minor injuries and were taken to Newton-Wellesley Hospital. They were then taken to the MBTA medical clinic, where they were tested for alcohol and illegal drugs. One seriously injured passenger was air-evacuated to Boston Medical Center; two passengers with minor injuries were transported to St. Elizabeth’s Hospital in Boston; and two were transported to Metro West Medical Center in Metick, Massachusetts. All the injured passengers had been aboard the striking train. (See table 1.) Table 1. Injuries. Injuriesa

Train Crew Passengers

Fatal 1 0

Serious 0 1

Minor 3 4 a Title 49 Code of Federal Regulations 830.2 defines a fatal injury as: any injury that results in death within 30 days of the accident. A serious injury is defined as: an injury 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 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. Damage MBTA car 3667, the lead car of the striking train, was destroyed in the accident. It sustained substantial crush damage and also derailed as a result of the collision. (See figure 4.) The second car of the striking train, 3706, sustained minor damage. MBTA car 3703, the second car of the struck train, was severely damaged. The lead car of the struck train, 3681, was derailed with minor damage. The total damage was estimated to be about $8.6 million. Both trains were examined in detail at the MBTA’s Riverside shop on May 30 and 31,

1. Damage to the lead car on the struck train and to the trailing car of the striking train was

found to be minimal. Damages to the lead car of the striking train and to the trailing car of the stuck train are detailed below.

NTSB Railroad Accident Report

Figure 4. Crushed lead car of striking train. Train 3667—Striking Train Train 3667 was operating A-end forward. (See figure 5.) In the A-end, the operator’s cab and A1 door were crushed toward the rear and under the car body. This crushed area extended for a distance of 121 inches from the front of the cab. From the first row of passenger seats to the center doors, the ceiling was sloped downward, and it angled toward the right side of the front of the car. The floor in this area was buckled upward. The B-end of the train (car 3706) was generally intact. Windows were secure, and the doors were functional. The first passenger seat behind the operating compartment was unlatched from its pedestal and leaning rearward. The double seat behind the B2 door was slightly loose. A restraining latch on the pedestal secures the seat bottom to the pedestal. The latch normally attaches to a bar beneath the seat. The restraining latch was found on the outside of the seat. Train 3681—Struck Train Train 3681 was operating B-end forward. In the A-end (the end that was struck—car 3703), the operator’s cab and the A1 door were crushed toward the front of the car body. This crushed area extended from the front of the cab for a distance of 120 inches. The floor began to 7

NTSB Railroad Accident Report buckle upward near the third row (from the rear of the car) of passenger seats. From this point to the rear of the car, the floor sloped downward. Figure 5. Each train involved in accident consisted of two permanently coupled cars, as shown in drawing. Car 3667 was A-end and lead car of striking train; car 3681 was B-end and lead car of struck train. The anticlimber9 of car 3703 was raised upward and toward the left side (in the direction of travel) of the car. The center of the anticlimber had been moved 13 inches to the left of its normal centerline. The anticlimber’s highest point measured 39 1/8 inches above the top of the rail, and the centerline measured 38 7/8 inches above the top of the rail. All three doors on the struck car were functional. On the left side of the car, one window was separated from its frame. On the right side of the car, one window was shattered. The remaining windows were intact. In the center of the car above the center truck, interior ceiling body panels were torn. The B-end of the train (car 3681) car was generally intact. Windows were secure, and the doors were functional.

9 An anticlimber is a component on each end of the car that is designed to resist vertical forces and, thereby, prevent one car being overridden by another in a collision. 8

NTSB Railroad Accident Report 9 Personnel Information Train 3667—Striking Train Operator. The operator of train 3667, who was fatally injured in the accident, was a part- time streetcar operator hired in 2007. As a part-time employee, she was limited to working a maximum of 6 hours per day. The dates of her physical examination and annual training were current with her qualification as an operator. A Green Line light rail instructor who had met the operator in August 2007 and had become her instructor with daily contact from September 19 until October 9, 2007, said that the operator “was a great student, very bright, very smart.” She said she was not aware of anything in her life that might have been a basis for distraction or preoccupation from performing her duties. An MBTA light rail instructor who had worked with the operator from October 10 until October 14, 2007, said that the operator “was an excellent student. She followed the rules and regulations. She enjoyed her job.” The two became friends and spoke by phone four to five times per week. The instructor said she was not aware of anything in the operator’s life that may have been a distraction or that would have interfered with her ability to safely operate a trolley. According to MBTA records, the operator worked Monday through Friday and was off Saturday and Sunday. Her normal early shift began at 11:57 a.m. and ended at 1:22 p.m. Her afternoon shift began at 4:35 p.m. and ended at 8:59 p.m. This is the shift the operator worked on Wednesday, May 28, the day of the accident, as well as on the previous day, Tuesday, May 27. Monday had been a holiday, and the operator worked an early shift from 9:58 a.m. until 2:45 p.m. and an afternoon shift from 4:18 p.m. until 5:25 p.m. At the time of the accident, she had been on duty for about 1 hour and 15 minutes. An examination of the operator’s cell phone records showed that she had used her cell phone twice during her morning shift and once during her afternoon duty shift. The cell phone was not in use at the time of the collision. MBTA policy strictly prohibits the use of cell phones while operating any MBTA vehicle. Interviews with those familiar with the train operator’s routine indicated that she normally went off duty about 9:00 p.m. and arrived home between 10:00 and 10:30 p.m., at which time she retired for the evening. Interviews also revealed that a friend of the operator phoned her each morning at 6:30 a.m. “to say hello.” Her normal days off were Saturday and Sunday. Trail Operator. The trail operator of train 3667 was hired by the MBTA in 2007 as a part-time streetcar operator and completed his initial training in January 2008. He told investigators that he awoke on May 28 at 4:40 a.m., began his morning tour at 6:42 a.m., and completed that tour at 9:30 a.m. He then returned home and remained there until he reported for his evening tour, which began at 4:35 p.m. At the time of the accident, he had been on duty for about 1 hour and 15 minutes. He characterized his workload on the afternoon of the accident as “average.” An examination of the

NTSB Railroad Accident Report 10 trail operator’s cell phone records showed that he had not used his cell phone during his duty shift. Train 3681—Struck Train Operator. The operator of train 3681 was hired by the MBTA in 1985 as a bus operator. He was assigned to trolley service as a streetcar operator in 1988 and completed his MBTA recertification in 2008. He was classified a full-time streetcar operator. The operator stated that on Wednesday, May 28, he had worked a morning tour that began at 7:15 am and ended just before noon. He said he then went home and took a nap before returning for his second tour, which began at 2:52 p.m. He characterized his workload on the day of the accident as “moderate” with no problems with the equipment. An examination of the operator’s cell phone records showed that he had not used his cell phone during his duty shift. Trail Operator. The trail operator of train 3681 was hired by the MBTA on May 15, 2006, as a part-time streetcar operator. She became a full-time operator on June 23, 2007. She told investigators she awoke at 6:00 a.m. on May 28 and went on duty at 7:57 a.m. MBTA records show that she was off duty from 12:44 p.m. until 2:50, at which time she returned to duty for her second tour of the day. She would have gone off duty at 6:05 p.m. At the time of the accident, she had been awake for almost 12 hours and on duty for about 3 hours. An examination of the trail operator’s cell phone records showed that she had not used her cell phone during her duty shift. Medical and Toxicological Information After the accident, the MBTA arranged to have the surviving crewmembers of the accident trains undergo postaccident toxicological testing as required by U.S. Department of Transportation (DOT) regulations. Testing was conducted for ethyl alcohol and for five illegal drugs: cannabinoids, cocaine metabolites, opiates, amphetamines, and phencyclidine. The results were negative for the presence of alcohol and the tested drugs. The Office of the Chief Medical Examiner for the Commonwealth of Massachusetts performed the toxicological tests on the fatally injured operator of the striking train and found no evidence of the use of alcohol or illegal drugs. Additional test specimens were then sent to the Civil Aerospace Medical Institute in Oklahoma City, Oklahoma, for independent toxicological analysis. The results were negative for the presence of alcohol and illegal drugs; however, doxylamine10 was present in the urine but was not detected in her blood. The MBTA requires: that safety-sensitive employees consult with Medical Operations before using prescription or over-the-counter medications that contain alcohol or other substances that may impair their ability to perform safety-sensitive duties…. A Medical Operations physician or nurse will make the determination as to whether

10Doxylamine is found in over-the-counter medications used in the short-term treatment of insomnia (difficulty falling asleep or staying asleep).

NTSB Railroad Accident Report 11 the employee’s use of the medication could impair the employee’s performance or jeopardizes the safety of the employee, his/her co-workers and/or the public.11 The investigation found no evidence that the operator of the striking train had reported the use of a medication containing doxylamine. A complete autopsy performed on the operator by the Office of the Chief Medical Examiner of Massachusetts noted only the presence of a large acne-type lesion on her abdomen, with a large surrounding area of swollen skin. The report contained no notation of any other preexisting medical condition, specifically noting no abnormalities upon examination of the heart, lungs, or brain. The operator’s August 6, 2007, history and physical examination form recorded the operator’s height as 66 1/2 inches, weight as 243 pounds, and blood pressure as 140/80. The form did not contain any inquiries of an operator regarding sleep disorders, sleeping problems, snoring, or daytime sleepiness. Meteorological Information It was daylight at the time of the accident, the skies were clear, there were light winds of 5 mph, and the temperature was 68° F. Visibility was 10 miles. This information was recorded by the National Oceanic and Atmospheric Administration’s surface weather station in Boston, about 10 miles east of Newton. Site Description Newton, Massachusetts, is a city of about 83,800 (2000 data) in Middlesex County, the most populated county in the state. Newton is a suburban area consisting of 13 villages located 6 miles west of Boston. The MBTA Green Line operates through five of the villages and has seven station stops within the city. (See figure 6.) Beginning at Chestnut Hill in the east, trains move over the Green Line westward to Newton Center. The track then turns to the southwest to Newton Highlands and Eliot. At Eliot, the Green Line swings back to the northwest through Waban and Woodland before ending at Riverside. The MBTA operates about 154 trips in each direction by 48 trains daily, with fewer movements on the weekend. The MBTA’s ridership for all modes12 makes it the nation’s fifth largest mass transit system. The system serves a population in excess of 4.6 million residing in 175 towns and cities within the greater Boston metropolitan area. The average weekday ridership for the entire system is about 1.1 million passenger trips.

11 Massachusetts Bay Transportation Authority Drug and Alcohol Policy and Testing Program, Effective: August 1, 2001, pp. 3-4. 12 This includes buses; commuter, heavy, and light rail; and trackless street cars.

NTSB Railroad Accident Report The accident occurred between the Waban and Woodland stations, which are 4,300 feet apart. Normal transit time between the two stations ranges from 73 seconds to 2 minutes. The point of impact was determined to be 1,408 feet from the west end of the Waban station.

Figure 6. Partial diagram of MBTA commuter rail system. Inset arrow indicates accident location on D Branch of the Green Line. Operations Information General The Riverside station is on the D Branch of the MBTA Green Line. Trains originating from Riverside travel east to Government Center, loop, and then return west to their originating station. Train movements on the D Branch are governed by signal indications provided by an automatic block signal system. Operators control their trains based on indications displayed by wayside signals. MBTA trains operating on the Green Line do not incorporate systems such as the following: trip stops (mechanical arms or electrical inductors that slow or stop a train if the 12

NTSB Railroad Accident Report 13 operator fails to comply with a signal indication), cab signals (a display of signal aspects inside the operating compartment, sometimes incorporating audible warnings of restrictive signals), or positive train control (a system that automatically intervenes if a train operator fails to comply with signal indications or speed restrictions). Because MBTA Green Line trains are governed by automatic signal indication, they do not need written authority from a train dispatcher to occupy main tracks. Consequently, train dispatchers in the MBTA Operations Control Center do not normally issue any documents to MBTA trains except when non-revenue equipment, such as maintenance trucks or inspection cars, is operating on the route. Control center dispatchers monitor operations and become involved in train movements only when circumstances require it, such as when workers are present along the right-of-way. Control center dispatchers also maintain service logs of equipment defects and failures. The train dispatcher on duty at the time of the accident stated that the Green Line D Branch route was relatively self-dispatching and that he had no real involvement in the movement of these trains. He stated that the train crews have the ability and responsibility to route their trains by lining switches themselves; they do not rely on the train dispatcher to line switches. Because operations on this line are governed strictly by signal indications, the dispatcher does not issue train orders for MBTA Green Line operations. MBTA operating employees are governed by MBTA hours-of-service restrictions. The MBTA’s Rule 12A, “Limitation of Work Hours,” places limits on duty and is based on an order from the Massachusetts Department of Public Utilities issued on January 12, 1980. Under the order, covered employees may not work more than 16 consecutive hours and are required to receive at least 6 hours off-duty time before going on duty. The rule also prohibits a covered employee from working more than 60 hours in a 7-day workweek. Operating Rules Relevant to Accident Rules for Trainpersons and Other Employees of the Light Rail Lines specifies the required procedures for complying with wayside signals. Regarding signal H-64, near the west end of Waban station, the rules state that (because of a permanent speed restriction in that area) a train departing Waban station on a permissive aspect shall not exceed 25 mph until reaching a “resume” sign 871 feet past the signal. Other applicable rules include the following: Rule 19. “Attention to Duty” All employees have an inherent responsibility to pay attention to their duties at all times. To insure a safe operation of any vehicle and to maintain a high level of professionalism…. Rule 55. “Restricted Speed”

NTSB Railroad Accident Report 14 Proceed at a speed NOT EXCEEDING TEN (10) MILES PER HOUR: the Operator must watch for a broken rail or a switch not properly lined and must stop their car or train short of a car, train or other obstruction…. Rule 56. “Observance of Signals” (a) Operators will be held to a strict observance of the indication given by automatic block and interlocking signals: also by hand, flag or lantern signals. (b) The use of automatic block signals in no way relieves Operators from exercising the greatest care and vigilance. Mechanical Information Each train consisted of two Kinki Sharyo Type 7 trolley cars. The striking train consisted of cars 3667 (the lead car) and 3706 coupled in tandem. The struck train consisted of cars 3681 (the lead car) and 3703. The trains were driven by electric motors receiving power from a 600- volt overhead catenary system. All four cars were in the MBTA series 3600-3719 and were built by Kinki Sharyo Co., Ltd. Cars 3667 and 3681 were built in 1988; cars 3703 and 3706 were built in 1997. Each car was designed to carry 50 passengers seated and 151 standing with an operation maximum load of 269 passengers. The vehicles weighed 85,500 pounds each and were 74 feet long. Each car had three two-axle trucks. The outboard trucks13 were powered; the center truck was non-powered. The train operator’s compartment was at the left front of the lead car. The operator’s right foot activated pedals for braking and accelerating. A “dead man” pedal activated by the operator’s left foot had to remain depressed or the train brakes would automatically apply to stop the train. The operating compartment in the rear car, usually occupied by the trail operator was the same as the one in the lead car. Both operating compartments had a “mushroom” button that activated emergency braking. Investigators examined inspection and maintenance records for all four cars involved in this accident. The records indicated that all inspections and scheduled maintenance had been performed as required. The previous year’s maintenance records for the lead car (car 3667) on the striking train showed that all reported defects had been corrected. Pre-Departure Tests Trains 3681 and 3667 were prepared for service by the MBTA mechanical department on the evening of May 27, 2008, and then placed in a ready location for departure the next morning. An outbound operator is required to inspect the equipment and report any defects. The MBTA yardmaster was not informed of any defects being identified with either train during the initial inspection, nor was the MBTA control center notified of any defective condition during the day.

13 Outboard trucks refers to the wheel arrangement at each end of a car consisting of two solid axles, left and right side frames, and an electric motor.

NTSB Railroad Accident Report 15 Postaccident Inspection of Striking Train The cars, 3667 and 3706, of the striking train, were given initial inspections at the accident site and more detailed inspections after the equipment was moved to the MBTA Riverside maintenance facility. Before the cars were removed from the accident site, all the brakes were applied on both cars in their original at-rest positions. Initial and subsequent inspections revealed that the brake pads of the two cars were slightly worn but with service life remaining. The rotors displayed a work-polished surface with no apparent signs of overheating, scoring, or checking in the contact areas. Wheel profiles were all well within MBTA standards. No binding or chafing was observed between any components or between the trucks and their respective car bodies. No evidence was found that anything had dragged along the track structure before the accident. Track Information General The portion of the MBTA Green Line on which the accident occurred consists of two main tracks: an outbound, or westbound, track and an inbound, or eastbound, track. The two main tracks are oriented geographically east to west between the Waban and Woodland stations, with the outbound track to the north of the inbound track. The track grade ascends slightly from Waban to Woodland. Trains departing Waban station proceed on the west main track and pass signal H-64 on straight track before travelling under an overhead bridge and over a switch for a crossover from the eastbound to westbound main tracks. After this crossover is a 2° curve about 500 feet long. Just to the west of this curve is signal H-66, where train 3681 had stopped moments before the collision. The main track is owned, inspected, maintained, and operated by the MBTA. The track structure at the point of collision consists of continuous 115-pound welded rail14 affixed to wooden crossties resting on double shoulder tie plates held in place by spikes or Pandrol15 fasteners. The track structure is held in place with granite ballast. The section of track at the point of collision showed no signs of improper drainage. The entire Green Line is powered by a 600-volt overhead catenary system that provides the energy for train movements on both main tracks. The catenary system is affixed to steel poles spaced about 100 feet apart and placed outside of the clearance envelope of the tracks. Track Inspections MBTA policy calls for main track to be inspected three times weekly with at least 1 calendar day between inspections. Bimonthly switch certification reports are also required.

14 Continuous welded rail consists of rail sections that have been welded together in lengths greater than 400 feet. 15 Pandrol is a type of rail fastener that clips to the rail and is screwed into the crosstie.

NTSB Railroad Accident Report 16 MBTA track inspectors had inspected the tracks in the accident area earlier on the day of the accident and had noted no defects. Investigators reviewed the two previous sets of inspection records for the crossover between the Waban and Woodland stations and did not take any exceptions. Investigators reviewed the MBTA’s inspection records for D Branch main track between Reservoir and Riverside covering the period from February 29, 2008, to May 28, 2008. The records indicated that all inspection criteria had been met. Switch inspection records for the previous 4 months did not identify any exceptions for the switches east of the point of collision. After the accident, on May 29 and 30, 2008, a walking track inspection was conducted that covered portions of the main track preceding the point of collision. No defects were noted. Permanent Speed Restriction In the area of the derailment, the main tracks were maintained for 40-mph operation, which was the maximum authorized speed between the Waban and Woodland stations. However, the MBTA had placed a permanent 25-mph speed restriction on the westbound main track over the turnout of the crossover from eastbound to westbound track. The track segment with the speed restriction begins 215 feet west of the Waban station and continues for 667 feet. Because of the proximity of the speed-restricted track segment to Waban station, a train operator could manage the acceleration of the train out of the station so that it would not reach 25 mph until after it has passed over that segment. Signal Information General The automatic block signal system in use on the D Branch of the MBTA Green Line incorporates four-aspect Union Switch & Signal (US&S) color light type signals and US&S hand-operated switch machines operating in conjunction with 25-hertz a.c. track circuits. Dual- filament 10-volt lamps illuminate signal heads. Signals in this territory are arranged for single- direction running on each track. The signal system is configured to display the aspects and indications shown in Table 2. Table 2. Green Line signal aspects and indications. Aspect Indication Red over Red Stop Red Stop. Proceed after 1 minute at restricted speed. (Proceed, prepared to stop short of a train, car, or other obstruction and watch for broken rail or switch not properly lined, not exceeding 10 mph to next signal). Yellow Proceed prepared to stop at next signal. Green Proceed at authorized speed.

NTSB Railroad Accident Report 17 Postaccident Inspection/Testing of Signal System Representatives from the MBTA and the Massachusetts Department of Public Utilities participated with NTSB investigators in the postaccident field inspection and testing of the signal system in the accident area. Because of the age of the signal system, it did not incorporate a signal data recorder. The postaccident inspection found all signal units, signal cases, and switches locked and secured, with no indications of tampering or vandalism that would interfere with the operation of the signal system. Relay positions were consistent with the physical location of the accident trains and the displayed signal aspects. None of the signal units or switches was damaged in the accident. The collision resulted in the wreckage of the two trains occupying track circuits H-66 and H-64. This condition resulted in signals H-66 and H-64 both displaying the appropriate red aspect. After the train wreckage was removed from the track circuits and the signal was tested, signal H-66 continued to display a red aspect when, during the tests, it should have displayed green. A subsequent visual inspection identified two locations with broken rail bonds.16 At these locations, the rail ends had been double bonded, and the breaks in some of the bonds appeared to be fresh, suggesting that they likely occurred during removal of the wreckage. But the breaks in other bonds were rusted over, indicating that they had been in that condition before the accident.17 In order to conduct postaccident testing, all the bonds were replaced, after which signal H-66 displayed the appropriate clear signal indication (green aspect) with no trains on the track circuits. Operational tests of signals H-64 and H-66 showed both signals to be performing as designed. After testing, the relays from signals H-64 and H-66 were removed and taken to the MBTA relay shop where they were bench tested and where operating values were recorded. All the relays were operating within specifications. No exceptions were identified with either the design or operation of the MBTA signal system. All tests indicated that the signal system was working as designed with lamp voltages to signals H-64 and H-66 within acceptable limits. Signal Maintenance Records Investigators examined MBTA maintenance records for signals H-64 and H-66, as well as for the switches for the crossover. The MBTA requires that signal inspections be performed monthly. The records indicated that all signal tests and inspections had been conducted in accordance with MBTA requirements. Test and inspection records indicated that the ground tests, monthly tests, wayside signal, and switch obstruction tests were performed for both crossover switches in April 2008. Insulation resistance testing was performed in 1993. Relays

16 Bonds are wires that form a connection between the ends of rail sections in order to maintain electrical continuity across a joint. 17 The signal system was designed so that, in the event of a malfunction of a system component, the affected signal would display its most restrictive indication. For signal H-66, this was a single red aspect.

NTSB Railroad Accident Report 18 were tested in 2006. All test records indicated that the signal system was functioning as designed. A review of MBTA monthly signal inspection reports for the previous 6 months did not identify any exceptions to signal performance in the vicinity of the accident. MBTA Rules Regarding Anomalous Signal Displays MBTA signal and switch rules require certain actions when a train operator encounters an imperfectly displayed or defective signal. The procedures are explained in MBTA Rules 59 and 60(a), which state the following: Rule 59: A. An interlocking signal imperfectly displayed, such as where there is no light or a white light, is a defective signal. The indication is STOP. Under no circumstances are Operators to pass through interlocking signals imperfectly displayed except under personal direction by an authorized person. B. An automatic block signal imperfectly displayed such as when there is no light or a white light, or more than one light at points where one light normally shows, is a defective signal. The indication is STOP. Wait one (1) minute, and then proceed at restricted speed. (Proceed, prepared to stop short of a car, train, or other obstruction and watch for broken rail or switch not properly lined, not exceeding ten (10) miles per hour). C. At locations where there is a crossover with facing point switches, you will find on the automatic block signal a multiple number of aspects. With no aspect, Operators must wait for orders from an authorized person to proceed. It’s the Operator’s responsibility to see that the switches are properly set before passing on its points and proceed at a speed no greater than ten (10) mph. The conditions described in (a), (b) and (c) above must be reported at once to the first Official reached or the OCC [operations control center] dispatcher. Rule 60(a) Flagging by signals – Central District, Highland Branch, High Speed Operations: (a) Signal Holding Red or is Defective: When a block signal holds red or is defective, the Motorperson [train operator], after waiting one (1) minute, will proceed at restricted speed (proceed, prepared to stop short of car, train or other obstruction and watch for broken rail, switch not properly aligned, not exceeding TEN (10) MILES PER HOUR) to the next signal. The operator of the struck train in this accident stated that signal H-66 was displaying a single red aspect when he encountered it just before the collision. He said he stopped his train for the required 1 minute before proceeding even though he could see that no other trains were occupying the block. He did not report the red signal aspect to the Operations Control Center on the accident trip, even though he could see that the track ahead was clear, nor did MBTA rules require that he do so.

NTSB Railroad Accident Report 19 Because of an absence of train operator reports regarding red aspects at signal H-66, investigators were not able to determine how long the signal had been displaying a red aspect before train 3681 arrived. Investigators did determine that after the broken bonds were replaced, signal H-66 displayed an aspect correct for the conditions. Investigators also determined that at the time of the accident, signal H-64 was displaying a proper single red aspect for the striking train because of the presence of the stopped train in the block governing that signal. Governmental Oversight of MBTA Federal Transit Administration A part of the DOT, the Federal Transit Administration (FTA) administers funding to public transportation systems throughout the Unites States. Unlike administrations within the DOT whose authority stems from the Constitution’s Interstate Commerce Clause, the FTA was authorized using the General Welfare Clause. It therefore received from Congress no regulatory authority. Title 49 United States Code Section 5334(b) specifically prohibits the secretary of transportation from regulating the operation, routes, or schedules of a public transportation system. The primary enforcement mechanism available to the FTA is the ability to withhold Federal funds from states that do not comply with the terms and conditions of its Federal assistance agreement. In response to passage of the Intermodal Surface Transportation Efficiency Act of 1991, the FTA implemented the State Safety Oversight Program, which placed the responsibility for rail transit safety on the states maintaining public transit systems. The FTA has established minimum safety requirements that all states and rail transit agencies must adhere to in order to receive Federal funding. These requirements address the techniques that are to be used to conduct inspections and testing, the required maintenance audits and inspection programs, and the procedures to be used for employee training and certification. Massachusetts Department of Public Utilities The MBTA is subject to oversight by the FTA through the offices of the Massachusetts Department of Public Utilities Transportation Oversight Division, which has developed and implemented a System Safety Program Plan comprising 21 safety elements defined in Title 49 Code of Federal Regulations Part 659. The MBTA’s safety department is responsible for an annual internal audit of compliance with a portion of the plan elements so that over a 3-year period, compliance with all 21 elements will have been audited. The results of these audits are provided as annual reports to the Department of Public Utilities. The MBTA provided investigators with the annual report of internal audits for 2007. Investigators focused on the sections for safety and security and right-of-way. The report states the following: While the MBTA Safety Department provides management oversight to the implementation of and adherence to the Authority’s System Safety Program Plan,

NTSB Railroad Accident Report 20 the success of this plan is largely dependent on the safety culture that is fostered within each department and work group throughout the Authority. To achieve this, management staff is expected to define, understand, and integrate effective safety practices into the day-to-day work activities, to ensure that the safety of employees, passengers and guests remain a top priority. The Safety Program Plan states that critical safety department activities include the following: …developing and implementing programs to increase public, passenger and employee safety awareness; reporting preventive and corrective solutions for identified safety hazards; establishing and maintaining safety guidelines through employee training programs. MBTA Employee Performance Monitoring Chapter 8 of the Safety System Program Plan addresses rules and procedures compliance by MBTA employees. The section does not include a requirement that MBTA supervisors conduct field tests of operating employees in order to determine overall compliance with operating rules. According to MBTA officials, observations of operating personnel on Green Line trains and buses were not formalized at the time of this accident. Most observations of employee performance were made during chance meetings of supervisory employees and operating crews, although some operational checks resulted from customer complaints or were done randomly based on supervisor availability. The MBTA had established no formal efficiency testing program that would, through check rides, planned observations, or set-up situations, provide a comprehensive evaluation of employee rule compliance. Supervisors did document instances in which an employee was observed violating an operating or safety rule, but the total number of observations was not recorded. The MBTA was unable to provide investigators with a detailed history of the deceased operator’s performance history during her relatively short period of employment. On February 14, 2009, the MBTA, through issuance of a standard operating procedure, established a safety rules compliance program designed to: provide for unannounced operational testing, inspection and observations under the various operating conditions of the system during operation to determine the extent of compliance with operating rules, policies and procedures, Special Instructions, Special Orders, Special Bulletins, training, etc. By performing these inspections, the Authority’s goals are to: • Reduce accidents caused by human error. • Improve and enhance the vigilance of employees to comply with established rules and procedures.

NTSB Railroad Accident Report 21 • Determine the degree of compliance with established rules to improve compliance. • Focus attention on rules and areas where there is a need to improve employees’ knowledge, training and skill level. • Incorporate lessons learned into existing training Programs. • The new procedure was also designed with the following objectives: • To serve as reinforcement for established rules and procedures. • To establish a ‘baseline’ of documentation that tracks an individual employee’s compliance with operating rules absent of an accident investigation. • Allows management, training staff and supervisory personnel to assess trends and incorporate this information into established training Programs.

1. Allows

an individual employee the opportunity for additional training/instruction if an issue with compliance is identified (before an accident/incident occurs). For rail operations, the procedure contains schedules, instructions, and forms for evaluating employees with regard to compliance with speed restrictions, door procedures, signal indications, and cab operating procedures. According to MBTA representatives, as of May 21, 2009, the agency had conducted 2,088 employee compliance audits under the new procedures with a pass rate of 97.6 percent. Sight-Distance Tests On June 1, 2008, investigators conducted sight-distance tests at the accident site. The weather at the time the tests were begun was partly clear skies (some clouds), and temperatures were in the 70s. The tests began about 5:20 p.m. The MBTA provided two train sets for the tests. The simulated struck train traveled westward from Waban station and stopped east of signal H-66, where the standing train had held at the red signal before the accident. In the first two test scenarios, the simulated striking train was positioned at different positions within Waban station with the operator in the normal seated position on the left side of the cab. From all tested positions, investigators could clearly see the aspect of signal H-64. The third through sixth test scenarios were designed to determine how soon after leaving Waban station the striking train operator could have seen the rear of the train stopped ahead. The tests revealed that the operator would have had the first, partial, view of the rear of the stopped train when the striking train was about 1,037 feet (linear rail distance) away. A better view of the rear of the stopped train and its markers lights was obtained when the striking train was 910 feet away. From a distance of 764 feet, the operator would have had an unobstructed view of the rear

NTSB Railroad Accident Report 22 of the stopped train and would have been able to see that the train was stopped on the westbound track. In the sixth scenario, the simulated striking train returned to the Waban station to view signal H-64 at the approximate time of day the accident train would have encountered the signal. Investigators reported having a clear view of the signal and its aspect. For the seventh scenario, the position of the simulated standing train was marked, and the train was moved. The simulated striking train then departed the station on a permissive signal and proceeded westward. The test train operator complied with the permanent 25-mph speed restriction in place over the switch on the westward track. At the end of the speed-restricted track segment, the operator resumed acceleration until the train reached a speed of 38 mph. At that point, about 7 seconds and 394 feet from the point of impact, the test operator initiated normal (full service) braking. The train came to a stop 25 feet short of the mark indicating the rear of the standing train. Other Information MBTA Actions Taken Since Accident MBTA officials reported to the NTSB that, in the wake of the accident, the agency took the following actions: In the weeks following the accident, MBTA management initiated a pilot program to assist in the development of a comprehensive rules compliance program. The pilot program culminated in the issuance of the previously discussed February 14, 2009, standard operating procedure regarding rules compliance testing. As part of that program, the agency also implemented a data tracking system that allows management to detect trends in rules compliance so that enforcement procedures or training may be modified as necessary. The director of subway operations instituted a Human Factors Task Group that is reviewing accident data to identify ways to prevent accidents caused by human error. The group meets monthly and includes management representatives from the areas of operations, training, safety, labor relations, human resources, and occupational health services. Before the accident, the MBTA had adopted a requirement that newly procured vehicles be equipped with event recorders. Currently, for heavy rail, all Blue Line No. 5 cars have event recorders. For light rail, all No. 8 cars have event recorders. For commuter rail, all locomotives and control cars have event recorders. A pilot program to evaluate an automatic train operation system on one MBTA rail line has been developed and is pending funding. Typical automatic train operation systems incorporate controlled speed, programmed station stopping, door operation, performance level modification, and other functions traditionally assigned to the train crew.

NTSB Railroad Accident Report 23 Emergency Preparedness The MBTA has an agreement with the state Department of Public Utilities to conduct an annual transit emergency response exercise. The MBTA also conducts training for local emergency responders. The training, which consists of an 8-hour course for new recruits and a refresher course for experienced responders, includes subway and light rail operations and safety procedures. The training is offered at the request of fire departments and, for light rail, covers right-of-way safety, electrical safety, and vehicle familiarization, including jacking procedures. An 8-hour light rail program was conducted for the Newton and Brookline fire departments on May 14, 2007. Eleven attendees participated in this training. A 2-hour refresher was also conducted on May 14, 2007, with 16 attendees from the Newton Fire Department participating in the training. Fault Loggers Each of the cars involved in the accident was equipped with three fault loggers. The primary purpose of the fault loggers is to facilitate maintenance and troubleshooting; they do not serve as traditional event recorders. They are triggered whenever a fault is generated on board the train, and they store vehicle information relating to the fault at the time it was generated. The fault loggers thus provide only a snapshot of selected parameters. Each fault logger samples independently and will not necessarily register the same faults as other loggers on a particular car or train. The “A” and “B”’ loggers on each car monitor the wheel truck assemblies at either end of the car, while the “C” logger monitors the center, non- powered, truck assembly. Data from the fault loggers on the trains involved in this accident were downloaded and used to determine the speed of each train at the time of impact.

NTSB Railroad Accident Report 24 Analysis Exclusions NTSB investigators reviewed the signal system and performed postaccident signal testing. The postaccident examination revealed that the signal system was configured to allow for safe train operations and to provide adequate stopping distances. Signal H-64, just west of the Waban station, was showing the proper red aspect (because of the stopped train ahead) when the striking train departed the station, and the signal was clearly visible from the operating compartment of the striking train. Investigators also examined the MBTA train equipment and reviewed maintenance records. The equipment that was tested, including the braking systems, worked as intended. The track and structures had been maintained within the appropriate tolerances. All surviving crewmembers stated that the workload up until the time of the accident had been moderate, with nothing abnormal to report. Toxicological tests of all crewmembers were negative for alcohol and illegal drugs. A review of employee records indicated that the operators and trailing operators of both trains were trained and qualified to perform their duties. None of the crewmembers were using a cell phone or radio at the time of the accident. The weather was warm with clear skies; neither precipitation nor sunlight affected the visibility of the signals. The operator of the struck train had stopped in accordance with MBTA rules when his train encountered the red aspect at signal H-66. The train was already beginning to move forward when it was struck. The NTSB therefore concludes that the following were neither causal nor contributory to the accident: weather conditions, equipment performance, track condition, crewmember use of alcohol or illegal drugs, crewmember use of cell phones, crew training and qualifications, or the performance of the crew of the struck train. Elements of the Newton fire and police departments were dispatched to the scene of the accident within 6 minutes and arrived within about 8 minutes. They established a triage area and arranged for the evacuation of the injured. An MBTA superintendent also arrived quickly and requested additional MBTA resources and additional rescue personnel. The NTSB therefore concludes that the emergency response to this accident was timely and appropriate. The Accident Under normal conditions, a train departing Waban station will accelerate toward the next station stop at Woodland, about 4,300 feet away. The trip from station to station takes anywhere from 73 seconds to 2 minutes in the absence of any obstructions. About 215 feet from Waban station, a train will encounter a sign restricting train speed to 25 mph beginning at that point. After another 667 feet, a sign indicates that speed can be resumed to the 40-mph limit imposed on that track segment. In practice, the speed restriction typically does not require any unusual action on the part of the operator in that a westbound train can accelerate out of Waban station so that it will not reach 25 mph before the end of the speed restriction area. On the day of the accident, train 3681, the struck train, arrived at and served the Waban station shortly before the arrival of train 3667, the striking train. Train 3681 departed the station normally and accelerated until encountering signal H-66, which, because of broken bond wires, was displaying a red aspect even though the track ahead was clear. By this time, train 3667, the

NTSB Railroad Accident Report 25 striking train, was approaching or entering Waban station. According to the operator of train 3681, he stopped his train short of the red signal H-66 in accordance with MBTA rules. The presence of train 3681 caused signal H-64, just outside Waban station, to also display a red aspect. Seeing this aspect, the operator of train 3667 should have held short of signal H-64 for 1 minute before proceeding at a speed not to exceed 10 mph while looking out for other trains or obstructions. According to the trail operator of the striking train, on the day of the accident, the train served the station normally. He did not indicate that the train held at the station any longer than usual. Instead, he said the train began to accelerate normally out of the station. Operating the train after the station stop would have required that the operator wait until the doors were closed and then, while depressing the dead man pedal, move her right foot from the brake pedal to the accelerator pedal. She must have performed these actions on the day of the accident without waiting the required 1 minute, in violation of the signal indication being displayed by signal H-64. If the operator had simply failed to observe or note the red aspect at signal H-64, she had more than ample time to correct the mistake. Postaccident sight-distance tests showed that she would have had a partial view of the stopped train when the trains were still 1,037 feet apart. After traveling 127 feet farther, she would have had a full view of the rear of the train and its marker lights. After another 146 feet, she would have had an unobstructed view of the stopped train and would have been aware that it was on the same track as her train. At any of these points, she could have slowed her train and prevented the accident. In fact, the sight-distance tests showed that even if the operator had achieved a speed of 38 mph and waited until the trains were only 394 feet apart, she could have used normal (not emergency) braking to bring her train to a safe stop short of a collision. Performance of Operator of Striking Train The NTSB considered why the operator of the striking train did not comply with the signal indication and subsequently failed to take actions to avoid the accident even though she had ample opportunity to do so. Discounting an intentional and willful disregard for her own safety and that of the passengers, for which the investigation found no evidence, the only reasonable explanation is that the operator, during or slightly after beginning to accelerate out of Waban station, lost awareness of her environment. The thorough autopsy performed on the operator by the state’s chief medical examiner revealed no preexisting medical condition that would have had the potential for causing this loss of awareness, and no postmortem evidence was found that the operator suffered a sudden medical event that would have precipitated a loss of consciousness. Instead, the evidence indicates that the most likely explanation of the operator’s loss of awareness is that she experienced a micro-sleep18 episode shortly after departing Waban station.

18 A micro-sleep is an episode of sleep that may last from a fraction of a second up to 30 seconds or more. Although often associated with sleep disorders such as sleep apnea, narcolepsy, or hypersomnia, episodes of micro- sleep can occur in any individual suffering from fatigue or inadequate sleep.

NTSB Railroad Accident Report 26 The operator worked a regular schedule and was not subject to irregular work/rest cycles, which have been shown to promote fatigue. According to her family and acquaintances, she normally retired between 10:00 and 10:30 p.m. and was called by a friend at 6:30 a.m. each day. Her normal schedule would thus have provided her with an 8-hour period within which to obtain sleep. However, the investigation could not determine whether the operator had maintained this schedule in the days leading up to the accident. The drug doxylamine, commonly found in over-the-counter sleep aids, was found in the operator’s urine. This suggests that she might have taken the medication because she had some trouble sleeping during at least one of the several nights leading up to the accident but that she had not used the medication since the night before the accident at the latest. The operator was found to have a lesion on her abdomen that would likely have been painful enough to have interfered with her ability to gain restful sleep, and she may have taken the doxylamine to counter that pain or discomfort. The fact that the medication was not found in the operator’s blood makes it unlikely that she would have been impaired by it on the day of the accident.19 The circumstances of this accident included several additional factors that placed the operator at risk for diminished alertness and for subsequently lapsing into episodes of micro- sleep. The 5:51 p.m. time of the accident coincided with the later afternoon low of the human circadian rhythm, a time of day in which studies have shown that individuals can fall asleep rapidly.20 Moreover, the low level of muscular activity required of the seated operator and her relatively low workload are both factors that have been established as contributors to diminished alertness.21 Based on the operator’s height and weight at the time of her last physical examination, she had a calculated body mass index (BMI) of 38.6. By this calculation, the operator would have been considered obese (a BMI greater than 30 constitutes obesity). Obesity is significantly associated with an increased risk for obstructive sleep apnea. In one study, obstructive sleep apnea was exhibited in more than 50 percent of patients with an average BMI of 40.0.22 Obstructive sleep apnea is associated with fatigue and significant cognitive and psychomotor deficits that are at least partially reversible with appropriate treatment.23 Accident rates have been shown to be considerably higher in drivers with obstructive sleep apnea than in

19 The presence of the medication in the operator’s urine but not in her blood indicates that the medication had already been metabolized and that its effects had subsided. 20 U.S. Congress, Office of Technology Assessment, Biological Rhythms: Implications for the Worker, OTA- BA-463 (Washington, DC: U.S. Government Printing Office, September 1991). 21 M. Moore-Ede, The Twenty-Four Hour Society: Understanding Human Limits in a World That Never Sleeps (Reading, MA: Addison-Wesley Publishing Company, 1993). 22 O. Resta and others. “Sleep-Related Breathing Disorders, Loud Snoring and Excessive Daytime Sleepiness in Obese Subjects.” International Journal of Obesity-Related Metabolic Disorders. May 2001; 25(5): pp. 669-675. 23 L. Ferini-Strambi and others. “Cognitive Dysfunction in Patients with Obstructive Sleep Apnea (OSA): Partial Reversibility After Continuous Positive Airway Pressure (CPAP).” Brain Research Bulletin. June 30, 2003; 61(1): pp. 87-92.

NTSB Railroad Accident Report 27 those without the disorder.24 The Federal Motor Carrier Safety Administration (FMCSA) medical review board recently recommended that the FMCSA require screening for obstructive sleep apnea in all drivers with a BMI over 30. The NTSB concludes that the operator of the striking train was at a high risk for having undiagnosed sleep apnea and that she may have been chronically fatigued as a result of the condition. Once the operator had departed Waban station, she likely would have had no operational matters to attend to other than those routine and long-practiced tasks, such as controlling train speed, that would almost be second nature to an experienced person operating along a familiar route. Such a low demand on her mental resources, in concert with fatigue from poor sleep quality due to discomfort and/or to undiagnosed sleep apnea, likely caused her to become relaxed and to disengage from her environment consistent with lapsing into a micro-sleep sometime after she departed Waban station. It is possible that if she observed the red signal at Waban station, she proceeded based on the belief that any train ahead would clear by the time her train arrived. She may have intended to hold her train’s speed below 10 mph through the block, but during an episode of micro-sleep, the train would have continued to accelerate. The NTSB therefore concludes that the operator of the striking train failed to respond appropriately to the controlling signal indication or to take advantage of several opportunities to slow or stop the train and to prevent the accident likely because she experienced a micro-sleep episode after departing Waban station. In its investigation of an August 15, 2000, accident involving the Maryland Transit Administration Central Light Rail Line System at the Baltimore-Washington International Airport light rail transit station,25 the NTSB identified as an element of the probable cause the previously undiagnosed obstructive sleep apnea of the train operator. The condition caused the operator to fall asleep and fail to brake the train before it stuck a bumping post at the terminus. As a result of that accident investigation, the NTSB issued the following safety recommendation to all U.S. rail transit systems: R-01-27 Ensure that your fatigue educational awareness program includes the risks posed by sleeping disorders, the indicators and symptoms of such disorders, and the available means of detecting and treating them. In March 20, 2002, and June 18, 2002, responses to Safety Recommendation R-01-27, the MBTA informed the NTSB that it did not have a formal fatigue awareness program but that, in response to the NTSB recommendation, it had completed an introductory fatigue awareness campaign and that:

24 J. Teran-Santos, A. Jimenez-Gomez, and J. Cordero-Guevara. “The Association Between Sleep Apnea and the Risk of Traffic Accidents.” Cooperative Group Burgos-Santander. New England Journal of Medicine. March 18, 1999; 340(11): pp. 847-851. 25Maryland Transit Administration Light Rail Vehicle Accidents at the Baltimore-Washington International Airport Transit Station Near Baltimore, Maryland, February 13 and August 15, 2000, Railroad Special Investigation Report NTSB/SIR-01/02 (Washington, DC: National Transportation Safety Board, 2001).

NTSB Railroad Accident Report 28 The Wellness Program will continue to provide informational material to our employees. In addition, the MBTA University’s Wellness Institute will collaborate with the Operations division in designing a fatigue education program. The MBTA also responded that its medical clinic would “enhance” its data collection sheets “to include specific questions on the signs and symptoms of sleep disorders.” Based on these responses, the NTSB, on May 17, 2002, classified Safety Recommendation R-01-27 “Open—Acceptable Response.” During the investigation of the Newton, Massachusetts, accident, NTSB investigators examined material currently provided formally by the MBTA to its train operators with regard to fatigue and sleep disorders. This material consisted of a single audio-visual slide titled “Fatigue/Drowsiness” and a single paragraph in the current Green Line Light Rail Vehicle Operation Defensive Driving Manual. The paragraph in the operator’s manual quotes the text of the audio-visual slide and states, in part: All you need to do is get enough rest. Most people need 8 hours of sleep per night. Know what sleep you require and take care of yourself by getting the proper rest. Based on the examination of these materials, the NTSB believes that the MBTA continues to have a fatigue awareness program that fails to adequately address potential sleep disorders among its train operators. Thus, the agency has not appropriately responded to the intent of Safety Recommendation R-01-27. The NTSB therefore reclassifies Safety Recommendation R-01-27 “Open—Unacceptable Response” and reiterates this recommendation to the MBTA. With regard to revisions or enhancements the MBTA indicated to the NTSB that it would make to its medical data collection form, the form continues to lack any inquiries about sleep disorders, snoring, or any difficulties with sleep. Such inquiries could provide a basis for identifying train operators and others in safety-sensitive positions who are at risk for obstructive sleep apnea or other disorders so that those individuals can receive additional evaluation and, if necessary, appropriate treatment. The NTSB concludes that the MBTA continues to have an inadequate fatigue awareness program to educate train operators about the risks of fatigue and an inadequate program to identify and address potential sleep disorders for its train operators. Further, given the seriousness of the risks posed by undiagnosed sleep apnea among transit operators, the NTSB recommends that, not only the MBTA, but all U.S. rail transit agencies should review their medical history and physical examination forms and modify them as necessary to ensure that they elicit specific information about any previous diagnosis of obstructive sleep apnea or other sleep disorders and about the presence of specific risk factors for such disorders. The NTSB further recommends that all U.S. rail transit agencies establish a program to identify operators who are at high risk for obstructive sleep apnea or other sleep disorders and require that such operators be appropriately evaluated and treated.

NTSB Railroad Accident Report 29 The NTSB also believes that the Federal Transit Administration should promote awareness, throughout the transit industry, of the safety risks associated with sleep disorders and should assist transit agencies in developing programs to minimize that risk. The NTSB therefore recommends that the Federal Transit Administration develop and disseminate guidance for operators, transit authorities, and physicians regarding the identification and treatment of individuals at high risk for obstructive sleep apnea and other sleep disorders. MBTA Signal Rules Reporting of Anomalous Signal Aspects The MBTA defines defective signals in Rule 59 of the Rules for Trainpersons and Other Employees of the Light Rail Lines. The rule defines a defective signal as one that is imperfectly displayed, typically with conflicting aspects or no aspect. In this accident, signal H-66—which caused the struck train to stop and thus created the conditions under which this particular accident could occur—was not imperfectly displayed. The only aspect illuminated was red, indicating stop and proceed. The reason the signal showed red was the presence of broken bond wires. Operators of trains made to stop by the signal indication could easily see that the track ahead was unoccupied and that the signal was possibly displaying an inappropriate aspect. The investigation could not determine how long signal H-66 had been displaying red before the accident. While the operator of the struck train told NTSB investigators that he had observed a similar occurrence at this location on one of his trips that morning and that he had reported it, there was no record of a trouble report at this location. Because train operators are not required to report such apparent anomalies to the train dispatcher, maintenance employees may not be notified of a possible problem with the signal system and thus may not effect any necessary repairs. The NTSB concludes that the broken bonds associated with signal H-66 caused a delay that placed train 3681 in a position to be struck by train 3667. The NTSB further concludes that because MBTA operating rules do not require that train operators report signals displaying red when the block of track governed by that signal can be determined to be unoccupied, possible problems in the signal system could remain undetected and unrepaired, which could increase safety risks on the rail line. Signal aspects other than red can also appear to be inappropriate for the apparent track conditions, and these apparent anomalies should also be made known to MBTA dispatchers. The NTSB therefore recommends that the MBTA require that train operators immediately report to the train dispatcher any inappropriately displayed aspects and all red signal aspects they encounter when the block of track governed by that signal can be seen to be clear of other trains. Notification of Restrictive Signals When the striking train departed Waban station, the trail operator did not know that the train was operating under a restrictive signal indication. If he had known, he might have been able to contact the train operator via the train intercom, had it been working, to question why the train did not hold for the specified time and, once it departed the station, why it was accelerating normally, as if under a clear signal indication. Even if the train operator had been disengaged from her duties at that time (assuming she was not so disengaged earlier that she failed to note

NTSB Railroad Accident Report 30 the red signal), such a call may have alerted her so that she could have responded in a way that would have prevented the accident. If she did not respond, the trail operator would have had the option of stopping the train. However, MBTA rules do not require that train operators keep other crewmembers informed of restrictive signal indications. By not being so informed, the other crewmembers are limited in their ability to participate fully in the operation of the train and are thus limited in their ability to implement effective crew resource management. The NTSB concludes that, had the MBTA required train operators to inform trail operators of restrictive signal indications and had the operator of the striking train informed her trail operator of the restrictive signal indication just west of Waban station, the trail operator might have been able to prevent the accident by questioning the operator about the train speed or by applying the brakes. As it was, however, the trail operator did not know that anything was wrong until the moment of impact. The NTSB therefore recommends that the MBTA require train operators to notify other train crewmembers when the train encounters a restrictive signal and to inform crewmembers of the operator’s intended means of complying with the restrictions. This should also include a requirement that the other crewmembers acknowledge receiving this notification. Positive Train Control Four decades of NTSB investigations of railroad accidents have shown that the most effective means of avoiding train-to-train collisions is through use of a positive train control system that will automatically stop a train if the crew fails to comply with a signal indication. Previous investigations have identified a wide range of factors that can affect a train crew’s response to signal indications, such as multiple simultaneous distractions, cell phone usage, dense fog, crew inattention, use of prescription medications, and fatigue. This accident in Newton, Massachusetts, is another in a long series of accidents that could have been prevented had the territory been equipped with a positive train control system. Such a system could have detected that train 3667 was operating above the allowable speed of 10 mph as required by the signal indication at signal H-64 and could have provided an over speed warning or stopped the train if the operator failed to comply with the signal indication. The NTSB therefore concludes that this accident could have been prevented had the MBTA Green Line been equipped with a positive train control system that could have intervened to stop train 3667 before it could strike the rear of train 3681. The Rail Safety Improvement Act of 2008 requires each class I, intercity, and commuter rail carrier (carriers regulated by the Federal Railroad Administration) to develop and submit to the U.S. Secretary of Transportation, within 18 months, its plan for the implementation of a positive train control system by December 31, 2015. Transit agencies that operate trolley, light rail, and heavy rail systems are not included in the requirements of the Rail Safety Improvement Act of 2008. The NTSB therefore recommends that the FTA facilitate the development and implementation of positive train control systems for rail transit systems nationwide. The NTSB further recommends the MBTA develop and implement a positive train control system for all of its rail lines.

NTSB Railroad Accident Report 31 Trolley Car Crashworthiness The lead car of train 3667 (car 3667) and the trailing trolley car of train 3681 (car 3703) sustained substantial damage. Although the anticlimber showed indications of engagement, the forward end of car 3667 overrode the rear end of car 3703. The understructure and end structure failed on both trolley cars, resulting in the loss of more than 10 feet of survivable space on both cars. The operator’s compartment was crushed such that the operator could not have survived this accident. The NTSB concludes that the failure of the structure of the trolley cars resulted in the catastrophic loss of survivable space. There are no Federal standards for transit car crashworthiness. The NTSB addressed this issue during its investigation of the November 3, 2004, collision of two Washington Metropolitan Area Transit Authority Metrorail trains in Washington, D.C.26 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 last railcar’s passenger compartment. As a result of the accident, the NTSB made the following recommendation to the FTA: R-06-6 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. The FTA responded in February 2008 that, in cooperation with the American Public Transportation Association and the American Society of Mechanical Engineers, it will develop new standards for light and heavy rail transit vehicles that incorporate crash energy management principles. The agency also noted that it is researching crash energy management specifications for overhauling the front ends of existing light rail vehicles. Based on this response, the NTSB has classified Safety Recommendation R-06-6 “Open–Acceptable Response.”

26 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: National Transportation Safety Board, 2006).

NTSB Railroad Accident Report 32 Conclusions Findings

1. The following were neither causal nor contributory to the accident: weather conditions,

equipment performance, track condition, crewmember use of alcohol or illegal drugs, crewmember use of cell phones, crew training and qualifications, or the performance of the crew of the struck train.

1. The emergency response to this accident was timely and appropriate.
2. The operator of the striking train was at a high risk for having undiagnosed sleep apnea, and

she may have been chronically fatigued as a result of the condition.

1. The operator of the striking train failed to respond appropriately to the controlling signal

indication or to take advantage of several opportunities to slow or stop the train and to prevent the accident likely because she experienced a micro-sleep episode after departing Waban station.

1. The Massachusetts Bay Transportation Authority continues to have an inadequate fatigue

awareness program to educate train operators about the risks of fatigue and an inadequate program to identify and address potential sleep disorders for its train operators.

1. The broken bonds associated with signal H-66 caused a delay that placed train 3681 in a

position to be struck by train 3667.

1. Because Massachusetts Bay Transportation Authority operating rules do not require that train

operators report signals displaying red when the block of track governed by that signal can be determined to be unoccupied, possible problems in the signal system could remain undetected and unrepaired, which could increase safety risks on the rail line.

1. Had the Massachusetts Bay Transportation Authority required train operators to inform trail

operators of restrictive signal indications and had the operator of the striking train informed her trail operator of the restrictive signal indication just west of Waban station, the trail operator might have been able to prevent the accident by questioning the operator about the train speed or by applying the brakes.

1. This accident could have been prevented had the Massachusetts Bay Transportation

Authority Green Line been equipped with a positive train control system that could have intervened to stop train 3667 before it could strike the rear of train 3681.

1. The failure of the structure of the trolley cars resulted in the catastrophic loss of survivable

space.

NTSB Railroad Accident Report 33 Probable Cause The National Transportation Safety Board determines that the probable cause of the May 28, 2008, collision of two Massachusetts Bay Transportation Authority Green Line trains in Newton, Massachusetts, was the failure of the operator of the striking train to comply with the controlling signal indication, likely as a result of becoming disengaged from her environment consistent with experiencing an episode of micro-sleep. Contributing to the accident was the lack of a positive train control system that would have intervened to stop the train and prevent the collision.

NTSB Railroad Accident Report 34 Recommendations As a result of its investigation of the May 28, 2008, collision between two Massachusetts Bay Transportation Authority Green Line trains, the National Transportation Safety Board makes the following safety recommendations: New Recommendations To the Federal Transit Administration: Facilitate the development and implementation of positive train control systems for rail transit systems nationwide. (R-09-08) Develop and disseminate guidance for operators, transit authorities, and physicians regarding the identification and treatment of individuals at high risk for obstructive sleep apnea and other sleep disorders. (R-09-09) To all U.S. rail transit agencies: Review your medical history and physical examination forms and modify them as necessary to ensure that they elicit specific information about any previous diagnosis of obstructive sleep apnea or other sleep disorders and about the presence of specific risk factors for such disorders. (R-09-10) Establish a program to identify operators who are at high risk for obstructive sleep apnea or other sleep disorders and require that such operators be appropriately evaluated and treated. (R-09-11) To the Massachusetts Bay Transportation Authority: Require that train operators immediately report to the train dispatcher any inappropriately displayed aspects and all red signal aspects they encounter when the block of track governed by that signal can be seen to be clear of other trains. (R-09-12) Require train operators to notify other train crewmembers when the train encounters a restrictive signal and to inform crewmembers of the operator’s intended means of complying with the restrictions. Include a requirement that the other crewmembers acknowledge receiving this notification. (R-09-13) Develop and implement a positive train control system for all of your rail lines. (R-09-14)

NTSB Railroad Accident Report Recommendation Reiterated in Report To the Massachusetts Bay Transportation Authority: R-01-27 Ensure that your fatigue educational awareness program includes the risks posed by sleeping disorders, the indicators and symptoms of such disorders, and the available means of detecting and treating them. Recommendation Reclassified in Report To the Massachusetts Bay Transportation Authority: R-01-27 Ensure that your fatigue educational awareness program includes the risks posed by sleeping disorders, the indicators and symptoms of such disorders, and the available means of detecting and treating them. Safety Recommendation R-01-27, previously classified “Open—Acceptable Response,” is reclassified “Open—Unacceptable Response” in the “Performance of Operator of Striking Train” section of this report.

BY THE NATIONAL TRANSPORTATION SAFETY BOARD MARK V. ROSENKER KATHRYN O’LEARY HIGGINS Acting Chairman Member DEBORAH A. P. HERSMAN ROBERT L. SUMWALT Member Member

Adopted: July 14, 2009

35

NTSB Railroad Accident Report 36 Appendix A Investigation The National Response Center notified the NTSB of the accident about 7:00 p.m. on May 28, 2008. The investigator-in-charge and other members of the NTSB investigative team were launched from the Washington, D.C., headquarters office and from the Chicago, Illinois; Gardena, California; and Jacksonville, Florida; field offices. Investigative groups were established in the areas of operations, track, signals, mechanical, human performance, survival factors, and event recorder issues. No hearings or depositions were held in conjunction with this accident. Member Kathryn O’Leary Higgins was the Board Member on scene. Parties to the investigation included the Massachusetts Bay Transportation Authority, the Massachusetts Department of Public Utilities, and the Amalgamated Transit Union (Boston Carmen's Union).

FD07372 ｜ 2010_美国_AAR1001.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2010 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

Loss of Control on Approach Colgan Air, Inc. Operating as Continental Connection Flight 3407 Bombardier DHC-8-400, N200WQ Clarence Center, New York February 12, 2009

Accident Report NTSB/AAR-10/01 PB2010-910401

National Transportation Safety Board

NTSB/AAR-10/01 PB2010-910401 Notation 8090A Adopted February 2, 2010

Aircraft Accident Report Loss of Control on Approach Colgan Air, Inc. Operating as Continental Connection Flight 3407 Bombardier DHC-8-400, N200WQ Clarence Center, New York February 12, 2009

National Transportation Safety Board

490 L’Enfant Plaza, S.W. Washington, D.C. 20594

National Transportation Safety Board. 2010. Loss of Control on Approach, Colgan Air, Inc., Operating as Continental Connection Flight 3407, Bombardier DHC-8-400, N200WQ, Clarence Center, New York, February 12, 2009. NTSB/AAR-10/01. Washington, DC.

Abstract: This report discusses the accident involving a Colgan Air, Inc., Bombardier DHC-8-400, N200WQ, operating as Continental Connection flight 3407, which experienced a loss of control on an instrument approach to Buffalo-Niagara International Airport, Buffalo, New York, and crashed into a residence in Clarence Center, New York, about 5 nautical miles northeast of the airport. The safety issues discussed in this report focus on strategies to prevent flight crew monitoring failures, pilot professionalism, fatigue, remedial training, pilot training records, airspeed selection procedures, stall training, Federal Aviation Administration (FAA) oversight, flight operational quality assurance programs, use of personal portable electronic devices on the flight deck, the FAA’s use of safety alerts for operators to transmit safety-critical information, and weather information provided to pilots. Safety recommendations concerning these issues are addressed to the FAA.

The National Transportation Safety Board (NTSB) 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 NTSB 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 Internet at http://www.ntsb.gov. Other information about available publications also may be obtained from the website or by contacting:

National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, SW Washington, DC 20594 (800) 877-6799 or (202) 314-6551

NTSB publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2010-910401 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 NTSB reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

NTSB Aircraft Accident Report Contents Figures .............................................................................................................................................v  Tables ..............................................................................................................................................v  Abbreviations ............................................................................................................................... vi  Executive Summary .......................................................................................................................x  1.  .................................................................................................................1  Factual Information 1.1  ...................................................................................................................1  History of Flight 1.2  ................................................................................................................6  Injuries to Persons 1.3  ..............................................................................................................6  Damage to Aircraft 1.4  ......................................................................................................................6  Other Damage 1.5  ..........................................................................................................6  Personnel Information 1.5.1  .................................................................................................................6  The Captain 1.5.1.1  ...............................................8  Activities in the 72 Hours Preceding the Accident 1.5.1.2  .....................................................................................................9  Federal Aviation Administration Certificate Disapprovals and Colgan Air Training Events 1.5.2  .......................................................................................................11  The First Officer 1.5.2.1  .............................................13  Activities in the 72 Hours Preceding the Accident 1.5.2.2  .......................................................................................14  Previous Stall Training 1.6.  ...........................................................................................................15  Aircraft Information 1.6.1  .........................................15  Weight and Balance Information and Performance Data 1.6.2  .................................................................................................16  Airspeed Indications 1.6.3  .............................................................................................18  Stall Protection System 1.6.4  ............................................................................19  Ice Detection and Deicing System 1.6.5  ................................................................................................21  Maintenance Records 1.7  ...............................................................................................22  Meteorological Information 1.8  .............................................................................................................23  Aids to Navigation 1.9  ................................................................................................................24  Communications 1.10  ............................................................................................................24  Airport Information 1.10.1  ....................................................................................................24  Air Traffic Control 1.11  .................................................................................................................25  Flight Recorders 1.11.1  ............................................................................................25  Cockpit Voice Recorder 1.11.2  .................................................................................................26  Flight Data Recorder 1.12  ....................................................................................26  Wreckage and Impact Information 1.13  ..............................................................................28  Medical and Pathological Information 1.14  .....................................................................................................................................28  Fire 1.15  ................................................................................................................28  Survival Aspects 1.15.1  .........................................................................................28  Fire Emergency Response 1.15.2  ............................................................................28  Natural Gas Emergency Response i

NTSB Aircraft Accident Report 1.16  .............................................................................................................30  Tests and Research 1.16.1  ......................................................................................30  Aircraft Performance Study 1.16.2  ....................................................................31  Aircraft Performance Simulation Study 1.17  ...................................................................33  Organizational and Management Information 1.17.1  ................................................................................................34  Flight Crew Training 1.17.1.1  ......................................................................................................35  Stall Training 1.17.1.2  ................................................................................38  Winter Operations Training 1.17.1.3  ..............................................................................................39  Remedial Training 1.17.1.4  ...............................................................39  Crew Resource Management Training 1.17.1.5  ..............................................................................41  Captain Leadership Training 1.17.2  ..........................................................................................................42  Flight Manuals 1.17.2.1  ........................................................................42  Reference and Approach Speeds 1.17.2.2  ...........................................................................42  Operations in Icing Conditions 1.17.2.3  ..........................................44  Descent, Approach, and Before Landing Checklists 1.17.2.4  ...........................................44  Approach Profile and Stabilized Approach Criteria 1.17.3  ........................................................................................45  Sterile Cockpit Procedures 1.17.4  ....................................................................................................46  Commuting Policy 1.17.4.1  ....................................................47  Commuting Status of Pilots Based at Newark 1.17.5  ...........................................................................................................48  Fatigue Policy 1.17.6  ....................................................................................................50  Crew Room Policy 1.17.7  ........................................................................................................51  Safety Programs 1.17.7.1  .........................................................................51  Safety Management and Culture 1.17.7.2  ..................................................................................53  Safety Reporting Methods 1.17.7.3  .........................................................................54  Aviation Safety Action Program 1.17.7.4  .............................................................................55  Line Operations Safety Audit 1.17.7.5  ................................................................55  Flight Operational Quality Assurance 1.17.7.6  .........................................................................56  Additional Postaccident Actions 1.17.7.7  ......................................................57  Safety Communications at the Newark Base 1.18  ......................................................................................................57  Additional Information 1.18.1  ...........................................................................57  Previous Safety Recommendations 1.18.1.1  ..................................................................................57  Sterile Cockpit Adherence 1.18.1.2  .........................................................................................58  Situational Awareness 1.18.1.3  ..........................................................................................58  Pilot Professionalism 1.18.1.4  .......................................................................59  Monitoring Pilot Responsibilities 1.18.1.5  ............................................................................................60  Flight Crew Fatigue 1.18.1.6  ......................................................................................................63  Stall Training 1.18.1.7  .....................................................65  Remedial Training and Additional Oversight 1.18.1.8  .......................................................................................................66  Pilot Records 1.18.1.9  ...............................................................................69  Air Carrier Safety Programs 1.18.1.10  ..........................................................................................70  Air Carrier Oversight 1.18.1.11  ..........................................................................71  Low-Airspeed Alerting System 1.18.1.12  .....................................................................................................72  Airplane Icing 1.18.1.13  ...........................................................................73  Weather Information for Pilots 1.18.2  ..............................................................74  Federal Aviation Administration Guidance 1.18.2.1  ..........................................................................74  Pilot Records Improvement Act 1.18.2.2  ............................................................................74  Line Operations Safety Audits ii

NTSB Aircraft Accident Report 1.18.2.3  ................................................................75  Flight Operational Quality Assurance 1.18.2.4  ..........................................................................75  Standard Operating Procedures 1.18.3  ....................................................................................................76  Interview with Colgan Air Flight Crew of Burlington, Vermont Stick Shaker Event 1.18.4  ........................................................................................77  Previous Related Accident 1.18.5  .............................................................78  Gulfstream Training Academy Information 2.  ...................................................................................................................................80  Analysis 2.1  ...............................................................................................................................80  General 2.2  .............................................................................................................81  Accident Sequence 2.2.1  ...................................................................................................................81  Overview 2.2.2  ..................................................................................................83  Approach to Airport 2.2.2.1  .........84  Possible Reasons for Failed Detection of Impending Stick Shaker Onset 2.2.3  ........................................................................86  Response to Stick Shaker Activation 2.2.3.1  .............................................89  Possible Reasons for Failed Recovery Procedures 2.2.4  ..............................................................................91  Captain’s Management of Flight 2.3  .........................................................................93  Strategies to Prevent Monitoring Failures 2.3.1  .............................................................................93  Flight Crew Monitoring Training 2.3.2  .............................................................................................95  Flight Deck Procedures 2.3.3  ....................................................................................95  Low-Airspeed Alert Systems 2.4  .........................................................................................................98  Pilot Professionalism 2.4.1  ..................................................................................................98  Leadership Training 2.4.2  ...............................................100  Sterile Cockpit and Standard Operating Procedures 2.4.3  ..................................................................................103  Crew Resource Management 2.5  .............................................................................................................................104  Fatigue 2.5.1  ..........................................................106  Role of Fatigue in Flight Crew Performance 2.5.2  ........................................................................108  Industry Fatigue Mitigation Efforts 2.6  .....................................................................................113  First Officer’s Illness Symptoms 2.7  ..............................................................114  Captain’s Disapprovals and Training Problems 2.7.1  .........................................................117  Remedial Training and Additional Oversight 2.7.2  ............................................................................................119  Pilot Training Records 2.7.3  ..............................................................................121  Pilot Records Improvement Act 2.8  ........................................................................................123  Airspeed Selection Procedures 2.9  ...................................................................................................................126  Stall Training 2.9.1  ..............................................................................................128  Stick Pusher Training 2.9.2  ...................................................................................................130  Simulator Fidelity 2.9.3  ..........................................................................................134  Tailplane Stall Training 2.10  ....................................................................135  Federal Aviation Administration Oversight 2.11  ............................................................................................................139  Company Policies 2.11.1  ....................................................................139  Flight Operational Quality Assurance 2.11.2  ...........................142  Use of Personal Portable Electronic Devices on the Flight Deck 2.12  ..............................................................................................144  Safety Alerts for Operators 2.13  ....................................................145  Preflight Weather Documents and Icing Terminology 2.13.1  .................................................................................145  Preflight Weather Documents 2.13.2  ..................................................................................................148  Icing Terminology iii

NTSB Aircraft Accident Report 3.  ...........................................................................................................................151  Conclusions 3.1  ...........................................................................................................................151  Findings 3.2  ................................................................................................................155  Probable Cause 4.  ................................................................................................................156  Recommendations 4.1  ...................................................................................................156  New Recommendations 4.2  .....................................159  Previously Issued Recommendations Reiterated in This Report 4.3  ..................................160  Previously Issued Recommendations Reclassified in This Report Board Member Statements .......................................................................................................161 

1. Appendixes..............................................................................................................................174 

Appendix A—Investigation and Hearing ....................................................................................174 Appendix B—Cockpit Voice Recorder Transcript ......................................................................175 iv

NTSB Aircraft Accident Report Figures Figure 1. Q400 Indicated Airspeed Display .................................................................................17  Figure 2. Q400 Reference Speeds Switch .....................................................................................18  Figure 3. Q400 Engine Display Showing Ice Detected and Increased Reference Speeds Message ...........................................................................................20  Tables Table 1. Injury Chart .......................................................................................................................6  Table 2. Colgan Air’s Approach-to-Stall Training Events ...........................................................35  Table 3. Geographic Distribution of Colgan Air Pilots Based at Newark, New Jersey ...............48  Table 4. Icing Definitions ...........................................................................................................149 

v

NTSB Aircraft Accident Report vi Abbreviations AAIB

Air Accidents Investigation Branch of the United Kingdom AC advisory circular ACARS aircraft communications addressing and reporting system AFM airplane flight manual agl above ground level AIM Aeronautical Information Manual AIRMET Airmen’s Meteorological Information ALB Albany International Airport ALPA Air Line Pilots Association AOA angle-of-attack AOM airplane operating manual APM aircrew program manager ASAP aviation safety action program ASIAS aviation safety information analysis and sharing ASOS automated surface observing system ASRS Aviation Safety Reporting System ATC air traffic control ATCT air traffic control tower ATIS automatic terminal information service ATOS air transportation oversight system BTV Burlington International Airport BUF Buffalo-Niagara International Airport

NTSB Aircraft Accident Report vii CFM

company flight manual CFR Code of Federal Regulations CRM crew resource management CVR cockpit voice recorder CWA Center Weather Advisory DOD Department of Defense eice en route ice accumulation EWR Newark Liberty International Airport FAA Federal Aviation Administration FDR flight data recorder FOQA flight operational quality assurance FRMS fatigue risk management system FSDO flight standards district office GIA Gulfstream International Airlines Hg mercury IAH George Bush Intercontinental Airport IAS indicated airspeed IATA International Air Transport Association ICAO International Civil Aviation Organization IEP internal evaluation program IFR instrument flight rules ILS instrument landing system InFO information for operators IOE initial operating experience

NTSB Aircraft Accident Report viii LOSA

line operations safety audit MEM Memphis International Airport METAR meteorological aerodrome report msl mean sea level MSP Minneapolis-St. Paul International/Wold-Chamberlain Airport NASA National Aeronautics and Space Administration NDB nondirectional beacon nm nautical mile NOTAM notice to airmen NPRM notice of proposed rulemaking NTSB National Transportation Safety Board NWS National Weather Service ORF Norfolk International Airport PF pilot flying PFD primary flight display PIC pilot-in-command PIREP pilot report PM pilot monitoring POI principal operations inspector PRIA Pilot Records Improvement Act PST Pacific standard time QAR quick access recorder RDU Raleigh-Durham International Airport ROC Greater Rochester International Airport

NTSB Aircraft Accident Report ix SAFO

safety alert for operators SEA Seattle-Tacoma International Airport SIC second-in-command SIGMET Significant Meteorological Information SMS safety management system TSB Transportation Safety Board of Canada Vfri flap retract speed Vga go-around speed Vref reference landing speed VSR reference stall speed VMC visual meteorological conditions VOR very high frequency omnidirectional radio range VVM verbalize, verify, and monitor YYZ Toronto Pearson International Airport

NTSB Aircraft Accident Report x Executive Summary On February 12, 2009, about 2217 eastern standard time, a Colgan Air, Inc., Bombardier DHC-8-400, N200WQ, operating as Continental Connection flight 3407, was on an instrument approach to Buffalo-Niagara International Airport, Buffalo, New York, when it crashed into a residence in Clarence Center, New York, about 5 nautical miles northeast of the airport. The 2 pilots, 2 flight attendants, and 45 passengers aboard the airplane were killed, one person on the ground was killed, and the airplane was destroyed by impact forces and a postcrash fire. The flight was operating under the provisions of 14 Code of Federal Regulations Part 121. 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 captain’s inappropriate response to the activation of the stick shaker, which led to an aerodynamic stall from which the airplane did not recover. Contributing to the accident were (1) the flight crew’s failure to monitor airspeed in relation to the rising position of the low- speed cue, (2) the flight crew’s failure to adhere to sterile cockpit procedures, (3) the captain’s failure to effectively manage the flight, and (4) Colgan Air’s inadequate procedures for airspeed selection and management during approaches in icing conditions. The safety issues discussed in this report focus on strategies to prevent flight crew monitoring failures, pilot professionalism, fatigue, remedial training, pilot training records, airspeed selection procedures, stall training, Federal Aviation Administration (FAA) oversight, flight operational quality assurance programs, use of personal portable electronic devices on the flight deck, the FAA’s use of safety alerts for operators to transmit safety-critical information, and weather information provided to pilots. Safety recommendations concerning these issues are addressed to the FAA.

NTSB Aircraft Accident Report 1

1. Factual Information
2. 1

History of Flight On February 12, 2009, about 2217 eastern standard time,1 a Colgan Air, Inc., Bombardier DHC-8-400 (Q400),2 N200WQ, operating as Continental Connection flight 3407,3 was on an instrument approach to Buffalo-Niagara International Airport (BUF), Buffalo, New York, when it crashed into a residence in Clarence Center, New York, about 5 nautical miles (nm) northeast of the airport. The 2 pilots, 2 flight attendants, and 45 passengers aboard the airplane were killed, one person on the ground was killed, and the airplane was destroyed by impact forces and a postcrash fire. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121. Night visual meteorological conditions (VMC) prevailed at the time of the accident. The home base of operations for both the captain and the first officer was Liberty International Airport (EWR), Newark, New Jersey. On February 11, 2009, the captain had completed a 2-day trip sequence, with the final flight of the trip arriving at EWR at 1544. Also that day, the first officer began her commute from her home near Seattle, Washington, to EWR at 1951 Pacific standard time (PST), arriving at EWR (via Memphis International Airport [MEM], Memphis, Tennessee) on the day of the accident at 0623. The captain and the first officer were both observed in Colgan’s crew room on February 12 before their scheduled report time of 1330.4 The flight crew’s first two scheduled flights of the day, from EWR to Greater Rochester International Airport (ROC), Rochester, New York, and back, had been canceled because of high winds at EWR and the resulting ground delays at the airport.5 The company dispatch release for flight 3407 was issued at 1800 and showed an estimated departure time of 1910 and an estimated en route time of 53 minutes. The airplane to be used for flight 3407, N200WQ, arrived at EWR at 1854. A first officer whose flight arrived at EWR at 1853 saw, as he exited his airplane, the flight 3407 captain and first officer walking toward the accident airplane. The airplane’s aircraft communications addressing and reporting system (ACARS) showed a departure clearance request at 1930 and pushback from the gate at

1 All times in this report are eastern standard time based on a 24-hour clock unless otherwise noted. 2 According to Bombardier’s website, the DHC-8 has been known as a Q-series airplane since 1996. The Q400 entered service in 2000. 3 Continental Airlines and Colgan Air were involved in a code-sharing arrangement, but each air carrier had separate 14 Code of Federal Regulations Part 121 certificates, and Federal Aviation Administration oversight of each air carrier was conducted by separate certificate management teams. 4 The captain’s and the first officer’s activities before and after their scheduled report time are detailed in section 1.5. 5 As part of the airlines’ code-sharing arrangement, Colgan flights were subject to cancellation by Continental. The Colgan EWR regional chief pilot stated, during a postaccident interview, that Continental’s EWR operations center had called him to cancel multiple Continental Connection flights that day.

NTSB Aircraft Accident Report 2 1945.6 According to the cockpit voice recorder (CVR) recording, the EWR ground controller provided taxi instructions for the flight at 2030:28,7 which the first officer acknowledged. About 2041:35, the first officer stated, “I’m ready to be in the hotel room,” to which the captain replied, “I feel bad for you.” She continued, “this is one of those times that if I felt like this when I was at home there’s no way I would have come all the way out here.”8 She then stated, “if I call in sick now I’ve got to put myself in a hotel until I feel better … we’ll see how … it feels flying. If the pressure’s just too much … I could always call in tomorrow at least I’m in a hotel on the company’s buck but we’ll see. I’m pretty tough.” The captain responded by stating that the first officer could try an over-the-counter herbal supplement, drink orange juice, or take vitamin C. The CVR recorded the tower controller clearing the airplane for takeoff about 2118:23. The first officer acknowledged the clearance, and the captain stated, “alright cleared for takeoff it’s mine.” According to the dispatch release, the intended cruise altitude for the flight was 16,000 feet mean sea level (msl).9 The flight data recorder (FDR) showed that, during the climb to altitude, the propeller deice and airframe deice equipment were turned on (the pitot static deicing equipment had been turned on before takeoff) and the autopilot was engaged. The airplane reached its cruising altitude of 16,000 feet about 2134:44. The cruise portion of flight was routine and uneventful. The CVR recorded the captain and the first officer engaged in an almost continuous conversation throughout that portion of the flight, but these conversations did not conflict with the sterile cockpit rule, which prohibits nonessential conversations within the cockpit during critical phases of flight.10 About 2149:18, the CVR recorded the captain making a sound similar to a yawn. About 1 minute later, the captain interrupted his own conversation to point out, to the first officer, traffic that was crossing left to right. About 2150:42, the first officer reported the winds to be from 250° at 15 knots gusting to 23 knots; afterward, the captain stated that runway 23 would be used for the landing. About 2153:40, the first officer briefed the airspeeds for landing with the flaps at 15° (flaps 15) as 118 knots (reference landing speed [Vref]) and 114 knots (go-around speed [Vga]), and the captain acknowledged this information. About 2156:26, the first officer stated, “might be easier on my ears if we start going down sooner.” About 2156:36, the captain instructed the first officer to “get discretion to twelve [thousand feet].” Less than 1 minute later, a controller from Cleveland Center cleared the flight to descend to 11,000 feet, and the first officer acknowledged the clearance.

6 ACARS enables pilots to communicate with company personnel on the ground. ACARS is used to exchange routine flight status messages and weather information. Some of these messages, such as the time that a flight leaves the gate, takes off, and touches down, are sent and received automatically. 7 About 7 minutes earlier, the captain had made an announcement over the public address system, indicating that the taxi delay was the result of the weather conditions at the time. 8 The CVR recorded the first officer sneezing and sniffling. 9 All altitudes in this report are expressed as msl unless otherwise noted. 10 The sterile cockpit rule refers to 14 CFR 121.542, “Flight Crewmember Duties,” which is discussed in section 1.17.3.

NTSB Aircraft Accident Report 3 About 2203:38, the Cleveland Center controller instructed the flight crew to contact BUF approach control, and the first officer acknowledged this instruction. The first officer made initial contact with BUF approach control about 2203:53, stating that the flight was descending from 12,000 to 11,000 feet with automatic terminal information service (ATIS) information “romeo,”11 and the approach controller provided the airport altimeter setting and told the crew to plan an instrument landing system (ILS) approach to runway 23. About 2204:16, the captain began the approach briefing. About 2205:01, the approach controller cleared the flight crew to descend and maintain 6,000 feet, and the first officer acknowledged the clearance. About 30 seconds later, the captain continued the approach briefing, during which he repeated the airspeeds for a flaps 15 landing. FDR data showed that the airplane descended through 10,000 feet about 2206:37. From that point on, the flight crew was required to observe the sterile cockpit rule. About 2207:14, the CVR recorded the first officer making a sound similar to a yawn. About 2208:41 and 2209:12, the approach controller cleared the flight crew to descend and maintain 5,000 and 4,000 feet, respectively, and the first officer acknowledged the clearances. Afterward, the captain asked the first officer about her ears, and she indicated that they were stuffy and popping. About 2210:23, the first officer asked whether ice had been accumulating on the windshield, and the captain replied that ice was present on his side of the windshield and asked whether ice was present on her windshield side. The first officer responded, “lots of ice.” The captain then stated, “that’s the most I’ve seen—most ice I’ve seen on the leading edges in a long time. In a while anyway I should say.” About 10 seconds later, the captain and the first officer began a conversation that was unrelated to their flying duties. During that conversation, the first officer indicated that she had accumulated more actual flight time in icing conditions on her first day of initial operating experience (IOE) with Colgan than she had before her employment with the company.12 She also stated that, when other company first officers were “complaining” about not yet having upgraded to captain, she was thinking that she “wouldn’t mind going through a winter in the northeast before [upgrading] to captain.” The first officer explained that, before IOE, she had “never seen icing conditions … never deiced … never experienced any of that.” About 2212:18, the approach controller cleared the flight crew to descend and maintain 2,300 feet, and the first officer acknowledged the clearance. Afterward, the captain and the first officer performed flight-related duties but also continued the conversation that was unrelated to their flying duties. About 2212:44, the approach controller cleared the flight crew to turn left onto a heading of 330°. About 2213:25 and 2213:36, the captain called for the descent and approach checklists, respectively, which the first officer performed. About 2214:09, the approach controller cleared the flight crew to turn left onto a heading of 310°, and the autopilot’s

11 An ATIS broadcasts continuous weather observations and other advisory information to pilots operating on or near an airport. ATIS broadcasts are updated hourly or more frequently if conditions change. ATIS information “romeo” relayed information from a BUF weather observation at 2154; see section 1.7 for information about the observation. 12 According to the CVR, the first officer stated, about 2210:58, that she had accumulated 1,600 hours during flights in the Phoenix, Arizona, area. Section 1.5.2 provides additional details about the first officer’s flying experience.

NTSB Aircraft Accident Report 4 altitude hold mode became active about 1 second later as the airplane was approaching the preselected altitude of 2,300 feet. The airplane reached this altitude about 2214:30; the airspeed was about 180 knots at the time. About 2215:06, the captain called for the flaps to be moved to the 5° position, and the CVR recorded a sound similar to flap handle movement. Afterward, the approach controller cleared the flight crew to turn left onto a heading of 260° and maintain 2,300 feet until established on the localizer for the ILS approach to runway 23. The first officer acknowledged the clearance. The captain began to slow the airplane less than 3 miles from the outer marker to establish the appropriate airspeed before landing. According to FDR data, the engine power levers13 were reduced to about 42° (flight idle was 35°) about 2216:00, and both engines’ torque values were at minimum thrust about 2216:02. The approach controller then instructed the flight crew to contact the BUF air traffic control tower (ATCT) controller. The first officer acknowledged this instruction, which was the last communication between the flight crew and air traffic control (ATC). Afterward, the CVR recorded sounds similar to landing gear handle deployment and landing gear movement, and the FDR showed that the propeller condition levers had been moved forward to their maximum RPM position and that pitch trim14 in the airplane- nose-up direction had been applied by the autopilot.15 About 2216:21, the first officer told the captain that the gear was down; at that time, the airspeed was about 145 knots. Afterward, FDR data showed that additional pitch trim in the airplane-nose-up direction had been applied by the autopilot and that an “ice detected” message appeared on the engine display in the cockpit. About the same time, the captain called for the flaps to be set to 15° and for the before landing checklist. The CVR then recorded a sound similar to flap handle movement, and FDR data showed that the flaps had been selected to 10°.16 FDR data also showed that the airspeed at the time was about 135 knots. At 2216:27.4, the CVR recorded a sound similar to the stick shaker. (The stick shaker warns a pilot of an impending wing aerodynamic stall17 through vibrations on the control column, providing tactile and aural cues.) The CVR also recorded a sound similar to the autopilot disconnect horn, which repeated until the end of the recording. FDR data showed that,

13 The pilots set the power lever angle and the propeller condition lever angle for each engine. 14 Pitch trim is used to reduce the long-term pilot or autopilot forces required to maintain a target attitude and counter the effects of changes to the airplane’s center of gravity, airspeed, or lift during flap extension or retraction. The pitch trim actuators can be either automatically controlled by the autopilot or manually controlled by a pilot. For the accident flight, after the autopilot was selected on (shortly after takeoff), the FDR pitch trim adjustments were applied by the autopilot. (There was no activity in the four discrete parameters dedicated to each pilot’s use of manual pitch trim once the autopilot was selected on.) 15 FDR data showed the airplane’s airspeed as the following for each of these events: landing gear selected down, about 180 knots; propeller condition levers selected to maximum, about 170 knots; and pitch trim applied by the autopilot in the airplane-nose-up direction, about 160 knots. 16 Although the captain called for flaps 15, the flap handle needed to be positioned in the 10° detent before moving to the 15° detent. The trailing edge flap position reached 10° about 2216:34. 17 Stalls occur when the AOA of the wing—that is, the angle between the direction of airflow and the wing— exceeds a critical angle at which the air can no longer flow smoothly over the wing. Stalls disrupt lift, increase drag, and decrease roll control.

NTSB Aircraft Accident Report 5 when the autopilot disengaged, the airplane was at an airspeed of 131 knots. FDR data showed that the control columns moved aft at 2216:27.8 and that the engine power levers were advanced to about 70° (rating detent was 80°) 1 second later.18 The CVR then recorded a sound similar to increased engine power, and FDR data showed that engine power had increased to about 75 percent torque. FDR data also showed that, while engine power was increasing, the airplane pitched up; rolled to the left, reaching a roll angle of 45° left wing down; and then rolled to the right. As the airplane rolled to the right through wings level, the stick pusher activated (about 2216:34), and flaps 0 was selected. (The Q400 stick pusher applies an airplane-nose-down control column input to decrease the wing angle-of-attack [AOA] after an aerodynamic stall.) About 2216:37, the first officer told the captain that she had put the flaps up. FDR data confirmed that the flaps had begun to retract by 2216:38; at that time, the airplane’s airspeed was about 100 knots. FDR data also showed that the roll angle reached 105° right wing down before the airplane began to roll back to the left and the stick pusher activated a second time (about 2216:40). At the time, the airplane’s pitch angle was -1°. About 2216:42, the CVR recorded the captain making a grunting sound. FDR data showed that the roll angle had reached about 35° left wing down before the airplane began to roll again to the right. Afterward, the first officer asked whether she should put the landing gear up, and the captain stated “gear up” and an expletive. The airplane’s pitch and roll angles had reached about 25° airplane nose down and 100° right wing down, respectively, when the airplane entered a steep descent. The stick pusher activated a third time (about 2216:50). FDR data showed that the flaps were fully retracted about 2216:52. About the same time, the CVR recorded the captain stating, “we’re down,” and a sound of a thump. The airplane impacted a single-family home (where the ground fatality occurred), and a postcrash fire ensued.19 The CVR recording ended about 2216:54.

18 The rating detent for the engine power levers (80° in this case) is a low-force, or soft, detent on the power quadrant at which the engines’ fully rated power for takeoff, climb, and cruise is achieved. Power lever travel beyond the rating detent is possible but is available only for emergency use. 19 The postcrash fire was also the result of a severed natural gas service pipeline at the home, as discussed in section 1.15.2.

NTSB Aircraft Accident Report 6 1.2 Injuries to Persons Table 1. Injury Chart Injuries Flight Crew Cabin Crew Passengers Other Total Fatal 2 2 45 1 50 Serious 0 0 0 0 0 Minor 0 0 0 0 0 None 0 0 0 0 0 Total 2 2 45 1 50 1.3 Damage to Aircraft The airplane was destroyed by impact forces and a postcrash fire. 1.4 Other Damage One house and two cars in the driveway of the house were destroyed as a result of the airplane’s impact and the postcrash fire. The house’s detached garage remained intact, but an attached garage of an adjacent house was damaged from the impact of a section of the airplane’s outboard right wing. 1.5 Personnel Information 1.5.1 The Captain The captain, age 47, held an airline transport pilot certificate and a Federal Aviation Administration (FAA) first-class medical certificate dated August 22, 2008, 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 DHC-8 on November 18, 2008. According to his application for employment with Colgan, from August 2004 to April 2005,20 the captain attended the first officer program at Gulfstream Training Academy, Fort Lauderdale, Florida, where he was the second-in-command (SIC) on the Beech BE-1900D for Gulfstream International Airlines (GIA).21 Between April and August 2005, the captain worked

20 FAA records indicated that the captain received his private pilot single-engine and instrument certificates in June 1990 and October 1991, respectively. FAA records also indicated that the captain received his commercial pilot instrument and single-engine certificates in June 2002 and his multiengine certificate in April 2004. 21 The CVR recorded the captain stating, about 2050:33, “I went through Gulfstream’s program ‘cause … it was the best program for … the timeframe that I had. You know how fast I wanted to get into the one twenty one environment … so it really worked out well for me.” Information on the Gulfstream Training Academy is provided in section 1.18.5.

NTSB Aircraft Accident Report 7 in a non-aviation-related field. He was hired by Colgan in September 2005. The captain reported on his employment application that, in addition to the BE-1900D, he had flown the Piper PA-32 and PA-28 and the Cessna C-172. He also reported 618 total flight hours, including 38 hours of actual instrument time, and 71 hours of simulator instrument time. Colgan’s flight records indicated that the captain had accumulated 3,379 hours of total flying time, including 3,051 hours in turbine airplanes, 1,030 hours as a pilot-in-command (PIC), and 111 hours on the Q400. He had flown 116, 56, and 16 hours in the 90, 30, and 7 days, respectively, before the accident.22 (These times do not include the accident flight.) The captain’s transition (from the Saab 340 to the Q400) ground training occurred on October 31, 2008; his transition proficiency check occurred on November 18, 2008; and his transition line check occurred on December 3, 2008. FAA records indicated that the captain received four certificate disapprovals (as discussed in section 1.5.1.2). FAA records also 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 check airman who conducted the captain’s Q400 simulator training and line-oriented flight training characterized the captain’s decision-making abilities as very good. The check airman stated that the captain, when receiving unusual attitude23 training in the simulator, had somewhat overcontrolled the roll axis but had progressed during his subsequent simulator experience. The check airman who provided the captain with his IOE described the captain’s performance as good and indicated that his greatest strength was being methodical and meticulous. Other check airmen indicated that the captain had difficulties with the Q400 flight management system, but one of the check airmen pointed out that such difficulties were typical for pilots transitioning to the Q400. The first officer who flew with the captain on February 10 and 11, 2009, stated that the captain handled the airplane well, used checklists, and did not miss callouts. The first officer reported that, during their flights, the captain stated that the workload for the Q400 was significantly less than that for the Saab 340. First officers who flew with the captain in January 2009 indicated that he flew the Q400 competently. These first officers also indicated that the captain created a relaxed atmosphere in the cockpit but adhered to the sterile cockpit rule. The captain’s wife reported that his health was good and that he did not have any injuries or illnesses in the days before the accident. She also reported that no changes in his health had occurred in the year preceding the accident. The captain’s wife further reported that the captain did not take any medications, other than those to treat his hypertension,24 or nutritional supplements in the days before the accident and that he drank alcohol occasionally.

22 Colgan could not explain the discrepancy between the captain’s total number of hours on the Q400 (111 hours) and his flight time during the 90 days that preceded the accident (116 hours). There is no record of the captain flying an airplane other than the Q400 during the 90 days before the accident. 23 Attitude describes an aircraft’s pitch, roll, and yaw in relation to the horizon. 24 According to his wife, the captain was taking Gemfibrozil, Diltiazem, and Hydrochlorot for this purpose. FAA medical records indicated that the captain had been undergoing treatment for hypertension since 1999, and these medications were included in his medical records.

NTSB Aircraft Accident Report 8 In addition, the captain’s wife reported that normally he went to sleep about 2200 and awoke about 0900 or earlier if he were getting up with their children. The captain’s wife indicated that he would normally receive between 8 and 10 hours of sleep each night and that he slept well and would sometimes nap. She further indicated that his sleep and wake times when he worked depended on his schedule. A first officer who flew with the captain frequently during January 2009 remembered that the captain had stated that he wanted to get a “crash pad” 25 near EWR but that he was trying to get around having to pay for a crash pad by bidding trips that had overnights or commutable ends. This first officer also indicated that the captain had slept in hotels or the EWR crew room26 during their trips. Another first officer who had flown with the captain in January 2009 indicated that the captain did not have a crash pad and that he would commute to his home in Florida after a trip had concluded. According to Colgan, after the accident, the captain’s wife reported that he did not have a crash pad but that he would sometimes stay overnight with a friend in the EWR area. 1.5.1.1 Activities in the 72 Hours Preceding the Accident On February 9, 2009, the captain traveled aboard a commercial air carrier from his home near Tampa International Airport, Tampa, Florida, to EWR,27 departing about 1713 and arriving about 2005.28 His last known activity on February 9 (a telephone call) ended about 2247. The first officer who flew with the captain the next day stated that the captain spent the night in the crew room at EWR. On February 10, the captain began a 2-day trip with a report time of 0530. The first day of the trip comprised three flights. About 0641, the captain departed EWR and arrived about 0819 at Toronto Pearson International Airport (YYZ), Toronto, Canada. About 0911, he departed YYZ and arrived about 1049 at EWR. About 1139, the captain departed EWR and arrived at BUF about 1259. The captain spent the rest of the day at a hotel in the BUF area. The captain’s duty day on February 10, 2009, was 7 hours 49 minutes, of which 4 hours 36 minutes was flight time. The first officer stated that the airplane encountered icing conditions briefly while en route to the destination airports. He indicated that the captain engaged the deicing system and selected the “increase” position for the reference speeds switch29 before entering clouds (and disengaged the systems after exiting the clouds). The first officer also

25 This term denotes temporary lodging, such as an apartment or a shared room, used by pilots. 26 The EWR regional chief pilot stated, during a postaccident interview, that the company’s crew room at the airport has couches, recliners, and a television. The chief pilot described the room as a place for pilots to relax but indicated that the room was not adequate for rest before a trip. Section 1.17.6 provides additional information about Colgan’s policy concerning the use of the EWR crew room. 27 The captain had been a commuting pilot since he was hired by the company. 28 The captain’s most recent flight activity before February 9, 2009, began on February 2, when he flew as a nonrevenue passenger to Albany International Airport (ALB), Albany New York, for a 3-day trip that started the next day. The trip ended on February 5 at 1522 in ALB; the captain then flew as a nonrevenue passenger to EWR, arriving at 1742. The captain’s specific activities after that flight are not known (including information about his return to Tampa), but the captain’s wife described his activities in the days before the accident as routine. 29 The reference speeds switch (commonly referred to as the ref speeds switch) and the deicing system are discussed in sections 1.6.2 and 1.6.4, respectively.

NTSB Aircraft Accident Report 9 indicated that the captain used the autopilot on approaches and disengaged the autopilot by 800 feet above ground level (agl). The first officer further stated that no extraneous conversations took place below 10,000 feet (the altitude at which sterile cockpit procedures are in effect). On February 11, 2009, the captain and the first officer departed the hotel about 0515 to check in for the second day of their trip, which had a report time of 0615. The second day of the trip comprised three flights. The captain departed BUF about 0722 and arrived at EWR about

1. The captain departed EWR about 1003 and arrived at Raleigh-Durham International

Airport (RDU), Raleigh, North Carolina, about 1138. The captain departed RDU about 1334 and arrived at EWR about 1544. The captain’s duty day on February 11, 2009, was 9 hours, 49 minutes, of which 5 hours was flight time. The first officer stated that the captain was well rested and alert during the trip. The captain’s last known activity that day (logging into the CrewTrac computer system, which Colgan pilots use to access company-related information, including crew schedules and company messages) ended about 2151. No information was found regarding where the captain slept that night. On February 12, 2009, the captain was scheduled to begin a 3-day trip. At 0310, the captain logged into the CrewTrac system. While the captain was logged into the system, he acknowledged a revision to that day’s trip schedule. The captain logged into the CrewTrac system again at 0726. Two flight crewmembers, who reported at 0655 for a flight that departed at 0754, saw the captain in the crew room. Another first officer, who reported to EWR at 0525 for a 0632 flight and returned to EWR at 0956, saw the captain asleep in the crew room during the morning. Between 1012 and 1058, the captain made and received telephone calls. A flight attendant, who reported to EWR at 1130 for an 1153 flight, stated that she saw the captain eating lunch. The EWR regional chief pilot stated that the captain had offered to do office work and was inserting revisions into airplane manuals between 1200 and 1400.30 During this time, the captain made a telephone call to his wife, which lasted a few minutes. The captain’s specific activities during the remainder of the afternoon are not known, but he was observed in the crew room watching television and talking with other company pilots. He logged into the CrewTrac system at 1421 and 1658, made telephone calls at 1624, 1801, 1915, and 1930,31 and received a call at 1649. 1.5.1.2 Federal Aviation Administration Certificate Disapprovals and Colgan Air Training Events The captain’s record of FAA certificate disapprovals showed the following:

30 The EWR regional chief pilot reported that such administrative duties are considered part of duty time. 31 The call at 1930, to the EWR regional chief pilot’s mobile telephone, lasted 43 seconds.

NTSB Aircraft Accident Report 10 • On October 1, 1991, the captain was disapproved for his instrument airplane rating during his initial flight check. He flew a PA-28 during the flight test, and the tasks disapproved were ATC clearance and compliance with ATC clearance, instrument cockpit check, partial panel32very high frequency omnidirectional radio range (VOR) approach, nondirectional beacon (NDB) approach, and holding. He passed the flight test for the rating on October 25, 1991. On his 2005 application for employment with Colgan,33 the captain stated that he had failed his FAA checkride for an instrument rating and provided the following explanation: “I missed the NDB approach, received additional instruction, then repeated the approach and passed.”

• On May 14, 2002, the captain was disapproved for his commercial single-engine land airplane flight certificate during his initial flight check. He flew a Cessna C-177 during the flight test, and the tasks disapproved were takeoffs, landings, go-arounds, and performance maneuvers. (He did not report this disapproval on his application for employment with Colgan.) He passed the flight check for the certificate on June 25, 2002. • On April 9, 2004, the captain was disapproved for his commercial multiengine land airplane flight certificate during his initial flight check. He flew a PA-44 during the flight test and was notified that the entire flight portion of the practical exam would need to be repeated. (He did not report this disapproval on his application for employment with Colgan.) He passed the flight check for the certificate on April 29, 2004. • On October 15, 2007, while a first officer for Colgan, the captain was disapproved for his airline transport pilot certificate during his initial flight check. He flew a Saab 340 during the flight test, and the disapproved task was approach and landing with a powerplant failure in a multiengine airplane. He passed the flight check for the certificate on October 18, 2007. Colgan’s training records indicated that the captain, while a first officer, needed additional training in the following areas: • On October 28, 2005, the captain was graded “train to proficiency” on his initial proficiency check in the Saab 340. This grade indicated that his overall performance was satisfactory but that a checkride item (in this case, normal and abnormal procedures) needed to be repeated during the checkride. • On October 17, 2006, the captain received an unsatisfactory grade on his recurrent proficiency check in the Saab 340. The unsatisfactory tasks were rejected takeoffs, general judgment, landings from a circling approach, oral exam, and nonprecision approach. The captain attended recurrent training and completed his requalification proficiency training on November 1, 2006.

32 Partial panel means that certain instruments are covered or are intentionally failed. 33 Colgan’s application for employment asked whether the applicant had “ever failed any proficiency check, FAA check ride, IOE, or line check.”

NTSB Aircraft Accident Report 11 • On October 3, 2007, the captain received an unsatisfactory grade on his upgrade proficiency check in the Saab 340. The disapproved task was approach and landing with a powerplant failure in a multiengine airplane (as stated previously in the FAA information about this failed flight check). He accomplished upgrade line-oriented flight training on October 14 and simulator training on October 14 and 15. He completed a satisfactory upgrade proficiency checkride on October 15, 2007. (These dates conflict with those in the FAA’s record, which indicated that the captain’s unsatisfactory checkride occurred on October 15 and his satisfactory checkride occurred on October 18.) 1.5.2 The First Officer The first officer, age 24, held a commercial pilot certificate and an FAA first-class medical certificate dated January 22, 2009, with no limitations. The first officer received a type rating (SIC privileges only) on the DHC-8 on March 16, 2008. According to a résumé in her personnel file at Colgan and her application for employment with the company, from August to December 2006, the first officer worked part time as a flight instructor at Sawyer Aviation, Scottsdale, Arizona. From January 2007 to January 2008, the first officer was a flight instructor at Sabena Airline Training Center, Phoenix, Arizona.34 She was hired by Colgan in January 2008. Her résumé indicated that she had flown the following piston-powered airplanes: Piper PA-44, PA-34, and PA-28; Cessna C-152 and C- 172; Beech BE-19 and BE-23; and Diamond DA-40. (The first officer reported no experience with turbine-powered airplanes on her résumé and employment application.) The first officer had accumulated 1,470 total flight hours, including 6 hours of actual instrument time, and 86 hours of simulated instrument time before her employment with Colgan. Colgan’s flight records indicated that the first officer had accumulated 2,244 hours of total flying time, including 774 hours in turbine airplanes and on the Q400. She had flown 163, 57, and 16 hours in the 90, 30, and 7 days, respectively, before the accident. (These times do not include the accident flight.) The first officer’s initial proficiency check occurred on March 16, 2008; her IOE occurred on March 22, 2008; and her recurrent ground school occurred on January 15, 2009. FAA records indicated that the first officer received a notice of disapproval, issued on May 7, 2006, for her initial flight instructor certificate. The areas that needed to be reexamined were technical subject areas; performance maneuvers; preflight procedures; airport base operations; and takeoff, landings, and go-arounds. (These areas pertained to her instructional methods and abilities.) She subsequently passed the test and was issued her flight instructor certificate (airplane single-engine land) on May 12, 2006. FAA records also 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.

34 The first officer’s résumé and employment application indicated additional aviation-related experience before her flight instructor positions. She worked as a mechanic’s assistant for Big Bend Aviation, Moses Lake, Washington, from 2003 (month unknown) to January 2004. Also, she worked at Midstate Aviation, Ellensburg, Washington, from January 2004 to August 2006, dispatching aircraft, assisting pilots on the Unicom (a common traffic frequency), and performing office duties.

NTSB Aircraft Accident Report 12 A first officer who went through training with the accident first officer stated that she had good knowledge of the airplane. The check airman who conducted the first officer’s IOE recalled that she did not have any problems with handling the airplane and described her as a good pilot who was sharp, assertive, and thorough. A captain who had flown with the first officer numerous times indicated that she was average to above average for her level of experience. This captain further indicated that the first officer, as a monitoring pilot, was always ahead of the airplane and cross-checked her actions. Other captains indicated that, because of her abilities, the first officer could have upgraded to captain. None of the captains interviewed after the accident reported any problems with the first officer’s adherence to sterile cockpit procedures or stated that the first officer had made any unprompted configuration changes to the airplane while they were the flying pilot. The ground school instructor for the first officer’s recurrent training stated that she had good knowledge of the airplane, and another first officer in the class stated that the accident first officer had more technical knowledge than an average first officer. In late January 2009, the first officer relocated from Norfolk, Virginia, to the Seattle area to be closer to family. (She and her husband were living at her parents’ home at the time of the accident.) She also changed her base from Norfolk International Airport (ORF)35 to EWR because it was reportedly easier to commute to EWR from Seattle-Tacoma International Airport (SEA) than from ORF.36 The first officer’s husband indicated that she had no significant changes in her life during the year preceding the accident. He reported that her finances were stable but that she had taken a significant pay decrease when she began working for Colgan.37 The first officer’s husband described her as “very healthy” and indicated that she had no injuries or illnesses in the days before the accident. He acknowledged that she would get sniffles from cold air but stated that no medication was necessary. The first officer’s husband reported that she did not take any medications regularly but had taken some ibuprofen 2 days before the accident after returning home from skiing. He also reported that she drank alcohol occasionally in social situations. In addition, the first officer’s husband indicated that she would normally go to sleep between 2000 and 2200 and awake between 0700 and 1000. Her husband described her sleep and wake schedule as “very adaptable” and stated that she would sometimes sleep until 1300. He further stated that she had no difficulties sleeping and no diagnosed sleep disorders.

35 The first officer, while based at ORF, had worked briefly at a coffee shop when not flying. At the time of the accident, she was not employed outside of Colgan. 36 According to her mother, the first officer had spoken to two other company pilots who lived in the Seattle area and told her that the commute to EWR was easier from SEA than from ORF because more flights were available and the distance allowed for sleep opportunities during the flights. The first officer’s mother also stated that the first officer’s decision to move to the Seattle area was also based on her concern that the ORF base would close. 37 The CVR recorded the first officer stating, about 2030:02, that she earned a gross salary of $15,800 during the previous year (her date of hire with the company was January 16, 2008) and that “I’m just lucky ‘cause I have a husband that’s working.” (The CVR recorded the captain stating that he earned a gross salary of about $60,000 during the previous year.) About 2103:03, the first officer stated that her husband had earned more in one weekend of military drill exercises than she earned in an entire pay cycle. She added that a recent pay raise would result in an extra $200 each paycheck.

NTSB Aircraft Accident Report 13 The first officer did not have a crash pad in the EWR area.38 A captain who had flown with the first officer when she was based at ORF stated that she planned to stay overnight at hotels once she began commuting from SEA to EWR.39 According to a cargo air carrier captain who met the first officer in December 2008 while they were jumpseat passengers, the first officer stated that she did not need a crash pad at EWR because she could stay in the crew lounge. A flight attendant who saw the first officer on the morning of the accident asked her how commuting was going, to which the first officer replied, “great.” 1.5.2.1 Activities in the 72 Hours Preceding the Accident On February 8, 2009, the first officer completed a 5-day trip that ended at EWR at 1455. Specifics of the first officer’s trip from EWR to her home are not known. The first officer’s husband described her activities in the days preceding the accident as routine. Her telephone records for February 9 indicate that outbound text messages were sent between 2152 and 2218 PST. According to her husband, the first officer awoke between 0900 and 1000 PST on February

1. Her activities that day included skiing and watching television at home. She went to sleep

between 2000 and 2200 PST. On February 11, 2009, the first officer awoke between 0900 and 1000 PST. She arrived at SEA about 1730 PST to board a cargo flight, as a jumpseat passenger,40 that departed for MEM about 1951 PST. The captain of this flight spoke with the first officer while the airplane was being loaded. The captain stated that she seemed to be alert, well rested, and in a good mood and that she did not show any symptoms of being sick. Another jumpseat passenger (a captain for the cargo air carrier) reported that the first officer slept for about 90 minutes during the flight. The flight arrived in MEM about 2330 PST (0230 eastern standard time on February 12). On February 12, 2009, the first officer traveled from MEM to EWR aboard another cargo flight that departed about 0418 and arrived about 0623.41 According to the captain of this flight, after the airplane landed, the first officer told him that she had slept during the entire flight. The captain stated that he asked the first officer whether she had a crash pad at EWR and that she replied that she did not need one. The captain also stated that he asked her what she would be doing until her report time and that she responded that one of the couches in the crew room “had her name on it.” In addition, the captain, who met the first officer in December 2008 when both were jumpseat passengers, stated that she did not appear to be tired and showed no symptoms of being sick.

38 According to her mother, the first officer was looking into the possibility of getting a crash pad, but she was concerned about finding appropriate accommodations for a female pilot in a male-dominated profession. The first officer’s mother also stated that the first officer had planned to bid trips that would allow her to commute. 39 The first officer’s mother stated that the first officer thought it would be less expensive to stay in a hotel when needed rather than maintain a crash pad. 40 The jumpseat was a normal passenger-type seat located in the cabin of the airplane. The area was free from interruptions associated with flight deck activities, and no cabin service was provided. 41 The first officer’s mother stated that the first officer had done the same commute before and described it as easy, stress-free, and less time-consuming than the commute from ORF to EWR.

NTSB Aircraft Accident Report 14 At 0651 the first officer logged into the CrewTrac system and acknowledged changes to her upcoming trip sequence. At 0732 she made a telephone call to a number associated with Colgan operations. Two flight crewmembers, who reported at 0655 for a flight that departed at 0754, saw the first officer in the crew room. The first officer’s specific activities on the day of the accident are not known, but several pilots reported seeing the first officer in the crew room watching television, talking with other pilots, and sleeping.42 The first officer also logged into the CrewTrac system at 1459 and 1625. In addition, telephone records indicated text message activity during several periods of the day,43 as well as calls she placed at 1425, 1747, and 1851 and received at 1726.44 Notable text messages or text message activity included the following: • At 0729, the first officer sent a text message indicating that she had arrived at EWR and that her only flight of the day was to BUF. She also indicated that she would be going to sleep and would call when she woke up. • At 1305, the first officer sent a text message indicating that she felt good and had taken a 6-hour nap on a recliner. • At 1534, the first officer sent a text message referring to her sleep. • At 2113, during the taxi phase of the accident flight, the first officer sent a text message. 1.5.2.2 Previous Stall Training In the year before her employment with Colgan, the first officer was a certified flight instructor on the Piper PA-28 Archer, which is a light propeller-driven, trainer-type airplane. According to her supervisor during that time, the first officer had taught or performed between 600 and 1,000 approach-to-stall recoveries. These recoveries would have been performed by the flying pilot by raising the flaps incrementally during the recovery (at an airspeed that was at least 10 to 15 knots above stall speed) as the airplane accelerated while maintaining altitude. Also, when she was demonstrating approach-to-stall recoveries to a student, the first officer would have retracted the flaps herself using her left hand while sitting in the right seat. These procedures were in contrast with the approach-to-stall training that the first officer received for the Q400, which was to be performed as a coordinated maneuver with flap changes commanded by the flying pilot.45

42 A first officer who reported to EWR at 0525 for a 0632 flight and returned to EWR at 0956 reported seeing the first officer asleep during the morning. A captain, who had reserve duty at EWR starting at 1400, recalled seeing the first officer asleep about 1200. Another first officer, who arrived at EWR at 0910 and departed at 1437, reported seeing the accident first officer asleep in the afternoon. A captain reported that the first officer might have been asleep during the 1100 to 1400 time period. 43 These periods included the following: 1305 to 1312, 1355, 1416 to 1424, 1514, 1522 to 1534, 1611 to 1612, 1635 to 1636, 1646 to 1647, 1659, 1723, and 1958. The first officer’s husband stated that he and the first officer had sent text messages throughout the morning (PST) and that he had awakened her from a nap with a text message or a telephone call that he initiated. 44 The husband of the first officer indicated that he spoke with her sometime between 1400 and 1500 and that she sounded “great” during the conversation. 45 Colgan’s approach-to-stall training is discussed in section 1.17.1.1.

NTSB Aircraft Accident Report 15 1.6. Aircraft Information The Q400 is manufactured by Bombardier, Inc., as a medium-range, all metal, high-wing, T-tail airplane powered by two turbopropellers. The airplane was certified for flight in icing conditions according to the requirements of 14 CFR Part 25 Appendix C and was designed to carry 74 passengers and 4 crewmembers. The accident airplane was manufactured in April 2008. The airplane was equipped with two Pratt & Whitney Canada PW150A engines and two Dowty R408/6-123-F17 six-bladed propellers. At the time of the accident, the airplane had accumulated 1,819 total hours and 1,809 total flight cycles. (A flight cycle is one complete takeoff and landing sequence). 1.6.1 Weight and Balance Information and Performance Data Colgan was authorized by the FAA to contract with AeroData, Inc., for weight and balance information and real-time takeoff, en route, and landing performance data for its Q400 airplanes. (AeroData’s information was derived from the Bombardier Q400 Airplane Flight Manual [AFM].) Flight crews were to request these performance data using ACARS. The Colgan Q400 company flight manual (CFM) explained how flight crews were to transmit a landing data request and receive landing performance data from AeroData. Specifically, crews were required to enter the airport, runway, and airplane gross landing weight and could enter a secondary runway, flap setting, and wind.46 This information was transmitted via datalink to the AeroData computer system, which would provide the required performance data on the ACARS display within 10 to 30 seconds. These data included Vref (reference landing speed), Vga (go-around speed), the flap retract speed (Vfri), the climb speed, and the maximum allowable landing weight and landing distance. The AeroData system provided the accident flight crew with landing performance information, including a Vref of 118 knots, at 2153. A Colgan check airman explained that, in the remarks section of the data request screen, flight crews could enter the keyword “icing,” which would cause the Vref speed provided by the AeroData computer system to increase by 20 knots for a flaps 15 landing and 15 knots for a flaps 35 landing. The check airman also stated that crews could enter the keyword “eice” (en route ice accumulation), which would add 90 pounds to the airplane’s calculated landing weight to compensate for the accumulated ice. The accident flight crew did not enter the keywords “icing” or “eice” in its request to AeroData. (AeroData provided the downlink from the accident airplane, and the area in which the keywords “icing” and “eice” would have appeared if they had been entered was blank.) If the flight crew had made either entry, then AeroData would have provided a Vref of 138 knots to the crew. On November 23, 2009, Colgan issued Flight Standards Memo 09-013 regarding AeroData keyword inputs. The memo stated that, if keywords such as “icing” or “eice” were misspelled, AeroData would provide the clean (no ice) landing speeds. The memo indicated that,

46 If a flap setting or wind was not entered, then the AeroData system would provide an optimal flap setting and assume that the winds were calm.

NTSB Aircraft Accident Report 16 for any previous AeroData requests that included a misspelling of these words, the discrepancy could have been noticed in the remarks section of the landing report returned by AeroData, which would have shown “none” instead of “icing conditions.” The memo further stated that AeroData has corrected this issue so that any misspelled keywords would result in the error message, “invalid keyword,” and include the keyword that is not recognized. 1.6.2 Airspeed Indications Airspeed indications on the Q400 are located on the left and right primary flight displays (PFD). According to the Q400 Airplane Operating Manual (AOM), indicated airspeed (IAS) is displayed digitally on the vertical scale (or airspeed tape) on the left side of the PFD. The vertical scale shows the airplane’s current IAS with marks every 10 knots to ± 42 knots from the actual IAS. The airspeeds that could be displayed on the vertical scale ranged from 30 to 500 knots. An airspeed trend vector (an upward- or downward-facing white arrow) indicates whether the airspeed is increasing or decreasing. According to Bombardier, the airspeed trend vector predicts the airspeed at which the airplane will be flying in 10 seconds. Five “bugs” indicate the airspeeds that may be programmed by the flight crew for takeoff, and two bugs indicate the airspeeds that may be programmed for landing. The two bugs that can be displayed for landing are represented on the airspeed indicator by a solid blue triangle and an open blue triangle, which Colgan used for Vref and Vga, respectively. A low-speed cue is shown as a red and black vertical bar that extends from the bottom right of the vertical scale. The low-speed cue warns pilots of an inappropriately low airspeed for the airplane configuration or operating condition.47 If the airplane’s IAS is less than or equal to the IAS at the top of the low-speed cue, the stick shaker activates. Also, the numbers on the IAS display change from white to red, providing pilots with another visual warning of an inappropriately low airspeed. Figure 1 shows the IAS digital display on the Q400 PFD.

47 The low-speed cue can also represent the minimum control speed during approach and landing with all engines operating.

NTSB Aircraft Accident Report 17

Figure 1. Q400 Indicated Airspeed Display Source: Bombardier. The ice protection panel, which is located on the overhead panel on the captain’s side of the cockpit, includes a “REF SPEEDS” switch that can be set to the INCR (increase) or OFF positions, as shown in figure 2. During the May 2009 public hearing on this accident,48 an engineering manager from Bombardier stated that the ref speeds switch, when set to the increase position, advances the stall warning so that the stick shaker would activate at a lower AOA;49 as a result, the airplane would have the same performance margins relative to the stall speed during operations in icing conditions as it would have with a clean (no ice accretion) configuration (and the ref speeds switch set to the off position). The engineering manager also stated that, because the stick shaker would activate at a lower AOA with the ref speeds switch set to the increase position, the flight crew would need to increase landing airspeeds between 15 and 25 knots depending on the flap setting (to remain above the stall warning threshold).

48 Appendix A provides information about the public hearing for this accident. 49 The ref speeds switch position does not change the AOA value that triggers stick pusher activation.

NTSB Aircraft Accident Report

Figure 2. Q400 Reference Speeds Switch Source: Bombardier. The Bombardier Q400 AFM, section 4.7.2, Ice Protection Procedures, dated July 13, 2005, stated that the ref speeds switch was to be in the increase position before entering icing conditions and in the off position after the airplane is aerodynamically clean (that is, all ice is removed from the visible leading edges and wing tips). The Q400 AFM also cautioned that a stall warning might occur if airspeed was not increased before the ref speeds switch was selected to the increase position. The ref speeds switch on the accident airplane was found in the increase position. 1.6.3 Stall Protection System The Q400 stall protection system includes a stick shaker and stick pusher. The stick shaker is a stall warning device on each control column that provides pilots with an aural and tactile warning of an impending stall. Even though the stick shaker on each control column is independently controlled by one of two units in the stall protection system, both columns vibrate simultaneously when a stick shaker activates because both columns are interconnected. 18

NTSB Aircraft Accident Report 19 The Q400 stick pusher is a stall identification device that, according to Bombardier, positions the elevator to 2° nose down and provides a nose-down input to both control columns after an AOA threshold has been reached and an aerodynamic stall has occurred.50 The stick pusher thus provides pilots with a tactile cue that they need to push forward on the control column to gain airspeed and alleviate the stall condition rather than pull back on the column. The stick pusher was designed to remain engaged (subject to certain constraints)51 until the AOA decreases below the stick shaker activation angle. The engineering manager from Bombardier testified at the public hearing that the stick pusher system could be overpowered or disengaged by flight crew action.52 The airplane’s two stall protection modules provide output commands to the stick shaker and stick pusher. The stall protection modules use AOA, flap position, body axis attitudes, normal acceleration, true airspeed, Mach number,53 engine torque, and icing status data to calculate when the airplane is approaching a stall condition. The stick shaker activates when these parameters, in particular AOA, reach a specific threshold. The Q400 AOM stated that, when the stall protection modules operate the stick shakers, the autopilot automatically disengages,54 and the ground proximity warning system “pull up” alert is inhibited. In addition, the stall protection modules use AOA, flap position, body axis attitudes, normal acceleration, true airspeed, Mach number, power lever angle, and condition lever angle data to calculate the AOA at which the stick pusher activates. 1.6.4 Ice Detection and Deicing System At the public hearing, an engineering manager from Bombardier testified that visual cues provide the most reliable means of ice detection.55 In addition, ice detector probes are installed on each side of the Q400 forward fuselage, below the pilot’s and copilot’s windows, to detect when ice is accumulating on the airplane. When ice accumulates on the probe sensors, the probes send an electronic signal to the avionics system to indicate that ice is present. The ice detector probes also cycle heat to the sensors to melt ice and ensure that the sensors can continue

50 It is important to note that the Q400 stick pusher system differs from the stick pusher systems on other regional airplanes (for example, the CRJ-200 and ATR-42/72), which activate before a stall occurs. These stick pusher systems were designed to warn pilots of, and prevent them from encountering, undesirable pre-stall and stall characteristics. 51 These constraints include limits on radio altitude, bank angle, pitch attitude, and normal load factor. 52 The Bombardier engineering manager further testified that the nominal control column force was significant enough to get a pilot’s attention to relax back pressure on the column but was not too excessive for a pilot to override if an inadvertent system failure had occurred. Overriding the stick pusher requires 80 pounds of opposite breakout force and then 66 pounds of sustained force. Disengaging the pusher is accomplished by pressing the stick pusher shutoff switchlight on the glareshield. 53 Mach number equals an object’s speed divided by the speed of sound. 54 The airplane’s autopilot can also be disengaged manually. An autopilot button is located on the automatic flight control system control panel, which is mounted on the glareshield directly in front of a flight crew. An autopilot disengage button is also located on each control wheel. 55 According to Bombardier, observations of the outboard wing leading edge and the windshield wiper spigots are the primary means to indicate when an airplane has entered icing conditions. During nighttime operations, the spigots can be illuminated by a lamp inside the cockpit.

NTSB Aircraft Accident Report 20 detecting ice. The ice detection probe sensors have a continuous self-testing feature to ensure that they are working properly. When both sensors fail, an “ice detect fail” light illuminates on the caution and warning panel in the cockpit.56 The Q400 engine display shows an “ICE DETECTED” message, as shown in figure 3, when one or both ice detector probes detect more than 0.5 millimeter (0.02 inch) of ice. The message appears in reverse video (black letters on a white background) for 5 seconds if the ref speeds switch has already been set to the increase position. After the 5-second period, the message appears in normal video (white letters on a black background, as shown in figure 3) when ice is detected and the ref speeds switch remains set to the increase position. If the ref speeds switch is set to the off position when ice is detected, the message flashes with yellow letters on a black background until the switch is turned to the increase position. In addition, when the switch has been selected to the increase position, an “INCR REF SPEED” message (also shown in figure 3) appears in normal video, regardless of whether ice has been detected.

Figure 3. Q400 Engine Display Showing Ice Detected and Increased Reference Speeds Message Source: Bombardier. The ice detected message appears periodically during icing conditions—the message is in view for a minimum of 60 ± 5 seconds when ice is detected—and is out of view when no ice is

56 The CVR did not record the crew discussing the illumination of this or any other caution light.

NTSB Aircraft Accident Report 21 detected. For the accident flight, FDR data showed that the ice detected parameter transitioned from “not detected” to “detected” and then transitioned back to “not detected” during the following times: 2207:53 to 2208:53, 2209:21 to 2211:05, and 2211:17 to 2212:17. FDR data also showed that the parameter transitioned from “not detected” to “detected” from 2216:25 to the end of the recording.57 The airplane’s airframe deicing system uses bleed air from the engines to inflate rubber boots that break apart accumulated ice on the wing and tail (horizontal stabilizer and vertical stabilizer) leading edges as well as the nacelle air intakes.58 The propeller deicing system includes electrical heating elements in the leading edge of each propeller blade to remove ice accumulations. A rotary switch on the ice protection panel is used to select propeller heat. Both front windshields and the pilot’s side window have electronically controlled heater elements that are laminated into the panels. These heater elements are designed to keep the windshield and windows at a predetermined temperature to prevent icing and misting. 1.6.5 Maintenance Records Two line checks were performed on the accident airplane on the day of the accident after the airplane had arrived at Albany International Airport (ALB), Albany, New York, from EWR.59 The ice detector probes and deice boots were checked visually, with no discrepancies reported. Also, the flight crew of the flight from EWR to ALB reported, in the airplane’s logbook, that an “ice detect fail” caution light had illuminated during the flight. Maintenance personnel at ALB replaced the right-side ice detector probe and reported that an operational check of the ice detection system was satisfactory. A review of the accident airplane’s logbook from April 2008 to February 2009 revealed no chronic issues with the airplane’s primary or secondary flight control systems. Also, no discrepancies with the primary or secondary flight control systems were reported after the airplane’s last L-1, L-2, and A checks.60

57 The FDR showed that the airplane was at the following altitudes when the ice detected parameter transitioned from “not detected” to “detected”: about 8,700 feet, about 7,300 feet, about 5,300 feet, and about 2,400 feet. 58 The ice protection panel, shown in figure 2, includes a total of 14 boot inflation advisory lights that allow pilots to monitor deicing boot operation. Pilots can also check the operation of the wing deice boots by looking out their windows at the boots. 59 Line checks involve servicing and a walk-around visual inspection of the airplane’s general condition. The first line check, known as the L-1 check, is accomplished every 3 days or 36 flight hours, whichever occurs first. The second line check, known as the L-2 check, is performed every 6 days or 50 flight hours, whichever occurs first. 60 A checks are performed every 400 flight hours. The accident airplane’s last A and 2A checks were performed on December 24, 2008, and the last 3A check was performed on October 23, 2008.

NTSB Aircraft Accident Report 22 1.7 Meteorological Information BUF has an automated surface observing system (ASOS) that is maintained by the National Weather Service (NWS). The FAA is responsible for the augmentation and backup of the ASOS, which are provided by NWS-certified observers at BUF. The ASOS records continuous information on wind speed and direction, cloud cover, temperature, precipitation, and visibility in statute miles. The ASOS transmits an official meteorological aerodrome report (METAR) each hour and special weather observations as conditions change. The ASOS also records weather observations every 5 minutes, but this information is not disseminated to pilots. The 2154 METAR for BUF indicated winds from 240° at 15 knots gusting to 22 knots, visibility 3 miles in light snow and mist, a few clouds at 1,100 feet agl, ceiling broken at 2,100 feet agl, overcast at 2,700 feet agl, temperature 1° C, dew point -1° C, and altimeter 29.79 inches of mercury (Hg). (This METAR became the basis for ATIS information “romeo.”) The 5-minute observation at 2215 indicated wind from 250° at 14 knots, visibility 3 miles in light snow and mist, a few clouds at 1,100 feet agl, ceiling overcast at 2,100 feet agl, temperature 1° C, dew point -1° C, and altimeter 29.80 inches of Hg. The NWS terminal aerodrome forecast that was current at the time of the accident was an amended forecast issued at 1920. The amended forecast expected, from 1900 to 2100, winds from 240° at 15 knots, visibility 1 1/2 miles in light snow showers, and ceiling overcast at 1,500 feet agl. From 2100 to 0100, the forecast expected winds from 250° at 14 knots gusting to 24 knots, visibility 5 miles in light snow showers and mist, and ceiling overcast at 2,000 feet agl. Numerous pilot reports (PIREPs) about icing conditions in the BUF area were received during the day of the accident between 1250 and 1815. These PIREPs included reports of light, light-to-moderate, and moderate rime icing from 3,000 to 14,000 feet in the BUF area.61 The 1815 PIREP, which was received from an Airbus A319 pilot about 4 hours before the accident, reported light-to-moderate rime icing at 5,000 feet and a temperature of -7° C. The weather document for the accident flight (which accompanied the dispatch release) did not include pertinent NWS Airmen’s Meteorological Information advisories (AIRMETs),62 which inform pilots of significant weather phenomena. One of these AIRMETs extended over the airplane’s route and expected moderate rime icing from below 8,000 feet. Another AIRMET extended over a larger region in the northeast, including the accident site, and expected occasional moderate icing below 18,000 feet. The icing conditions in both AIRMETs were expected to continue from 2145 to 0400 the next day. Other AIRMETs were in effect for instrument flight rules (IFR) conditions and turbulence over the BUF area. The only icing information included in the weather document consisted of the reports and forecast of snow at

61 The FAA’s Aeronautical Information Manual, chapter 7, Safety of Flight, section 7-1-21, describes rime ice as rough, milky, opaque ice formed by the instantaneous freezing of small supercooled water droplets. 62 An AIRMET is one of five weather advisory categories used by the NWS. The other categories are Severe Weather Forecast Alerts, Significant Meteorological Information (SIGMETs), Convective SIGMETs, and Center Weather Advisories (CWAs). AIRMETs, SIGMETs, and Convective SIGMETs are issued from the NWS Aviation Weather Center in Kansas City, Missouri, and CWAs are issued from NWS Center Weather Service Units within FAA centers.

NTSB Aircraft Accident Report BUF and two PIREPs indicating light-to-moderate rime icing in the BUF area between 3,000 and 14,000 feet. The ATC transcript showed that, after the accident, the controller who was handling the accident flight asked pilots of other airplanes whether icing was occurring. About 2221:12, a Delta Air Lines pilot, whose airplane was at an altitude of 2,300 feet at the time, told the controller that the airplane was not accumulating any ice at that altitude but that some ice might have been accumulating while descending between 6,500 and 3,500 feet. About 2225:11, the pilot reported that the airplane had accumulated between 1/4 and 1/2 inch of ice during the descent. About 2225:25, a US Airways pilot reported that his airplane, which was south of the airport and had been cleared to descend from 5,000 to 2,300 feet, had been accumulating rime ice for about 10 minutes. The controller asked the pilot to let him know when the airplane was out of icing conditions and mentioned that pilots of other arriving airplanes that were south of the airport did not report similar icing conditions. About 2227:04, after being instructed to maintain 2,300 feet until established on the localizer, the pilot reported that ice was starting to come off the windscreen. The National Transportation Safety Board (NTSB) conducted a postaccident survey of pilots operating into BUF about the time of the accident to determine the icing environment at the time. Of the 22 surveys issued, 12 (about 55 percent) were returned. The survey found that varying (trace, light-to-moderate, and moderate) intensities of icing conditions were occurring between 2,000 and 12,000 feet. The surveys indicated that the pilots were aware of the potential for icing conditions and were not surprised by the encounters. None of the pilots indicated that they had formally reported the icing conditions because the pilots did not consider the icing conditions to be significant. Ten of the surveys were from pilots of air carrier jet airplanes; two of the surveys were from pilots of turboprop airplanes. The two turboprop airplanes were an AirNow Embraer EMB- 110 and another Colgan Q400 (flight 3268, also from EWR to BUF), which landed about 2200 and 2230, respectively. The AirNow pilot reported moderate rime ice while descending between 5,000 and 2,000 feet, with 2 to 3 inches of ice accumulation noted on the propeller spinners and some unprotected areas after arriving at BUF. The AirNow pilot also stated that the flight was in icing conditions for about 10 minutes. The Colgan Q400 pilot reported light-to-moderate rime ice while descending between 5,000 and 3,000 feet. 1.8 Aids to Navigation During a postaccident interview, one air carrier reported that, when some of its airplanes attempted to intercept the BUF runway 23 ILS from a right downwind position, the glideslope would indicate that the airplane was well above the glideslope. The air carrier further reported that, just before intercepting the localizer, the glideslope would move upward to the proper interception indication. As a result, airplanes that had the autopilot and flight director engaged 23

NTSB Aircraft Accident Report 24 would capture the glideslope as it moved up, which would result in a climb and loss of airspeed.63 The accident flight intercepted the ILS from the left side,64 and no problems with this or any other navigational aid was reported for flight 3407. 1.9 Communications No technical communications problems were reported. 1.10 Airport Information BUF is located 5 miles east of Buffalo, New York, at an elevation of 728 feet. BUF has two runways, 5/23 and 14/32; runways 5/23 and 32 had published ILS instrument approach procedures. The ILS runway 23 approach plate, dated April 20, 2007, included a note stating, “glideslope unusable beyond 5° right of course.” 1.10.1 Air Traffic Control BUF is a combined ATCT and terminal radar approach control. Radar data are provided by an airport surveillance radar-9 at the airport. The accident flight was handled by the BUF approach controller at the east radar position. The controller stated that, after he instructed the flight crew to contact the ATCT, he continued to monitor the airplane’s progress. The controller reported seeing the altitude readout in the radar display data block change to “XXX,” which was an indication that the radar system had interpreted the altitude readout to be unreliable. Afterward, the airplane target and the data block disappeared from the radar display. The approach controller contacted the tower controller to find out if something had happened to the flight and asked the tower controller to attempt to contact the airplane. The ATC transcript showed that both controllers attempted to contact the airplane during the next minute. The approach controller also asked the pilot of a Delta Air Lines airplane (which was being vectored for an ILS approach to runway 23) to see if the Colgan airplane was off to the right. The pilot of the Delta flight reported that he did not see the airplane and that no target for it appeared on the traffic alert and collision avoidance system. The approach controller reported that this information seemed to be confirmation that the airplane had been involved in an

63 The National Aeronautics and Space Administration’s Aviation Safety Reporting System (described in section 1.17.7.3) received several reports regarding the BUF glideslope issue, including one report dated December 2004, two reports dated January 2009, and one report dated April 2009. 64 The FDR showed that the airplane had not captured the glideslope.

NTSB Aircraft Accident Report 25 accident. The controller asked the controller-in-charge to call the airport fire department, which coordinated all off-airport events. The approach controller who handled the accident flight stated that he then began trying to figure out what had happened to the flight. He asked other airplanes operating in the area about icing (as previously indicated in section 1.7) and learned that some airplanes had encountered icing but that the conditions did not seem to be “especially serious.” The controller also checked the ILS monitor panel to see if a problem had occurred with the ILS equipment but found everything working normally. The controller was notified that an accident had occurred by the controller-in-charge, who had been told of the accident by the airport fire department about 10 minutes after the loss of contact with the flight. The controller stated that icing conditions were common in the BUF area throughout most of the winter and characterized the icing conditions on the day of the accident as “routine stuff that pilots fly in here every day.” Also, he indicated that the air traffic at the time of the accident was “fairly typical.” 1.11 Flight Recorders 1.11.1 Cockpit Voice Recorder The airplane was equipped with a Honeywell model 6022 SSCVR 120 solid-state CVR, serial number 97896. The CVR did not sustain any heat or structural damage. The audio information was extracted normally and without difficulty. The CVR was sent to the NTSB’s laboratory for readout. The CVR recording contained a 2-hour 1-minute digital recording of a flight crew microphone channel and a cockpit area microphone channel. Both channels contained excellent-quality audio data.65 Also, for the last 30 minutes of flight, the CVR contained four channels66 of excellent-quality audio data. (The last 30 minutes of the two 2-hour channels recorded the same information as the four 30-minute channels.) A transcript was prepared of the recording (see appendix B). A CVR sound spectrum study was performed to resolve an inconsistency involving stick shaker activation information. Specifically, the CVR transcript indicated the stick shaker was only audible from 2216:27.4 to 2216:34.1 and from 2216:35.4 to the end of the recording (2216:53.9). During the 1.3-second time period during which the stick shaker was not audible on

65 The NTSB rates the audio quality of CVR recordings according to a five-category scale: excellent, good, fair, poor, and unusable. The NTSB considers an excellent-quality audio recording to be characterized by the following traits: virtually all of the crew conversations could be accurately and easily understood. The transcript that was developed might indicate only one or two words that were not intelligible. Any loss in the transcript was usually attributed to simultaneous cockpit/radio transmissions that obscured each other. 66 The first through fourth channels were the passenger address system, the captain’s station, the first officer’s station, and the cockpit area microphone, respectively.

NTSB Aircraft Accident Report 26 the CVR, an FDR sample (at 2216:34.6) indicated that the stick shaker was active.67 The sound spectrum study revealed evidence of stick shaker operation between 2216:34.4 and 2216:35.4, but the study did not identify any frequency content consistent with stick shaker activation between 2216:34.1 and 2216:34.4. 1.11.2 Flight Data Recorder The airplane was equipped with a Honeywell model 980-4700 FDR, serial number 14241. The FDR recorded flight information in a digital format using solid-state memory as the recording medium. Of the total number of parameters recorded by the FDR, 121 parameters were deemed to be relevant to the circumstances of the accident.68 The FDR was sent to the NTSB’s laboratory for readout and evaluation. The FDR was in good condition, and the data were extracted normally. About 26 hours 30 minutes of data were recorded on the FDR, including about 58 minutes of data from the accident flight. The FDR recording ended about 2216:53. 1.12 Wreckage and Impact Information The airplane wreckage was mostly contained within the property boundaries at 6038 Long Street, Clarence Center, New York.69 The airplane was severely fragmented with extensive fire damage. About 60 percent of the main structural components could be conclusively identified, including structure from the radome and both wingtips. The empennage was found intact in the wreckage. Numerous small pieces of airplane structure were recovered but were not conclusively identified. The airplane wreckage was on a magnetic heading of 070°. All of the examined fracture surfaces exhibited signs that were consistent with overload failure; no evidence indicated any preimpact failures. Flight control continuity could not be determined because of severe fragmentation and burn damage. The airplane impacted the south side of the house near ground level, and pieces of the airplane traveled through the house, coming to rest beyond the northeast corner of the house’s foundation. A ground scar, which was found on the south side of the house about 10 feet south of the south foundation wall, measured 15 feet long, 5 feet wide, and 3 feet deep. Two trees along the southern boundary of the property were impacted by the airplane and had their tops sheared off. One tree strike occurred about 20 feet agl, and the other occurred about 25 feet agl. Tree

67 The FDR recorded the activation of the stick shaker at 2216:30.6. 68 Title 14 CFR 121.343, “Flight Data Recorders,” required the airplane to be equipped with an FDR that recorded a minimum of 88 parameters. 69 As discussed in section 1.4, a section of the outboard leading edge of the right wing impacted the garage of an adjacent house located to the south of the destroyed house. Also, the right forward cargo door was recovered across the street from, and east of, the destroyed house with impact damage but little fire damage. In addition, the only structure found after a search of the rooftops and yards that surrounded the destroyed house was a small section of propeller spinner.

NTSB Aircraft Accident Report 27 debris located between the property boundary and the house exhibited clean, angled cuts that were consistent with propeller impact. The right main landing gear exhibited minor fire damage to the tires, the retract actuator was broken off in the almost fully retracted position, and the right main landing gear uplock (a mechanical lock to hold the gear in the up position) was found in the open position. The left main landing gear exhibited severe fire damage with the retract actuator broken off in the almost fully retracted position, but the left main landing gear uplock was not conclusively identified. The nose landing gear was found with severe fire damage, but no conclusive evidence of the gear’s position was found. The stage 1 low pressure compressors in both engines were found with blades bent in the direction opposite rotation, fractured blades, airfoil leading edge impact damage, and ingested dirt. No evidence of a turbine failure or an uncontainment was found in either engine. Both engine power levers and the No. 1 engine condition lever appeared to be in the full forward position, and the No. 2 engine condition lever appeared to be in its midrange position. Parts of each blade tip from both propellers were found. Six No. 1 propeller blades and four of six No. 2 propeller blades were found almost full length and were fractured near the root of the blades (where the blades are installed into the propeller hub). The ice protection panel was recovered in the wreckage and was found to be severely burned. As indicated in section 1.6.2, the ref speeds switch was found set to the increase position. The ice detector probes were not identified in the wreckage. No segments of the leading edge deice boots from the left wing were identified. Two leading edge sections from the right wing were located in the wreckage. The deice boots from these sections appeared to still be bonded to the leading edge, except in some areas that appeared to be associated with impact damage. The pneumatic lines leading to the connections on the inside of the leading edge sections were intact. These and other deice system pneumatic lines did not show any evidence of leaks, ruptures, or missing or damaged line couplings.70 The leading edge deice boots for the horizontal and vertical stabilizer were found in good condition. The boots were still bonded to the leading edge structure, with only minor tears in the boot surfaces and slight charring on the left horizontal stabilizer boot. Portions of all eight flap actuators (which move the flap surfaces to a selected position and maintain the selected position against the aerodynamic forces acting on the flap surfaces) were recovered. Seven of the actuators contained the appropriate portions to measure the dimension between the overtravel stop on the jackscrew and the body of the actuator. All measurements were consistent with the flaps being close to the fully retracted position.

70 Other deice system pneumatic lines found in the wreckage were from the center wing area, the dorsal fairing (which extends from the lower portion of the vertical stabilizer to the top of the fuselage), the aft fuselage, and the horizontal and vertical stabilizers.

NTSB Aircraft Accident Report 28 1.13 Medical and Pathological Information Toxicology tests were performed by the FAA’s Civil Aerospace Medical Institute on tissue specimens from both pilots. Specimens from the captain tested negative for ethanol. Also, with the exception of Diltiazem,71 his specimens tested negative for a wide range of drugs, including major drugs of abuse (marijuana, cocaine, phencyclidine, amphetamines, and opiates). Specimens from the first officer tested negative for ethanol and a wide range of drugs, including major drugs of abuse. The Erie County Medical Examiner’s Office determined that the cause of death for the airplane occupants and the ground victim was multiple blunt force trauma. 1.14 Fire No evidence indicated an in-flight fire. The fire damage that occurred to the airplane and the house it impacted occurred as a result of the crash. 1.15 Survival Aspects 1.15.1 Fire Emergency Response The Clarence Center Fire Company reported that it was the first emergency response organization to respond to the accident scene. The fire company also reported that the following other local emergency response organizations responded to the accident site within 15 minutes of the accident: Niagara Airport Police, Erie County Sheriff Department, New York State Police, Clarence Fire Company, Swormville Fire Company, and East Amherst Fire Department. 1.15.2 Natural Gas Emergency Response About 2358 on the night of the accident, the operator of the natural gas distribution pipeline system serving the accident area, National Fuel Gas Distribution Corporation, was notified of blowing and burning gas at the home that was destroyed by the airplane’s impact. A National Fuel crew truck was dispatched at 0009 on February 13, 2009, and arrived on scene about 0033. The crew shut off the flow of gas at the homes on both sides of the accident site. The crew was initially unable to shut off the flow of gas at the destroyed home because the gas shutoff valve and gas meter were directly in the fire area. About 0130, after National Fuel had completed all of the work that it could safely accomplish, the incident commander at the accident site requested that the crew retreat from the

71 The captain’s FAA medical records indicated that he was taking this medicine to control hypertension.

NTSB Aircraft Accident Report 29 site. After 0130, National Fuel developed a plan for shutting off the flow of gas at the destroyed home, which would have also required shutting down gas service to about 50 homes in the area of the accident site. National Fuel discussed the plan with the Clarence Center fire chief, who, after consultation with the incident commander, instructed National Fuel to hold off on the shutdown because it would have required the evacuation of residents in the early morning hours and in freezing temperatures. About 0855, the incident commander allowed National Fuel to enter the front yard of the destroyed home to secure the flow of gas at the home, which put out the natural gas fire. The flow of gas into the home stopped about 1045 when the natural gas service pipeline for the home (as well as three other homes near the accident site) was squeezed off72 from the natural gas distribution main pipeline. About 1320, the service pipeline was physically disconnected from the main pipeline. National Fuel’s investigation of the accident scene found that the fire was fed by the natural gas service pipeline. (The natural gas distribution main pipeline was not damaged and was subsequently returned to service.) National Fuel also found that the gas shutoff valve at the destroyed home’s gas meter had been broken in half, causing the valve to be in the full open position and allowing natural gas to flow and feed the fire. In addition, National Fuel found that the service gas pipeline leading to the destroyed home was not installed with an excess flow valve.73 The service gas pipeline was installed in September 1984; at the time, service pipelines were not required to be installed with an excess flow valve.74 Computer modeling demonstrated that, if an excess flow valve had been installed at the destroyed home, there would have been enough gas flow for the valve to have closed and stopped the flow of gas to the fire.75

72 This term denotes the flattening of a plastic pipe (using a hydraulic tool) to the point at which no gas can flow through it. 73 An excess flow valve (which is also called a gas fuse) shuts off the flow of gas if it exceeds a certain level, as determined by the utility company that services a residence. 74 Legislation enacted in 2006 required the installation of excess flow valves after June 1, 2008, on all new and replacement service lines to single-family residences. 75 The NTSB has issued several recommendations regarding the use of excess flow valves. For example, on June 22, 2001, the NTSB issued Safety Recommendation P-01-2, which asked the Pipeline and Hazardous Materials Safety Administration (which was the Research and Special Programs Administration at the time) to require the installation of excess flow valves in all new and renewed gas service lines, regardless of customer classification, when the operating conditions were compatible with readily available valves. Safety Recommendation P-01-2 was classified “Open—Acceptable Response” on March 18, 2008, pending publication of a final rule addressing integrity management for gas distribution pipelines.

NTSB Aircraft Accident Report 30 1.16 Tests and Research 1.16.1 Aircraft Performance Study An aircraft performance study was performed to determine the time alignment among CVR events, FDR data, and ATC radar data; calculate the airplane’s flightpath; correlate the airplane’s position with local reference points; and examine the actions of the stall protection system during the final portion of the flight. Data from the FDR and a Bombardier Q400 stall protection system design document were used to calculate the fuselage AOA during the stall sequence.76 The calculated fuselage AOA at the time that the autopilot disengaged was about 8°. The calculated fuselage AOA at the time of stick shaker activation would have been about 7.6° with the ref speeds switch selected to the increase position and about 12° with the ref speeds switch selected to the off position.77 These AOA calculations, combined with the available CVR and FDR evidence, showed that the ref speeds switch was in the increase position at the time of stick shaker activation.78 Data from the FDR and the Bombardier Q400 stall protection system design document were also used to calculate the expected low-speed cue data (with and without the ref speeds switch set to the increase position).79 The FDR airspeed and the calculated low-speed cue data were then compared with the expected approach and reference speeds for the accident flight (flaps 15, 118 knots; flaps 15 in icing conditions, 138 knots) to determine if and when the accident airplane’s actual airspeed was below either the applicable approach speed schedule or the low-speed cue. The comparison showed that the airspeed was below the minimum approach speed in icing conditions for about 8 seconds before stick shaker activation and below the low- speed cue from the initial stick shaker activation to the end of the flight. The reference stall speeds were estimated using a flap position of 6.5°, which was the approximate flap position at the time of the stall (based on an analysis of available FDR parameters and an event simulation match). On the basis of an interpolation of Bombardier Q400 AFM data, the airplane would stall at 107 knots in unaccelerated (that is, a vertical acceleration of 1 G)80 flight for a flap position of 6.5° and an estimated landing weight of 54,700 pounds (the approximate landing weight of the accident airplane).81 The airplane performance study

76 Fuselage AOA is calculated from the local vane AOA using body axis pitch rate and true airspeed, among other parameters, and is an important input to the stick shaker, stick pusher, and low-speed cue calculations. 77 The stick shaker activation angle is a function of the ref speeds switch selection, flap position, engine torque, and Mach number. 78 The position of the ref speeds switch was not recorded by the FDR. 79 The low-speed cue is a function of engine torque, propeller speed, fuselage AOA, vertical acceleration, flap position, calibrated airspeed, and ref speeds switch position, among other parameters. 80 G is a unit of measurement that is equivalent to the acceleration caused by the earth’s gravity (32.174 feet/second2). 81 This weight did not consider the effects of ice accumulation because the flight crew had not made icing entries into the ACARS system when transmitting the landing performance data request, as previously explained in section 1.6.1.

NTSB Aircraft Accident Report 31 calculated that, with the extra lift required for a nose-up pitching maneuver, a Q400 airplane with no ice accretion could achieve 1.38 Gs before encountering a wing stall at 125 knots (the airspeed at the time that the airplane entered the stall).82 The FDR indicated that the accident airplane had achieved a vertical acceleration of about 1.42 Gs during the initial pitch-up maneuver after the aft control column movement. Thus, the actual airplane performance was slightly better than the clean wing (no ice accretion) performance assumed in the AFM. 1.16.2 Aircraft Performance Simulation Study Bombardier Q400 aerodynamics, engine, and flight controls simulation models were used to evaluate the accident airplane’s performance relative to the nominal airplane simulation model (with no airframe or engine ice accumulation) and an airplane model with a degraded performance level (which was consistent with that documented in the original certification for the Q400 while operating within the Part 25 Appendix C icing envelope).83 The calculated AOA, elevator, aileron, and rudder time history values from the closed-loop event simulation84 closely matched the accident airplane’s motion, as documented on the FDR, during the 2-minute time period that preceded the stall. The Q400 simulation model contained an ice accumulation factor that ranged from 0.0, representing a clean airplane, to 1.0, representing an airplane with ice contamination equivalent to that demonstrated during the Q400’s certification for flight in icing conditions (per Part 25 Appendix C).85 The NTSB found that the ice accumulation factors of 0.1 and 0.2 provided the best match with the FDR data before the stall. The ice accumulation factor simulation results indicated that the accident airplane experienced a small airplane performance degradation resulting from ice accretion compared with the icing certification performance level. The Bombardier Q400 aerodynamics, engine, and flight controls simulation models were also used to perform a kinematics parameter extraction. This method performs a dynamic trim calculation for each point in the data time history, with aircraft motion data (that is, linear and angular accelerations derived from load factor and attitude data, respectively)86 defining the trim

82 Aerodynamic stall depends on AOA and occurs at basically the same AOA regardless of load factor. A load factor greater than 1 G, generated by either a pitch-up or turning maneuver, requires extra lift created by an increased AOA and/or an increased airspeed. Thus, at a load factor greater than 1 G, when the stall AOA threshold is reached, the stall occurs at a higher airspeed than with a load factor of 1 G. 83 References to Appendix C icing in this section describe performance degradations resulting from ice accretions on Q400 unprotected surfaces and protected surfaces between boot cycles while operating in icing conditions with the flaps at 0° and the airplane operating at holding speeds. The operational icing speed increments were based on the Q400 icing certification flight tests. 84 A closed-loop event simulation attempts to replicate the target airplane pitch, roll, and heading angles as a function of time by applying small increments to the nominal FDR elevator, aileron, and rudder surface position parameters used to backdrive the airplane motion. The airplane engine settings, flap position, and gear position are specified as a function of time. 85 In the simulation study, the Q400 aerodynamic drag and lift effects of ice accretion were incremented linearly for ice accumulation factors between 0.0 and 1.0. 86 The load factor data include the longitudinal, lateral, and vertical acceleration parameters. The attitude data include the airplane pitch attitude, bank angle, and heading angle parameters.

NTSB Aircraft Accident Report 32 target. The incremental aerodynamic force and moment87 coefficients required to match the recorded airplane motion are calculated using specific data.88 The kinematics parameter extraction results for aerodynamic coefficients (that is, incremental lift, drag, pitching moment, side force, rolling moment, and yawing moment) indicated that the accident airplane did not experience any (1) linear or progressive lift coefficient degradation over time, (2) measurable lift coefficient loss, or (3) sudden, substantial, progressive, or sustained increase in drag coefficient (which could be clearly isolated from Q400 engine simulation and/or airplane configuration transition modeling uncertainties) for the 2- minute time period evaluated. Only small increments in the moment coefficient values for pitch, roll, and yaw were observed before the stall.89 Three alternate flight control input scenarios were evaluated, with and without performance degradation as a result of icing for three engine torque settings, to quantify the airplane performance effects of (1) holding the control column at the expected autopilot disengage position, (2) targeting constant pitch attitude, and (3) targeting constant altitude. The evaluation of these alternate flight control input scenarios showed that pilot intervention was required to avoid stalling the airplane after autopilot disconnect; that is, holding the control column at a fixed position (the expected autopilot disengage position) and adding power would result in the airplane continuing to increase AOA up to an aerodynamic stall. However, the Q400 simulation airplane with a conservative icing accumulation factor of 0.3 still had adequate performance capability, with appropriate pitch axis inputs, to maintain either a constant pitch attitude of 10° or constant altitude with engine torque values at or above the values for the accident airplane. In addition, the accident airplane’s fuselage AOA achieved at the peak normal load factor90 (13°) was compared with both the stick shaker and the stick pusher AOA schedules for the nominal stall protection system. According to calculations provided by the supplier of the Q400 stall protection system, the stick shaker for the accident flight condition was scheduled to activate at a fuselage AOA of about 11.9° with the ref speeds switch selected to the off position. The calculations also showed that the stick pusher for the accident flight condition was scheduled to activate (after an aerodynamic stall) at a fuselage AOA of 17.5°. Because the accident airplane achieved a peak normal load factor at a calculated fuselage AOA of about 13°, the airplane’s AOA for maximum lift was greater than the AOA for the Q400 clean-wing stick shaker onset (by about 1°) and was less than the AOA for the Q400 stick pusher (by about 4.5°).

87 A moment is distance multiplied by force. 88 These data are the simulation models for the airplane aerodynamics, propulsion, and flight control system; airplane motion/state data (including altitude, airspeed, attitudes, AOA, calculated sideslip angle, and load factors); airplane configuration (such as high-lift device and landing gear position); flight control inputs and/or control surface positions; airplane loading (for example, weight and center-of-gravity location); and environment data (including winds, temperature, and pressure). 89 The results after 2216:29 were subject to increased uncertainty because of uncertainties with the accident airplane’s actual angular acceleration. 90 The peak normal load factor was achieved after autopilot disconnect but before the development of significant bank angles.

NTSB Aircraft Accident Report 33 1.17 Organizational and Management Information According to its website, Colgan began operations in December 1991. In July 1997, the company began Continental Connection service through a marketing alliance and code-sharing agreement with Continental Airlines.91 In December 1999, Colgan started operating as a US Airways Express carrier under a code-sharing and service agreement with US Airways. In March 2005, Colgan resumed Continental Connection service.92 In October 2005, the company started providing flights for United Express under a code-sharing and service agreement with United Airlines. In January 2007, Colgan became a wholly owned subsidiary of Pinnacle Airlines Corporation (which was also the parent company of Pinnacle Airlines, a regional air carrier that operated as Northwest Airlink). In February 2008, Colgan began providing Continental Connection service out of EWR.93 At the time of the accident, Colgan’s headquarters was located in Manassas, Virginia, but, on December 1, 2009, the company relocated to Memphis (where Pinnacle Airlines’ headquarters is located). At the time of the accident, the company offered about 350 daily flights to 53 cities in 15 states and Canada. Also, the company had about 1,300 employees and 34 Saab 340 and 15 Q400 airplanes (including the accident airplane) in its fleet. In February 2007, Colgan announced the introduction of the Q400 into its fleet, and initial training of company flight crews on the Q400 began in September 2007 at FlightSafety International’s facility in Toronto, Canada.94 Colgan began Q400 service in February 2008 and became fully qualified to conduct its own training on the Q400 in July 2008. The Colgan certificate is managed by the FAA’s Washington Flight Standards District Office (FSDO) in Herndon, Virginia. The FAA’s operational oversight of the company is conducted by a principal operations inspector (POI) and aircrew program managers (APM) for the Saab 340 and the Q400. The POI and Saab 340 APM are based at the Herndon FSDO, and the Q400 APM is based at the Teterboro, New Jersey, FSDO. According to the Colgan vice president of administration, at the time of the accident, the company’s minimum flight time requirement for pilot applicants was 600 hours total flight time with 100 hours multiengine time. This vice president also stated that a pilot with 250 to 300 hours in a Part 121 operation would be a more appealing candidate than a pilot with 1,500 hours in a general aviation airplane. The vice president further stated that, as part of a pilot applicant’s

91 According to FAA guidance, code-sharing is a marketing arrangement in which an airline (in this case, Continental) places its designator code on flights operated by another airline (in this case, Colgan) and sells and issues tickets for those flights. Airlines involved in code-sharing operations are required to disclose to consumers the corporate name of the transporting carrier. 92 At an earlier point in time, Colgan’s initial marketing alliance and code-sharing agreement with Continental had ended. 93 Colgan operates at EWR in rooms below one of the airport’s terminals. The rooms include management and administrative offices as well as three rooms for pilots and flight attendants. One of these rooms has computers, a bulletin board, and crew mailboxes. Another room has a kitchen area, a television, tables, and chairs. The other room, as previously discussed in section 1.5.1, is referred to as the crew room and has couches, recliners, and a television. 94 Colgan was authorized to outsource initial, transition, and upgrade training, and three FlightSafety International locations, including Toronto, were permitted to conduct this training for the Q400.

NTSB Aircraft Accident Report 34 background check, the company checked the paperwork required by the Pilot Records Improvement Act (PRIA)95 but that many of the pilots that the company had hired did not have previous experience with other airlines. Colgan indicated that it revised its flight time requirements on April 30, 2009. Newly hired pilots are now required to have 1,000 hours total flight time and 100 hours in multiengine aircraft. Q400 captains are now required to have 3,500 hours total flight time and one of the following: 1,000 hours as a PIC at Colgan, 1,500 hours in aircraft type, or 2,000 hours at Colgan. Saab 340 captains are now required to have 2,500 hours total flight time and 1,000 hours at Colgan. 1.17.1 Flight Crew Training The Colgan Crewmember and Dispatcher Training Program Manual, page 1-7, dated April 11, 2008, contained instructions and information for training company pilots according to company policies and procedures, the Federal Aviation Regulations, and operations specifications. The director of crewmember and dispatcher training96 was responsible for reviewing and implementing the policies and procedures in the company’s training manual. The director was also responsible for (1) ensuring that all pilots were trained according to the airline transport pilot practical test standards, (2) continuously reviewing the adequacy and completeness of the program, and (3) tracking the failure rate of pilots during training and checkrides to ensure compliance with 14 CFR 121.401(e).97 The training manual stated the following with regard to performance standards: Flight crewmembers will be required to receive a satisfactory grade on all flight maneuvers, procedures and duties. A satisfactory grade is obtained ONLY when the student demonstrates the ability to operate the aircraft/simulator in a manner that shows he/she is obviously the master of the aircraft, and with successful outcome of each maneuver never in doubt. Colgan used a computer record system to maintain training records for pilots, dispatchers, instructors, and check airmen. Paper training forms were used for grading simulator

95 PRIA records include information on accidents, incidents, violations, and drug or alcohol issues during the previous 5 years for pilots that have worked for Part 121, 125, or 135 operators. Section 1.18.2.1 contains additional information about PRIA. At the time of the accident, Colgan’s PRIA records were reviewed by either the company’s human resources manager or administration vice president. PRIA records are now also reviewed by Colgan’s flight standards or flight operations manager. 96 According to the Colgan Flight Operations Policies and Procedures Manual, the director of crewmember and dispatcher training reports to the vice president of flight operations. 97 Title 14 CFR 121.401(e) states the following: “a person who progresses successfully through flight training, is recommended by his instructor or a check airman, and successfully completes the appropriate flight check for a check airman or the Administrator, need not complete the programmed hours of flight training for the particular airplane. However, whenever the Administrator finds that 20 percent of the flight checks given at a particular training base during the previous 6 months under this paragraph are unsuccessful, this paragraph may not be used by the certificate holder at that base until the Administrator finds that the effectiveness of the flight training there has improved.”

NTSB Aircraft Accident Report 35 training events and showing satisfactory completion of a training course. The course completion information would be entered electronically into the computer training record system, and the paper training records, including pilot grading, would then be destroyed.98 1.17.1.1 Stall Training Stall training for the Q400 occurs during three of eight simulator sessions during initial, transition, upgrade, and requalification training. These three simulator sessions included three approach-to-stall profiles—in the clean (cruise flight), takeoff, and landing configurations—that are evaluated during a proficiency check. The company’s approach-to-stall profiles were consistent with the FAA’s airline transport pilot practical test standards. The simulator training events for the clean, takeoff, and landing approach-to-stall profiles are detailed in table 2. The Colgan training manual indicated that check airmen could waive two of the three approach-to-stall configurations when a pilot’s performance in other events indicated a high degree of proficiency. Table 2. Colgan Air’s Approach-to-Stall Training Events Stall profile Entry into stall During stall Exit from stall Clean stall 180 knots and minimum altitude of 5,000 feet agl with power at flight idle and gear and flaps retracted PF maintains altitude and heading

PF calls “stall,” advances power to rating detent, and calls “check power” PF adjusts power to maintain 180 knots Takeoff stall 180 knots and minimum altitude of 5,000 feet agl with flaps at 15°, gear down, and power at flight idle PF maintains altitude and begins a 20° bank turn at 120 knots

PF calls “stall,” advances power to rating detent, rolls wings level, and calls “check power”

PM calls “positive rate”

PF calls “gear up”

PM calls “Vfri”

PF calls “flaps 0” PF adjusts power to maintain180 knots

98 As a result, the NTSB did not have access to the accident flight crew’s grading on simulator training events, including the approach-to-stall profiles.

NTSB Aircraft Accident Report 36 Stall profile Entry into stall During stall Exit from stall Landing stall 180 knots and minimum altitude of 5,000 feet agl with flaps at 35°, gear down, and power at flight idle PF maintains altitude and heading

PF calls “stall,” advances power to rating detent, and calls “check power, flaps 15”

PM calls “positive rate”

PF calls “gear up.”

PM calls “Vfri”

PF calls “flaps 0” PF adjusts power to maintain 180 knots Note: PF, pilot flying; PM, pilot monitoring.

During postaccident interviews, the NTSB learned that, during the approach-to-stall recovery exercises for initial simulator training, pilots were instructed to maintain the assigned altitude and complete the recovery without deviating more than 100 feet above or below the assigned altitude, which had been previously required by the practical test standards for the checkride.99 Some company check airmen indicated that any deviation outside of that limit would result in a failed checkride, but other company check airmen considered this altitude limitation to be a minimal loss of altitude (which is consistent with the current practical test standards). Company training personnel and Q400 check airmen stated that demonstration of the airplane’s stick pusher system was not part of the training syllabus for simulator training at the time of the accident. Nevertheless, one check airman indicated that he demonstrated the stick pusher during initial simulator training. The check airman stated that most of the pilots who were shown the pusher in the simulator would try to recover by overriding the pusher. Most of the company pilots interviewed after the accident reported that they had not received a demonstration of or instruction on the stick pusher. At the public hearing for this accident, Colgan’s chief Q400 instructor testified that, after the accident, pilots began receiving a demonstration of the stick pusher system during simulator training. The Q400 instructor stated that pilots were set up for a stall in the landing configuration with the autopilot on. Once the stick shaker activated, the autopilot would turn off, and the pilots would apply back pressure to the control column so that they could feel the activation of the stick pusher.100 The instructor added that pilots also received a demonstration on how to overpower the stick pusher so that they could feel the operation of the pusher. On April 6, 2009, Colgan issued CFM Operations Bulletin 09-004, Q400 Enhanced Flight Maneuvers Training, which described the maneuvers that would be added to initial, upgrade, transition, and recurrent training and checkrides. The additional flight maneuvers included new stall recovery training (recovery from stalls entered during actual flight scenarios

99 The 100-foot maximum altitude standard was consistent with other practical test standards, including those for performance maneuvers, holding, and instrument approaches. 100 The resulting airplane motion from this control input may exceed the validated simulator envelope.

NTSB Aircraft Accident Report 37 rather than the “traditionally rigid profile based maneuver demonstration”), a stick pusher demonstration, and unusual attitude/upset recovery training. All three stall recoveries were to be performed by each pilot during proficiency checks, including stall conditions involving autopilot disconnect. NTSB investigators conducted Q400 simulator observations at FlightSafety International’s facility in Toronto.101 The observations were conducted using nighttime conditions, and the temperature, winds, and altimeter settings were set to the approximate conditions at the time of the accident. The airplane gross weight was set at 54,700 pounds (the approximate landing weight of the accident airplane), and the airspeed bugs were set to 118 knots (Vref) and 114 knots (Vga). A clean airplane (no simulated ice) was used. FlightSafety personnel stated their belief that scenarios in which the airplane was flown to activation of the stick pusher and then recovered were within the capabilities of the simulator model but that fighting against the stick pusher and not recovering would cause the simulator to be outside of its capabilities.102 During observations of the planned clean, takeoff, and landing approach-to-stall profiles, the pilots in the simulator cab (the Colgan lead simulator instructor for the Q400 and the Bombardier Q-series customer service liaison pilot) noted that the recoveries did not require significant or dynamic control inputs to accomplish.103 NTSB investigators noted that forward pressure on the control column and nose-down trim were needed during the recovery and that the numbers on the IAS display would turn red about 1 to 3 knots before the onset of the stick shaker. Other simulator observations were made in which the airplane, while under autopilot control, decelerated until the stick shaker activated and the pilot flew the airplane to recovery. Several scenarios were demonstrated with the airplane’s flaps and gear up, including one in which the ref speeds switch was off. The stick shaker onset for this scenario occurred when the airplane was at an airspeed of 125 knots. In a scenario in which the ref speeds switch was set to the increase position, the stick shaker onset occurred at an airspeed of 142 knots. The stick pusher did not activate during any of these demonstrated scenarios. NTSB investigators noted that the recoveries did not result in unusual attitudes and that the stick shaker ceased as airspeed increased during the recoveries. The investigators also noted that, when the ref speeds switch was changed from the increase to the off position at stick shaker onset, the stick shaker would immediately stop, and the low-speed cue would appear in a lower position on the IAS display (compared with its position at stick shaker onset). During a simulator demonstration of the ILS approach to runway 23 at BUF, the stick shaker activated at an airspeed of 127 knots. Afterward, the pilot intentionally applied aft control

101 FlightSafety’s simulator was capable of full motion, and the motion platform was on during the observations. 102 Bombardier subsequently stated that the post-stall onset of the stick pusher was outside the bounds of the simulator data package the company provided to FlightSafety. 103 The altitude deviations during recovery ranged from an altitude loss of 50 feet to an altitude gain of about 120 feet.

NTSB Aircraft Accident Report 38 column movement and pulled up the airplane’s nose from 10° to 30°.104 As the airspeed decreased to between 105 and 110 knots, the stick pusher activated, but the nonflying pilot and the observers were not aware of the pusher’s activation (that is, they could not tell whether the control inputs were being made by the pilot or the pusher). The recovery was successful. 1.17.1.2 Winter Operations Training Colgan provided its flight crews with training on winter operations during initial, transition, and recurrent ground school. Subjects presented in this course included airplane deicing and anti-icing procedures, checks, and responsibilities; airplane surface contamination and its effects on performance and handling characteristics; and identification of contamination on critical surfaces. (The accident captain and first officer last received this training during his October 2008 transition ground training and her January 2009 recurrent ground training, respectively.) In addition, a training video produced in 1999 by the National Aeronautics and Space Administration (NASA), “Icing for Regional and Corporate Pilots,” was shown during winter operations training. The purposes of the video were to review icing fundamentals, enhance pilots’ ability to assess hazardous icing conditions, enhance pilots’ understanding of icing effects on the airplane’s stability and control, present strategies that pilots can use to exit a hazardous icing encounter, and discuss supercooled large droplets. The video also discussed the possibility of a tailplane stall, which results from an ice- contaminated horizontal stabilizer. The video described the warning signs of a tailplane stall, which included lightening of the controls, pitch excursions, difficulty in trimming pitch, buffeting of the controls, and sudden nose-down pitching.105 The video indicated that the differences between a wing stall and a tailplane stall could be subtle but that pilots needed to properly diagnose the icing problem because the recovery techniques for the stalls were different. According to the video, the wing stall recovery technique requires pilots to reduce the AOA by lowering the nose, adding power, and maintaining the flap setting, whereas the tailplane stall recovery technique requires pilots to pull back on the control column; reduce flap setting; and, for some aircraft, reduce power.106 The NTSB notes that, at the public hearing for this accident, a Bombardier engineering manager testified that the Q400 was not susceptible to tailplane stalls. The Bombardier official described the flight testing—the 0 G pushover maneuver—that was performed by Bombardier and Transport Canada to make this determination. The Bombardier engineer explained that the maneuver, which was conducted with ice accumulation on the airplane’s tail (with both natural

104 As with Colgan’s stick pusher demonstration in the simulator, the resulting airplane motion from this control input may exceed the validated simulator envelope. 105 This video was part of NASA’s and the FAA’s response to previous NTSB recommendations, as discussed in section 1.18.1.11. 106 Colgan’s training manual did not include any references to tailplane stalls or tailplane stall recovery techniques.

NTSB Aircraft Accident Report 39 icing conditions and artificial ice shapes), involved pushing the control column forward to lower the nose of the airplane and increase the airplane’s descent rate. The Bombardier engineer further stated that this maneuver tested “the most severe condition” (that is, the most negative tailplane AOA) and that the airplane showed no evidence of tailplane stall characteristics, even at -0.2 G.107 1.17.1.3 Remedial Training The Colgan director of flight standards stated that pilots that failed a checkride could retrain on the specific failure item. If the pilot passed the subsequent checkride, then no further followup after this retraining would occur. The director also stated that, for pilots with multiple failed checkrides, he or the flight standards manager would coordinate with the training director to assign additional training. The director indicated that pilots could be terminated if they did not receive the additional training and pass the checkride. The Colgan chief pilot stated that, if a pilot were considered marginal, then he would ask the flight standards department to have a check airman observe the pilot to ensure that his or her performance was satisfactory. The chief pilot indicated that, at the time of the accident, the company did not have a formal program for those pilots that were considered to be weak. In August 2009, Colgan began a formal pilot monitoring program. Colgan stated that the program had specific criteria and processes for entry into and exit from the program and that the flight operations department has been reviewing and revising the program’s operation. The Colgan director of flight standards stated that he had not tracked the accident captain in terms of his performance. The company chief pilot stated that he was aware that the captain had failed his initial Saab 340 upgrade training proficiency check and had to be retrained and perform the checkride again. The chief pilot also stated that he had informed the accident captain that his subsequent proficiency check needed to be “right on.” 1.17.1.4 Crew Resource Management Training Colgan presented crew resource management (CRM) training during initial new hire indoctrination training (an 8-hour class) and recurrent training (a 2-hour class).108 The training was taught by either a ground school instructor or the manager of crewmember and dispatcher training, and the average class size was 12 students.109 One of the CRM training instructors stated that the course addressed, among other things, the relationship between flight crewmembers and the need to indicate when pilots are not observing sterile cockpit procedures.

107 The superintendent of flight test engineering at Transport Canada testified that 0 G in the maximum landing configuration was the Q400’s lower end structural limit. This official also stated that Transport Canada accomplished the pushover maneuver in a controlled maneuver down to -0.1 G. 108 Videos, team-building exercises, and some case studies used during initial CRM training were not used during recurrent CRM training. 109 Pilots and dispatchers attend CRM training at Colgan’s headquarters. Flight attendants had occasionally attended the CRM training until their training was moved to ALB.

NTSB Aircraft Accident Report 40 Two slide presentations were included in CRM training. One presentation had 45 slides that addressed topics including command, leadership and leadership styles, expectations and standardization, team management, communication, situational awareness, decision-making, and automation awareness. The other presentation had 11 slides that focused on situational awareness. One slide in the situational awareness presentation detailed the following operational clues to indicate a loss of situational awareness: failing to meet targets, using undocumented procedures, departing from standard operating procedures, violating minimums or limitations, not flying the airplane, and not looking outside. Another slide detailed the following human factor clues associated with a loss of situational awareness: communications, ambiguity, unresolved discrepancies, preoccupation or distraction, and confusion or “empty feeling.” The final slide in the presentation showed an error chain and indicated that breaking the chain involved maintaining situational awareness, checklist discipline, and standard operating procedures. CRM training also included accident case studies that demonstrated good human factors and crew interaction.110 Also, the manager of crewmember and dispatcher training stated that the class provided pilots with enough information to develop monitoring skills. A ground school instructor stated that CRM training discussed that the monitoring pilot needed to be attentive and assertive in communicating any concerns. Colgan was in the process of revising its CRM training before the accident.111 According to the POI, although the company’s CRM program met the FAA’s CRM guidance (see section 1.18.1.2), he and the director of flight operations, vice president of safety and regulatory compliance, and the director of crewmember and dispatcher training wanted additional emphasis in several areas to make the program more robust. These areas included decision-making, leading and following, positively communicating, and setting expectations. The POI indicated that the new CRM training would be modeled after Continental Airlines’ advanced CRM components and would use information from CRM programs offered at other airlines.112 In addition, the revised training was expected to be facilitated by line pilots (instead of a ground school instructor or the manager of crewmember and dispatcher training) to encourage more participation from students.

110 One case study involved the United Airlines flight 232 accident in Sioux City, Iowa. In its report on this accident, the NTSB concluded that the airplane could not have been successfully landed on a runway because of the loss of all hydraulic flight controls (resulting from a catastrophic separation of the stage 1 fan disk from the No. 2 engine) and that, with these circumstances, the flight crew’s performance was highly commendable and greatly exceeded reasonable expectations. For more information, see National Transportation Safety Board, United Airlines Flight 232, McDonnell Douglas DC-10-10, Sioux Gateway Airport, Sioux City, Iowa, July 19, 1989, Aircraft Accident Report NTSB/AAR-90/06 (Washington, DC: NTSB, 1990). 111 Information from Colgan’s third quarter 2008 safety department review included “CRM Re-design” as an issue and a challenge. (Colgan’s safety departments and safety programs are discussed in section 1.17.7.) 112 Information from the fourth quarter 2008 safety department review indicated that Pinnacle Airlines was also assisting with the CRM program redesign.

NTSB Aircraft Accident Report 41 Colgan provided the NTSB with a 209-slide presentation, dated July 1, 2009, for the revised CRM/threat and error management course.113 The slides presented industry safety data and trends and addressed CRM decision-making, situational awareness, communication, team building, workload management, threat and error management, monitoring, safety culture and safety programs, automation, fatigue, hazards associated with deviations from standard operating procedures, the company’s “VVM” (verbalize, verify, and monitor) program, and professionalism. Also, industry accidents and incidents, including those involving Colgan pilots, were discussed. During the summer of 2009, Colgan began providing a 2-day CRM course to pilots, dispatchers, flight attendants, and managers at its bases at EWR and George Bush Intercontinental Airport (IAH), Houston, Texas. In addition to the revised CRM course, the company’s revised Flight Operations Policies and Procedures Manual, dated September 20, 2009, contained a review of CRM/threat and error management, including discussions on error management and descriptions of behavioral skills that are necessary for effective CRM. 1.17.1.5 Captain Leadership Training Colgan’s captain upgrade training included a 1-day course on leadership to help upgrading captains transition to their new role.114 (The accident captain received this training in October 2007 when he became a new Saab 340 captain.) The director of crewmember and dispatcher training stated that the course focused on captains’ duties, their interaction with different departments, and the use of CRM in their expanded work activities. Captain leadership training included a nine-slide presentation that discussed a captain’s authority, responsibilities, and duties; the dispatch release; logbook and maintenance discrepancies; and cabin area and flight attendant duties. The leadership training also included the 11 slides on situational awareness that were presented as part of indoctrination and recurrent CRM training. The director of crewmember and dispatcher training stated that captains needed extra emphasis on situational awareness because of the additional crewmembers that they are responsible for overseeing. The syllabus showed that, of the 6 hours 45 minutes that had been programmed for this training, at least 4 hours 45 minutes were dedicated to captain administrative duties. In addition to the training, the Colgan Flight Operations Policies and Procedures Manual provided information about the captain’s leadership responsibilities during flight. Section 5 of the manual, dated August 22, 2008, stated that the captain was “to maintain at all times a businesslike environment in the cockpit that is conducive to the safe and proper conduct of the

113 The FAA’s guidance on threat and error management is contained in appendix 1 of Advisory Circular (AC) 120-90, “Line Operations Safety Audits.” (See section 1.18.2.2 for more information about this AC.) The guidance clarifies the relationship between threat and error management and CRM, stating the following: “It is important to clarify that TEM [threat and error management] is not crew resource management (CRM) and should not be considered a replacement for it. TEM and CRM refer to overlapping but not equivalent activities. CRM refers specifically to activities conducted by the crew to optimize performance. These activities include threat and error countermeasures such as briefing, contingency planning, and monitor/cross-checking, but they also include higher- order concepts such as leadership and establishing open communication in the cockpit. Similarly, TEM includes crew countermeasures, but it also encompasses equipment, procedural, and regulatory countermeasures.” 114 Captain leadership training is not mandated by the FAA.

NTSB Aircraft Accident Report 42 flight.” Section 2 of the manual stated that the captain was responsible for actively promoting and utilizing CRM while on duty. After a new captain completed IOE, Colgan provided no further scheduled oversight of the captain until the annual line check. After the accident, Colgan changed its policy so that all new captains would have a line check after 6 months. 1.17.2 Flight Manuals 1.17.2.1 Reference and Approach Speeds The Bombardier Q400 AFM, section 5, dated August 4, 1999, provided reference and approach speed information for various configurations of the airplane. The information showed the following for the accident airplane at its estimated landing weight: • With flaps set at 0°, the 1.23 reference stall speed (VSR) was 145 knots and a minimum of 170 knots (1.23 VSR plus 25 knots) during icing conditions.115 • With flaps set at 5°, the approach speed was 133 knots and a minimum of 153 knots (flaps 5 approach speed plus 20 knots) during icing conditions. • With flaps set at 10°, the approach speed was 124 knots and a minimum of 144 knots (flaps 10 approach speed plus 20 knots) during icing conditions. • With flaps set at 15°, the Vref for the planned landing was 118 knots and a minimum of 138 knots (flaps 15 Vref speed plus 20 knots) during icing conditions. On March 18, 2009, Colgan issued CFM Operations Bulletin 09-003, REF SPEEDS Switch and Speed Guidance. The bulletin set the following specific target airspeeds during the approach phase of flight: before landing gear extension, a minimum of 180 knots; before the final approach fix, a minimum of 160 knots; and on final approach, Vref plus 10 knots minus 0 knots (that is, airspeeds could deviate up to 10 knots above the Vref speed, but no airspeeds below Vref were allowed). 1.17.2.2 Operations in Icing Conditions

The Q400 AFM, section 4.7.2, Ice Protection Procedures, dated July 13, 2005, included the following information about operations in icing conditions:116 • For takeoff into icing conditions, the engine intake door, windshield heat, and propeller deice are to be turned on before takeoff, and the ref speeds switch is to be

115 The Q400 AFM contained three reference stall speeds, 1.4, 1.3, and 1.23 VSR, and Colgan used 1.23 VSR. 116 The Q400 Quick Reference Handbook, dated May 15, 2005, also contained procedures for flight into icing conditions. Quick reference handbooks are intended for flight crew use in the cockpit.

NTSB Aircraft Accident Report 43 moved to the increase position at 400 feet agl. When airframe ice is detected, the deice boots are to be operated in the fast mode. • For flight before encountering icing conditions, when ice is first detected, or when a flashing “ice detected” message appears on the engine display, the ref speeds switch is to be moved to the increase position at the same time as the engine intake door switches, the propeller selector, and the windshield heat are selected on. Also, the pilot’s side window heat switches are to be turned on if ice is forming on the pilot’s side window. • For climb, cruise, and descent in icing conditions, the minimum airspeed is to be maintained, the deice boots are to be operated, and wing and tail boot advisory lights are to be monitored for normal operation. • For holding, approach, and landing in icing conditions, the minimum airspeeds for icing are to be maintained, the deice boots are to be operated in fast mode, and a performance weight penalty is to be applied. The AFM also stated that, when the airplane was no longer in icing conditions, the deice boots should continue to be used in the fast mode until the airplane is aerodynamically clean. At that point, the deice boots and the ref speeds switch are to be turned off, and normal airspeeds are to resume. In addition, several airplane systems on the Q400, including the ice protection system, required daily checks. The Colgan CFM, section 5, “Expanded Checklist,” dated May 20, 2008, explained that the following items were to be checked on the ice protection system: airframe deice pressure indicator, airframe mode select switch, airframe manual select switch, propeller selector, ref speeds switch, engine intake doors, windshield heat, and stall protection system. (A Q400 check airman explained that this 24-hour check was normally accomplished during flight instead of preflight.)117 Finally, the Q400 AFM and Colgan CFM stated, in the Limitations section, that the autopilot must be disengaged during severe icing. On February 20, 2009, Colgan issued CFM Operations Bulletin 09-001, Speed Bugs for Landing, Icing Definitions, and Ice Equipment Operations. The bulletin emphasized the importance of setting the proper Vref bugs, especially when icing conditions might be expected; reiterated the proper icing terminology to use with the ACARS system to ensure that the proper ice speeds are received (from AeroData) for Vref and Vga; and introduced three levels of ice protection.118 The bulletin prohibited selecting the ref speeds switch to the increase position during takeoffs, and changing the position of the ref speeds switch during landings, while the airplane was below 1,000 feet agl. The Colgan POI stated that the company conducted mandatory briefings about the information in the bulletin with its Q400 pilots.

117 About 2132:13, the first officer detected, while reviewing the airplane’s logbooks, that a previous flight crew had not performed the 24-hour ice protection test. The captain responded that he had just performed the test. 118 Level one was for all flight conditions and on the ground. Level two occurred in flight with a saturated air temperature of 5° C or colder and visible moisture or 1 mile or less visibility in clouds. Level two occurred on the ground with a saturated air temperature of 10° C or colder and visible moisture or 1 mile or less visibility with fog. Level two also occurred on the ground when an airplane was operating on a surface that was contaminated with snow, ice, standing water, or slush. Level three occurred when ice accretion was visible or when the ice detected message appeared on the engine display.

NTSB Aircraft Accident Report 44 1.17.2.3 Descent, Approach, and Before Landing Checklists The Q400 CFM, section 5, stated that the pilot flying normally called for the descent checklist when the airplane was descending through an altitude of 18,000 feet or at the top of the descent if the cruise altitude was below 18,000 feet. The CFM indicated that the flying pilot was to call for the approach checklist, with sufficient time to complete the checklist, before (1) crossing the initial approach fix or transitioning to the initial approach phase during an instrument approach or (2) turning onto the base leg on a visual approach. The CFM further stated that the before landing checklist was to be performed 1 nm before the final approach fix. The Colgan Flight Operations Policies and Procedures Manual, section 5, stated that checklists were to be performed in the challenge-response manner with the monitoring pilot performing and double-checking the action called for by the checklist item (as announced by the captain).119 The manual also stated that all pilots, while performing checklists, needed to avoid becoming so engrossed in cockpit duties that their outside vigilance would be reduced. Further, the manual indicated that additional information about the company’s “checklist philosophy” was included in the Q400 CFM, but the CFM did not contain such information.120 Colgan’s postaccident CFM Operations Bulletin 09-003 (see section 1.17.2.1) announced that the company’s approach checklist had been changed to include a callout for the ref speeds switch, which required a response from both flight crewmembers. The bulletin further indicated that the decision to turn the switch to the increase or off positions during an approach should be made before entering the initial approach phase and prohibited changing the position of the ref speeds switch below 1,000 feet agl. (This information was also communicated in Colgan’s postaccident CFM Operations Bulletin 09-001; see section 1.17.2.2.) In addition, CFM Operations Bulletin 09-003 stated that, when the ref speeds switch was set to the increase position, the only speeds that could be set were for Vref (ice) and Vga (ice) but that, if the ref speeds switch was subsequently turned to the off position, the airspeed targets could be changed to Vref and Vga as long as the airplane was above 1,000 feet agl. 1.17.2.4 Approach Profile and Stabilized Approach Criteria The Q400 CFM, section 10, dated May 20, 2008, included information for approaches with vertical guidance. According to this information, the monitoring pilot was to advise the flying pilot of airspeed deviations greater than ± 10 knots. The information did not include a reminder to pilots to check the airspeed against the position of the ref speeds switch. The Colgan Flight Operations Policies and Procedures Manual, section 5, included the company’s stabilized approach criteria. Among these criteria was the following: below 1,000

119 After the accident, Colgan implemented an initiative to train its check airmen to evaluate the performance of the monitoring pilot (in addition to the flying pilot) during checkrides. 120 In addition, the Flight Operations Policies and Procedures Manual indicated that a statement about “monitoring responsibility” during the required approach briefing was explained in the expanded checklist procedures section of the Q400 CFM, but the CFM did not contain this statement.

NTSB Aircraft Accident Report 45 feet agl in instrument meteorological conditions or 500 feet agl in VMC, the airplane is to be at an airspeed that is not less than Vref and is not greater than Vref plus 20 knots. 1.17.3 Sterile Cockpit Procedures Colgan’s sterile cockpit procedures are discussed as part of ground school indoctrination training during a review of the subjects covered in the company’s Flight Operations Policies and Procedures Manual. The manager of crewmember and dispatcher training stated that ground school instructors referenced applicable policies and pages in the manual. (The slides presented during indoctrination training did not include this information.) Section 3 of the manual, dated December 20, 2007, referenced 14 CFR 121.542, “Flight Crewmember Duties,” which discusses the sterile cockpit rule. Sections (a) through (c) of the regulation state the following: No flight crewmember may perform any duties during a critical phase of flight not required for the safe operation of the aircraft. No flight crewmember may engage in, nor may any PIC permit, any activity during a critical phase of flight which could distract any flight crewmember from the performance of his/her duties or which could interfere in any way with the proper conduct of those duties. Critical phases of flight include all ground operations involving taxi (movement of an airplane under its own power on the surface of an airport), take-off and landing, and all other flight operations conducted below 10,000 feet MSL, except during cruise flight. The director of crewmember and dispatcher training stated that sterile cockpit procedures were referenced in the flight attendant training program more than the pilot training program because newly hired flight attendants from outside the aviation industry needed to be made aware of the importance of not interrupting the flight crew during critical phases of flight. The director of crewmember and dispatcher training added that pilots were instructed on the critical phases of flight during indoctrination training. Check airmen stated that, during checkrides, captains were expected to brief sterile cockpit procedures before the flight, and the procedures were expected to be followed during the flight. The company chief pilot stated that he issued a CrewTrac message in summer 2008 about the need to adhere to rules,121 including the sterile cockpit rule, and avoid complacency, but the company was not able to identify any such message in response to a request from the NTSB.122

121 CrewTrac messages are presented to pilots when they log into the company’s computer system. Pilots need to review and acknowledge the information in the CrewTrac messages before they can check in or view their flight schedule. 122 Colgan was asked to provide CrewTrac messages that addressed sterile cockpit adherence or standard operating procedures and were sent to pilots based at EWR or ORF from January 2008 to the date of the accident. No message on either topic was found.

NTSB Aircraft Accident Report 46 One first officer indicated that company pilots adhered to sterile cockpit procedures. Another first officer indicated that captains with whom he had flown deviated rarely from sterile cockpit procedures but that, when they did, he would speak up by redirecting them to the tasks at hand. Check airmen and captains indicated that sterile cockpit adherence was good but that, when the sterile cockpit rule was not being followed, they would either remind the pilot about the rule or they would ignore the pilot’s statement to convey the message that the pilot should not be talking. The company POI stated that FAA surveillance of Colgan before the accident (as well as the company’s own surveillance) did not indicate a problem with crew adherence to sterile cockpit procedures. According to the company’s director of crewmember and dispatcher training, after the accident, he tasked the manager of crewmember and dispatcher training with enhancing the ground school presentations to ensure that pilots were doing their jobs and following procedures. The manager of crewmember and dispatcher training and a ground school instructor added a recurrent training slide that explicitly addressed adherence to sterile cockpit procedures. The slide referenced cockpit decorum, the sterile cockpit concept, maintaining cockpit stations (including airplane control), and preflight procedures (including the captain’s briefing and other preflight information). On February 26, 2009, the company chief pilot issued a CrewTrac message addressing sterile cockpit adherence. The message defined sterile cockpit during the ascent as beginning when the flight attendant closes the cockpit door and ending when the airplane climbs through 10,000 feet. The message defined sterile cockpit during the descent as the time from when the airplane is descending through 10,000 feet to the completion of the parking checklist. The message indicated, “when in sterile cockpit no extraneous conversation of any kind may take place. Remember this also covers non essential activities such as eating.” In October 2009, the company reported that it had added to its checklists an item for the 10,000-foot sterile cockpit period. The company further reported that it also expanded the scope of the sterile cockpit period to include (1) 1,000 feet above or below a level-off altitude and (2) approaching the top of descent on crossing restrictions and pilot-discretion descents.123 1.17.4 Commuting Policy Colgan’s Flight Crewmember Policy Handbook, dated March 2008, stated that a commuting pilot was expected to report for duty in a timely manner. Commuting pilots were expected to be listed in an airline reservation system aboard two separate flights that had adequate seat availability and were scheduled to arrive at the pilot’s duty station at a reasonable time before the pilot was scheduled to report for duty. If the pilot missed the first flight, then the pilot was required to notify crew scheduling of the estimated time of departure for the second flight so that plans could be made in case the second flight was missed. If the pilot missed the

123 Colgan’s September 20, 2009, revision of its Flight Operations Policies and Procedures Manual incorporated this information.

NTSB Aircraft Accident Report 47 second flight, then the pilot was to contact crew scheduling and make every effort to report to the location where the pilot was scheduled to begin duty. The policy recognized that pilots might be unable to report for duty because of unforeseen flight schedule disruptions and, as a result, provided relief from disciplinary actions to pilots twice in any 12-month period for this reason. The policy stated that pilots who demonstrated a pattern of missed trips would no longer be able to use the company’s commuting policy, even if the pilot had complied with the above requirements of the policy. The February 2006 edition of the Flight Crewmember Policy Handbook stated the following information:124 While commuting by Flight Crewmembers is understood and accepted by the Company, in no way will commuting be deemed a mitigating factor in the Flight Crewmember’s scheduling, punctuality and demeanor. All Flight Crewmembers will be fully accountable for their timely arrival and appearance at their base. Any and all expenses incurred because of commuting will be borne by the Flight Crewmember. Flight Crewmembers should not attempt to commute to their base on the same day they are scheduled to work. This statement did not appear in the March 2008 handbook (which was the edition current at the time of the accident). 1.17.4.1 Commuting Status of Pilots Based at Newark During a February 2009 postaccident interview, the EWR regional chief pilot stated that he did not know the number of commuting pilots at EWR.125 The regional chief pilot also stated that no restrictions were placed on pilots regarding commuting but that pilots had to meet schedule requirements. An EWR-based first officer thought that most commuting pilots had crash pads or shared apartments. Another EWR-based pilot stated that the reason for the large number of commuting pilots was the high cost of living in the EWR area and the low wages that company pilots received. In response to an NTSB request for information, Colgan asked its 137 EWR-based pilots, in April 2009, about their commuting status. Of these 137 pilots, 93 (68 percent) identified themselves as commuters. Colgan also responded with address information for its EWR-based pilots, which the NTSB cross-checked against the FAA’s airmen certification database between April 9 and 13, 2009. Of the 137 addresses provided by Colgan, 136 were found in the FAA’s database. Table 3 shows the geographic distribution for these 136 EWR-based pilots.

124 Colgan’s Employee Handbook, dated February 2005, contained the following similar statement about commuting: “Colgan understands it may be necessary for employees to commute, however, in no way will commuting be deemed a mitigating factor in an employee’s schedule, punctuality or demeanor. All employees will be fully accountable for on time appearance at their base (for their shift). Any and all expenses incurred because of commuting will be the responsibility of the employee.” 125 The EWR chief pilot commuted from his home in North Carolina to EWR and had a crash pad in the EWR area.

NTSB Aircraft Accident Report 48 Table 3. Geographic Distribution of Colgan Air Pilots Based at Newark, New Jersey Distance from EWR (in statute miles) Number of pilots States represented Less than 100 45 Connecticut, New Jersey, New York, Pennsylvania 100 to 199 13 Maryland, Massachusetts, New York, Pennsylvania, Rhode Island 200 to 399 29 Maine, Massachusetts, New Hampshire, New York, North Carolina, Pennsylvania, Virginia 400 to 999 20 Florida, Georgia, Illinois, Iowa, Michigan, Ohio, South Carolina, Tennessee, West Virginia 1,000 or more 29 California, Colorado, Florida, Louisiana, Minnesota, Nevada, Texas, Utah, Washington Note: Geographic distances from EWR were determined using the pilots’ address on record with the FAA. The number of statute miles was based on straight-line distances between zip codes. 1.17.5 Fatigue Policy Colgan’s fatigue policy for its pilots (and flight attendants) is addressed during basic indoctrination ground school and is included in the Flight Operations Policies and Procedures Manual. The fatigue policy at the time of the accident was as follows: Colgan recognizes that there may be occasions and/or circumstances where a Crewmember’s ability to accept or complete an assignment is altered by fatigue. While our concerns are oriented to serve safe operations, we need to review all of the known factors which have led to a call of Crewmember fatigue and any resultant operations impact. This information will facilitate the development of fatigue history and identify factors which led to fatigue. We can then evaluate fatigue and [its] relationship to operational considerations which may improve our planning and prevent recurrence. When a Crewmember is unable to complete an assignment or reassignments because of fatigue, he/she must accomplish the following: • Immediately notify SOC [Systems Operations Control] and the Operations Duty Officer. • Complete the Crewmember Fatigue Form[ ] 126 …. Within 24 hours of being released from duty because of declared fatigue, [provide] the completed form to the Chief Pilot or Duty Officer.

The EWR regional chief pilot stated that, between May 2008 and February 2009, only about a dozen pilots had called in fatigued. The regional chief pilot also stated that, if pilots were fatigued, they could call in as such to crew scheduling or use sick leave.127 In addition, the

126 Crewmembers were required to include, on the fatigue form, their duty time on the day of the fatigue call and their flight and duty times during the 6 days preceding the fatigue call, including the number of hours of rest before duty. 127 The Colgan Employee Handbook indicated that pilots earn 0.5 day of sick leave after 90 days of employment with the company and then 0.5 day of sick leave each month, with a maximum carryover of 30 days.

NTSB Aircraft Accident Report 49 regional chief pilot stated his philosophy about the policy, indicating that, if a pilot’s fatigue call was a one-time event, he would only file a report but that, if a pilot were to repetitively call in fatigued, he would talk with that pilot to figure out what was prompting the calls. A check airman stated that he had called in fatigued one or two times and that no followup occurred afterward. Colgan’s September 20, 2009, revision to its Flight Operations Policies and Procedures Manual contained additional information about the company’s fatigue policy. According to the manual, Colgan’s safety department was the focal point for the company’s fatigue policy to gather information to identify fatigue and scheduling issues. As a result, crewmembers were required to submit fatigue forms to the safety department instead of the chief pilot or duty officer. The manual also stated, “managing fatigue is one of the most critical elements of maintaining a safe operation. Recognizing fatigue and its effects on human performance is important, but preventing fatigue is equally essential.” At the time of the accident, Colgan did not provide any information to its pilots about fatigue prevention. The manager of flight safety stated that he had been developing a pamphlet for pilots that provided information on reasons for fatigue and industry fatigue trends. The vice president of safety and regulatory compliance stated that the document developed by the flight safety manager was not implemented because it focused on changing duty times and report periods as a countermeasure to fatigue, which would not have been feasible. The Colgan POI stated that he was aware of the company’s fatigue policy. Although the POI did not have any specific concerns with the policy, he did state, “pilots commute … they get up early … any regional airline tries to be as productive as possible with its folks … I’m always concerned about that.” 128 Colgan’s revised CRM course (see section 1.17.1.4) discussed the effects of fatigue on performance, fatigue warning signs, alertness management strategies, and accidents involving flight crew fatigue. Also, on April 29, 2009, Colgan issued Operations Bulletin 09-001 to its Flight Operations Policies and Procedures Manual, which addressed crewmember fatigue.129 The bulletin discussed the company’s fatigue policy, causes of fatigue, the recognition of fatigue and its effects on performance, strategies to combat fatigue by effectively utilizing rest periods, and the procedures to use if a crewmember were unable to complete an assignment because of fatigue. The bulletin stated that any crewmember who conducted a flight when fatigued or otherwise physically incapable of completing a flight safely would be in violation of company policy. The bulletin emphasized, using bold face and capital letters, the following statement: “commuting to arrive at a base with either insufficient rest to prepare for flight duties, or to arrive with minimal time before a duty day begins is inappropriate for your responsibilities as a professional pilot!”

The EWR regional chief pilot explained that no followup would occur after a pilot has called in sick unless the sick leave calls became repetitive, which he defined as four calls within a 12-month period. 128 Information from Colgan’s third quarter 2008 safety department review identified “crew rest challenges” as an issue. The information also indicated that declarations of crew fatigue were increasing. 129 The information contained in this bulletin was incorporated into the September 20, 2009, revision of the company’s Flight Operations Policies and Procedures Manual.

NTSB Aircraft Accident Report 50 On December 30, 2009, Colgan’s director of operations issued read-and-sign memo 09-12, “Interim Fatigue Policy” to all company pilots and flight attendants. The memo stated that, although Colgan’s nonpunitive fatigue policy had provided helpful information in understanding scheduling issues that created fatigue among crewmembers and had resulted in crewmembers recognizing and declaring true fatigue situations, abuse of the fatigue policy was increasing. The memo noted the following: “in the last 2 months, the instances of fatigue calls with no valid reason for fatigue have increased to the point where frivolous fatigue calls are now the majority” and “frivolous use of sick policy and fatigue policy at the expense of our customers and our operational reliability is not an acceptable practice.” The memo contained revised fatigue policy information developed by the Colgan vice president of safety and regulatory compliance. This interim policy, which became effective on December 31, 2009, stated that fatigue calls would not be accepted if the crewmember had a rest period of at least 12 hours before the start of the duty day, was returning from days off, or wanted to use the policy for a future flight. The memo noted that the safety department would consider mitigating circumstances preventing a rest period from being fully used when determining whether a fatigue call was acceptable. The memo cautioned, “any further blatant abuse of the fatigue option will be addressed as a disciplinary action, and fatigue resulting from an improper use of rest periods or personal time off duty will be treated as missed trips.” In addition, the memo stated that the company was working with pilot and flight attendant unions to establish a comprehensive fatigue program, including a review board process, by February 15, 2010. 1.17.6 Crew Room Policy The EWR regional chief pilot stated that Colgan had a policy that prohibited crewmembers from using the crew room to sleep overnight. A May 24, 2008, read-and-sign memo from the regional chief pilot addressed sleeping in the crew room and included the following information:130 If a Crew Member is based in EWR [then] you are responsible for your own overnight accommodations. Sleeping in Operations or any crew room in EWR is strictly prohibited and will have severe disciplinary consequences, up to and including termination. Company records indicated that the accident captain and the accident first officer acknowledged receipt of this policy information. The EWR regional chief pilot also stated that, even though the crew room was accessible at all times, he did not know of anyone who had stayed in the crew room overnight.131 He further

130 A first officer interviewed by the NTSB knew that Colgan had a policy against sleeping overnight in the crew room but did not know if the policy was a written one. A check airman interviewed by the NTSB recalled the read-and-sign memo indicating that it was not permissible to sleep overnight in the crew room. 131 One check airman stated that he had not seen any pilots sleeping overnight in the crew room. Another check airman stated that he had stayed overnight in the crew room but only when he was traveling home the next day.

NTSB Aircraft Accident Report 51 stated that Colgan did not get involved with rest issues beyond the FAA regulations for proper crew rest but encouraged pilots to have an appropriate place to stay overnight while in Newark. The Colgan vice president of administration stated that commuting pilots needed to have suitable accommodations because they would not receive adequate rest if they slept in the crew room. She further stated that the company “can’t make someone have a crash pad, but we can certainly make them not … sleep in the crew room.” In March 2009, the EWR regional chief pilot began requiring that some lights remain on at all times in the crew room to ensure that pilots were not using the room as a crash pad. 1.17.7 Safety Programs 1.17.7.1 Safety Management and Culture The Colgan vice president of safety and regulatory compliance, who reports directly to the president of the company, is responsible for all safety-related situations. Other Colgan officials who are responsible for safety at the company include the director of safety and the manager of flight safety.132 The responsibilities of the director of safety were overseeing safety programs, investigating and reviewing occurrences involving safety, and overseeing manual revisions for consistency. The director of safety also attended new-hire indoctrination training to provide an overview of the company’s safety programs. During this training, all newly hired employees received information about submitting safety reports, contacting safety personnel, accessing safety information on the company’s website, and finding safety information in the company’s manuals. The responsibilities of the flight safety manager included overseeing the aviation safety action program (ASAP), providing information for the line operations safety audit (LOSA) program, and developing the flight operational quality assurance (FOQA) program.133 Colgan held quarterly safety council meetings, which were chaired by the president of the company and included senior management personnel (at the vice president and director levels) from all of the company’s departments. According to the company’s Safety Program Manual,134 the purpose of the safety council meetings was to increase safety awareness, discuss unresolved issues, facilitate group discussions, and develop positive outcomes. Colgan also held quarterly safety review board meetings, which involved personnel at the middle management level. In addition, safety personnel attended the company’s daily operations meetings, and safety department reviews occurred quarterly.

132 An organizational chart in the company’s Airline Administrative Guide showed that the manager of flight safety reported directly to this vice president, whereas the Flight Operations Policies and Procedures Manual indicated that the manager of flight safety reported directly to the director of safety, who then reported to the vice president of safety and regulatory compliance. 133 The ASAP, LOSA, and FOQA programs are discussed in sections 1.17.7.3 through 1.17.7.5, respectively. 134 Colgan’s Safety Program Manual outlined the company’s safety policies, procedures, and reporting programs. The manual was issued in June 2001 and was revised in April 2002, December 2005, and June 2007.

NTSB Aircraft Accident Report Colgan’s guiding principle regarding safety was presented in two company manuals. The Employee Manual stated, “Safety – Our primary goal is to provide 100% safe transportation for our customers. Safety is the first priority of Colgan. No other value or goal has priority over safety.” The Flight Operations Policies and Procedures Manual stated, “In all aspects of Colgan’s operation, safety shall be given primary consideration. Each and every employee is responsible for ensuring safety in his own daily operations and shall promote safety among his fellow employees.” In August 2008, Colgan safety personnel (including the vice president of safety and regulatory compliance) and the company president traveled to all company bases to present a “safety road show” to pilots and other operational personnel. This safety briefing addressed ASAP and LOSA and included a 31-slide presentation that discussed expectations for safety (one of which was to operate the safest airline in the industry), industry accidents involving organizational and management factors, and methods to prevent such accidents by ensuring that a company safety culture existed. The presentation also discussed that a way to change safety culture was by providing top-down guidance that is practiced and reinforced. In addition, the presentation reviewed accidents involving error chains and included a slide that stated that the cause of accidents was “rarely a single event, often a failure of common procedure, and inattention to routine tasks and complacency.” The third quarter 2008 safety department review indicated that the presentation had been provided to 525 employees at company headquarters and bases. After the accident, Colgan announced that it would be increasing the visibility of the company’s safety department by having department personnel conduct monthly observations of crew bases and observe flight crews during line operations. The Colgan manager of flight safety stated that the safety culture at the company was good because of programs, such as ASAP and LOSA, that allowed employees to provide feedback and the corrective actions implemented by the company based on the feedback. This manager added that pilots have also volunteered other information outside of the programs about the company’s operations. The Q400 fleet manager also stated that the safety culture at the company was good because of the safety message being conveyed throughout the company by the company president and vice presidents. The manager of flight standards stated that the safety road show helped to improve the company’s safety culture because it reinforced the importance of safety and the message that everyone needed to work together. The director of flight standards stated the following regarding the company’s safety culture: “the pilots that are out there every day performing the job flying the airplanes around wouldn’t dream of doing anything but keeping it a safe operation for themselves and their passengers and their flight attendants.” The POI for Colgan stated that the safety culture at the company was “more reactive than I’d like … not quite as proactive.” The POI indicated that the company needed more middle management-level personnel to advance safety programs and conduct additional monitoring. He 52

NTSB Aircraft Accident Report 53 further stated that Colgan’s plans to implement the FAA’s air transportation oversight system (ATOS) and a company safety management system (SMS) would facilitate change.135 1.17.7.2 Safety Reporting Methods According to the company’s Flight Operations Policies and Procedures Manual, Colgan has a 24-hour safety hotline for employees to anonymously report any safety-related concern. The safety hotline is a voicemail system that is directed to the vice president of safety and regulatory compliance. The director of safety stated that no hotline calls had been received and that the lack of calls was not an issue because employees could raise safety concerns directly rather than anonymously. The company also has several forms that employees can use to report a safety concern. These forms are available in the company’s Flight Operations Policies and Procedures Manual and on the company’s website. Once completed, these forms are routed to the vice president of safety and regulatory compliance. One of the forms is the feedback reporting form, which can be used to report manual errors and suggestions for improvements in addition to safety-related concerns. Another form used to report safety concerns is the irregularity event report form. Pilots can use this form, which is routed to the director of safety, to submit reports of events or situations affecting the safe and efficient operation of the airplane while on the ground or during flight. The director of safety stated that the irregularity event report form would be used for reporting an incident or occurrence, whereas an ASAP form (discussed in section 1.17.7.3) would be used when a pilot believed that a company policy or a Federal Aviation Regulation had been breached. The Colgan POI stated that, even though the company’s feedback reporting forms were discussed in initial and recurrent ground school, pilots might not be providing enough feedback to the company. The company’s APM for the Q400 fleet also stated his concern that pilots might not be providing enough information to Colgan, even with the company reporting forms available in their manuals. He indicated that he had previously told company personnel that either pilots did not know the reporting methods that were available to them or managers were not emphasizing the use of these reporting methods. The APM noted that the EWR regional chief pilot had since placed company reporting forms on the flight crew website and was encouraging their use to effect change. Colgan’s Safety Program Manual stated that disciplinary actions would not be taken against anyone who immediately discloses an occurrence involving safety.

135 ATOS employs a systems safety approach to air carrier oversight. SMS incorporates proactive safety methods for air carriers to identify hazards, mitigate risk, and monitor the extent that air carriers are meeting their objectives. ATOS and SMS are complementary and are designed to work in an integrated manner.

NTSB Aircraft Accident Report 54 1.17.7.3 Aviation Safety Action Program Colgan’s ASAP, which began in 2005, involves company pilots, flight attendants, dispatchers, mechanics, and ground personnel. The manager of flight safety, as the ASAP coordinator, participates in event review committee meetings,136 which also include the manager of flight standards, an FAA representative, and a company pilot representative. The ASAP coordinator manages the submission of ASAP reports, ensures that the findings from the event review committee meetings are disseminated to the appropriate personnel for corrective action, analyzes ASAP data each quarter to identify trends, and prepares quarterly and annual reports that are provided to managers in the flight standards and flight operations departments and are posted on the company’s website. ASAP reporting forms are available on the company’s website. The ASAP form includes a box that can be checked if the report should also be sent to NASA’s Aviation Safety Reporting System (ASRS),137 which is a national repository for voluntary reports regarding aviation safety- related issues and events.138 The Colgan manager of flight safety stated that about 25 ASAP reports were submitted each month. This manager also recalled that the only deviations of standard operating procedures identified in ASAP data involved overspeeds while descending. He could not recall any reports, during the 12 months before the accident, describing problems with sterile cockpit adherence. The company chief pilot reported that most of the ASAP data he reviewed involved altitude, route, or clearance deviations. Company personnel stated that no ASAP reports had been submitted before the accident regarding stall warning activations,139 severe icing, or temporary loss of control of an airplane. Also, the fourth quarter 2008 safety department review indicated that ASAP trends and focus areas were runway incursions and altitude and clearance deviations. After the accident, Colgan announced that an ASAP “reemphasis campaign” for all crew bases would occur during summer and fall 2009. In October 2009, Colgan stated that ASAP was being regularly emphasized to promote the program’s use; pilot participation in the program has been “robust”; and program participation by mechanics, dispatchers, and flight attendants was increasing. ASAP was also included as a discussion topic in the company’s revised CRM/threat and error management training.

136 The director of safety and the vice president of safety and regulatory compliance assumed the role of ASAP coordinator in March 2009 when the manager of flight safety left the company. A new flight safety manager was hired in May 2009. Colgan indicated that he has emphasized the use of ASAP through base meetings and general communications to employees. 137 Colgan uses an FAA contractor to manage the ASAP forms and the ASAP database. Colgan had asked the contractor to change the default setting on the ASAP form so that it would not automatically be sent to the ASRS. The company made this request after receiving feedback from pilots that the ASAP form was already similar to other company reporting forms and that minor events, such as gate returns, were being included in the ASRS database. 138 Because ASRS reports are submitted voluntarily, the existence of reports concerning a specific topic in the ASRS database cannot be used to infer the prevalence of that problem within the National Airspace System. 139 A stall warning activation was reported to the ASAP database in March 2009. This event is discussed in section 1.18.3.

NTSB Aircraft Accident Report 55 1.17.7.4 Line Operations Safety Audit Colgan began conducting LOSA observations in 2008. The company’s manager of flight safety stated that the purpose of these nonpunitive observations of flight deck procedures was to identify and rectify those performance trends that deviate from standard operating procedures. The manager of flight safety stated that “really nothing” had come up during the LOSA observations; in particular, no problems with sterile cockpit adherence were found. According to Colgan, company check airmen were initially used as LOSA observers because they were already trained to be observers of operational standards. The manager of flight safety stated that the use of check airmen for LOSA observations might raise concerns among pilots about whether the observations were actually nonpunitive, so the company was taking action to recruit line pilots to be LOSA observers. As of March 2009, two pilots had been trained as LOSA observers, one who conducted observations aboard Q400 airplanes and one who conducted observations aboard Saab 340 airplanes. The flight safety manager explained that 5 to 10 observers were needed to fully implement the LOSA program for the Q400 fleet. After the accident, Colgan had announced that it would train LOSA observers by July 2009 and that its goal was to conduct 50 LOSA observations by September 2009. The company did not accomplish this goal but now plans to complete a minimum of 100 LOSA observations by the end of the first quarter of 2010. 1.17.7.5 Flight Operational Quality Assurance FOQA programs collect, deidentify, and analyze flight data to identify and correct possible operational risks at an air carrier. Colgan had initiated actions to establish a FOQA program, but the program was not fully implemented at the time of the accident. After the accident, the company announced plans to equip the Q400 fleet with quick access recorders (QARs) and targeted program implementation for July 1, 2009.140 The company’s director of safety stated that the installation of this equipment required a supplemental type certificate and that the company would finalize the schedule to equip the Q400 fleet with the recorders once the installation was approved. Other actions that Colgan had taken to initiate a FOQA program included identifying a vendor to support FOQA data analysis and establishing a FOQA steering committee. This committee consisted of personnel from the maintenance, quality control, and safety departments and was planned to be expanded to include the flight operations department and line pilots. Also, in a letter dated May 4, 2009, to the Air Line Pilots Association (ALPA), the Colgan vice president of flight operations proposed including CVR data in the company’s FOQA program. This vice president explained that overlaying flight deck communications and other sounds

140 QARs are recording units installed on aircraft to store data recorded during flight. The recorders provide quick and easy access to a removable medium, such as an optical disk or personal computer memory card, on which the flight information is recorded. According to the FAA, QARs have been developed to record an expanded data frame; some of the recorders support more than 2,000 parameters at higher sample rates than FDRs.

NTSB Aircraft Accident Report generated within the flight deck from the CVR on the visual representation provided by FDR data would provide additional safety information for accident prevention. In October 2009, Colgan stated that it received 14 QARs for its Q400 fleet, installed QARs on four Q400 airplanes, and planned to install the remaining 10 QARs on Q400 airplanes by the end of December 2009. The four currently installed QARs were being periodically downloaded to collect data to validate flight information from the recording medium to the ground station. The company expected to receive the FOQA ground station for analysis in November 2009, and user training was scheduled to occur in November and December 2009. Further, a memorandum of understanding between Colgan and ALPA was expected to be signed by December 2009, and analysis of QAR data was expected to begin by the end of January 2010. Colgan reported in early January 2010 that the remaining 10 QARs have been installed on Q400 airplanes and that the memorandum of understanding between Colgan and ALPA was “almost ready” for signature. 1.17.7.6 Additional Postaccident Actions The safety department review held after the accident included a slide titled, “Flight Ops Actions Since Feb 12.” The slide listed actions that the company had taken or planned, which included the following: • increased the surveillance by check airmen throughout the Q400 fleet as part of a “standardization push”; • increased the presence of flight operations management at crew bases; • required pilots to ride with a check airman after an infraction; • required dispatchers to check the icing box on the dispatch release if icing conditions existed in either the departure or the arrival city; • implemented a zero-tolerance policy that holds pilots accountable for “egregious” mistakes; and • increased the communications flow to crews with frequent CrewTrac messages and read-and-sign memos for each event or challenge encountered by a crew. Also, Colgan reported that it was in the process of reviewing the top-of-descent to touchdown phase of flight for its Saab 340 and Q400 fleets. In addition, the company also introduced the “VVM” (verbalize, verify, and monitor) program. The VVM program was presented as part of the company’s revised CRM/threat and error management course and was described in the September 20, 2009, revision to the Flight Operations Policies and Procedures Manual. The manual instructed pilots to use the VVM program “during every phase of the flight, beginning when you arrive in the weather room until you leave the flight deck at the end of the flight. It will help you deal effectively with the threats and errors encountered in daily operations – frequency congestion, fatigue, distractions, etc.” 56

NTSB Aircraft Accident Report 57 1.17.7.7 Safety Communications at the Newark Base The EWR regional chief pilot stated that one way that safety information was provided to pilots at the base is through the CrewTrac system. Pilots at the EWR base also receive safety information through read-and-sign memos, bulletins, and manual revisions. In addition, a safety bulletin board is posted at EWR, and the company’s website for its flight crews contains safety information from the safety department and the flight standards department. 1.18 Additional Information 1.18.1 Previous Safety Recommendations 1.18.1.1 Sterile Cockpit Adherence On February 7, 2006, the NTSB issued Safety Recommendation A-06-7 as a result of the accident involving Corporate Airlines flight 5966 in Kirksville, Missouri.141 Safety Recommendation A-06-7 asked the FAA to do the following: 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. On May 31, 2006, the FAA stated that it would issue a Safety Alert for Operators (SAFO)142 to address the intent of the recommendation. According to the FAA, the SAFO would call attention to sterile cockpit rules and remind inspectors and Part 121 and 135 operators that strict compliance with those rules was required and that breaches had contributed to at least one recent air carrier accident. On November 9, 2006, the NTSB acknowledged that SAFO 06004, “Approach and Landing Accident Reduction: Sterile Cockpit, Fatigue,” had been issued on April 28, 2006,143 with a purpose of emphasizing sterile cockpit discipline.144 As a result, the NTSB classified Safety Recommendation A-06-7 “Closed—Acceptable Action.”

141 For more 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). 142 FAA Order 8000.87A, dated October 24, 2006, stated that a SAFO contained important, often critical, safety information and recommended (nonregulatory) action to be taken voluntarily by the operators identified in the SAFO. (This order replaced FAA Order 8000.87, dated August 29, 2005, which introduced SAFOs.) 143 The NTSB notes that the issuance date of the SAFO actually preceded the date of the FAA’s letter. 144 SAFO 06004 was also issued in response to Safety Recommendation A-06-11, which is discussed in section 1.18.1.5.

NTSB Aircraft Accident Report 58 1.18.1.2 Situational Awareness On October 16, 1996, the NTSB issued Safety Recommendation A-96-106 as a result of the accident involving American Airlines flight 965 near Cali, Colombia.145 Safety Recommendation A-96-106 asked the FAA to do the following: Revise Advisory Circular 120-51B to include specific guidance on methods to effectively train pilots to recognize cues that indicate that they have not obtained situational awareness, and provide effective measures to obtain that awareness. On December 11, 1998, the FAA stated that it issued Advisory Circular (AC)146 120-51C, “Crew Resource Management Training,” on October 30, 1998. According to the FAA, appendix 3 of the AC specifically addressed training for pilots in recognizing cues that indicate a lack or loss of situational awareness and training in countermeasures to restore that awareness. The AC also referenced the FAA’s February 1998 publication, Guidelines for Situational Awareness Training, which included expanded guidance on the subject. On March 1, 1999, the NTSB stated that the changes to AC 120-51B, which resulted in the issuance of AC 120-51C,147 met the intent of the recommendation. As a result, the NTSB classified Safety Recommendation A-96-106 “Closed—Acceptable Action.” 1.18.1.3 Pilot Professionalism On January 23, 2007, the NTSB issued Safety Recommendation A-07-8 as a result of the accident involving Pinnacle Airlines flight 3701 in Jefferson City, Missouri.148 Safety Recommendation A-07-8 asked the FAA to do the following: 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. On April 13, 2007, the FAA stated that it meets routinely with training committees from ALPA, the Air Transport Association, the Regional Airline Association, and other groups and

145 The investigation of this accident was conducted by the Aeronáutica Civil of the Government of Colombia, with assistance from the NTSB, in accordance with the provisions of Annex 13 to the Convention on International Civil Aviation. In September 1996, the Aeronáutica Civil issued its report on this accident and determined that its probable causes included the flight crew’s lack of situational awareness regarding vertical navigation, proximity to terrain, and the relative location of critical radio aids. 146 ACs are advisory and not regulatory in nature. 147 The most recent version of the AC, 120-51E, was issued on January 22, 2004. 148 For more information, see National Transportation Safety Board, 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: NTSB, 2007).

NTSB Aircraft Accident Report 59 that, in future meetings, the FAA would provide a copy of an information for operators (InFO)149 message to be issued in response to Safety Recommendation A-07-6.150 The FAA also stated that it would discuss Safety Recommendation A-07-8 with these groups to determine an effective approach for addressing the underlying safety issues. On January 22, 2008, the NTSB stated that the activities described by the FAA were appropriate actions to take after the development of an educational program that conveys the necessary safety information has been completed. The NTSB also stated that meetings with ALPA, the Air Transport Association, the Regional Airline Association, and other groups would be helpful in distributing program materials or disseminating program information. Safety Recommendation A-07-8 was classified “Open—Acceptable Response” pending completion of these actions. 1.18.1.4 Monitoring Pilot Responsibilities On February 27, 2007, the NTSB issued Safety Recommendation A-07-13 as a result of the accident involving a Cessna Citation 560 in Pueblo, Colorado.151 Safety Recommendation A- 07-13 asked the FAA to do the following: 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. On May 17, 2007, the FAA stated that the provisions of 14 CFR Part 61 and the practical test standards addressed the requirement for CRM in airman certification and checking. The FAA added that it would consider identifying, in its work program, a list of required inspections that would reemphasize, to regional office and FSDO managers, the need to validate the training that it already required and verify its effectiveness. On September 10, 2008, the NTSB noted that, even though current CRM regulations addressed the issues in Safety Recommendation A-07-13, the NTSB has investigated accidents and incidents for which improved monitoring and workload management skills might have interrupted the chain of events that led to the accidents and thus prevented their occurrence. The

149 On October 20, 2006, the FAA issued Order 8000.91 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. 150 Safety Recommendation A-07-6 was also issued as a result of findings from the Pinnacle accident. The recommendation asked the FAA to “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.” On January 22, 2008, the FAA stated that the InFO would discuss the circumstances of the Pinnacle accident (a repositioning flight) and other accidents involving nonrevenue flights and would emphasize the need for the same high standards of professionalism that are expected for revenue flights. On May 19, 2008, the NTSB classified Safety Recommendation A-07-6 “Open—Acceptable Alternate Response.” 151 For more information, see 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).

NTSB Aircraft Accident Report 60 NTSB stated that the FAA’s proposal to identify a list of required inspections would be responsive to the intent of the recommendation as long as the list provided a strong emphasis on the monitoring and workload management components of the CRM program. Safety Recommendation A-07-13 was classified “Open—Acceptable Response” pending the development of such a list and its incorporation into FAA work programs for regional offices and FSDOs. 1.18.1.5 Flight Crew Fatigue On February 7, 2006, the NTSB issued Safety Recommendation A-06-10 as a result of the Corporate Airlines flight 5966 accident (see section 1.18.1.1). Safety Recommendation A-06-10, which is on the NTSB’s list of Most Wanted Transportation Safety Improvements, asked the FAA to do the following:152 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. On September 9, 2009, the FAA stated that, during the past year, it had worked with different groups to develop an operations specification that requires a fatigue risk management approach to mitigating fatigue for flights that exceed 16 hours. According to the FAA, the work highlighted the need for using such an approach in ultra-long-range flights as well as commercial flight operations. The FAA also stated that, in June 2008, it held a 3-day international symposium that presented current scientific knowledge of fatigue in aviation.153 The FAA further stated that it planned the following actions: publishing the fatigue symposium proceedings, developing ACs to address fatigue in aviation operations and provide guidance for including a fatigue risk management system (FRMS) within an air carrier’s SMS, collecting and analyzing crewmember fatigue data during actual flight operations, and providing guidance for determining adequate rest periods.

In addition, the FAA stated that, in July 2009, it established an aviation rulemaking committee on flight and duty time limitations and rest requirements for Part 121 and 135 operations. According to the FAA, the committee developed recommendations to consolidate and replace existing regulations for Parts 121 and 135, apply current fatigue science and information on fatigue, address the development of FRMS, and harmonize with international

152 Safety Recommendation A-06-10 superseded Safety Recommendation A-99-45, which was issued on June 1, 1999. The recommendation asked the FAA to “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 requirements.” Also, Safety Recommendation A-06-10 was reiterated in the NTSB’s report on the accident involving Pinnacle Airlines flight 4712. For more information, see Runway Overrun During Landing, Pinnacle Airlines, Inc., Flight 4712, Bombardier/Canadair Regional Jet CL600-2B19, N8905F, Traverse City, Michigan, April 12, 2007, Aircraft Accident Report NTSB/AAR-08/02 (Washington, DC: NTSB, 2008). 153 Staff members from the NTSB gave presentations at the symposium, and Board Member Robert L. Sumwalt was the keynote speaker.

NTSB Aircraft Accident Report 61 fatigue mitigation initiatives. The FAA stated that it was reviewing the recommendations and that it would publish a notice of proposed rulemaking (NPRM) in December 2009 based on the committee’s work. On December 29, 2009, the NTSB stated that the FAA, after years of inaction, appeared to be on the verge of taking the recommended actions with regard to flight time limitations, duty period limits, and rest requirements for Part 121 and 135 pilots.154 The NTSB noted that the FAA had proposed publishing the NPRM in early 2010 but stated that the FAA had not informed the NTSB of the specific revisions that the NPRM would include. Thus, the NTSB was not able to determine at that time whether the revisions would fully satisfy the intent of Safety Recommendation A-06-10. As a result, Safety Recommendation A-06-10 remained classified “Open—Unacceptable Response” pending the publication of an NPRM proposing to mandate the recommended actions. (The recommendation first received this classification on November 9, 2006.) Also, on June 12, 2008, the NTSB issued Safety Recommendations A-08-44 and -45 as a result of previous accidents and incidents that highlighted (1) the dangers of human fatigue within airline operations, (2) the need to address fatigue factors related to company policies and crewmember responsibilities, and (3) the continued need for changes to flight and duty time regulations to effectively mitigate the dangers of fatigue to aviation operations. These recommendations asked the FAA to do the following:155 Develop guidance, based on empirical and scientific evidence, for operators to establish fatigue management systems, including information about the content and implementation of these systems. (A-08-44) Develop and use a methodology that will continually assess the effectiveness of fatigue management systems implemented by operators, including their ability to improve sleep and alertness, mitigate performance errors, and prevent incidents and accidents. (A-08-45) On August 11, 2008, the FAA stated that it had hosted a symposium on fatigue in aviation operations to gather and make public the best available knowledge on fatigue and

154 The NTSB’s response also addressed Safety Recommendations A-94-194 and A-95-113. Safety Recommendation A-94-194 asked the FAA to “revise the Federal Aviation Regulations contained in 14 CFR Part 135 to require that pilot flight time accumulated in all company flying conducted after revenue operations—such as training and check flights, ferry flights and repositioning flights—be included in the crewmember’s total flight time accrued during revenue operations.” Safety Recommendation A-95-113 asked the FAA 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 new regulations should prohibit air carriers from assigning flight crews to flights conducted under 14 CFR Part 91 unless the flight crews meet the flight and duty time limitations of 14 CFR Part 121 or other appropriate regulations.” Both of these recommendations, which were also on the NTSB’s Most Wanted List, had been classified “Open—Unacceptable Response.” 155 Safety Recommendation A-08-44 superseded Safety Recommendation A-06-11, which was issued as a result of the Corporate Airlines flight 5966 accident (see section 1.18.1.1). Safety Recommendation A-06-11 asked the FAA to “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.”

NTSB Aircraft Accident Report 62 fatigue mitigations. The FAA also stated that it was developing operations specification guidance for fatigue management for ultra-long-range flights (that is, flights that are greater than 16 hours in duration) but did not identify any such initiatives for shorter duration domestic Part 121 operations. On February 3, 2009, the NTSB encouraged the FAA to ensure that its planned activities proceed at an appropriate pace and that guidance on fatigue management systems be developed for all components of the aviation industry and not only for ultra-long-range operations. The NTSB asked the FAA to provide a schedule indicating when guidance for other aviation operations would be developed and issued. Safety Recommendations A-08-44 and -45 were classified “Open—Acceptable Response” pending receipt of this schedule and one for the development and implementation of methodologies to continually assess the effectiveness of fatigue management systems. In addition, on June 27, 2008, the NTSB issued Safety Recommendations A-08-19 and -20 as a result of the accident involving Delta Connection flight 6448 in Cleveland, Ohio.156 These recommendations asked the FAA to do the following: In cooperation with pilot unions, the Regional Airline Association, and the Air Transport Association, develop a specific, standardized policy for 14 Code of Federal Regulations Part 121, 135, and Part 91 subpart K operators that would allow flight crewmembers to decline assignments or remove themselves from duty if they were impaired by a lack of sleep. (A-08-19) Once the fatigue policy described in Safety Recommendation A-08-19 has been developed, require 14 Code of Federal Regulations Part 121, 135, and Part 91 subpart K operators to adopt this policy and provide, in writing, details of the policy to their flight crewmembers, including the administrative implications of fatigue calls. (A-08-20) On September 26, 2008, the FAA stated that its aviation fatigue management symposium addressed air carrier fatigue policies, including crewmembers declining flying assignments as a result of fatigue. The FAA stated that it was actively pursuing a multiyear action plan to address aviation fatigue, including (1) publishing symposium proceedings; (2) developing and distributing an AC that addresses, in general terms, policy guidance in major areas of fatigue mitigation, including crewmember scheduling and duty policies; (3) developing an AC on FRMS that addressed, within an SMS context, all elements of a systematic approach to mitigating aviation fatigue; (4) publishing operations specification guidance for fatigue management in ultra-long-range flight operations; and (5) incorporating fatigue science expertise during data collection and analysis and policy development. The FAA also stated that its plan would include the consideration of operator policies related to crewmembers declining flight and/or duty assignments because of fatigue and would lead to appropriate formal policy guidance.

156 For more information, see Runway Overrun During Landing, Shuttle America, Inc., Doing Business as Delta Connection Flight 6448, Embraer ERJ-170, N862RW, Cleveland, Ohio, February 18, 2007, Aircraft Accident Report NTSB/AAR-08/01 (Washington, DC: NTSB, 2008).

NTSB Aircraft Accident Report 63 On June 22, 2009, the NTSB stated that the FAA’s multiyear action plan to address aviation fatigue was responsive to both recommendations. The NTSB added that a satisfactory response to Safety Recommendation A-08-20 needed to include a requirement for operators to implement an appropriate policy for declining assignments based on fatigue and that the development of guidance by itself would not be sufficient. Safety Recommendations A-08-19 and -20 were classified “Open—Acceptable Response” pending the FAA’s completion of the recommended actions. 1.18.1.6 Stall Training On October 24, 1994, the NTSB issued Safety Recommendation A-94-173 as a result of the accident involving United Express flight 6291 in Columbus, Ohio.157 Safety Recommendation A-94-173 asked the FAA to do the following: Ensure that the training programs for 14 Code of Federal Regulations Part 135 pilots place an increased emphasis on stall warning recognition and recovery techniques, to include stick shaker and stick pusher, during training. On August 7, 1995, the FAA stated that it had issued Flight Standards Information Bulletin 95-10A, “Instrument Approach Procedures and Training,” on June 26, 1995. The bulletin directed POIs to ensure that their Part 135 operators emphasized stall warning recognition and recovery techniques, including stick shaker and stick pusher, during training. On November 14, 1995, the NTSB stated that Flight Standards Information Bulletin 95- 10A complied with the intent of the recommendation. As a result, Safety Recommendation A- 94-173 was classified “Closed—Acceptable Action.” Also, on July 29, 1997, the NTSB issued Safety Recommendation A-97-47 as a result of the ABX Air accident in Narrows, Virginia.158 Safety Recommendation A-97-47 asked the FAA to do the following: Evaluate the data available on the stall characteristics of airplanes used in air carrier service and, if appropriate, require the manufacturers and operators of flight simulators used in air carrier pilot training to improve the fidelity of these simulators in reproducing the stall characteristics of the airplanes they represent to the maximum extent that is practical; then add training in recovery from stalls with pitch attitudes at or below the horizon to the special events training programs of air carriers.

157 For more information, see section 1.18.4 and National Transportation Safety Board, Stall and Loss of Control on Final Approach, Atlantic Coast Airlines, Inc., United Express Flight 6291, Jetstream 4101, N304UE, Columbus, Ohio, January 7, 1994, Aircraft Accident Report NTSB/AAR-94/07 (Washington, DC: NTSB, 1994). 158 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).

NTSB Aircraft Accident Report 64 On June 9, 1999, the FAA stated that aerodynamic stalls and approaches to stalls are flown during aircraft certification flight testing and that sufficient data are obtained to determine the aircraft’s stall speed at an entry rate of 1 knot per second. The FAA also stated that an aircraft in an aerodynamic stall might handle and perform differently than the programming in the simulator might indicate for an identical circumstance. The FAA stated that the acquisition of data in this flight condition would have questionable accuracy and would be costly and dangerous to acquire. The FAA noted that, even if such data existed and were incorporated into simulators, it is unknown whether the simulators would be able to respond accurately to the data, given the limited nature of the motion systems on even the most advanced simulators. The FAA further stated that, to address the recommendation, it would revise the practical test standards to require pilots to adjust pitch, bank, and power to recover from an approach to stall and would add a note indicating, in part, that airspeed and/or altitude loss is critical at low altitudes and must be kept to an absolute minimum. On November 19, 1999, the NTSB stated that the ability of simulators to faithfully replicate an airplane’s actions in some stall and stall recovery regimes could be improved. The NTSB noted that generic simulator modules that were developed for some highly variable events have provided useful and necessary training for pilots. The NTSB pointed out, as an example, microburst and windshear simulator training, which provides realistic and effective training to pilots on specific models, even though an actual encounter is likely to be significantly different. The NTSB stated that it was disappointed that the FAA did not make changes to improve the fidelity of simulators in reproducing stall characteristics to the maximum extent feasible. The NTSB added that airline pilots need to be afforded this type of training so that they are fully prepared to recover stalled aircraft. As a result, Safety Recommendation A-97-47 was classified “Closed—Unacceptable Action.” In addition, on January 23, 2007, the NTSB issued Safety Recommendation A-07-4 as a result of the accident involving the Pinnacle Airlines flight 3701 accident (see section 1.18.1.3). Safety Recommendation A-07-4 asked the FAA to do the following: 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 stick pusher systems and, if warranted, establish training requirements for stick pusher-equipped airplanes based on the findings of this panel. On April 13, 2007, the FAA stated that it would ask the government-industry working group that developed the Airplane Upset Recovery Training Aid159 to reconvene to develop material addressing high-altitude performance issues and high-altitude stall prevention and recovery,160 including a discussion of stick pusher systems. The FAA also stated that, once these

159 The Airplane Upset Recovery Training Aid was issued in 1998 and was revised in August 2004 and November 2008. 160 The response to Safety Recommendation A-07-4 also addressed the high-altitude training issues discussed in Safety Recommendations A-07-1 and -2, which were issued as part of the Pinnacle Airlines accident investigation.

NTSB Aircraft Accident Report 65 materials were developed, it would strongly encourage air carrier managers, trainers, and pilots to include the materials in training programs and pilot operating manuals. On January 22, 2008, the NTSB acknowledged the FAA’s planned actions. The NTSB classified Safety Recommendation A-07-4 “Open—Acceptable Response” pending completion of these actions. 1.18.1.7 Remedial Training and Additional Oversight On May 31, 2005, the NTSB issued Safety Recommendation A-05-14 as a result of the accident involving Federal Express flight 647 in Memphis, Tennessee.161 Safety Recommendation A-05-14 asked the FAA to do the following: Require all 14 Code of Federal Regulations Part 121 air carrier operators to establish programs for flight crewmembers who have demonstrated performance deficiencies or experienced failures in the training environment that would require a review of their whole performance history at the company and administer additional oversight and training to ensure that performance deficiencies are addressed and corrected. On April 13, 2007, the FAA stated that it had issued SAFO 06015, “Remedial Training for Part 121 Pilots,” on October 27, 2006. The SAFO recommended implementation and incorporation of a voluntary remedial Part 121 pilot training module to supplement an air carrier’s approved training program. The FAA indicated that directors of safety at Part 121 air carriers that do not have a voluntary remedial training module for pilots should recommend such a program to top managers at their company. On December 12, 2007, the NTSB stated that the FAA needed to survey all Part 121 operators to determine whether they had taken the action recommended in SAFO 06015. Safety Recommendation A-05-14 was classified “Open—Acceptable Alternate Response” pending completion of this survey and demonstration that all Part 121 carriers had programs to address pilot performance deficiencies or failures during training. On April 23, 2009, the FAA issued Notice 8900.71, which discussed verification of remedial training for Part 121 carriers. The purpose of the notice was to provide guidance to POIs about a required inspection to determine whether their Part 121 carriers were voluntarily complying with SAFO 06015. The notice also instructed the POIs to make a Program Tracking and Reporting Subsystem entry within 90 days of the date of the notice for those air carriers that had in place, or had incorporated, the SAFO’s recommended actions in the carrier’s approved training program.

161 For more information, see National Transportation Safety Board, Hard Landing, Gear Collapse, Federal Express Flight 647, Boeing MD-10-10F, N364FE, Memphis, Tennessee, December 18, 2003, Aircraft Accident Report NTSB/AAR-05/01 (Washington, DC: NTSB, 2005).

NTSB Aircraft Accident Report 66 On October 30, 2009, the FAA reported that 29 of the 82 Part 121 air carriers had remedial training programs in place. The 82 carriers included 27 regional air carriers, 6 of which had instituted such programs. The FAA did not provide the identities of those carriers with remedial training programs. On December 10, 2009, the FAA Administrator testified before the Subcommittee on Aviation, U.S. Senate Committee on Commerce, Science, and Transportation, and stated that two-thirds of the carriers without advanced qualification programs had systems in place to identify and manage low-time pilots and pilots with persistent performance problems. The administrator also stated that, for those carriers without such systems, additional FAA oversight of their training and qualification programs would be conducted. On January 27, 2010, the FAA issued a fact sheet regarding its report, Answering the Call to Action on Airline Safety and Pilot Training.162 The fact sheet stated that, between June and September 2009, 85 air carriers without advanced qualification programs were inspected to determine if they had remedial training programs that were consistent with the guidance in SAFO 06015. The review determined that 62 air carriers had programs fully in place to meet the guidance for remedial training programs. The fact sheet also stated that, at the time of the review, 15 carriers had some part of a remedial training program in place and that 9 carriers had not implemented any component of a remedial training program. The fact sheet added that, since the time of the review, these 24 air carriers had developed remedial training programs for pilots.163 1.18.1.8 Pilot Records On November 15, 1995, the NTSB issued Safety Recommendations A-95-116 through -119 as a result of the accident involving American Eagle flight 3379 in Morrisville, North Carolina.164 These recommendations asked the FAA to do the following: Require all airlines operating under 14 CFR Parts 121 and 135 and independent facilities that train pilots for the airlines to maintain pertinent standardized information on the quality of pilot performance in activities that assess skills, abilities, knowledge, and judgment during training, check flights, initial operating experience, and line checks and to use this information in quality assurance of individual performance and of the training program. (A-95-116) Require all airlines operating under 14 CFR Parts 121 and 135 and independent facilities that train pilots for the airlines to provide the FAA, for incorporation

162 The FAA’s report stated that, as a result of the information that was learned at the Colgan public hearing and subsequent congressional hearings, the Secretary of Transportation and the FAA Administrator initiated, in June 2009, “a Call to Action on Airline Safety and Pilot Training for FAA, air carriers, and labor organizations to jointly identify and implement safety improvements.” For more information, see http://www.faa.gov/library/reports/media/call_to_action_Jan2010.pdf. 163 The NTSB notes that, although the FAA stated that 85 carriers were reviewed, the results presented were for 86 carriers. 164 For more information, see National Transportation Safety Board, Uncontrolled Collision With Terrain, Flagship Airlines, Inc., dba American Eagle Flight 3379, BAe Jetstream 3201, N918AE, Morrisville, North Carolina, December 13, 1994, Aircraft Accident Report NTSB/AAR-95/07 (Washington, DC: NTSB, 1995).

NTSB Aircraft Accident Report into a storage and retrieval system, pertinent standardized information on the quality of pilot performance in activities that assess skills, abilities, knowledge, and judgment during training, check flights, initial operating experience, and line checks. (A-95-117) Maintain a storage and retrieval system that contains pertinent standardized information on the quality of 14 CFR Parts 121 and 135 airline pilot performance during training in activities that assess skills, abilities, knowledge, and judgment during training, check flights, initial operating experience, and line checks. (A-95-118) Require all airlines operating under 14 CFR Parts 121 and 135 to obtain information, from the FAA’s storage and retrieval system that contains pertinent standardized pilot training and performance information, for the purpose of evaluating applicants for pilot positions during the pilot selection and hiring process. The system should have appropriate privacy protections, should require the permission of the applicant before release of the information, and should provide for sufficient access to the records by an applicant to ensure accuracy of the records. (A-95-119) With regard to Safety Recommendation A-95-116, on April 17, 1998, the FAA stated that the enactment of PRIA in 1996 addressed the NTSB’s concerns that led to the recommendation. The FAA pointed out that air carrier training requirements are predicated on training to proficiency and that the current record-keeping requirements thus certify a pilot’s proficiency during training. Further, the FAA stated that the inclusion of subjective evaluations by individual instructors, check airmen, or FAA inspectors in a pilot’s permanent record might make a training event a punitive experience rather than one in which pilots could learn from mistakes. On January 3, 2000, the NTSB stated that the FAA had provided a convincing argument about the inappropriateness of subjective information in pilot records and the possibility that pilot training could be negatively affected. As a result, Safety Recommendation A-95-116 was classified “Closed—Reconsidered.” With regard to Safety Recommendations A-95-117 through -119, on February 11, 2007, the FAA stated that the Federal Aviation Reauthorization Act of 1996 required air carriers to obtain, maintain, and share certain specified training records of a prospective employee. The FAA also stated that this legislation eliminated the need for the FAA to maintain a storage and retrieval system for pilot training records. On June 2, 1997, the NTSB stated that the legislation met the intent of the recommendations. As a result, Safety Recommendations A-95-117 through -119 were classified “Closed—Acceptable Alternate Action.” 67

NTSB Aircraft Accident Report 68 Also, on January 27, 2005, the NTSB issued Safety Recommendations A-05-1 and -2 as a result of the accident involving Air Sunshine flight 527 in Treasure Cay, Great Abaco Island, Bahamas.165 These recommendations asked the FAA to do the following: Require all Part 121 and 135 air carriers to obtain any notices of disapproval for flight checks for certificates and ratings for all pilot applicants and evaluate this information before making a hiring decision. (A-05-1) Conduct a study to determine whether the number of flight checks a pilot can fail should be limited and whether the existing system of providing additional training after a notice of disapproval is adequate for pilots who have failed multiple flight checks. On the basis of the findings of the study, establish a flight check failure limit and modify the recheck training requirements, if necessary. (A-05-2) With regard to Safety Recommendation A-05-1, on September 9, 2005, the FAA stated that notices of disapproval for flight checks for certificates and ratings are not explicitly required by PRIA. The FAA also stated that requiring all Part 121 and 135 air carriers to obtain these notices would require FAA rulemaking or a change to the PRIA statute. According to the FAA, some air carriers had been asking pilot applicants, as part of their preemployment screening, to sign a consent form that permitted the FAA to release records of notices of disapproval to the air carrier, and the FAA was, in turn, furnishing those records to the air carrier requesting them. The FAA added that, to address the recommendation, it would amend AC 120-68, “Pilot Records Improvement Act of 1996,” to indicate that a letter of consent signed by a pilot applicant could be used to authorize the FAA to release records of notices of disapproval for flight checks for certificates and ratings to an air carrier making such a request. On November 3, 2006, the NTSB stated that the FAA’s proposal to amend AC 120-68 might be an acceptable alternate action. The NTSB also stated that, because ACs are advisory only, the FAA should survey all operators (after the AC is revised) to determine how many require, as a condition of employment, a pilot applicant to submit a signed consent form permitting the FAA to release records of notices of disapproval. Safety Recommendation A-05-1 was classified “Open—Acceptable Alternate Response” pending the revision of AC 120-68 and the survey results. (The AC was revised on November 7, 2007; see section 1.18.2.1 for information. The survey has not been completed.) With regard to Safety Recommendation A-05-2, on September 9, 2005, the FAA stated that it conducted a study in 2004 to determine if a correlation existed between flight test failures and the airmen cited in enforcement actions. The FAA stated that it found the correlation to be “very low … less than one percent.” The FAA expressed concern about establishing a flight check failure limit. Specifically, the FAA stated that examiners might be extremely reluctant to find an applicant unsatisfactory as the failure limit is approached, which could result in applicants passing flight checks who would otherwise not pass the checks.

165 For more information, see National Transportation Safety Board, In-Flight Engine Failure and Subsequent Ditching, Air Sunshine, Inc., Flight 527, Cessna 402C, N314AB, About 7.35 Nautical Miles West-Northwest of Treasure Cay Airport, Great Abaco Island, Bahamas, July 13, 2003, Aircraft Accident Report NTSB/AAR-04/03 (Washington, DC: NTSB, 2004).

NTSB Aircraft Accident Report On November 3, 2006, the NTSB stated that FAA and NTSB staff held teleconferences in January and February 2006 to discuss the type of study that would support the intent of this recommendation. The NTSB also stated that, in March 2006, the FAA examined data from October 1995 to October 2005 for the study. The FAA found that, during this period, almost 164,000 notices of disapproval were issued and almost 4,800 pilots had three or more flight check failures. The NTSB further stated that it understood the FAA’s concern about imposing a flight check failure limit. Safety Recommendation A-05-2 was classified “Open—Acceptable Response” pending a formal written report on the study, including a description of the data analyzed and the results found. 1.18.1.9 Air Carrier Safety Programs On January 23, 2007, the NTSB issued Safety Recommendations A-07-9 through -11 as a result of the accident involving Pinnacle Airlines flight 3701 (see section 1.18.1.3). These recommendations asked the FAA to do the following: 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) With regard to Safety Recommendation A-07-9, on April 13, 2007, the FAA stated that it encouraged operators to voluntarily conduct LOSA observations and issued AC 120-90, “Line Operations Safety Audits,” to describe the steps, resources, and procedures for conducting the audits. The FAA noted that LOSA was not the only way for an operator to accomplish oversight of the safety of its operations and indicated, as an example, the advanced qualification program, which allowed most major carriers to conduct random flight checks on their flight crews. The FAA also stated that the most effective approach for addressing this recommendation was the effective implementation of SMS, which would include safety audits as a key element. The FAA indicated that it had initiated a rulemaking project for SMS. On January 22, 2008, the NTSB stated that air carriers should establish and operate a LOSA program because of its benefits and that the program could be part of an SMS. The NTSB also stated that the intent of the recommendation would be met if the FAA’s rulemaking project for SMS included a requirement for LOSA programs. Safety Recommendation A-07-9 was classified “Open—Acceptable Response” pending completion of these actions. (Additional information on LOSA programs appears in section 1.18.2.2.) 69

NTSB Aircraft Accident Report 70 With regard to Safety Recommendation A-07-10, on April 13, 2007, the FAA noted that the recommendation was similar to a recent amendment to Annex 6 of the International Civil Aviation Organization (ICAO) treaty that required SMS implementation by January 1, 2009. The FAA stated that its rulemaking project for SMS would meet the ICAO deadline and that it planned to impose SMS requirements on Part 121 and 135 air carriers and Part 145 repair stations. The FAA further stated that pilot project trials related to SMS implementation were scheduled to begin in 2007. On January 22, 2008, the NTSB acknowledged the FAA’s planned actions. Safety Recommendation A-07-10 was classified “Open—Acceptable Response” pending a requirement for all Part 121 air carriers to establish SMS programs. The NTSB notes that pilot project trials related to SMS implementation began in 2007 as scheduled and that the FAA has yet to finalize requirements and rulemaking for Part 121 and 135 air carriers and Part 145 repair stations. With regard to Safety Recommendation A-07-11, on April 13, 2007, the FAA stated that it encouraged all Part 121 air carriers to voluntarily implement ASAP and FOQA. The FAA also stated that there was significant participation by regional airlines in ASAP but that few regional airlines participated in FOQA. To encourage further participation, the FAA stated that it would (1) make available, at no cost, a comprehensive Web-based ASAP report submission and database management system that could be housed at the air carrier or managed by an FAA contractor and (2) participate, during fiscal years 2007 and 2008, in conferences and seminars sponsored by the Regional Airline Association to increase awareness of ASAP and FOQA in the regional airline community. The FAA also stated that AC 120-92, “Introduction to Safety Management Systems for Air Operators,”166 identified FOQA as one of the recommended tools that could contribute to the required safety assurance function of an SMS. The FAA further stated that it was engaged in rulemaking that would mandate SMS and that the expected SMS requirement, as well as the high level of industry support for SMS, could offer an increased incentive for regional airlines to participate in FOQA. On January 22, 2008, the NTSB stated that the programs and initiatives that the FAA described met the intention of the recommendation. As a result, Safety Recommendation A-07-11 was classified “Closed—Acceptable Action.” (Additional information on FOQA programs appears in section 1.18.2.3.) 1.18.1.10 Air Carrier Oversight On December 20, 1996, the NTSB issued Safety Recommendation A-96-163 as a result of its investigation of the December 1995 Tower Air flight 41 accident in Jamaica, New York.167 Safety Recommendation A-96-163 asked the FAA to do the following:

166 AC 120-92 was issued on June 22, 2006, to provide 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 worldwide SMS programs, its own internal SMS programs, and other system safety approaches. 167 For more information, see National Transportation Safety Board, Runway Departure During Attempted Takeoff, Tower Air Flight 41, Boeing 747-136, N605FF, JFK International Airport, New York, December 20, 1995, Aircraft Accident Report NTSB/AAR-96/04 (Washington, DC: NTSB, 1996).

NTSB Aircraft Accident Report 71 Develop, by December 31, 1997, standards for enhanced surveillance of air carriers based on rapid growth, change, complexity, and accident/incident history; then revise national flight standards surveillance methods, work programs, staffing standards, and inspector staffing to accomplish the enhanced surveillance that is identified by the new standards. On November 24, 2004, the NTSB stated that the FAA briefed NTSB staff in March 2004 about programs related to oversight and surveillance of air carriers, including ATOS and the Surveillance and Evaluation Program. The NTSB indicated that, during this briefing, the FAA stated that the risk indicators used by the Surveillance and Evaluation Program for targeting surveillance resources included rapid growth or expansion, new or major program changes, complexity of aircraft or new aircraft types, and accident and incident history. Because the FAA had developed these surveillance standards, the NTSB classified Safety Recommendation A-96-163 “Closed—Acceptable Action.” 1.18.1.11 Low-Airspeed Alerting System On December 2, 2003, the NTSB issued Safety Recommendations A-03-53 and A-03-54 as a result of the accident involving a King Air A100 in Eveleth, Minnesota.168 These recommendations asked the FAA to do the following: Convene a panel of aircraft design, aviation operations, and aviation human factors specialists, including representatives from the National Aeronautics and Space Administration, to determine whether a requirement for the installation of low-airspeed alert systems in airplanes engaged in commercial operations under 14 Code of Federal Regulations Parts 121 and 135 would be feasible, and submit a report of the panel’s findings. (A-03-53) If the panel requested in Safety Recommendation A-03-53 determines that a requirement for the installation of low-airspeed alert systems in airplanes engaged in commercial operations under 14 Code of Federal Regulations Parts 121 and 135 is feasible, establish requirements for low-airspeed alert systems, based on the findings of this panel. (A-03-54) Although these recommendations resulted from a stall accident that did not involve icing conditions, the NTSB reiterated the recommendations on July 10, 2006, based on preliminary findings of an incident involving a Saab 340 airplane (operated as American Eagle flight 3008) that experienced a loss of control during icing conditions.169

168 For more 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). 169 The safety recommendation letter in which the recommendations were reiterated also addressed three similar Saab 340 incidents investigated by the Australian Transport Safety Bureau. The letter stated, “if the flight crews had been alerted to the rapid airspeed decrease in a timely fashion, they may have been able to take corrective action and perhaps avoid the stall.”

NTSB Aircraft Accident Report 72 On October 3, 2006, the FAA stated that it formed an internal team of experts to assess the feasibility of a new low-airspeed alerting system. The FAA indicated that it would provide a status update in November 2006. On April 3, 2007, the NTSB stated that it was encouraged that the FAA had formed a team to begin addressing the recommendations and noted that the FAA’s status update was planned to occur in July 2007. As a result, Safety Recommendations A-03-53 and -54 were classified “Open—Acceptable Response.” (The FAA’s status update did not occur as planned.) 1.18.1.12 Airplane Icing On November 30, 1998, the NTSB issued Safety Recommendations A-98-90 and -107 to the FAA and NASA, respectively, as a result of the accident involving Comair flight 3272 in Monroe, Michigan.170 These recommendations asked the FAA and NASA to take the following actions along with each other as well as other interested aviation organizations: Organize and implement an industry-wide training effort to educate manufacturers, operators, and pilots of air carrier and general aviation turbopropeller driven airplanes regarding the hazards of thin, possibly imperceptible, rough ice accumulations, the importance of activating the leading edge deicing boots as soon as the airplane enters icing conditions (for those airplanes in which ice bridging is not a concern), and the importance of maintaining minimum airspeeds in icing conditions. With regard to Safety Recommendation A-98-90, on August 2, 2001, the FAA stated that it sponsored an icing conference in February 1999 and that, as a result of the conference, NASA, in cooperation with the FAA, produced two videos, “Tailplane Icing” and “Icing for Regional and Corporate Pilots.”171 According to the FAA, the tailplane icing video provided information about ice-contaminated horizontal stabilizers, described symptoms of tailplane ice contamination, and suggested recovery procedures. The FAA also stated that the other icing video, which was intended for pilots of turboprop aircraft, discussed ice protection systems, ice accretion on aircraft, the effects of ice on performance degradation and handling qualities, and recovery techniques from a roll or pitch upset. The FAA further stated that it distributed the videos to its regional offices and FSDOs and that it would distribute additional videos, once they became available, to aircraft manufacturers for use in air carrier and general aviation flight training programs. On January 3, 2002, the NTSB stated that the production and distribution of these icing videos met the intent of the recommendation. As a result, Safety Recommendation A-98-90 was classified “Closed—Acceptable Action.”

170 For more information, see National Transportation Safety Board, In-Flight Icing Encounter and Uncontrolled Collision With Terrain, Comair Flight 3272, Embraer EMB-120RT, N265CA, Monroe, Michigan, January 9, 1997, Aircraft Accident Report NTSB/AAR-98/04 (Washington, DC: NTSB, 1998). 171 After this date, NASA produced a third icing video, as detailed in the response to Safety Recommendation A-98-107.

NTSB Aircraft Accident Report 73 With regard to Safety Recommendation A-98-107, on March 3, 2004, NASA stated that it completed a computer-based training module for general aviation pilots titled “A Pilots Guide to In-Flight Icing” and three training videos for pilots titled “Icing for General Aviation Pilots,” “Icing for Regional and Corporate Pilots,” and “Tailplane Icing.” NASA also stated that the purpose of the training module and videos, which were developed in cooperation with the FAA, was to educate pilots on how to operate in and avoid icing conditions. On August 19, 2004, the NTSB stated that NASA’s work to provide training about the hazards associated with in-flight icing conditions met the intent of the recommendation. As a result, Safety Recommendation A-98-107 was classified “Closed—Acceptable Action.” 1.18.1.13 Weather Information for Pilots On August 15, 1996, the NTSB issued Safety Recommendation A-96-48 as a result of its investigation of the American Eagle flight 4184 accident in Roselawn, Indiana.172 Safety Recommendation A-96-48 asked the FAA to do the following: Direct principal operations inspectors (POIs) to ensure that all 14 Code of Federal Regulations (CFR) Part 121 air carriers require their dispatchers to provide all pertinent information, including airman’s meteorological information (AIRMETs) and Center Weather Advisories (CWAs), to flightcrews for preflight and in-flight planning purposes. On April 24, 1997, the FAA stated that it issued Flight Standards Information Bulletin for Air Transportation 97-03 on March 17, 1997, which directed POIs to ensure that air carriers require dispatchers to provide pertinent information, including AIRMETs and CWAs, when appropriate, for preflight and in-flight planning purposes. The FAA also stated that the information in the bulletin would be incorporated into FAA Order 8400.10, “Air Transportation Operations Inspector’s Handbook.”173 On August 20, 1997, the NTSB stated that the flight standards information bulletin addressed the intent of the Safety Recommendation A-96-48 and classified it “Closed—Acceptable Action.”

172 For more 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, Aircraft Accident Report NTSB/AAR-96/01 (Washington, DC: NTSB, 1996). 173 FAA Order 8400.10 has been superseded by FAA Order 8900.1, “Flight Standards Information Management System.”

NTSB Aircraft Accident Report 1.18.2 Federal Aviation Administration Guidance 1.18.2.1 Pilot Records Improvement Act On November 7, 2007, the FAA issued AC 120-68D, “Pilot Records Improvement Act of 1996.” The AC noted that PRIA (49 United States Code 44703) was enacted to ensure that air carriers adequately investigated a pilot’s background before allowing that pilot to conduct commercial air carrier flights. The AC also noted that a hiring employer could not place a pilot into service until the employer obtained and reviewed the last 5 years of the pilot’s background and other safety-related records. The AC included information for three different audiences: the pilot applicant, hiring employers that must request PRIA records (any Part 121, 125, or 135 operator), and former employers that must respond to PRIA record requests (any Part 121, 125, or 135 operator or any person that employed the applicant as a civil or public aircraft pilot). Also, the AC indicated that it contained expanded information to address operational situations that could affect a hiring employer’s PRIA records request compared with the previous version (AC 120-68C, dated January 28, 2004). In addition, the AC stated that a letter of consent signed by a pilot job applicant could be used to authorize the FAA to release records of notices of disapproval for flight checks for certificates and ratings to an air carrier making such a request. 1.18.2.2 Line Operations Safety Audits On April 27, 2006, the FAA issued AC 120-90, “Line Operations Safety Audits.” The AC provided the rationale and procedures for conducting a LOSA program at an air carrier. The AC stated that a LOSA program included the confidential collection of safety-related operational data by expert and highly trained observers riding in the jumpseat during regularly scheduled flights. These data are used to assess the carrier’s strengths and weaknesses to proactively improve safety margins and prevent degradation. The AC explained that a LOSA program is distinct from, but complementary to, a FOQA program and an ASAP. According to the AC, FOQA and ASAP rely on outcomes to generate data (flight parameter exceedances and adverse crew-reported events, respectively), but LOSA samples all activities in normal operations, including successful flights, near events, and reportable events, and notes how flight crews manage the problems they encounter. The AC also stated that LOSA is more project-based than FOQA and ASAP (which are continuous programs) because the full LOSA process, including advance planning, observer selection and training, data collection, analyses, and the final report, can take between 6 and 12 months. The AC further stated that data from any of these safety programs can be cross-referenced to guide data collection in another one of the programs. The AC recommended that air carriers conduct a LOSA every 3 years. The AC stated that the data collected during a LOSA could impact almost every department at an air carrier because the data could help (1) identify threats in the carrier’s operating environment, (2) 74

NTSB Aircraft Accident Report 75 identify threats from within the carrier’s operations, (3) assess any areas of training that are not successfully transferring to line operations, (4) check the quality and usability of procedures, (5) identify airplane design problems, (6) understand pilot shortcuts and workarounds, (7) assess the prevalence and management of incident and accident precursors (that is, vertical and lateral deviations and unstable approaches), (8) provide a baseline for organizational change, and (9) provide a rationale for resource allocation. The LOSA program also includes briefing management and line pilots on the audit findings detailed in the final report and implementing and monitoring a safety change process to address the findings. 1.18.2.3 Flight Operational Quality Assurance On April 12, 2004, the FAA issued AC 120-82, “Flight Operational Quality Assurance,” to provide guidance for developing, implementing, and operating a FOQA program. The AC stated that FOQA was a voluntary safety program that was designed to make commercial aviation safer by allowing air carrier operators and their pilots to share unidentified aggregate data with the FAA so that it could monitor industry trends in aircraft operations and target resources to address operational risk issues. The AC advised that FOQA programs could provide objective safety information that would not otherwise be obtainable. The AC explained that the basis of any FOQA program was the understanding among the FAA, air carriers, and pilots that data provided to the FAA would be kept confidential so that the identity of reporting pilots or air carriers would remain anonymous.174 The AC also stated that operator FOQA programs included provisions for the identification of safety issues and the development and implementation of corrective actions. According to the AC, in a FOQA program, data are periodically collected from an aircraft using a QAR or an FDR. The retrieved data are then sent to the air carrier’s FOQA office for validation and analysis. The data can be used to evaluate or effect change in the following areas: operational safety, aircraft performance, aircraft systems performance, flight crew performance, company procedures, training programs, training effectiveness, aircraft design, ATC system operation, airport operational issues, and meteorological issues. The data can also be shared with the FAA, other air carriers, and the aviation industry. 1.18.2.4 Standard Operating Procedures On February 27, 2003, the FAA issued AC 120-71A, “Standard Operating Procedures for Flight Deck Crewmembers.” The AC provided advice and recommendations about developing, implementing, and updating standard operating procedures, which, according to the AC, “are universally recognized as basic to safe aviation operations.”

174 Specifically, data submitted to the FAA as part of a FOQA program would be protected as “voluntarily submitted safety related data” under 14 CFR Part 193.

NTSB Aircraft Accident Report 76 The AC included an appendix addressing standard operating procedures for flight crew monitoring and cross-checking. The appendix provided examples of standard operating procedures that emphasized that monitoring was a primary responsibility of both flight crewmembers. The appendix also provided examples of standard operating procedures to support improved monitoring during vertical segments of flight (that is, climb, descent, and approach).175 In addition, the appendix addressed standard operating procedures to support improved monitoring of airport surface operations and automation. 1.18.3 Interview with Colgan Air Flight Crew of Burlington, Vermont, Stick Shaker Event On March 10, 2009, a Colgan Q400 airplane, N188WQ, was en route from EWR to Burlington International Airport (BTV), South Burlington, Vermont, during night VMC. While descending into BTV, the stick shaker activated, a recovery followed, and the airplane landed at BTV without further incident. After the event, the NTSB interviewed the flight crew and the check airman who was administering the captain’s 1-year line check at the time.176 The captain reported that, before the event, she had been manually flying the airplane, and her attention had been mostly focused outside of the airplane. She also reported that she asked the first officer for the no-ice and en route ice speeds and that the deice system (level two) had been selected.177 The captain reported that she and the first officer (the monitoring pilot) had programmed the no-ice speeds because she observed no indications of ice on the wings during the descent. The captain stated that the last airspeed she noticed before the event was about 140 knots and that the stick shaker had activated at an airspeed of about 135 knots and an altitude of about 1,800 feet. The first officer reported that, while performing the before landing checklist, he heard a noise, looked up, and saw that the numbers on the IAS display had turned red. The first officer further reported that he immediately called out “airspeed” and that the captain (the flying pilot) immediately responded by increasing power. The captain reported that she had lowered the airplane’s nose and added full engine power (but did not reach the detent) in response. The first officer reported that he did not notice any significant change in the airplane’s pitch when the captain applied full power, describing the airplane as being in a “gentle descent” at the time.

175 The AC referenced a study on crew monitoring by NASA’s ASRS, which found that 75 percent of the monitoring errors included in the study occurred while the aircraft was in a vertical phase of flight. 176 At the time of the event, the captain had been with Colgan for more than 3 years and had been flying the Q400 for 1 year, accumulating between 800 and 1,000 hours in the airplane. The first officer had been with Colgan about 1 year and had been flying the Q400 for about 10 months, accumulating between 450 and 500 hours in the airplane. The check airman had flown the Q400 for 1 year and had been a check airman for 3 1/2 years. 177 The check airman reported that the captain had selected the deice system to level two when the airplane was at an altitude of about 13,000 feet, even though the airplane was not in icing conditions at the time. (During postaccident interviews, the captain stated that the airplane had been in icing conditions at the time and that she planned to turn off the equipment before landing, and the first officer stated that the airplane had been in icing conditions earlier in the flight but that icing conditions were not occurring as the airplane was maneuvering toward the airport.) The check airman stated that selecting the deice system to level two with no icing conditions was not standard company procedure.

NTSB Aircraft Accident Report 77 The captain stated that the low-speed cue did not come into view until the event occurred. She also stated that, at the onset of the event, she realized that the ref speeds switch was selected to the increase position. The first officer stated that he then pointed out the status of the ref speeds switch. The captain reported that she asked the first officer for the ice speeds, and he told her that Vref was 140 knots. She then reportedly flew the airplane at that airspeed. The captain indicated that, after recovering the airplane, she did not execute a missed approach because she was in control of the airplane. The first officer reported that he did not call for a go-around because the stick shaker activation was “a very quick thing” (lasting less than 5 seconds) and the airplane had already captured the glideslope and was stable. The check airman stated that the stick shaker had momentarily engaged just before the airplane intercepted the glidepath. The captain added power, gaining about 150 to 200 feet, and reestablished a stabilized approach. The flight then continued uneventfully to a landing. The check airman stated that the last speed before the event that he recalled with certainty was 165 knots. He also stated that the airspeed was about 130 knots when the stick shaker activated and that the low-speed cue was visible at the time.178 He further stated that the event was “minute” and that he did not observe the airplane in an actual stall. The check airman indicated that the recovery appeared normal and that the remainder of the approach was flown at airspeeds between 150 and 155 knots. The check airman stated that, if he had been flying, he would have executed a missed approach but noted that the approach was stabilized and that the airplane was not in an unsafe condition after the recovery. 1.18.4 Previous Related Accident On January 7, 1994, United Express flight 6291, a Jetstream 4101, N304UE, operated by Atlantic Coast Airlines, crashed into a storage warehouse while on an ILS final approach to Port Columbus International Airport, Columbus, Ohio. The flight crew, the flight attendant, and two passengers were killed, two passengers received minor injuries, and one passenger was not injured. The airplane was destroyed. In its final report on this accident, the NTSB made the following conclusions: • The airplane’s autopilot maintained the airplane on the glideslope and localizer, but the flight crew was not monitoring or maintaining airspeed. • The first officer failed to alert the captain of the deteriorating airspeed, which was below the minimum specified for the approach, and the operator had no specified callouts for airspeed deviations during instrument approaches.

178 The check airman stated that, after landing, he discussed the stick shaker activation with the captain and told her that it would have to be reported. He also informed the captain that the checkride was unsatisfactory. The check airman stated that, besides the stick shaker event, the captain’s performance had been satisfactory with no other airspeed control issues.

NTSB Aircraft Accident Report 78 • The stall warning system operated properly, but the captain failed to apply full power and properly configure the airplane in a timely manner. • The operator did not give proper consideration to the possible consequences of pairing a newly upgraded captain with a first officer who had no experience (before being hired by the airline 3 months before the accident) with air carrier operations. The NTSB determined that the probable causes of the accident included (1) an aerodynamic stall that occurred when the flight crew allowed the airspeed to decay to stall speed and (2) an improper pilot response to the stall warning, including failing to advance the power levers to maximum and inappropriately raising the flaps.179 Although light-to-moderate mixed icing conditions occurred during the approach, the NTSB concluded that airframe icing was not a cause of the accident. 1.18.5 Gulfstream Training Academy Information The captain attended Gulfstream Training Academy from August 2004 to April 2005. According to its director, the academy is a comprehensive program for professional pilots who want to gain flight time without becoming a certified flight instructor. The academy is also directly associated with GIA.180 Pilots entering the academy’s program are required to have completed their instrument, commercial, and multiengine ratings and possess a current FAA medical certificate. The academy conducts complete applicant background checks. The director stated that some applicants enter the academy with only 200 flight hours, whereas others have accumulated between 1,000 and 1,500 flight hours. The program duration is from 6 to 8 months. The program begins with a 5-day IFR refresher course during which the academy assesses the pilots’ readiness. Those pilots that do not require additional training and experience progress through systems training, cockpit procedures training, verbal exams, and six to eight simulator sessions in a FlightSafety BE-1900D simulator in Orlando, Florida. This training culminates in a checkride in both the simulator and the airplane. After passing the checkrides, the pilot is qualified to be an SIC in the BE-1900D and then transitions to initial training and IOE. After accomplishing IOE and a line check, pilots fly with GIA for 250 hours and are assigned reserve status or scheduled line duty as probationary pilots. Once pilots complete the 250 flight hours, they are hired by the company as full-time first officers, are placed on furlough, or are released from the company. GIA’s initial training program was structured to teach pilots how to operate the BE-1900 in a Part 121 environment. As a result, the training focused on systems and procedures and not basic flying skills, which should have been learned while pilots were completing their instrument rating and commercial certificate.

179 Safety Recommendation A-94-173, which was issued as a result of this accident, is discussed in section 1.18.1.6. 180 According to Gulfstream Training Academy’s website, GIA is a regional air carrier with more than 200 scheduled daily flights within Florida and to the Bahamas.

NTSB Aircraft Accident Report The captain completed initial training and, in December 2004, began flying the BE-1900 for GIA as a fully qualified first officer. GIA maintained comprehensive training records for the captain. His training records showed that, even though he completed all entry, training, and operating phases without a failure, the captain had experienced continuing difficulties with aircraft control. For example, during simulator periods 3 and 4, the captain was graded unsatisfactory in “approach to stall – landing configuration,” although he received a satisfactory grade in later sessions. During simulator period 7, the captain’s altitude and airspeed control was unacceptable, and comments included, “airspeed more than 10 knots below Vref + 10. Fly correct airspeed!” “airspeed 10 knots below Vref crossing threshold,” “gear remains up during entire approach,” and “repeated deviation from altitude 200-300 feet.” During simulator period 8, the instructor noted, “basic attitude flying cause of repeated deviations,” “constant deviations up to full scale on glide slope,” and “additional training required.” All maneuvers were graded satisfactory the next day (by the same instructor as the day before) during an extra ninth simulator period, and the simulator checkride was completed that same day. The captain completed his IOE at GIA in 34.8 hours, and training captains made several positive remarks, such as “good progress,” “getting better,” and “good job, signed off from IOE.” No further comments appeared in the captain’s GIA file about his performance while flying as a first officer. When the captain completed his 250 flight hours in April 2005, GIA was not hiring pilots. According to GIA’s director of operations, the captain would have been eligible for hiring based on his record. However, the director pointed out that, to be hired, pilots must have at least three letters of recommendation from captains in their file, and no such letters were found for the captain. 79

NTSB Aircraft Accident Report

1. Analysis
2. 1

General The pilots were properly certificated and qualified in accordance with applicable Federal regulations. The airplane was properly certified, equipped, and maintained in accordance with Federal regulations. The recovered components showed no evidence of any preimpact structural, engine, or system failures, including no indications of any problems with the airplane’s ice protection system. The air traffic controllers who were responsible for the flight during its approach to BUF performed their duties properly and responded immediately and appropriately to the loss of radio and radar contact with the flight. Although PIREPs before the time of the accident could have provided additional real-time information of the flight conditions on approach to BUF, no evidence showed that the icing conditions that existed were abnormal for wintertime operations in the BUF area. Also, the NTSB’s postaccident survey of pilots operating into BUF about the time of the accident indicated that they were not surprised by the icing conditions and did not consider the conditions to be significant. This accident was not survivable. This analysis discusses the following information: • the accident sequence, including the minimal effect of icing on the airplane’s performance, the flight crew’s failure to monitor airspeed in relation to the rising position of the low-speed cue, and the captain’s incorrect actions in response to the stall warning; • strategies to prevent flight crew monitoring failures, including explicit pilot training for monitoring and standard operating procedures that promote effective monitoring; • pilot professionalism, including captain leadership skills and adherence to sterile cockpit and standard operating procedures; • fatigue, including commuting pilots’ use of company crew rooms as rest facilities and industry efforts to mitigate fatigue; • remedial training for poor-performing pilots, the need for detailed documentation of pilot training and checking events and retention of such records, and the information to be included in an air carrier’s assessment of a pilot applicant; • flight crew procedures and training to ensure that selected airspeeds are matched to the position of a ref speeds switch or similar device; 80

NTSB Aircraft Accident Report 81 • stall training that involves fully developed stall profiles (in addition to the approach- to-stall profiles that are currently required) and a demonstration of the stick pusher system; • the FAA’s oversight of Colgan, including the surveillance provided at the time that the company incorporated the Q400 into its fleet; • flight operational quality assurance programs, including the use of downloaded safety information to identify deviations from established norms and procedures; • the use of personal portable electronic devices on the flight deck; • the FAA’s use of SAFOs, which are advisory in nature, to transmit safety-critical information; and • preflight weather documents provided to flight crews and icing terminology presented in an FAA publication used by pilots for basic flight information. 2.2 Accident Sequence 2.2.1 Overview The FDR recorded the activation of the airframe and propeller deice equipment while the airplane was climbing to its assigned cruise altitude of 16,000 feet. At that time, the captain would have turned the ref speeds switch (on the ice protection panel above his seat) to the increase position. According to the Bombardier Q400 AFM, the ref speeds switch was to be set to the increase position before an airplane entered icing conditions (or upon initial detection of icing) and was to be set to the off position when the airplane was aerodynamically clean (that is, all ice was removed from the visible leading edges of the wing and wing tips). For the accident airplane, turning the ref speeds switch from the off to the increase position lowered the AOA reference for stick shaker activation and raised the position of the low-speed cue on the pilots’ IAS displays by about 15 knots. As a result, the airplane would have the same (or greater) performance margins relative to the stall speed during operations in icing conditions as it would have with a clean configuration as long as the landing airspeeds were appropriately increased to remain above the stall warning threshold.181 The first officer had received the BUF ATIS by 2150:42 and had entered planned landing information, including the intended runway and the airplane’s landing weight, into ACARS for transmittal to AeroData (see section 1.6.1) for landing performance data. However, she did not enter the keywords “icing” or “eice,” despite the icing conditions at the time, the deicing equipment in use, the ref speeds switch in the increase position, and the expected landing conditions (based on the ATIS information). ACARS returned the AeroData landing

181 The performance margins for operations in icing conditions were based on the worst-case ice accretions examined during icing certification. Ice accretions with less severe performance penalties than the worst-case ice accretions would result in a greater margin to stall.

NTSB Aircraft Accident Report 82 performance data to the airplane at 2153:00, showing a Vref of 118 knots and a Vga of 114 knots, but these speeds were not appropriate for an airplane configured for flight in icing conditions. (If the first officer had entered either “icing” or “eice,” then the Vref would have been 138 knots, which would have included a 20-knot icing increment.) The first officer provided the speeds to the captain, and he did not challenge them. Variable periods of snow and light-to-moderate icing were present during the accident airplane’s approach to BUF, and some ice accumulation was likely present on the airplane. However, FDR data and airplane performance models showed that the airplane responded to control inputs as expected, given the calculated ice accretion at the time, until the wing stalled. The CVR recorded the activation of the stick shaker about 2216:27, and FDR data showed that the activation occurred at an AOA of about 8°, a load factor of 1 G, and an airspeed of 131 knots, which was consistent with the AOA, airspeed, and low-speed cue during normal operations when the ref speeds switch was selected to the increase position. The airplane was not close to stalling at the time. However, because the ref speeds switch was selected to the increase (icing conditions) position, the stall warning occurred at an airspeed that was 15 knots higher than would be expected for a Q400 in a clean (no ice accretion) configuration. Stick shakers generally provide pilots with a 5- to 7-knot warning of an impending stall; thus, as a result of the 15-knot increase from the ref speeds switch, the accident flight crew had a 20- to 22-knot warning of a potential stall.182 CVR and FDR data indicated that, when the stick shaker activated, the autopilot disconnected automatically. The captain responded by applying a 37-pound pull force to the control column, which resulted in an airplane-nose-up elevator deflection, and adding power. In response to the aft control column movement, the AOA increased to 13°, pitch attitude increased to about 18°, load factor increased from 1.0 to about 1.4 Gs, and airspeed slowed to 125 knots. In addition, the speed at which a stall would occur increased.183 The airflow over the wing separated as the stall AOA was exceeded, leading to an aerodynamic stall and a left-wing-down roll that eventually reached 45°, despite opposing flight control inputs. Thus, the NTSB concludes that the captain’s inappropriate aft control column inputs in response to the stick shaker caused the airplane’s wing to stall. The airplane experienced several roll oscillations during the wing aerodynamic stall. FDR data showed that, after the roll angle had reached 45° left wing down, the airplane rolled back to the right through wings level. After the first stick pusher activation, the captain applied a 41-pound pull force to the control column, and the roll angle reached 105° right wing down. After the second stick pusher activation, the captain applied a 90-pound pull force, and the roll angle reached about 35° left wing down and then 100° right wing down. After the third stick pusher activation, the captain applied a 160-pound pull force. The final roll angle position

182 The airspeed at which an airplane would stall can be increased if the airplane experiences measurable loads (that is, variation from a 1 G load) because of, for example, maneuvering or external forces. The increased stall speed with loads greater than 1 G would erode the stall warning margin. 183 Numerous combinations of airspeed and load factor can result in the stall AOA being exceeded. The stall warning margin that existed at the time of stick shaker activation was consumed by the increase in load factor during the pull-up maneuver, leading to the stall AOA being exceeded at an airspeed that was much higher than the 1 G stall speed.

NTSB Aircraft Accident Report 83 recorded on the FDR was about 25° right wing down. At that time, the airplane was pitched about 25° airplane nose down. The airplane performance study and simulations showed that the airplane experienced minimal performance degradation because of ice accretion.184 Specifically, the AOA at the time of the wing stall was about 1° above the expected AOA for a clean wing (no ice accretion) stall warning. Thus, the airplane could have been operated in normal flight, at the non-icing Vref, and with a substantial margin remaining above the actual point of stall. As a result, the NTSB concludes that the minimal aircraft performance degradation resulting from ice accumulation did not affect the flight crew’s ability to fly and control the airplane. The flight crew’s actions during the accident sequence are further discussed in sections 2.2.2 through 2.2.4. 2.2.2 Approach to Airport The approach phase of flight is dynamic and requires heightened vigilance because it typically involves changes in the airplane’s altitude, heading, speed, and configuration. The captain, as the flying pilot, had the primary responsibility to monitor the instruments, and the first officer, as the monitoring pilot, was responsible for providing backup and corrective input to the captain’s efforts. About 2215:14, the controller informed the flight crew that the airplane was 3 miles from the outer marker and cleared the flight for the ILS runway 23 approach. The glideslope intercept point, as shown on the approach chart, was outside the outer marker. According to Colgan’s guidance, the airspeed at the time (184 knots) was too fast for the airplane’s position relative to the glideslope;185 as a result, the captain needed to initiate a rapid slowdown less than 3 miles from the outer marker. ATC requirements at busy airports, such as EWR (where both pilots were based), often necessitate such a maneuver. However, in this case, it is likely that the captain had to slow the airplane quickly because he was distracted by his conversation with the first officer and had lost positional awareness.186 A rapid slowdown is not unusual and is not unsafe if it is flown properly.187 The captain slowed the airplane by extending flaps to 5°, reducing power to near idle,188 extending the landing gear, and moving the condition levers to maximum rpm.189

184 The aircraft performance simulation study results for constant pitch attitude and constant altitude (see section 1.16.2) provide specific evidence showing that the airplane had more-than-adequate performance capability to return to a safe flight condition. 185 The 184-knot airspeed was 46 knots faster than Colgan’s maximum allowable approach speed on the glideslope, which is Vref plus 20 knots (in this case, 138 knots). 186 Air traffic was reported to be light at BUF at the time of the accident flight, and ATC had not issued any speed restrictions for the flight. 187 Several of the 13 previous flights recorded by the FDR had involved rapid slowdowns. The Colgan Q400 APM stated that a good technique for slowing an airplane rapidly is to increase the propeller rpm. 188 The primary power indication, torque, was displayed at the top of the engine display, which would have been in the direct view of the pilots. The power levers, which were being manipulated by the captain, were located on the center console.

NTSB Aircraft Accident Report 84 Airspeed indications were displayed on the pilots’ PFDs, as shown previously in figure 1. A vertical scale on the left side of each PFD showed the current airspeed (depicted in the center of the scale) and a range of ± 42 knots from the actual airspeed, and an airspeed trend vector predicted the airspeed at which the airplane would be flying in 10 seconds. The low-speed cue, consisting of alternating red and black bars, appeared on the bottom right of this scale to warn pilots of the calculated airspeed at which the stick shaker would activate. The cue’s red color is consistent with a warning indication requiring immediate recognition and corrective action by either pilot. The ref speeds switch, when set to increase, adjusts the position of the low-speed cue to account for the increased stall protection margin. About 2216:09, the low-speed cue began to rise from the bottom of the airspeed display as the airspeed slowed. However, the flight crew made no remarks and took no actions that were consistent with the recognition of this cue. Also, because the autopilot altitude hold mode was engaged when the airplane leveled off at 2,300 feet, the autopilot continued to add nose-up pitch trim to maintain altitude as the airspeed slowed. During the time that the low-speed cue was in view, the airplane’s pitch trim increased from 1° to 7° nose up, and the pitch attitude of the airplane increased from 3° to 9° nose up. Neither pilot remarked about the increasing pitch attitude, even though it was a cue indicating that airspeed was slowing. In addition, the numbers on the airplane’s IAS display changed from white to red as the airplane reached the calculated stick shaker activation speed. About 2216:27, the stick shaker activated at an airspeed of 131 knots, which was 13 knots higher than the Vref that the flight crew had set but 7 knots lower than the Vref icing speed. It is not unusual for a flight crew to see the low-speed cue appear during an approach given the airspeed range displayed on the PFDs. When the cue does appear, however, increased vigilance is necessary to ensure that the airspeed does not slow into the low-speed cue region, which would result in stick shaker activation. Pilots can accomplish such vigilance by using cues from the airspeed (actual IAS versus desired IAS), airplane configuration, pitch attitude, and power, all of which are part of a normal instrument scan. In this accident, the rise of the low- speed cue toward the decreasing IAS during an 18-second period should have been a salient cue to elicit action from either pilot. The NTSB concludes that explicit cues associated with the impending stick shaker onset, including the decreasing margin between indicated airspeed and the low-speed cue, the airspeed trend vector pointing downward into the low-speed cue, the changing color of the numbers on the airplane’s IAS display, and the airplane’s excessive nose- up pitch attitude, were presented on the flight instruments with adequate time for the pilots to initiate corrective action, but neither pilot responded to the presence of these cues. 2.2.2.1 Possible Reasons for Failed Detection of Impending Stick Shaker Onset To identify possible reasons the pilots failed to detect and correct the impending stick shaker onset, the NTSB examined how the pilots’ attention was directed and what their workload

189 Even though the autopilot had been on throughout most of the flight, power was controlled manually by the captain because the airplane was not equipped with autothrottles. Both pilots recognized, as a result of their training, that the airplane did not have an autothrottle system and that power had to be applied manually.

NTSB Aircraft Accident Report 85 had been during the seconds preceding the event. As the flying pilot, the captain should have been alerted to the rising low-speed cue and should have taken corrective actions during the 18 seconds between the first appearance of the cue and the onset of the stick shaker. Although the CVR contained statements and actions that were consistent with the captain referencing the PFD,190 the NTSB could not precisely determine when he was, or was not, looking at the airspeed indicator or where else he might have been focusing his attention during this period.191 As the monitoring pilot, the first officer should have been the primary backup to the captain and noticed his monitoring error. However, during the time between the first appearance of the low-speed cue and the onset of the stick shaker, the first officer was performing tasks that directed her attention toward the center pedestal and the center of the instrument panel and away from the PFD. About 2216:06, in response to the captain’s “gear down” callout, the first officer lowered the landing gear and adjusted the condition levers.192 About 6 seconds later, the first officer acknowledged a change to the ATCT frequency, and about 3 seconds afterward made a double chime notification to the flight attendant. About 2216:21, the first officer confirmed that the gear was down. About 2 seconds later, the captain requested that the flaps be set to 15° and that the before landing checklist be accomplished. About 5 seconds afterward, and about 1 second before the stick shaker activated, the first officer moved the flap handle to the 10° position in response to the captain’s callout for flaps 15. (The flap handle had previously been in the 5° position.)193 The NTSB concludes that the reason the captain did not recognize the impending onset of the stick shaker could not be determined from the available evidence but that the first officer’s tasks at the time the low-speed cue was visible would have likely reduced opportunities for her timely recognition of the impending event; the failure of both pilots to detect this situation was the result of a significant breakdown in their monitoring responsibilities and workload management. The NTSB also considered the possibility that the pilots were unaware of the effect that the ref speeds switch position had on the stick shaker activation speed. However, both pilots were familiar with the airplane’s ice protection system, and the Bombardier Q400 AFM cautioned that a stall warning might occur if airspeed was not increased before the ref speeds switch was selected to the increase position. As a result, it is unlikely that the pilots were unaware of the switch’s effect.

190 These statements included “approach is armed” about 2215:32, “gear down loc’s [localizer is] alive” about 2216:04, and “flaps fifteen before landing checklist” about 2216:24. In addition, a sound similar to a decrease in engine power was recorded about 2216:00. 191 The captain could have possibly been referencing the approach chart. It is also possible that he was inspecting the condition of the wings or the ice protection system because an ice detect message appeared on the engine display about 2216:25. It is important to note that no correlation existed between the timing of the message and the activation of the stick shaker 2 seconds later. 192 Colgan procedures indicated that these tasks were to be performed by the monitoring pilot. 193 Less than 1 second before the stick shaker activated, the first officer stated, “uhhh.” This statement could have indicated her recognition of the position of the low-speed cue on the PFD, or it could have been associated with the start of the before landing checklist. The available information was not sufficient to attribute the meaning of this statement.

NTSB Aircraft Accident Report 86 The CVR did not record the captain, during the climb to cruise altitude, stating that he had changed the position of the ref speeds switch from off to increase. However, the CVR did record the captain and the first officer referring to the 24-hour ice protection check, which included turning the ref speeds switch to the increase position and then back to the off position.194 Also, neither the captain nor the first officer mentioned the status of the switch during the flight, even with the “INCR REF SPEED” indication that would have appeared on the engine display.195 Further, if the ref speeds switch had been turned to the off position after stick shaker activation, the shaker would have stopped. As a result, the NTSB concludes that the flight crew did not consider the position of the ref speeds switch when the stick shaker activated. As indicated in section 1.18.3, after the accident, another Colgan flight crew experienced the activation of the stick shaker during a night VMC approach to BTV after losing awareness of the position of the ref speeds switch (which had been set to increase) and failing to recognize the impending stick shaker onset.196 The BUF accident, the BTV event, and postaccident interviews with company pilots demonstrated that Colgan’s approach procedures for setting airspeed bugs did not reinforce awareness of the ref speeds switch position, which created an opportunity for confusion. Specifically, pilots were not provided with specified airspeed targets beyond Vref, and no procedures were in place to ensure that the selected airspeeds were above the top of the low- speed cue. For example, if the captain and the first officer had recalled that the switch was set to the increase position, then they should have recognized that the airspeed for the approach needed to increase by 20 knots. Additional information on Colgan’s airspeed selection procedures is discussed in section 2.8, along with the company’s postaccident changes to these procedures. 2.2.3 Response to Stick Shaker Activation After the stick shaker activated, the autopilot disconnected automatically, as designed. The airplane was not in an aerodynamic stall at that time. The stick shaker activated with enough airspeed available to correct the situation because the wings were level and the load factor was 1 G. However, as stated previously, the captain’s inappropriate aft control column inputs in response to the stick shaker led to an aerodynamic stall. CVR and FDR data showed that the captain made an initial aft control column input after stick shaker onset and before the application of power. The stick forces at the time of autopilot disconnect were likely less than 2 pounds and would not account for his control input, which was

194 The CVR recorded the captain stating that the 24-hour ice protection check had been accomplished. The first officer subsequently confirmed that the check had been performed after she noticed in the airplane’s logbooks that a previous flight crew had not completed the daily check. 195 In addition, if the ref speeds switch was in the off position, the ice detected message on the engine display would appear in flashing yellow letters, which would have provided the pilots with information about the mismatch between the position of the ref speeds switch and the airspeed bugs. 196 When the event occurred, the airplane was not under autopilot control. The captain, who was the flying pilot, reported that she had been looking outside for the runway when the stick shaker activated, and the first officer reported that he had been performing a checklist at the time. The captain successfully recovered the airplane, and the flight continued to a landing without further incident.

NTSB Aircraft Accident Report 87 abrupt and inappropriate.197 The aft control column input occurred within 1 second of the stick shaker activation, which suggested that the captain’s hands were close to or resting on the control column. However, it was not possible to determine whether the captain’s hands were lightly placed on the control wheel before the onset of the stick shaker and the initial aft input was the result of a rough grab in response to being startled by the activation of the stick shaker.198 The aft control column movement was relaxed momentarily, but no evidence showed that the control column was pushed forward enough to prevent or recover from a stall. (The control column did not move forward of its neutral position any time after stick shaker activation.) NTSB postaccident observations in a Q400 flight simulator (with no simulated ice) showed that Colgan’s recovery procedures after initial stick shaker activation did not require exceptional piloting skills or aggressive inputs on the flight controls, even when full power was applied during the recovery effort. The captain’s subsequent control inputs were also not appropriate because he pulled back on the column rather than pushed forward to reduce AOA. As a result, the airplane’s pitch attitude and AOA increased and its airspeed decreased. After the stall, the AOA oscillated between 10° and 27°, the airspeed remained below the low-speed cue value, and the stick shaker remained active. According to Colgan’s procedures for a stall recovery, the captain, as the flying pilot, was to call “stall,” increase power to the rating detent, and call “check power,” but he did not follow these procedures. Even though the captain added power in response to the stall warning, he did not add full power as required.199 Also, the first officer did not call “stall” when the captain failed to do so, inform him that power had not been increased to the rating detent (she would have been able to observe the position of the power levers), or advance the power to the rating detent when the captain failed to do so. The next steps in the stall recovery procedure would have been for (1) the first officer, as the monitoring pilot, to call “positive rate” as an indication that the airplane was climbing; (2) the captain to call “gear up”; (3) the first officer to raise the gear and call “Vfri” when the airspeed had accelerated to 125 knots; and (4) the captain to call for flaps 0. In addition, the captain had not yet called for the landing gear to be raised or for the flaps to be retracted. However, about 7 seconds after the stick shaker activated, the first officer raised the flaps and then told the captain about the action she had just taken. All of Colgan’s procedures

197 The NTSB considered the possibility that the captain’s initial aft input was the result of unrecognized spatial disorientation. Accelerations and decelerations can be misinterpreted by pilots as pitch cues, which is a condition known as the somatogravic illusion. However, for this event, the deceleration would not have provided perceived nose-down pitch cues of sufficient magnitude to explain the captain’s action. 198 To facilitate pilot corrective action in the event of an unexpected autopilot disconnect and minimize the potential for errant flight as the pilot takes manual control, it is good technique for a pilot to lightly follow along with the flight controls during approaches flown with the autopilot engaged. 199 FDR data showed that the captain advanced the power levers to about 70°, but the rating detent was 80°. The rating detent was not a physical stop and required tactile feedback to positively identify its location as the power levers were advanced. It is possible that the captain missed this feedback as he advanced the throttles.

NTSB Aircraft Accident Report 88 pertaining to flap movement required a command from the flying pilot and acknowledgment from the monitoring pilot before the flaps could be moved. The stick pusher activated when the airplane’s airspeed had decreased to about 100 knots and its AOA was about 18° (which was about 10° higher than the AOA at the time of stick shaker onset). FDR data showed that the control column moved forward temporarily after stick pusher activation and then moved aft. The stick pusher activated a second time when the AOA was about 21° and a third time when the AOA was about 22°, but the control column continued to remain aft of its neutral position. The NTSB is concerned that the captain pulled against the stick pusher three separate times during the stall event and that his control inputs fought the stall protection system’s attempts to decrease the AOA and reduce the severity of the situation.200 Before transitioning to the Q400, the captain had previously flown the Saab 340, which had a stick pusher. It is possible that he had seen a demonstration of the stick pusher during simulator training for that airplane.201 However, it could not be determined whether the captain had seen a stick pusher demonstration on the Q400. Even if the captain had seen this demonstration, his actions in pulling against the pusher were not consistent with any trained procedure or the basic requirements for recovery from an aerodynamic stall. If the captain had not overridden the stick pusher’s action to decrease AOA, then the pusher would have forced the nose of the airplane downward. Also, if the captain would have responded properly to this nose-down input, then the airplane might have recovered flying speed in sufficient time to avoid the impact. However, the raising of the flaps, in addition to the vertical loading at the time, increased the stall speed and reduced the lift being produced by the wings at a time when the airplane was already stalled. About 7 seconds after notifying the captain about the status of the flaps, the first officer asked him whether she should raise the gear, and he consented. The raising of the gear was not appropriate but had minimal effect on the attempted stall recovery. In general, the captain’s performance suggests that he was surprised by the stick shaker’s activation, and he responded by making control inputs that were inappropriate for the situation. The captain’s failure to make a standard callout or even a declarative statement associated with a recovery attempt and his failure to silence the autopilot disconnect horn (which continued for the remainder of the flight and could have been silenced using a button on the control wheel) further suggest that he was not responding to the situation using a well-learned habit pattern. The first officer was not providing guidance consistent with an understanding of the situation, suggestions for corrective input, or standard callouts. In addition, neither flight crewmember made reference to the airplane’s airspeed at any time after the activation of the stick shaker. During the public hearing for this accident, the NASA-Ames Research Center chief scientist for aerospace human factors stated that people under stress might not respond appropriately to events in their

200 Overriding the stick pusher required an 80-pound opposite breakout force and then 66 pounds of continued aft force. FDR and stall protection system data showed that the stick pusher activated a second time about 2216:40, and the CVR recorded the captain making a grunting sound about 2216:42. 201 The syllabus for Saab 340 simulator training showed “demonstration to pusher” as an instructor’s discretion item listed under stalls.

NTSB Aircraft Accident Report 89 environment. In this case, the airplane was in a low-speed, nose-high attitude and was aerodynamically stalled, and neither pilot responded appropriately to the situation. The captain’s response to the stick shaker should not have required cognitive effort to make the correct inputs or standard callouts. Although the conditions under which the captain had practiced stall recoveries—which should have formed the sequence of actions used in his response—did not involve an autopilot disconnect or an element of surprise, the captain’s experience should still have allowed him to quickly adapt to the situation and perform correctly, as demonstrated by the pilot response during the Colgan BTV event.202 The accident captain’s history of training failures (previously discussed in section 1.5.1.2 and analyzed in section 2.7) showed that he had demonstrated weaknesses throughout his career with instrument flying skills and had relied heavily on the autopilot to help him stabilize the airplane, which might have contributed to his deficient performance during the accident flight. However, research has shown that it could be difficult for pilots to recognize and recover from unusual attitudes that were unexpected. In addition, the night and poor visibility conditions at the time precluded the use of external visual cues for reliable attitude reference, and the airplane’s G loads and proximity to the ground would have increased the stress associated with the event. The NTSB concludes that the captain’s response to stick shaker activation should have been automatic, but his improper flight control inputs were inconsistent with his training and were instead consistent with startle and confusion. The NTSB further concludes that the captain did not recognize the stick pusher’s action to decrease AOA as a proper step in a stall recovery, and his improper flight control inputs to override the stick pusher exacerbated the situation. 2.2.3.1 Possible Reasons for Failed Recovery Procedures The captain and the first officer had performed approach-to-stall recoveries multiple times during training at Colgan, with no documented or reported deficiencies. As a result, the NTSB considered possible reasons for the captain’s and the first officer’s actions during the attempted recovery. The NTSB evaluated whether the captain responded incorrectly to the stick shaker onset because he was applying corrective techniques that would have been more appropriate for a tailplane stall event. The captain (as well as the first officer) had seen, during initial and recurrent ground school, a NASA-produced icing video that discussed tailplane stalls and recovery techniques.203 The video indicated that tailplane stalls were most likely to occur with regional and corporate turboprop airplanes204 and during flight in icing conditions with ice

202 During the BTV event, the captain’s response to the stick shaker was consistent with the company’s stall recovery procedures. The captain applied forward pressure on the control column and full power. The airspeed immediately increased, and the stick shaker discontinued. 203 Colgan personnel did not specify the total number of times that the flight crew would have seen the video during training, but the NTSB estimates that the captain and the first officer would have most likely seen the video four and two times, respectively. 204 The Q400 was not specifically mentioned as an example of a regional turboprop airplane that was prone to tailplane stalls; the video was produced before the airplane entered service.

NTSB Aircraft Accident Report 90 present on the horizontal stabilizer. Bombardier, Transport Canada, and the FAA stated during public hearing testimony that the Q400 was not susceptible to tailplane stalls.205 In addition, Colgan had no written procedure for tailplane stalls and did not include tailplane stall training for the Q400. The tailplane stall recovery procedure presented in the video called for pulling back on the control column and reducing flaps, which the accident flight crew did. However, the video also stated that tailplane icing symptoms were lightening of the controls, pitch excursions, difficulty in pitch trim, control buffeting, and sudden nose-down pitch, none of which occurred before the stick shaker activation during the accident flight. Further, the activation of the stick shaker was a clear warning of an impending conventional aerodynamic stall and not a tailplane stall, and the change in the IAS numbers to red (which occurred after the airspeed was equal to or below that of the low-speed cue) was a conspicuous signal that was not consistent with a tailplane stall. Also, indications of a tailplane stall, for those airplanes determined to be susceptible, would likely occur at higher airspeeds and/or higher flap deflections. For a tailplane stall recovery, the captain would have had to interpret the situation, identify the tailplane stall, and apply a recovery procedure that he had never practiced. The CVR showed that he did not verbally identify a tailplane stall, and the FDR showed that he did not fully apply the tailplane stall recovery procedure described in the video. The NTSB concludes that it is unlikely that the captain was deliberately attempting to perform a tailplane stall recovery. The NTSB further concludes that no evidence indicated that the Q400 was susceptible to a tailplane stall. (Tailplane stall training is discussed further in section 2.9.3.) The NTSB also evaluated why the first officer had raised the flaps without being so directed by the captain. The stick shaker activated within 1 second of the first officer moving the flap handle from 5° to 10°. It is possible that, because of the close timing of these events, the first officer’s retraction of the flaps was an attempt to undo her last action. However, after returning the handle to the 5° position, the first officer continued moving the handle to the 0° position.206 It is also possible that she misinterpreted the event as a tailplane stall, and retracting the flaps to the last position before a tailplane stall was a recommended technique that she had been exposed to while watching the NASA icing video during recurrent ground school less than 1 month before the accident. Also, the absence of standard callouts from the captain impeded the first officer’s abilities to coordinate actions to support him. Further, it is possible that she raised the flaps as part of the steps associated with a landing stall recovery profile. However, if that were the case, the first officer failed to make the “positive rate” or “Vfri” callouts or confirm that power was set, which were required before raising the flaps. Finally, it is possible that the first officer raised the flaps because she had reverted to her previous general aviation experience; as a certified flight instructor, stall recoveries were not crew-coordinated maneuvers, and the flying pilot raised the flaps incrementally during th 207 e recovery.

205 The testing that was performed to make this determination is described in section 1.17.1.2. 206 Although each flap handle position has a detent, it is possible to traverse a particular detent quickly (in about 1 second). The FDR flap handle position parameter is sampled every 2 seconds, so the actual time between the positioning of the flap handle in the detents for 5° and 0° is not known. 207 Section 1.5.2.2 describes the first officer’s previous approach-to-stall training.

NTSB Aircraft Accident Report 91 In addition, the NTSB evaluated why the first officer suggested raising the landing gear. Her suggestion could have been in response to the ambiguous statement made by the captain following his grunting sound about 2216:42 (*ther bear).208 However, her suggestion occurred about 4 seconds later and not immediately afterward. Another possibility is that the first officer was attempting to provide support to the captain because raising the gear is one of the steps in the stall recovery procedure, but the “gear up” callout was the responsibility of the flying pilot, and the steps that preceded that callout had not been accomplished. The NTSB concludes that, although the reasons the first officer retracted the flaps and suggested raising the gear could not be determined from the available information, these actions were inconsistent with company stall recovery procedures and training. 2.2.4 Captain’s Management of Flight The captain was responsible for the management of the flight. However, he and the first officer engaged in conversations for much of the flight,209 starting about 6 minutes 40 seconds after takeoff as the airplane was climbing to 12,000 feet during the ascent to its cruise altitude. (The airplane had reached an altitude of 10,000 feet about 2 minutes before the conversations began.) Although the conversations during cruise flight did not conflict with Federal regulations or company policy, their depth and duration likely contributed to the delayed performance of callouts and checklists.210 For example, Colgan’s Q400 CFM indicated that the cruise checklist should be performed after the airplane attained its assigned cruising altitude,211 as the flying pilot leveled the airplane and allowed it to accelerate to the maximum operating limit speed minus 10 knots. However, the captain called for the cruise checklist about 2138:47, which was about 2.5 minutes after the airplane had accelerated to cruise speed.

The airplane began descending from its 16,000-foot cruise altitude about 2157:20. Although Colgan’s Flight Operations Policies and Procedures Manual stated that approach briefings should generally be accomplished before the top of the descent (when the crew’s workload was expected to be minimal), the captain did not start this briefing until 2204:16, as the airplane descended below 12,000 feet.212 The manual also required a callout by the flying pilot when the airplane was descending through 10,000 feet, but the captain was conducting the approach briefing at that time and omitted the callout.

208 The asterisk denotes an unintelligible word. 209 Between the time that the airplane left the gate at EWR and the time that it was cleared for takeoff, 1 hour 33 minutes had elapsed. During the ground time at EWR that was captured by the CVR, the flight crew engaged in lengthy conversations that were not directly related to the operation, which set the tone for the flight. 210 The captain was also late with a checklist callout earlier in the flight. Colgan’s Q400 CFM indicated that the taxi checklist should begin after an airplane leaves the ramp area. However, the captain called for the checklist about 2115:51, which was 45 minutes after the airplane left the ramp area. 211 The 24-hour ice protection check was performed as part of the cruise checklist. 212 The captain conducted a complete and accurate approach briefing in accordance with Colgan procedures with the exception of one briefing item. A flight data center notice to airmen had been issued to modify the ILS runway 23 missed approach procedure. Even though the captain should have briefed this information, the flight crew would have received instructions from ATC for the missed approach procedure.

NTSB Aircraft Accident Report 92 Once the airplane had descended through 10,000 feet (about 2206:37), sterile cockpit procedures, prohibiting nonpertinent conversations within the cockpit, were required. However, the flight crewmembers engaged in a nonpertinent conversation during the final minutes of the descent, which distracted them from their flying duties.213 About 2210:23, the first officer asked whether ice was present on the windshield. After a brief exchange between the pilots as they inspected the ice, the captain stated that it was the most ice he had seen on the leading edges in a long time. About 2210:58, the first officer initiated a nonpertinent conversation about her experience flying in icing conditions. The captain participated in this conversation, which continued for a period of about 80 seconds, until it was interrupted by an ATC clearance to descend to 2,300 feet. About 2212:33, after the pilots confirmed the altitude entry in the autopilot and had a brief discussion about the autopilot mode, they resumed their conversation until ATC called 11 seconds later with a heading instruction. About 2213:01, the captain and the first officer again resumed the conversation for another 15 seconds until the altitude alerter sounded to indicate that the airplane was descending through 3,300 feet. At that point, the captain called for the descent checklist, but Colgan’s Q400 CFM stated that the descent checklist was to begin at the top of the descent if the cruise altitude was below 18,000 feet. The captain called for the approach checklist about 11 seconds later, immediately after completion of the descent checklist. However, the CFM stated that this checklist was to be completed before an airplane on an instrument approach transitioned to the initial approach phase, but the accident airplane was at a point inside the initial approach fix at the time of the captain’s callout. After the descent and approach checklists were completed, the first officer resumed the conversation until about 2214:09, when another ATC call was received. The pilots were responsible for performing operational tasks during their 3-minute 11- second nonpertinent conversation. In addition, the conversation followed the first officer’s identification of a possible threat to the airplane (ice), but neither pilot took appropriate actions, such as confirming the ice protection system’s status or the airspeed targets, to ensure that the threat was mitigated. As previously stated in section 2.2.2, the captain had the primary responsibility to monitor the instruments, and the first officer was responsible for providing backup to the captain. However, as part of his overall workload management responsibilities, the captain should have been cognizant of the tasks that he requested the first officer to perform and their effect on her ability to reliably provide the expected monitoring and cross-check. As a result, he should have been especially focused on the flight instruments during these periods. However, he did not notice the rising low-speed cue on the IAS display (especially during the 18 seconds before stick shaker activation, when the first officer would have been configuring the airplane for landing), even though the pilots’ nonpertinent conversation had ended about 2 minutes before the appearance of the low-speed cue.

213 About 2207:22, the first officer made the “in-range” call to Colgan operations at BUF. However, according to the company’s Flight Operations Policies and Procedures Manual, this call should have been made before leaving cruise flight.

NTSB Aircraft Accident Report 93 Because of their conversation, the flight crewmembers squandered time and their attention, which were limited resources that should have been used for attending to operational tasks, monitoring, maintaining situational awareness, managing possible threats, and preventing potential errors. As a result, the NTSB concludes that the captain’s failure to effectively manage the flight (1) enabled conversation that delayed checklist completion and conflicted with sterile cockpit procedures and (2) created an environment that impeded timely error detection. Additional information on captain leadership and sterile cockpit procedures appears in sections 2.4.1 and 2.4.2, respectively. 2.3 Strategies to Prevent Monitoring Failures The flight crewmembers failed to monitor the airplane’s pitch attitude, power, and especially its airspeed and failed to notice, as part of their monitoring responsibilities, the rising low-speed cue on the IAS display. Multiple strategies can be used to protect against catastrophic outcomes resulting from these and other monitoring failures, including flight crew training, flight deck procedures, and low-airspeed alert systems, which are discussed in sections 2.3.1 through 2.3.3, respectively. 2.3.1 Flight Crew Monitoring Training The NTSB has long recognized the importance of flight crew monitoring skills in accident prevention. In its 1994 safety study of 37 flight crew-involved major accidents, the NTSB found that, for 31 of these accidents, inadequate monitoring and/or cross-checking had occurred.214 The study also found that flight crewmembers frequently failed to recognize and effectively draw attention to critical cues that led to the accident sequence, which was further demonstrated by the circumstances of this accident. As part of its safety study, the NTSB 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 Part 121 air carriers 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 the carriers’ IOE should include training and experience for check airmen and pilots “in enhancing the monitoring and challenging functions.” On January 16, 1996, the NTSB classified these recommendations “Closed—Acceptable Alternate Action” based on the FAA’s revised training guidance (AC 120-51B), which emphasized the importance of monitoring. Another accident involving monitoring failures occurred in February 2005 when a Cessna Citation crashed on approach to Pueblo, Colorado. In its report on the accident (see

214 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).

NTSB Aircraft Accident Report 94 section 1.18.1.4), the NTSB cited the flight crew’s “failure to effectively monitor and maintain airspeed” as part of the probable cause and issued Safety Recommendation A-07-13, which asked the FAA to do the following: 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. On May 17, 2007, the FAA stated that it would consider identifying, in its work program, a list of required inspections that would reemphasize, to regional office and FSDO managers, the need to validate the training that was already required and verify its effectiveness. On September 10, 2008, the NTSB stated that such a list would be responsive to the intent of the recommendation as long as the list provided a strong emphasis on the monitoring and workload management components of a CRM program. The NTSB classified the recommendation “Open—Acceptable Response.” The importance of monitoring was referenced in some of Colgan’s guidance to its pilots215 and was discussed and evaluated during simulator training and IOE. However, the company did not provide specific pilot training that emphasized the monitoring function. Further, the company’s CRM training did not explicitly address monitoring or provide pilots with techniques and training for improving their monitoring skills.216 During public hearing testimony, the NASA-Ames Research Center chief scientist for aerospace human factors stated that people have limited attention and must select from among those features in their environment to direct their attention. Also, distractions and interruptions can increase workload and redirect attention, thus complicating the monitoring task. As a result, effective monitoring requires active effort. To improve monitoring skills, pilots must proactively seek information and ask questions. The NASA chief scientist testified that current pilot training programs do not typically train these skills in a systematic manner. The NTSB concludes that the monitoring errors made by the accident flight crew demonstrate the continuing need for specific pilot training on active monitoring skills. Almost 3 years have passed since Safety Recommendation A-07-13 was issued, and more than 2.5 years have passed since the FAA described to the NTSB the planned actions to address the recommendation. Since that time, the FAA has reported no further action on this recommendation, even after receiving the NTSB’s September 2008 response letter. Therefore, the NTSB reiterates Safety Recommendation A-07-13 and reclassifies it “Open— Unacceptable Response.”

215 The CFM made only minimal reference to the responsibilities of the monitoring pilot during approach profiles. 216 The company’s current training for CRM/threat and error management presents information on the importance of monitoring as a strategy to detect and prevent errors.

NTSB Aircraft Accident Report 95 2.3.2 Flight Deck Procedures The FAA has developed guidance on the design of procedures to facilitate pilot monitoring and cross-checking. These procedures are contained in an appendix to AC 120-71A, “Standard Operating Procedures for Flight Deck Crewmembers.” The guidance provides examples of and supporting rationale for standard operating procedures that promote monitoring. The guidance also recommends establishing standard operating procedures to support improved monitoring during climb, descent, and approach. Colgan’s standard operating procedures did not include speed targets during approaches; these targets would have facilitated the detection of speed deviations by the monitoring pilot. Colgan also lacked standardized procedures for setting airspeeds and using the ref speeds switch, which did not promote effective cross-checking between airspeeds and the switch’s status. (These issues are discussed in section 2.8.) If such procedures had been in place, then the flight crew might have detected the inconsistency between the 118-knot Vref (a non-icing speed) and the position of the ref speeds switch (icing conditions assumed) and ensured that a Vref of 138 knots (an icing speed) was selected. Further, although company procedures required the flying pilot to make a 1,000-foot callout when changing altitudes, the director of flight standards stated that the callout was not required before the altitude alerter sounded. Such a practice can impede monitoring because flight crews may become passive and wait for an automated backup system to prompt their required callout.217 After the accident, the company introduced the “VVM” (verbalize, verify, and monitor) program to improve flight crew monitoring.218 The NTSB concludes that Colgan Air’s standard operating procedures at the time of the accident did not promote effective monitoring behavior. The NTSB is concerned that other air carriers’ standard operating procedures may also be deficient in this area. Therefore, the NTSB recommends that the FAA require Part 121, 135, and 91K219 operators to review their standard operating procedures to verify that they are consistent with the flight crew monitoring techniques described in AC 120-71A; if the procedures are found not to be consistent, revise the procedures according to the AC guidance to promote effective monitoring. 2.3.3 Low-Airspeed Alert Systems The low-speed cue and the stick shaker on the Q400 were intended to warn the pilots of an impending stall. In this case, even though both systems functioned as designed, neither pilot responded appropriately to prevent the stall. Features on the airspeed display, including the indicated airspeed, trend vector, and low-speed cue, should have provided the pilots with adequate time to detect the rising low-speed cue and respond appropriately. However, distraction

217 This practice, known as primary backup reversion, is characterized by a human operator using an automated backup system as the primary signal to be monitored. 218 Colgan also discussed the importance of monitoring in its revised CRM/threat and error management course. Also, the company’s revised Flight Operations Policies and Procedures Manual reinforced this training by stating that all pilots were expected to “actively demonstrate monitoring and challenging” as a CRM skill during line operations. 219 Title 14 CFR 91 Subpart K applies to fractional ownership operations.

NTSB Aircraft Accident Report 96 and workload considerations may have made it difficult for the pilots to visually detect features on the airspeed display depicting the development of this condition (including the trend vector and the low-speed cue), so a redundant aural alert might have provided them with an effective warning about the decreasing airspeed in relation to the rising position of the low-speed cue. In its report on the October 2002 King Air A100 accident in Eveleth, Minnesota, the NTSB found that the pilots had allowed the airspeed to decrease to dangerously low levels while attempting to execute a nonprecision instrument approach during instrument meteorological conditions. As a result, the airplane entered an aerodynamic stall from which the flight crew did not recover. Because the flight crew failed to recognize that the stall was imminent, the NTSB concluded that the development of and requirement for the installation of a low-airspeed alert system could substantially reduce the number of accidents and incidents involving a flight crew’s failure to maintain airspeed. On December 2, 2003 the NTSB issued Safety Recommendations A-03-53 and -54, which asked the FAA to do the following: Convene a panel of aircraft design, aviation operations, and aviation human factors specialists, including representatives from the National Aeronautics and Space Administration, to determine whether a requirement for the installation of low-airspeed alert systems in airplanes engaged in commercial operations under 14 Code of Federal Regulations Parts 121 and 135 would be feasible, and submit a report of the panel’s findings. (A-03-53) If the panel requested in Safety Recommendation A-03-53 determines that a requirement for the installation of low-airspeed alert systems in airplanes engaged in commercial operations under 14 Code of Federal Regulations Parts 121 and 135 is feasible, establish requirements for low-airspeed alert systems, based on the findings of this panel. (A-03-54) On October 3, 2006, the FAA stated that it had formed a team to assess the feasibility of low-airspeed alert systems. On April 3, 2007, the NTSB stated it was encouraged that the FAA had formed the team and would begin addressing the recommendation. As a result, the recommendation was classified “Open—Acceptable Response.” During the almost 6 years since the NTSB issued Safety Recommendations A-03-53 and -54, (which were reiterated in July 2006 after another event involving decreasing airspeed and loss of control),220 accidents and incidents involving a lack of flight crew awareness of decreasing airspeed have continued, indicating that existing stall warnings are not a reliable method for preventing inadvertent hazardous low-speed conditions. The NTSB notes that human

220 The recommendations were reiterated in a safety recommendation letter addressing an incident involving American Eagle flight 3008, a Saab 340 airplane that experienced a loss of control during icing conditions. The letter also addressed three similar Saab 340 incidents investigated by the Australian Transport Safety Bureau and stated, “if the flight crews had been alerted to the rapid airspeed decrease in a timely fashion, they may have been able to take corrective action and perhaps avoid the stall.”

NTSB Aircraft Accident Report 97 factors concerns associated with a low-airspeed alert do not require more than 6 years of study for a solution to be implemented.221 The NTSB notes that several other airplanes certificated under 14 CFR Part 25, including the Boeing 747-400 and 777, provide pilots with an amber band on the airspeed display above the low-speed cue. This amber band typically represents the airspeed between the stall warning speed and the minimum maneuvering speed. Operations are not normally conducted with airspeeds in the amber band, which, in effect, provides pilots with a visual indication of a developing low-speed condition before the onset of the stall warning. AC 25-11A, “Electronic Flight Displays,” discusses the visual design of low-speed awareness cues and states, “the preferred colors to be used are amber or yellow to indicate that the airspeed has decreased below a reference speed that provides adequate maneuver margin, changing to red at the stall warning speed. The speeds at which the low speed awareness bands should start should be chosen as appropriate to the airplane configuration and operational flight regime. For example, low speed awareness cues for approach and landing should be shown starting at Vref with a tolerance of +0 and -5 knots.” The NTSB concludes that the Q400 airspeed indicator lacked low-speed awareness features, such as an amber band above the low-speed cue or airspeed indications that changed to amber as speed decrease toward the low-speed cue, which would have facilitated the flight crew’s detection of the developing low-speed situation. Therefore, the NTSB recommends that the FAA require that airspeed indicator display systems on all aircraft certified under 14 CFR Part 25 and equipped with electronic flight instrument systems depict a yellow/amber cautionary band above the low-speed cue or airspeed indicator digits that change from white to yellow/amber as the airspeed approaches the low-speed cue, consistent with AC 25-11A, “Electronic Flight Displays.” At the public hearing for this accident, an FAA certification specialist testified that current certification rules under 14 CFR 25.1329 indicate that there should be speed protection and/or alerting within the normal speed range while under flight guidance system (autopilot) control. The certification specialist stated, “there should be low speed alerting occurring prior to stall warning, if you’re under flight guidance system or autopilot control. And that low speed alerting can take many forms, but it needs to be aural and visual.”222 On July 9, 2009, the FAA issued an NPRM for flight crew alerting, which included a requirement that alerts necessitating immediate crew awareness be presented using two sensory modalities. For example, a visual alert accompanied by an aural alert can help to capture and

221 After the March 19, 2001, incident involving Comair flight 5054, a low-airspeed alert system was developed for Embraer EMB-120 airplanes. The system was designed to provide pilots with an aural and a visual alert of low airspeed while operating in icing conditions. FAA Airworthiness Directive 2001-20-17, effective October 22, 2001, mandated installation of the system on the EMB-120. 222 The Q400 was certificated before the amendment to Section 25.1329. AC 25.1329-1B, “Approval of Flight Guidance Systems,” states, “standard stall warning and high-speed alerts are not always timely enough for the flight crew to intervene to prevent unacceptable speed excursions during FGS [flight guidance system] operation.” The AC also states, “a low speed alert and a transition to the speed protection mode at approximately 1.13 Vsr for the landing flap configuration has been found to be acceptable.” In addition, the AC states, “low speed protection alerts should include both an aural and visual component.”

NTSB Aircraft Accident Report focus a pilot’s attention in the event that the pilot is not looking at the alerting cue. In this accident, the pilots did not likely see the rising low-speed cue on the IAS display, the downward- pointing trend vector, or the airspeed indications change to red. As a result, the NTSB concludes that an aural warning in advance of the stick shaker would have provided a redundant cue of the visual indication of the rising low-speed cue and might have elicited a timely response from the pilots before the onset of the stick shaker. Therefore, the NTSB recommends that, for all airplanes engaged in commercial operations under 14 CFR Parts 121, 135, and 91K, the FAA require the installation of low-airspeed alert systems that provide pilots with redundant aural and visual warnings of an impending hazardous low-speed condition. Because of the FAA’s inactivity with regard to Safety Recommendations A-03-53 and -54, the NTSB classifies the recommendations “Closed—Unacceptable Action/Superseded” and classifies Safety Recommendation A-10-12 “Open—Unacceptable Response.” 2.4 Pilot Professionalism 2.4.1 Leadership Training The captain was responsible for setting the appropriate tone in the cockpit and managing communications and workload in a manner that promoted professionalism and adherence to standard operating procedures. On the basis of his actions during the flight, including the late performance of checklists and callouts because of an ongoing conversation, the captain showed inadequate leadership. His failure to establish the appropriate cockpit tone during the initial stages of the operation and show strong command authority during the flight is disconcerting, especially because he had been a captain for more than 2 years. In March 1998, the FAA mandated CRM training for all Part 121 operators. CRM training helps facilitate effective crew communication and coordination and the use of available resources to protect against error. The concepts associated with CRM training have been expanded to include techniques for threat and error detection, management, and mitigation. Many operators integrate CRM concepts in their training programs and evaluate CRM skills during simulator training and line observations. Colgan’s CRM training included 5 slides (of 45 slides total) that addressed command, leadership, and leadership styles. (Colgan’s CRM training is further discussed in section 2.4.3.) In contrast, Part 121 operators are not required to provide upgrading captains with specific training on the leadership skills necessary to make the transition from SIC to PIC. For many new captains, including the accident captain, the initial upgrade represents the first time in which they are held responsible for leading and managing multiple crewmembers during air carrier operations. Because of the PIC’s critical role in establishing and maintaining safe operating conditions, upgrading captains would greatly benefit from specific training on command and leadership skills. The captain upgraded in October 2007; at that time, Colgan provided to its upgrading captains a 1-day training course on duties and responsibilities. Although the director of 98

NTSB Aircraft Accident Report 99 crewmember and dispatcher training stated that the course was designed to help a new captain make the transition to the new role, the NTSB’s review of the course content showed that it focused on the administrative duties associated with becoming a captain. The upgrade training course did not contain significant content applicable to developing leadership skills, management oversight, and command authority. Some air carriers provide leadership training to their upgrading captains. For example, one regional air carrier expanded its leadership training, from 2 to 8 hours, so that additional information on leadership skills could be presented. This change was made in response to an unacceptable level of training failures (primarily because of leadership and judgment factors) for upgrading captains.223 The expanded course contained modules on leadership, authority, and responsibility; briefing and debriefing scenarios; decision-making processes, including those during an emergency; dry-run line-oriented flight scenarios; and risk management and resource utilization. Industry changes (including two-pilot cockpits and the advent of regional carriers) have resulted in opportunities for pilots to upgrade to captain without having accumulated significant experience as a first officer in a Part 121 operation. Without these important opportunities for mentoring and observational learning, which characterize time spent in journeyman pilot positions, it may be difficult for a pilot to acquire effective leadership skills to manage a multicrew airplane. In addition, airlines must instill their leadership values and safety culture in their captains because they are the ones who are ultimately responsible for the safety of each flight. At the public hearing for this accident, ALPA’s safety committee chairman discussed the need for companies to provide leadership skills to upgrading captains and for captains to set the proper tone in the cockpit. The POI for Colgan stated, during a postaccident interview, that training in this area was important and should be required. The NTSB concludes that specific leadership training for upgrading captains would help standardize and reinforce the critical command authority skills needed by a PIC during air carrier operations. Some operators are already providing this training, but others are not. Therefore, the NTSB recommends that the FAA issue an AC with guidance on leadership training for upgrading captains at Part 121, 135, and 91K operators, including methods and techniques for effective leadership; professional standards of conduct; strategies for briefing and debriefing; reinforcement and correction skills; and other knowledge, skills, and abilities that are critical for air carrier operations. The NTSB further recommends that the FAA require all Part 121, 135, and 91K operators to provide a specific course on leadership training to their upgrading captains that is consistent with the AC requested in Safety Recommendation A-10-13.

223 The company’s captain upgrade first-time failure rate had reached 22 percent when the target was 10 percent. The company’s POI stated that the failures had involved “captain thinking skills” and not “stick and rudder skills.” For more information, see the NTSB’s report on the Pinnacle Airlines flight 3701 accident (referenced in section 1.18.1.3).

NTSB Aircraft Accident Report 100 2.4.2 Sterile Cockpit and Standard Operating Procedures The pilots were involved in nonpertinent conversation during all phases of flight, including those that are defined as critical by the sterile cockpit rule. For example, the pilots’ nonpertinent conversation during the final minutes of the descent (which included a discussion of their previous experiences flying in icing conditions) distracted them from their operational tasks. In addition, the pilots deviated from standard operating procedures with the timing of checklists during the descent (as previously discussed in section 2.2.4). Colgan expected sterile cockpit procedures to be included in a captain’s briefing and adhered to during training, checkrides, and line operations. Most company pilots interviewed after the accident stated that sterile cockpit adherence was good and that pilots deviated rarely from sterile cockpit procedures. Company and FAA oversight before the accident did not identify any problems with sterile cockpit adherence, but some deviations were identified after the accident. Colgan stated that it had provided pilots with information on sterile cockpit procedures during ground school indoctrination training, but a review of all slides presented during the training at the time of the accident found none that specifically addressed sterile cockpit procedures. After the accident, the company revised its training program, and recurrent training now addresses the importance of sterile cockpit procedures. Also, the company’s chief pilot issued guidance on sterile cockpit adherence, including a reminder that no extraneous conversation of any kind could take place when sterile cockpit procedures were in effect.224 The NTSB is concerned that, during the accident flight, neither pilot seemed hesitant to engage in nonpertinent conversation or demonstrated correcting behavior when the other pilot deviated from sterile cockpit procedures. These facts suggest that nonpertinent conversation among company pilots during critical phases of flight was not unusual. The primary reason for 14 CFR 121.542, otherwise known as the sterile cockpit rule, is to ensure that a pilot’s attention is directed to operational concerns during critical phases of flight and is not redirected or degraded because of nonessential activities or conversation. The NTSB has investigated accidents demonstrating the catastrophic effects of pilot deviations from Section 121.542 and standard operating procedures. For example, in August 2006, the flight crew of Comair flight 5191 attempted to depart from the wrong runway, which resulted in an accident that killed 49 of the 50 people on board. The NTSB determined that the flight crew’s nonpertinent conversation during taxi, which resulted in a loss of positional awareness, was a contributing factor to the accident. The NTSB also found that the flight crew’s noncompliance with standard operating procedures had most likely created an atmosphere in the cockpit that enabled the crew’s errors.225 Nonpertinent conversation during a critical phase of flight and

224 In addition to these changes, Colgan incorporated a discussion of accidents and incidents involving sterile cockpit breakdowns to its CRM/threat and error management training. Also, Colgan procedures contained an expanded definition of sterile cockpit periods, including ± 1,000 feet of level-off altitude when making altitude changes and when approaching the top of descent on crossing restrictions and pilot-discretion descents. 225 For more information, see 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: NTSB, 2007).

NTSB Aircraft Accident Report 101 noncompliance with standard operating procedures were also issues found during the investigation of the Colgan accident. Other recent accidents have identified similar issues involving a breakdown in cockpit discipline and noncompliance with the sterile cockpit rule.226 Although it is difficult to identify a specific reason for this behavior, industry data have shown that pilots who had intentionally deviated from standard operating procedures were three times more likely to make other types of errors, mismanage more errors, and find themselves in more undesirable situations compared with those flight crewmembers who had not intentionally deviated from procedures.227 Nevertheless, most airline and FAA personnel have stated, after accidents, that no precursors to such deviations were identified during their previous oversight activities. The Q400 APM for Colgan acknowledged that an inspector’s observations of flight crew performance might not be representative of the crew’s usual performance. On February 7, 2006, the NTSB issued Safety Recommendation A-06-7, which asked the FAA to direct the POIs of all Part 121 and 135 operators to reemphasize the importance of strict compliance with the sterile cockpit rule. In response to this recommendation, the FAA issued SAFO 06004 on April 28, 2006, to emphasize the importance of sterile cockpit discipline. As a result of the FAA’s action, the NTSB classified Safety Recommendation A-06-7 “Closed— Acceptable Action” on November 9, 2006. However, the lasting effect of this SAFO is questionable given that the Comair flight 5191 accident occurred only 4 months after the SAFO was issued and the Colgan accident happened less than 3 years after the SAFO’s issuance. At the public hearing for this accident, an FAA manager stated that the agency has been addressing sterile cockpit issues through, among other actions, published guidance and oversight activities by inspection personnel.228 The NTSB identified only one FAA AC or handbook—the Instrument Procedures Handbook (FAA-H-8261-1A)—that references an accident involving the lack of sterile cockpit discipline.229 In addition, this publication does not include information that outlines the origin of the sterile cockpit rule, its rationale, and an explicit discussion of the safety consequences associated with the failure to adhere to sterile cockpit procedures during critical phases of flight.

226 These accidents include the Corporate Airlines flight 5966 accident (see section 1.18.1.1) and the Pinnacle Airlines flight 3701 accident (see section 1.18.1.3). 227 These data are from the LOSA Collaborative, which is a network of researchers, safety professionals, pilots, and airline representatives who collaborate to provide, among other things, oversight and implementation of LOSA and a forum for information exchange regarding LOSA. Deviations from sterile cockpit procedures are among the types of intentional noncompliance that can be detected through LOSA observations. In January 2007, the NTSB issued Safety Recommendation A-07-9 to require Part 121 operators to incorporate LOSA observations into their oversight programs. This recommendation and its status are discussed in section 1.18.1.9. Colgan has begun to implement a LOSA program, as discussed in section 1.17.7.4. 228 These publications include AC 120-71A, “Standard Operating Procedures for Flight Deck Crewmembers”; AC 120-74A, “Parts 91, 121, 125, and 135 Flightcrew Procedures During Taxi Operations”; AC 120-51E, “Crew Resource Management Training”; and AC 91-73A, “Part 91 and Part 135 Single-Pilot Procedures During Taxi Operations.” 229 The handbook references the September 1974 Eastern Air Lines flight 212 accident, which was caused by the flight crew’s lack of altitude awareness at critical points during the approach as a result of poor cockpit discipline. 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).

NTSB Aircraft Accident Report 102 Also at the public hearing, the Colgan director of flight standards testified that postaccident observations of company pilots revealed only “minor” sterile cockpit deviations, such as an individual pilot remark about something either heard on the radio or seen. The flight standards director stated that, in such instances, the other pilot would not respond to the comment. However, the NTSB recognizes that any nonpertinent remark during critical phases of flight has the potential to be distracting. Multiple opportunities exist during noncritical phases of flight to allow flight crewmembers to communicate, establish trust, and build rapport, but, during critical phases of flight, all conversations need to relate solely to the operation of the flight. These conversations should follow standard operating procedures and include the use of standard phraseology, which are proven tools for safely operating aircraft. Even though the responsibility for sterile cockpit adherence is ultimately a matter of a pilot’s own professional integrity, the NTSB notes that pilots work within a context of professionalism created through the mutual efforts of the FAA, operators, and pilot groups. These stakeholders need to work together to provide clear and unwavering guidance that helps to instill sound principles of professionalism and adherence to standard operating and sterile cockpit procedures. The stakeholders also need to provide detailed guidance on these topics to new commercial pilots as well as instruction and reinforcement on the topics to pilots throughout their career. On January 23, 2007, the NTSB issued Safety Recommendation A-07-8, which asked the FAA to do the following: 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. On April 13, 2007, the FAA stated that it would meet with ALPA, the Air Transport Association, the Regional Airline Association, and other groups to determine an effective approach for addressing these issues. On January 22, 2008, the NTSB stated that the FAA’s planned action would be appropriate after the development of an educational program that conveyed the necessary safety information and classified the recommendation “Open— Acceptable Response.” However, in the 3 years since the issuance of Safety Recommendation A- 07-8, the FAA has not produced guidance material or developed a program that meets the intent of the recommendation.230 The NTSB recognizes that most pilots strive to fly professionally and adhere to standard operating and sterile cockpit procedures. However, the continuing failure of some pilots to

230 In contrast, the FAA has created instructional materials on other aviation safety-related issues. For example, to address the increasing problem of runway incursions, the FAA distributed to all pilots a multimedia presentation and printed guidance on the issue. The presentation addressed runway safety, discussed accidents and operating rules, and offered best practices and techniques. Such an approach could be effective in addressing breakdowns in pilot professionalism and sterile cockpit discipline, especially if examples of accidents are included with standard operating procedures and best practices to help focus attention on the reasons for the standards and the potential results of not following them.

NTSB Aircraft Accident Report 103 refrain from nonpertinent conversation during critical phases of flight erodes proven margins of safety provided by the strict adherence to standard operating procedures, as demonstrated by the circumstances of this accident. More than 28 years have elapsed since sterile cockpit rulemaking was enacted based on the NTSB’s investigation of the Eastern Air Lines accident and the professional conduct recommendations that resulted from the investigation.231 However, industry action is still needed to provide all pilots with guidance discussing (1) the importance of following standard operating procedures, adhering to sterile cockpit procedures, and maintaining professionalism during aircraft operations and (2) the costs to safety when pilots do not operate according to these standards. The NTSB concludes that, because of the continuing number of accidents involving a breakdown in sterile cockpit discipline, collaborative action by the FAA and the aviation industry to promptly address this issue is warranted. Therefore, the NTSB recommends that the FAA (1) develop, and distribute to all pilots, multimedia guidance materials on professionalism in aircraft operations that contain standards of performance for professionalism; best practices for sterile cockpit adherence; techniques for assessing and correcting pilot deviations; examples and scenarios; and a detailed review of accidents involving breakdowns in sterile cockpit and other procedures, including this accident and (2) obtain the input of operators and air carrier and general aviation pilot groups in the development and distribution of these guidance materials. As a result of this new recommendation, and because the FAA has not taken any action in 3 years to address Safety Recommendation A-07-8, the recommendation is reclassified “Closed— Unacceptable Action/Superseded.” 2.4.3 Crew Resource Management Colgan provided CRM training to its pilots during initial and recurrent ground school. The training addressed topics such as command, leadership and leadership styles, communication, and decision-making. The training also included information on the importance of maintaining situational awareness, employing checklist discipline, and adhering to standard operating procedures. A CRM training instructor stated that the course also addressed the relationship between flight crewmembers and the need to indicate when pilots were not observing sterile cockpit procedures. The Colgan POI stated that the company’s training was consistent with the guidance discussed in AC 120-51E, “Crew Resource Management Training.”

231 Safety Recommendation A-74-85 asked the FAA to “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, 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, and d) circulate the pertinent information contained in accident reports to pilots through professional publications so that members can learn from the experience of others.” Safety Recommendation A-74-86 asked the FAA to “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.” Both recommendations were classified “Closed—Acceptable Action” on March 10, 1977.

NTSB Aircraft Accident Report 104 Colgan’s CRM training should have provided the captain with the communication, coordination, and resource management skills that were important to his role as PIC.232 However, the captain did not effectively use all of the resources available to him to ensure safety of flight. CRM training should also have provided the first officer with the skills to challenge the captain’s deviations from standard operating procedures. The first officer was characterized during postaccident interviews as being assertive, which was consistent with the CRM training that she received. On the basis of the first officer’s level of involvement in conversations with the captain, and the apparent ease with which they were communicating, it is unlikely that the first officer’s failure to challenge the captain was because of a lack of assertiveness. It is possible that she did not challenge the captain because she did not consider his deviations from standard operating procedures to be remarkable. The NTSB concludes that the flight crewmembers’ performance during the flight, including the captain’s deviations from standard operating procedures and the first officer’s failure to challenge these deviations, was not consistent with the CRM training that they had received or the concepts in the FAA’s CRM guidance. In late 2008, Colgan began the process of revising its CRM training. Even though the training was consistent with the FAA’s CRM guidance, the Colgan POI and the company’s director of flight operations, vice president of safety and regulatory compliance, and director of crewmember and dispatcher training wanted to expand the program. In developing the revised training, Colgan obtained guidance from Pinnacle Airlines and Continental Airlines. The expanded CRM training program now spans 2 days (compared with the previous initial and recurrent training programs, which lasted 8 and 2 hours, respectively). The revised CRM program includes techniques for threat and error detection, management, and mitigation and additional discussion of decision-making, leading and following, positively communicating, and setting expectations. In addition, to facilitate discussion, the course is taught by line pilots instead of ground instructors or management. During the summer of 2009, Colgan began providing the revised recurrent CRM training to pilots, dispatchers, flight attendants, and managers at its bases at EWR and IAH. 2.5 Fatigue Although both pilots had flown during the week before the accident, their schedules were within flight and duty time requirements and were not excessive in terms of accumulated flight time or duty periods worked. However, each pilot made an inappropriate decision to use the crew room to obtain rest before the accident flight, as discussed further in section 2.5.2. According to his wife, the captain would typically sleep from about 2200 to 0900 and would normally receive between 8 and 10 hours of sleep. (The captain’s wife explained that he would awake earlier than 0900 for family activities.) From February 3 to 5, 2009, the captain was working and had a duty period that started about 0500 and ended between 1200 and 1800 each day. The significantly earlier awakening time required for the report times, as well as being

232 As indicated in section 2.4.1, the NTSB has recommended the implementation of specific leadership training for upgrading captains.

NTSB Aircraft Accident Report 105 away from home, would have produced some chronic sleep loss. However, the captain would likely have been able to make up for this sleep loss while he was off duty and at home from February 6 to 9. On February 9, 2009, the captain commuted from his home in the Tampa area to EWR, arriving about 2005 for a 2-day trip to begin the next day. His last known activity on February 9 ended about 2247. The captain was reported to have stayed overnight in the crew room at EWR. On February 10 and 11, 2009, the captain had a report time of 0530, and his last known activities those days ended between 2130 and 2200. As with his schedule 1 week before, the captain’s earlier awakening time required for the report times, and his rest away from home, would have produced some chronic sleep loss. On the day of the accident, the captain was scheduled to report to EWR at 1330. Because his duty period on February 11, 2009, had ended about 1544, he had a 21-hour, 16-minute scheduled rest period before his report time. However, at 0310 on February 12, the captain logged into Colgan’s CrewTrac computer system. This activity would have meant that he had, at a minimum, a 5-hour opportunity for sleep followed by another sleep opportunity of about 4 hours. (The captain had logged into the CrewTrac system again at 0726.) The captain’s actual sleep during this period is unknown. However, his sleep would have been further interrupted and would likely have been of poor quality because he was again staying in the crew room.233 As a result, the captain would not have had an opportunity to restore his sleep loss from the previous 2 days. Also, it would have been difficult for the captain to nap in the crew room during the day based on observations of his activities before the flight (which included office work, watching television, and talking on the telephone or with other company pilots).234 According to her husband, the first officer would go to sleep between 2000 and 2200 PST and would awake between 0700 and 1000 PST. On February 4, 2009, the first officer commuted from SEA to EWR because of the 5-day trip that she would be starting later that day. The duty periods during the trip started between 1140 and 1235 (except for the first and last days, which started at 1800 and 0825, respectively) and ended between 2049 and 0032 (except for the last day, which ended at 1455).235 The times of the trip (shown in eastern standard time) were mostly consistent with the first officer’s PST home time zone.236 However, it was possible that she had accumulated some chronic sleep loss during this period because of the early awakenings required for the report times on both the first day (as a result of her commute) and the last day of the trip, as well as from being away from home.

233 This investigation found no evidence that the captain had stayed elsewhere that night. 234 According to Colgan’s Flight Operations Policies and Procedures Manual, the company’s dispatch release requires each captain to confirm that he or she is “physically qualified for this flight.” The manual also stated that, in signing this release, the captain was certifying that he or she is not fatigued and is physically capable of completing the flight safely. The manual further indicated that, although other crewmembers, including first officers, do not sign the dispatch release, it is a violation of company policy for any crewmember to conduct a flight when fatigued or otherwise physically incapable of completing the flight safely. 235 The 0032 end time occurred in the middle of the trip and not before the 0825 start on the last day of the first officer’s trip. 236 The first officer had moved from ORF (in the eastern time zone) to SEA 1 week before the trip but was likely acclimated to the PST time zone.

NTSB Aircraft Accident Report 106 The first officer was home from February 9 to the morning of February 11. Her activities each day began between about 0900 and 1000 PST and ended about 2230 PST, which would have facilitated restoration of any sleep debt that she might have been experiencing. From about 1951 to about 2330 PST (0230 eastern standard time), the first officer traveled as a jumpseat passenger on a cargo airplane from SEA to MEM and was reported to have slept 90 minutes during the flight. On February 12, 2009, from about 0418 to about 0623, the first officer traveled as a jumpseat passenger on a cargo airplane from MEM to EWR and was reported to have slept the entire flight. She was observed awake, and electronic records (telephone, text, and computer) showed activity from the time of her arrival at EWR to about 0732. Afterward, no activities on the part of the first officer were recorded until a text message she sent at 1305.237 During the 24 hours that preceded the accident, the first officer was reported to have slept 3.5 hours on flights and 5.5 hours in the crew room. Although the opportunity for sleep approached the first officer’s normal needs, her actual amount of sleep obtained is not known. However, even if the first officer did obtain her normal amount of sleep, its quality would have been diminished because of the manner in which it was obtained (on airplanes and in the crew room). It is not known whether she received additional sleep by napping later in the day.238 At the time of the accident, the captain would have been awake for at least 15 hours if he had awakened about 0700 and for a longer period if he had awakened earlier. The accident occurred about the same time that the captain’s sleep opportunities during the previous days had begun and the time at which he normally went to sleep. The first officer had been awake for about 9 hours at the time of the accident, which was about 3 hours before her normal bedtime. The captain had experienced chronic sleep loss, and both he and the first officer had experienced interrupted and poor-quality sleep during the 24 hours before the accident. 2.5.1 Role of Fatigue in Flight Crew Performance For fatigue to be considered a factor in the flight crew’s performance, deficiencies need to be clearly discernable and consistent with the known effects of fatigue, and any evidence supporting alternative explanations for such deficiencies needs to be considered. Scientific research and accident investigations have demonstrated the negative effects of fatigue on human performance,239 including reduced alertness and degraded mental and physical performance. For

237 The content of this text message indicated that the first officer had awakened from 6 hours of sleep. 238 The first officer’s opportunities for sleep at that time were reduced because of the recorded telephone, text, and computer activity throughout the afternoon (see section 1.5.2.1). 239 For the scientific research, see J.A. Caldwell, “Fatigue in the Aviation Environment: An Overview of the Causes and Effects as Well as Recommended Countermeasures,” Aviation, Space, and Environmental Medicine, vol. 68, pages 932-938, 1997; D.R. Haslam, “The Military Performance of Soldiers in Sustained Operations,” Aviation, Space, and Environmental Medicine, vol. 55, pages 216-221, 1984; and G.P. Kruger, “Sustained Work, Fatigue, Sleep Loss, and Performance: A Review of the Issues,” Work and Stress, vol. 3, pages 129-141, 1989. For the accident investigations, see, for example, the NTSB’s 1994 safety study on flight crew-involved major accidents (referenced in section 2.3.1) and its report on the Corporate Airlines flight 5966 accident (referenced in section 1.18.1.1).

NTSB Aircraft Accident Report 107 example, breakdowns in vigilance can occur, response time can slow and become inaccurate, decision-making and risk assessment can degrade, and motivation can decrease. In addition, task management and prioritization can be affected by fatigue, and some reports have indicated a reduction in leadership behavior with increased fatigue. The pilots’ failure to detect the impending onset of the stick shaker and their improper response to the stick shaker could be consistent with the known effects of fatigue. Workload management issues, as well as some minor errors that occurred during the flight (for example, a delayed response to an altitude alert about 2213:21) could also be consistent with fatigue. However, the research and accident data have shown that the errors made by the flight crewmembers, including their failure to monitor airspeed in relation to the position of the low- speed cue, adhere to standard operating and sterile cockpit procedures, and respond appropriately to the stick shaker, have also been observed in other pilots who were not fatigued. It is important to note that, throughout the flight, the pilots were conversational and engaged. Neither pilot acted withdrawn or lethargic or made any statements about being tired or receiving inadequate sleep.240 Also, the pilots demonstrated good performance during the flight by following sterile cockpit procedures during the takeoff and initial climb. Other examples of good performance by the flight crew include (1) the first officer’s detection, during her review of the airplane’s logbooks, that a previous flight crew had not completed the 24-hour ice protection check (the captain had just completed the check); (2) the captain’s interruption of his own conversation to point out crossing traffic; and (3) his continuation of the approach briefing after it was interrupted 50 seconds earlier by an ATC call. Company pilots had reported that both accident pilots were competent in their positions and adept with procedures and checklists. Also, the first officer had been described as being assertive and ahead of the airplane as a monitoring pilot. Thus, both pilots’ performance failures were inconsistent with these reports of their past performance, and, as stated in section 2.5, evidence suggests that both pilots were likely experiencing some degree of fatigue at the time of the accident. However, the errors and decisions made by the pilots cannot be solely attributed to fatigue because of other explanations for their performance. For example, the fundamental monitoring error made by the flight crew (the failure to recognize cues indicating the impending stick shaker onset) was also made 1 month after the accident by another Colgan flight crew. Also, the captain’s errors during the flight could be consistent with his pattern of performance failures during testing, which he had experienced throughout his flying career. In addition, research indicates that errors occur routinely during flight regardless of whether fatigue is present and that errors are typically caught and mitigated by existing systems without serious consequences.241

240 Two yawns were recorded on the CVR during a 2-hour period. One was attributed to the captain about 2149:18; the other was attributed to the first officer about 2207:14. 241 J.R. Klinect, J.A. Wilhelm, and R.L. Helmreich, “Threat and Error Management: Data From Line Operations Safety Audits,” Proceedings of the Tenth International Symposium on Aviation Psychology, Columbus, Ohio: The Ohio State University, pages 683-688, 1999. M.I. Nikolic and N.B. Sarter, “Flight Deck Disturbance Management: A Simulator Study of Diagnosis and Recovery From Breakdowns in Pilot-Automation Coordination,” Human Factors, vol. 49, pages 553-563, 2007.

NTSB Aircraft Accident Report 108 Because the effects of fatigue can exacerbate performance failures, its role in the pilots’ performance during the flight cannot be ruled out. The NTSB concludes that the pilots’ performance was likely impaired because of fatigue, but the extent of their impairment and the degree to which it contributed to the performance deficiencies that occurred during the flight cannot be conclusively determined. 2.5.2 Industry Fatigue Mitigation Efforts The NTSB has had a long-standing concern about the need to mitigate the effects of fatigue in aviation. Reducing accidents and incidents caused by human fatigue has been on the NTSB’s Most Wanted List since 1990. Also, the NTSB has issued numerous safety recommendations addressing fatigue, including Safety Recommendation A-06-10, which was issued on February 7, 2006, as part of the investigation of the Corporate Airlines flight 5966 accident. Safety Recommendation A-06-10 asked the FAA to do the following: 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. On September 9, 2009, the FAA stated that an aviation rulemaking committee had developed recommendations on flight and duty time limitations and rest requirements for Part 121 and 135 operators. The FAA indicated that it was reviewing the recommendations (which have not been publicly released) and that it had planned to publish a science-based fatigue NPRM in December 2009.242 On December 10, 2009, in testimony before the Subcommittee on Aviation, U.S. Senate Committee on Commerce, Science, and Transportation, the FAA Administrator stated that the FAA was reviewing the aviation rulemaking committee’s recommendations on flight and duty time limitations and rest requirements but that additional analysis needed to be completed, precluding the NPRM from being issued by the end of December 2009. The administrator also stated that the NRPM would be published as soon as possible. On December 29, 2009, the NTSB stated that the FAA, after years of inaction, appeared to be on the verge of taking the recommended actions with regard to flight time limitations, duty period limits, and rest requirements for Part 121 and 135 pilots. The NTSB noted that the FAA had proposed publishing the NPRM in early 2010 but stated that the FAA had not informed the NTSB of the specific revisions that the NPRM would include. Because the NTSB was not able to determine at that time whether the revisions would fully satisfy the intent of Safety

242 The FAA’s last fatigue-based NPRM was 95-18, “Flight Crewmember Duty Period Limitations, Flight Time Limitations, and Rest Requirements,” which was issued on December 20, 1995. The NTSB provided comments on the NPRM, indicating that the proposed rule did not (1) include effective mechanisms to address flight operations during the circadian night and circadian trough and (2) recognize the fatigue associated with multiple takeoffs and landings. No changes in the rules regarding flight time and rest requirements were made after the issuance of the NPRM. On November 23, 2009, the FAA officially withdrew the NPRM.

NTSB Aircraft Accident Report 109 Recommendation A-06-10, the recommendation remained classified “Open—Unacceptable Response.” One of the stated purposes of SAFO 06004 (previously discussed in sections 1.18.1.1 and 2.4.2) was to “call attention to fatigue as one of the most important elements to be addressed in CRM training.” Even though the SAFO recommended that Part 121 directors of safety become familiar with the document’s contents, a review of Colgan’s CRM course material at the time of the accident showed only a minimal mention of fatigue. The company’s director of crewmember and dispatcher training stated that fatigue was discussed as part of a review of situational awareness. Also, Colgan personnel were not able to describe how the company had incorporated the fatigue-related information in the SAFO. Colgan had a nonpunitive fatigue policy in effect at the time of the accident243 but did not have a formal fatigue management program in place at the time. (Such a program was still not in place as of January 2010.) After the accident, the company revised its CRM course material to include a specific discussion of fatigue management and the hazards associated with fatigue. Also, in April 2009, Colgan issued an operations bulletin to its pilots addressing the company’s fatigue policy, causes of fatigue, recognition of fatigue and its effects on performance, and prevention of fatigue by effectively using rest.244 In December 2009, Colgan issued a read-and-sign memo to its pilots and flight attendants, which stated that the company’s nonpunitive fatigue policy was being increasingly abused. (As stated in section 1.17.5, the company indicated that crewmembers had been calling in fatigued without a valid reason.) The memo also detailed interim changes to Colgan’s fatigue policy. The memo stated that, effective December 31, 2009, fatigue calls would not be accepted if a crewmember was returning from rest periods or personal time off duty (and did not properly use the time off). The memo indicated that the safety department would consider mitigating circumstances preventing a rest period from being fully utilized when evaluating a fatigue call. In addition, the memo stated that the company was working with its pilot and flight attendant unions to establish a comprehensive fatigue program, including a review board process, by February 15, 2010. At the public hearing for this accident, the FAA manager of air carrier operations stated that fatigue mitigation in aviation was a joint responsibility between the operator and the pilot. He also stated that company fatigue information can help pilots better manage their time off from work. The accident pilots did not wisely manage their time off from work, which contributed to the development of fatigue. In particular, the pilots chose to use the crew room during their rest

243 The policy allowed pilots to remove themselves from flight status without reprisals if they were too tired to fly. Pilots calling in fatigued would not be paid for that flight segment if it were over their 75-hour monthly guarantee. The company’s chief pilot indicated that the company tracked fatigue calls to identify trends but that no consistent factors had been identified. Also, the Colgan POI had not received any complaints about the company’s administration of the fatigue policy. 244 This information has also been incorporated into the Flight Operations Policies and Procedures Manual revision, dated September 20, 2009. In addition, the NTSB notes that ALPA has developed resources for pilots on preventing fatigue, recognizing fatigue symptoms, and mitigating the effects of fatigue.

NTSB Aircraft Accident Report 110 period, and their quality of sleep was affected by this decision.245 Although the crew room was supposed to be a quiet area with couches and recliners, it was not isolated and was subject to interruptions, sporadic noise and activity, lights, and other factors that prevent quality rest. As a result, neither pilot made use of the opportunity to obtain quality sleep and be as rested as possible before the flight. Company personnel stated that sleeping overnight in the crew room was against policy because the room was not an adequate rest facility.246 However, the captain used the crew room for overnight sleeping on February 9 and 11, which indicates that the company was not effectively enforcing its policy. In addition, the first officer’s decision to begin a transcontinental commute about 15 hours before her scheduled report time without having an adequate rest facility affected her ability to begin the trip as rested as possible. The commute from SEA to MEM and then from MEM to EWR did not afford her an opportunity for an uninterrupted sleep period. Even though the first officer arrived at EWR about 7 hours before her scheduled report time, this time period was less than her normal sleep period, and evidence indicates that she could not have used all of that time for sleep. Company guidance at the time of the accident, however, did not discourage pilots from commuting on the same day that a trip was scheduled to begin.247 The company’s commuting policy addressed ways to ensure that pilots were able to arrive at their base and report for duty on time (see section 1.17.4), but the policy did not reference ways to mitigate fatigue resulting from commuting. Testimony at the public hearing by ALPA’s air safety chairman indicated that Colgan’s commuting policy was consistent with industry practices. Commuting is considered a privilege for air carrier pilots because they are not required to live within a certain distance of their assigned base. Commuting may also be considered a necessity for air carrier pilots because of possible changes in the industry, including base closures, and the cost of living at some bases.248 To accommodate the need for rest areas when commuting, pilots often have “crash pads” (shared rooms or apartments) at their base if their operator does not provide crew rest facilities for uninterrupted sleep. However, Colgan did not have such a facility at EWR (or its other bases), and neither the captain nor the first officer had a crash pad.249

245 The NTSB notes that strategic napping in crew rooms during breaks is an effective countermeasure for pilot fatigue and that this type of rest would be appropriate use of a crew room. However, the accident captain used the EWR crew room for all of his sleep opportunity before the flight, and the first officer used the crew room for most of her sleep opportunity. 246 The EWR regional chief pilot issued policy guidance in May 2008 stating that crewmembers were responsible for their own overnight accommodations and that sleeping in the crew room was prohibited and would have disciplinary consequences. 247 The previous edition of the Colgan Flight Crewmember Policy Handbook (dated February 2006) stated that pilots should not commute to their base on the same day that they are scheduled to work. The handbook version current at the time of the accident was dated March 2008 and did not include this guidance. 248 Colgan did not have locality pay for its pilots, but its management personnel received locality pay. In 2008, the average salary of a company Q400 captain and first officer was $67,000 and $24,000, respectively. 249 Colgan does not require such an arrangement for its commuting pilots.

NTSB Aircraft Accident Report 111 Pilots who commute have a significant responsibility to make sure that they arrive fit for duty and are able to maintain this fitness throughout the duration of their assigned duty period.250 However, pilots who do not commute also have a responsibility to be fit for duty, and certain circumstances can affect a noncommuting pilot’s ability to obtain adequate rest. For example, in its investigation of the Federal Express flight 1478 accident in Tallahassee, Florida, the NTSB found that the captain (who lived close to MEM, the departure airport) had received interrupted sleep251 during the two nights that preceded the accident because he had been taking care of the family dog, whose health was deteriorating. The captain described his sleep during that time as “marginal” and “not really good.” The captain reported that he had received 3.5 hours of “pretty good” sleep before reporting about 0200 for the accident flight. The NTSB concluded that the captain was likely impaired by fatigue and that the impairment contributed to his degraded performance, especially in the areas of crew coordination and monitoring, during the approach to the airport.252 The NTSB notes that most pilots are cognizant of their personal responsibility to report to work fit for duty, including having received the proper amount of rest. However, the performance failures that occurred in the Tallahassee accident and this accident demonstrate the negative outcomes that can occur when a pilot fails to obtain adequate rest before a flight. The NTSB concludes that all pilots, including those who commute to their home base of operations, have a personal responsibility to wisely manage their off-duty time and effectively use available rest periods so that they can arrive for work fit for duty; the accident pilots did not do so by using an inappropriate facility during their last rest period before the accident flight. Companies can take actions to help mitigate fatigue in commuting pilots. Such actions include providing rest facilities, providing assistance to pilots in identifying affordable accommodations, planning flight schedules that support commuting without extended times of wakefulness, and considering ways to evaluate and account for the effect of commuting on subsequent duty periods. With regard to providing rest facilities, the FAA’s SAFO 09014, “Concepts for Fatigue Countermeasures in Part 121 and 135 Short-Haul Operations,” issued on September 11, 2009, stated that operators “should consider providing crew rest facilities that have rooms away from the general traffic for quiet, comfortable and uninterrupted sleep.”253 Most of Colgan’s EWR-based pilots (93 of 137 pilots) identified themselves as commuters. However, the EWR regional chief pilot stated that he did not know the number of commuting pilots at EWR. This lack of awareness is inconsistent with available information stressing the importance of mitigating hazards associated with crewmember fatigue, including SAFOs 06004 and 09014. The NTSB notes that, although many of the major accidents it has

250Air transportation is one mode of transportation that pilots use to commute to their home base. Commuting pilots can also use surface transportation to arrive at their base. 251 That captain had been released from duty on July 23, 2002, at 2353 and learned of the flight 1478 assignment on July 25 between 1800 and 1830. 252 For more information, see 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). 253 SAFO 09014 also stated that pilots “should understand their responsibility with regard to ensuring that they achieve the required rest so they are properly rested and fit for each assigned or scheduled flight.”

NTSB Aircraft Accident Report investigated during the last decade involved pilots who commuted, this accident is the first one in which the pilots’ rest location has been an issue. Operators have a fundamental responsibility to support their pilots’ efforts to mitigate fatigue. However, Colgan did not (1) enforce the policy prohibiting sleeping overnight in the crew room, which was an inappropriate rest facility for uninterrupted sleep, and (2) have in place a formal fatigue management program. The NTSB concludes that Colgan Air did not proactively address the pilot fatigue hazards associated with operations at a predominantly commuter base. On June 12, 2008, the NTSB issued Safety Recommendations A-08-44 and -45, which asked the FAA to do the following: Develop guidance, based on empirical and scientific evidence, for operators to establish fatigue management systems, including information about the content and implementation of these systems. (A-08-44) Develop and use a methodology that will continually assess the effectiveness of fatigue management systems implemented by operators, including their ability to improve sleep and alertness, mitigate performance errors, and prevent incidents and accidents. (A-08-45) On August 11, 2008, the FAA noted that, in June 2008, it had hosted an international symposium on fatigue in aviation operations to gather and make public the best available knowledge on fatigue and fatigue mitigations. The FAA also stated that it was developing operations specification guidance for fatigue management for ultra-long-range flights and that lessons learned could likely benefit other flight profiles. On February 3, 2009, the NTSB encouraged the FAA to ensure that guidance on fatigue management systems be developed for all components of the aviation industry and not only for ultra-long-range operations. Safety Recommendations A-08-44 and -45 were classified “Open—Acceptable Response” pending such guidance. A fatigue management system, also known as an FRMS, incorporates various components and strategies to mitigate the hazards of fatigue in aviation operations. Components of an FRMS include scheduling policies and practices, attendance policies, education, medical screening and treatment, personal responsibility during nonwork periods, task and workload issues, rest environments, commuting policies, and napping policies. An organizational plan for implementing an FRMS and measuring its ability to mitigate fatigue is important to the success of the system. Many operators are beginning to implement components of an FRMS, and countermeasures to address issues associated with commuting are expected to be part of an FRMS. However, some operators have not adopted an FRMS, and neither FAA guidance nor rulemaking currently exists in this area. As a result, the NTSB concludes that operators have a responsibility to identify risks associated with commuting, implement strategies to mitigate these risks, and ensure that their commuting pilots are fit for duty. Therefore, the NTSB recommends that the FAA require all Part 121, 135, and 91K operators to address fatigue risks associated with commuting, including identifying pilots who commute, establishing policy and guidance to mitigate fatigue risks for commuting pilots, using scheduling practices to minimize opportunities 112

NTSB Aircraft Accident Report 113 for fatigue in commuting pilots, and developing or identifying rest facilities for commuting pilots. 2.6 First Officer’s Illness Symptoms According to the first officer’s husband and mother, the first officer was not sick when she left home for her commute to EWR. In addition, pilots who spoke with and observed the first officer during her commute and on the ground at EWR reported that she was not showing any symptoms that were consistent with being sick. However, some of the accident pilots’ remarks suggest that the first officer was experiencing symptoms associated with congestion or the onset of a head cold. Also, the CVR recorded the first officer sniffling and sneezing multiple times during the flight.254 During the ground delay, the first officer stated, “I’m ready to be in the hotel room,” to which the captain replied, “I feel bad for you.” The first officer continued, “this is one of those times that if I felt like this when I was at home there’s no way I would have come all the way out here.” She also stated, “if I call in sick now I’ve got to put myself in a hotel until I feel better … we’ll see how … it feels flying. If the pressure’s just too much … I could always call in tomorrow at least I’m in a hotel on the company’s buck but we’ll see. I’m pretty tough.” During the descent, the pilots made some additional remarks regarding the first officer’s symptoms. For example, the first officer stated, “might be easier on my ears if we start going down sooner” Afterward, the captain asked the first officer about her ears, and she replied that they were stuffy and popping. Captains are responsible, as part of their initial crew briefing, for assessing the fitness for duty of other crewmembers and for removing crewmembers from flight status if necessary. The captain did not remove the first officer from flight status or question her remarks, so it is possible that he did not think that her symptoms would affect her performance during the flight.255 Postaccident toxicology testing on the first officer did not identify the presence of any prescription or over-the-counter medications. The NTSB attempted to determine whether the first officer’s symptoms would have affected her performance during the flight. The sneezing, sniffles, and ear congestion could have directly affected the first officer’s performance by interfering with communication. However, the mistakes made during the accident sequence cannot be attributed to her symptoms. It is also difficult to determine the extent of the first officer’s symptoms or their indirect effect on her performance. In addition, the NTSB was not able to determine whether the first officer’s symptoms contributed to her fatigued condition. Even with her comments about how she was feeling, the first officer did state that she was “pretty tough,” and she was conversational and

254 The first officer’s husband stated that she would get sniffles from the cold air but that these sniffles were not symptoms of a cold. 255 The CVR recorded the captain stating that the first officer could try an over-the-counter herbal supplement, drink orange juice, or take vitamin C.

NTSB Aircraft Accident Report 114 engaged throughout the flight. As a result, the NTSB concludes that the first officer’s illness symptoms did not likely affect her performance directly during the flight. The NTSB, however, is concerned about the first officer’s reluctance to use Colgan’s sick policy before the start of the trip. Company pilots were allowed to remove themselves from flight status, without penalty, if they were sick.256 If the illness began before the beginning of a duty period, then the pilots would be responsible for their own accommodations. (In the first officer’s case, she would have needed to pay for a hotel room until she felt well enough to return to duty.) This situation illustrates the need for all commuting pilots to have adequate accommodations, such as shared rooms or apartments, for obtaining rest (or recovering from the onset of an illness) while at their home base and for operators to develop or identify rest facilities for commuting pilots, as stated in Safety Recommendation A-10-16. 2.7 Captain’s Disapprovals and Training Problems The captain had received several disapprovals and had experienced training problems throughout his flying career.257 In October 1991, the captain was disapproved for his initial instrument airplane rating. The tasks disapproved were partial panel VOR approach, NDB approach, and holding. During training for the instrument rating, a pilot is introduced to the concept of attitude instrument flying (that is, the control of an aircraft’s spatial position using instruments inside the cockpit rather than visual references outside the airplane). Instrument training also teaches pilots to use a method known as cross-checking to continuously assess and interpret the performance, control, and navigation of aircraft instruments. This training establishes the foundation, skills, and habits a pilot uses for instrument flying. All pilots must pass a checkride before a certificate or rating can be issued. Checkride failures are not uncommon and are not necessarily an indication of incompetence.258 Because the captain’s initial instrument rating disapproval happened more than 17 years before the accident, when he had only 125 hours total flight time, this failure was not especially significant. He successfully completed the checkride 3.5 weeks later.

256 Colgan’s sick leave policy, which was adopted in June 2008, requested that pilots notify crew scheduling of a sick call 2 hours before a flight. The vice president of administration stated that, if that were not possible, pilots should not fly but cautioned that repeated events could be counted as a missed trip. Also, if pilots had not accumulated sick time, then they would lose pay for the flight if it would put them over the 75-hour monthly guarantee. (Section 1.17.5 discusses the sick leave earned by company pilots.) In addition, some commuting pilots had been using sick leave when they were bumped from a flight and could not get to work. No evidence indicated that this factor entered into the first officer’s decision-making, especially because the company had increased the number of times that a pilot could receive relief from disciplinary actions under the commuting policy. 257 Even though the first officer was disapproved for her initial flight instructor certificate, the areas that needed to be reexamined pertained to her instructional methods and abilities and not her flying skills. She passed the test and was issued her certificate 5 days later. 258 FAA statistics for 2008 showed that 10.3 percent of all tested applicants for an additional rating were disapproved, 28.5 percent of all tested applicants for an original commercial certificate were disapproved, and 9.4 percent of all tested applicants for an additional rating on a commercial certificate were disapproved. The 2008 overall failure rate for an original-issue FAA airline transport pilot certificate was 13.1 percent.

NTSB Aircraft Accident Report 115 In May 2002, the captain was disapproved for his initial commercial single-engine land certificate.259 The tasks disapproved were takeoffs, landings, go-arounds, and performance maneuvers. The performance maneuvers required skillful control of altitude, heading, bank angle, and airspeed. Failure to pass these tasks on a checkride could indicate poor control of the airplane. After additional training, the captain passed the checkride 5 weeks later. At that time, the captain had accumulated 296 hours total flight time. In March 2004, the captain was disapproved for his initial commercial multiengine land airplane certificate. The entire checkride needed to be repeated because the captain did not perform enough maneuvers properly to get credit for them on a subsequent checkride. He successfully completed the checkride on his next attempt 3 weeks later. The total number of flight hours that the captain had accrued at that time was not recorded,260 but his certificate application for the rating showed that he had received 7.1 hours of flight instruction before the test, which is minimal training for a multiengine certificate. The captain’s disapproval for a commercial multiengine land airplane certificate was his third successive failure to pass an initial attempt for an FAA certificate or rating, and it appeared that his performance was not improving as he gained experience. In its September 9, 2005, response to Safety Recommendation A-05-2 (see section 1.18.1.8), the FAA stated that multiple checkride failures showed no correlation with pilots’ accident and incident records. However, the captain’s established pattern of first-attempt failures might have indicated that he was slow to absorb information, develop skills, and gain mastery or that the training he received was not adequate. This pattern might also have indicated that the captain had difficulty performing required skills while under the stress conditions associated with a checkride. The captain attended Gulfstream Training Academy from August 2004 to April 2005 and completed initial training at GIA (which was directly associated with the academy) in December

1. Details from his training records, however, revealed his continuing difficulties with

aircraft control. During two simulator periods, he was graded unsatisfactory in “approach to stall – landing configuration.” During a later simulator period, he demonstrated unacceptable altitude and airspeed control. During the final planned simulator session, the instructor noted basic attitude flying problems and repeated deviations. Because additional training was required, an extra simulator session occurred the next day. All maneuvers were graded satisfactory at that time. The simulator checkride occurred the same day as the additional training. The captain’s GIA training records clearly showed that his flying skills needed improvement, but he had apparently met the minimum standards required for completion of the training. Thus, he began flying the BE-1900D as a fully qualified first officer. However, the captain’s GIA training records should have raised concerns about his suitability for employment at a Part 121 air carrier.

259 Standards of execution are higher for a commercial pilot certificate than for a private pilot certificate. 260 FAA medical records showed the captain reported 300 hours total flight time (with no hours during the previous 6 months) on his medical certificate application dated January 16, 2004. He reported 325 flight hours (with 25 hours accrued during the previous 6 months) on his medical certificate application dated July 27, 2004.

NTSB Aircraft Accident Report 116 The captain applied to Colgan in August 2005 and was hired the next month. At that time, the captain had 618 total flight hours, 290 of which were accumulated while at GIA in a multiengine airplane. His total number of flight hours met the company’s internal policy requirements at the time, which were a minimum of 600 hours total time, including 100 hours of multiengine time.261 This minimum was typical for new hires at regional airlines at that time. The Colgan employment application asked the question, “have you ever failed any proficiency check, FAA check ride, IOE or line check?” The captain responded, “yes, FAA check ride for instrument rating. I missed the NDB approach, received additional instruction, then repeated the approach and passed.” He did not disclose the two other certificate disapprovals that he had received. At the public hearing for this accident, the company’s vice president of administration stated that, if the captain’s incomplete answer had previously been known, it would have resulted in his dismissal from the company.262 The captain’s initial proficiency check at Colgan, as a first officer on the Saab 340, occurred in October 2005. The captain was graded “train to proficiency” for normal and abnormal procedures. This grade indicated that the captain had completed the checkride but needed additional training on normal and abnormal procedures before he would be considered fully successful. Colgan could not provide any further details about this event. In October 2006, the captain received an unsatisfactory grade on his next flight check, which was his first recurrent proficiency check as a first officer in the Saab 340. The unsatisfactory tasks were rejected takeoffs, general judgment, landings from a circling approach, oral exam, and nonprecision approach. According to company records, the captain attended recurrent training and then completed requalification proficiency training the next month. However, no evidence showed that Colgan considered the captain’s performance (as a Saab 340 first officer) to be a concern, even with the problems he demonstrated during the initial and recurrent proficiency checks. The captain began upgrade training on the Saab 340 in October 2007 and attempted a checkride for an FAA airline transport pilot certificate and type rating later in the month, but he was initially disapproved. The check airman indicated that the captain’s airspeed was too slow on a second missed approach while attempting to complete a single-engine ILS approach. After another check airman provided further training for the captain, the original check airman conducted the recheck and approved the captain for the certificate and type rating 3 days later. Even though the captain had demonstrated problems with the three checkrides he had performed, Colgan was not proactively addressing his training and proficiency issues. For example, the company’s director of flight standards stated that he had not tracked the captain in terms of his performance. Also, the company’s chief pilot stated that he could not recall talking to anyone at the company about the captain’s training record. The chief pilot further stated that

261 On April 30, 2009, Colgan began requiring newly hired pilots to have a minimum of 1,000 hours total flight time and 100 hours in multiengine aircraft. 262 The company stated that its current employment policy does not consider pilots with more than one failed checkride.

NTSB Aircraft Accident Report 117 he was aware of the captain’s initial upgrade failure in the Saab 340 and that he told the captain that his next proficiency check needed to be “right on.” The captain had satisfactorily completed recurrent proficiency training in April 2008 and a line check in September 2008, indicating that his mastery of the Saab 340 was improving. The chief pilot approved the captain for Q400 transition training,263 which he began in October 2008. The captain had satisfactorily completed his line-oriented flight training, IOE, line check, and type rating.264 However, at the time of the accident, the captain had been flying the Q400 for just over 2 months and thus was still new to the airplane. Interviews with Colgan instructors revealed that, even though the captain had progressed significantly in terms of his confidence, crew management, and execution of procedures, some of his problems with aircraft control remained. For example, the Q400 simulator instructor stated that, during unusual attitude training, the captain was “very rough” on the controls and had somewhat overcontrolled the roll axis. The basic concept of attitude instrument flying involves making the proper adjustments to flight and power controls to control aircraft attitude. The NTSB concludes that the captain had not established a good foundation of attitude instrument flying skills early in his career and that his continued weaknesses in basic aircraft control and instrument flying were not identified and adequately addressed. 2.7.1 Remedial Training and Additional Oversight Because of his continued weaknesses in basic aircraft control and attitude instrument flying, the captain would have been a candidate for remedial training. However, at the time of the accident, the company did not have a formal program for pilots who demonstrated ongoing weaknesses. The company’s director of flight standards stated that pilots who were found to be unsatisfactory because of a failed checkride could retrain on the specific failure item and that no further followup would occur if the pilot were found to be satisfactory on the subsequent checkride. This director also stated that, for pilots with multiple unsatisfactory checkrides, he or the flight standards manager would coordinate with the director of crewmember and dispatcher training to assign additional training. (As stated in section 1.17.1.3, Colgan began a formal pilot monitoring program in August 2009.) Even though the captain had failed two checkrides since beginning work for Colgan (and was graded “train to proficiency” on another checkride), he had received retraining on the specific failure items and then subsequently passed the checkrides. As a result, no additional training or overall review of his skills as a pilot occurred.

263 The chief pilot stated that the captain’s record did not show anything significant that would have prevented him from successfully transitioning to the Q400. 264 The check airman who conducted the captain’s initial proficiency check on the Q400 indicated that he did well on the oral portion of the check and was “well above average” in the simulator. The check airman further stated that the captain completed his transition IOE without difficulty, except that he was somewhat slow in adapting to the flight management system.

NTSB Aircraft Accident Report During its investigation of the Federal Express flight 647 accident, the NTSB found that the company had an oversight program that identified flight crewmembers with demonstrated performance deficiencies or training failures and provided them with additional oversight and training. The NTSB’s report on the accident (see section 1.18.1.7) concluded that such a proactive program would benefit flight safety at other Part 121 carriers. As a result, on May 31, 2005, the NTSB issued Safety Recommendation A-05-14, which asked the FAA to do the following: Require all 14 Code of Federal Regulations Part 121 air carrier operators to establish programs for flight crewmembers who have demonstrated performance deficiencies or experienced failures in the training environment that would require a review of their whole performance history at the company and administer additional oversight and training to ensure that performance deficiencies are addressed and corrected. On April 13, 2007, the FAA stated that it had issued SAFO 06015, “Remedial Training for Part 121 Pilots,” on October 27, 2006. The purpose of the SAFO was to promote voluntary implementation of remedial training for pilots with persistent performance deficiencies. The SAFO recognized that many air carriers had voluntarily incorporated remedial training to supplement their approved training programs and that these remedial training programs were effective in addressing and correcting below-standard pilot performance. For air carriers without a voluntary remedial training program, the SAFO recommended implementing a process to identify pilots with persistent performance deficiencies and/or multiple failures during training and checking. The SAFO advised that this process should (1) review the entire performance history of any pilot in question, (2) provide additional remedial training as necessary, and (3) provide additional oversight by the air carrier to ensure that performance deficiencies were effectively addressed and corrected. On December 12, 2007, the NTSB stated that the FAA needed to survey all Part 121 operators to determine whether they had taken the action recommended in SAFO 06015. Safety Recommendation A-05-14 was classified “Open—Acceptable Alternate Response” pending completion of this survey and demonstration that all Part 121 carriers had programs to address pilot performance deficiencies or failures during training. On April 23, 2009, the FAA issued Notice 8900.71, which discussed verification of remedial training for Part 121 carriers. The purpose of the notice was to provide guidance to POIs about a required inspection to determine whether their Part 121 carriers were voluntarily complying with SAFO 06015. The notice also instructed the POIs to complete the inspection within 90 days of the date of the notice. During the public hearing for this accident, the POI for Colgan stated that he was not aware of SAFO 06015. By definition, SAFOs are advisory only, and the decision to implement a SAFO rests with an operator. The NTSB notes that SAFO guidance may be an acceptable alternate response to a safety recommendation if an FAA survey finds that all of the operators have implemented the recommended actions. However, during public hearing testimony, the FAA’s manager of air carrier training indicated that he did not know which carriers had complied with SAFO 06015. 118

NTSB Aircraft Accident Report 119 On October 30, 2009, the FAA indicated that 29 of the 82 Part 121 carriers and 2 of the 24 Part 121/135 carriers had implemented the actions recommended in SAFO 06015. The total number of Part 121 carriers included 27 regional carriers, 6 of which had implemented the SAFO’s recommended actions. On December 10, 2009, the FAA Administrator stated, during his testimony before the U.S. Senate, that two-thirds of the air carriers without advanced qualification programs265 had systems in place to identify and manage low-time pilots and pilots with persistent performance problems. The administrator also stated that, for those carriers without such systems, additional FAA oversight of their training and qualification programs would be conducted. The FAA’s January 27, 2010, fact sheet regarding its “Call to Action” report stated that all air carriers (including the 14 carriers that had advanced qualification programs) had developed remedial training programs for pilots that were consistent with the guidance in SAFO 06015. The NTSB concludes that remedial training and additional oversight for pilots with training deficiencies and failures would help ensure that the pilots have mastered the necessary skills for safe flight. Because the NTSB has not determined the extent that air carrier remedial training programs address pilot performance deficiencies and failures during training, the NTSB reiterates Safety Recommendation A-05-14. 2.7.2 Pilot Training Records During the investigation of this accident, the NTSB found discrepancies between the dates entered into Colgan’s electronic training record system and those in the FAA’s certificate records. Specifically, the company’s records showed that the captain had failed his initial upgrade proficiency check on the Saab 340 on October 3, 2007, received upgrade line-oriented flight training and upgrade simulator training on October 14, received additional simulator training on October 15, and passed his upgrade proficiency check on that same day. However, FAA certificate records showed that the captain failed his initial Saab 340 upgrade proficiency check on October 15 and passed the check on October 18. Because Colgan used an electronic record-keeping system to maintain training records for pilots, detailed paper training records were destroyed once the information was entered into the system.266 As a result, the NTSB was not able to reconstruct the actual sequence of events concerning the captain’s Saab 340 upgrade proficiency check. Colgan’s director of crewmember and dispatcher training stated that the discrepancy between the company’s and the FAA’s dates was the result of a clerical error. However, a discrepancy also existed within the company. Specifically, the check airman who conducted the captain’s two upgrade proficiency checks

265 An advanced qualification program is a voluntary alternative to the traditional regulatory requirements under Parts 121 and 135 for pilot training and checking. 266 The NTSB’s investigation of a May 2003 accident involving Colgan showed that the company was retaining detailed paper records at that time. (The accident involved a Colgan Saab 340B, N277MJ, and a Dassault DA-50, N664B, at LaGuardia Airport, Flushing, New York. The NTSB determined that the probable cause of the accident was the inadequate visual lookout and inadequate crew coordination of the Dassault DA-50 flight crew while taxiing, which resulted in a ground collision with the taxiing Saab 340B.) Additional information about this accident, NTSB case number NYC03LA114A, is available on the NTSB’s website at http://www.ntsb.gov/ntsb/query.asp.

NTSB Aircraft Accident Report 120 stated that the second check was conducted the day after he failed the first check, but the company’s electronic records indicated that the second check was conducted 12 days after the failure. These discrepancies in the captain’s training records were notable because he had demonstrated previous training difficulties at the company and the events surrounding his upgrade proficiency check warranted further scrutiny. The company’s electronic training record system contained only a basic description of each training event, along with codes for specific items, including the type of airplane, crew position, and instructor name, and a brief statement of any maneuver that was performed unsatisfactorily. If a company manager wanted to reconstruct events from a pilot’s training, the manager would need to contact the instructor or check airman who conducted that training. However, interviews with instructors and check airmen who had trained the accident flight crew revealed that some of them could not remember specific details about training events, including the check airman who graded the captain as train to proficiency on his 2005 initial Saab 340 proficiency check and as unsatisfactory on his 2006 recurrent Saab 340 proficiency training. Thus, an air carrier cannot depend solely on the memory of instructors and check airman to identify trends in a pilot’s performance. Colgan’s Crewmember and Dispatcher Training Program Manual specified a grading legend to indicate a pilot’s performance on each training maneuver.267 The electronic training record system did not include these grades, even though this information could help company managers determine a pilot’s progress during training or events that needed repetitive training. Instructor comments at the time of the training are another source of valuable information regarding a pilot’s performance, but such comments were also not included in the company’s electronic training record system. During its investigation of the American Eagle flight 3379 accident, the NTSB was unable to locate instructor comments about the quality of the captain’s performance during activities that trained or assessed pilot skills and found that the air carrier’s management was unaware of critical aspects of the captain’s performance. As a result, on November 15, 1995, the NTSB issued Safety Recommendation A-95-116, which asked the FAA to require all air carriers and their training facilities to maintain pertinent information on the quality of pilot performance. On April 17, 1998, the FAA stated that the inclusion of subjective evaluations by individual instructors, check airmen, or FAA inspectors in a pilot’s permanent record might make a training event a punitive experience rather than one in which a pilot could learn from mistakes. On January 3, 2000, the NTSB stated that the FAA had provided a convincing argument about the inappropriateness of subjective information in pilot records and the possibility that pilot training could be negatively affected and classified the recommendation “Closed—Reconsidered.” Detailed paper records of the captain’s performance at his previous airline, GIA, were obtained during the investigation. These records provided greater insight into the captain’s

267 Grading was done on a scale of one through four. Grades of one and two indicated that the pilot understood the maneuver and completed it successfully; a grade of one was given when no further training was necessary, and a grade of two was given if further training for retention was necessary. A grade of three indicated that the pilot understood the maneuver but did not complete it satisfactorily and that further training was necessary. A grade of four indicated that the pilot did not understand the maneuver or complete it satisfactorily and that further instruction and explanation was needed before further flight or simulator training.

NTSB Aircraft Accident Report performance than the records maintained by Colgan. For example, remarks in the captain’s training record at GIA included “airspeed 10 knots below Vref,” “repeated deviation from altitude 200-300 feet,” and “constant deviations up to full scale on glide slope.” It is important to note that these remarks were not subjective evaluations (about which the FAA expressed concern in its response to Safety Recommendation A-95-116); rather, these remarks were criteria-based observations that provided an explanation for the captain’s unsatisfactory performance and his need for further training in attitude instrument flying. At the public hearing for this accident, the POI for Colgan stated that, although the company’s training records met regulatory requirements, he was concerned about the lack of detailed information in the system. The FAA’s manager of air carrier training stated that electronic record-keeping systems, such as the one used by Colgan, were approved individually for each air carrier by its POI and that his branch, which sets FAA policy on training, does not approve “software of that nature as a standalone item.” The FAA manager also indicated that the agency did not require training records to be verified or validated but stated that there should be a way to audit and amend records before they appeared in their final format. The NTSB notes that the use of electronic pilot training records is acceptable as long as the records contain detailed information from which a pilot’s performance during training and checking events can be fully determined. However, the NTSB concludes that Colgan Air’s electronic pilot training records did not contain sufficient detail for the company or its POI to properly analyze the captain’s trend of unsatisfactory performance. Therefore, the NTSB recommends that the FAA require Part 121, 135, and 91K operators to document and retain electronic and/or paper records of pilot training and checking events in sufficient detail so that the carrier and its POI can fully assess a pilot’s entire training performance. The NTSB also recommends that the FAA require Part 121, 135, and 91K operators to include the training records requested in Safety Recommendation A-10-17 as part of the remedial training program requested in Safety Recommendation A-05-14. The NTSB further recommends that the FAA require Part 121, 135, and 91K operators to provide the training records requested in Safety Recommendation A-10-17 to hiring employers to fulfill their requirement under PRIA. In addition, the NTSB recommends that the FAA develop a process for verifying, validating, auditing, and amending pilot training records at Part 121, 135, and 91K operators to guarantee the accuracy and completeness of the records. 2.7.3 Pilot Records Improvement Act Colgan’s vice president of administration stated that, as part of a pilot applicant’s background check, the company checked the paperwork required by PRIA (see section 1.18.2.1) but that many of the pilots hired by the company did not have previous experience with other airlines, so the information required under PRIA would not be available for them. However, as noted previously, the captain had failed, on three separate occasions, to pass an FAA checkride on his initial attempt. On his application for employment with Colgan, the captain acknowledged only one of the failures. PRIA requirements and FAA guidance (AC 120-68C, “Pilot Records Improvement Act of 1996,” dated January 28, 2004) in place at the time that the captain was 121

NTSB Aircraft Accident Report hired did not require operators to obtain notices of disapproval for flight checks for certificates and ratings. On January 27, 2005, the NTSB issued Safety Recommendation A-05-1 as a result of the accident involving Air Sunshine flight 527 in Treasure Cay, Great Abaco Island, Bahamas. Safety Recommendation A-05-1 asked the FAA to “require all Part 121 and 135 air carriers to obtain any notices of disapproval for flight checks for certificates and ratings for all pilot applicants and evaluate this information before making a hiring decision.” On September 9, 2005, the FAA stated that requiring all Part 121 and 135 air carriers to obtain these notices would necessitate FAA rulemaking or a change to the PRIA statute. Instead, the FAA stated it would amend AC 120-68C to indicate that a letter of consent signed by a pilot applicant could be used to authorize the FAA to release records of notices of disapproval for flight checks for certificates and ratings to an air carrier making such a request. On November 3, 2006, the NTSB stated that, because the AC information was not mandatory, the FAA needed to survey operators to determine how many were obtaining airman certification records for their pilot applicants from the FAA so that the effectiveness of the FAA’s planned action could be assessed. The NTSB classified this recommendation “Open—Acceptable Alternate Response” pending results from the survey and the revision of AC 120-68C. On November 7, 2007, the FAA issued AC 120-68D, which contained the following information in bold print: A request with a signed consent by the pilot/applicant may be used to authorize the FAA to release records of Notices of Disapproval for flight checks for certificates and ratings to an air carrier making such a request. Air carrier representatives involved in the pre-employment screening process may find this additional information helpful in evaluating the pilot/applicant. These requests, however, are not an integral part of the standard PRIA request process. At the public hearing for this accident, the FAA’s program manager for PRIA stated that air carriers have always had the ability to request records from the FAA beyond those required by PRIA as long as the carriers obtained a signed consent statement from the pilot applicant (as highlighted by the revised AC on PRIA). The program manager stated that he did not know how many air carriers had obtained additional FAA airman certification information for their pilot applicants, but he stated that only one or two air carriers had contacted him for such information. The FAA’s manager for air carrier certification also stated that he did not know how many operators were obtaining these data because the survey that the NTSB requested in its November 2006 letter has not been conducted. The NTSB continues to believe that airman certification information concerning previous notices of disapproval should be included in an air carrier’s assessment of the suitability of a pilot applicant. The NTSB also considers notices of disapproval to be safety-related records that must be included in an air carrier’s evaluation of a pilot’s career progression, along with the detailed training records requested in Safety Recommendations A-10-17 through -20. The revision to AC 120-68 is an interim solution for this safety issue; however, a more permanent action through rulemaking would ensure that air carriers would be required to obtain and 122

NTSB Aircraft Accident Report evaluate notices of disapprovals for pilot applicants. The NTSB concludes that notices of disapproval need to be considered along with other available information about pilot applicants so that air carriers can fully identify those pilots who have a history of unsatisfactory performance. Because of the FAA’s failure to demonstrate voluntary compliance with the advisory information in AC 120-68D, the NTSB reiterates Safety Recommendation A-05-1 and reclassifies it “Open—Unacceptable Response.” In addition, although AC 120-68D had not been issued when the captain was a pilot applicant, Colgan could have still obtained a signed consent statement from him that would have allowed the company to obtain and review his three notices of disapproval. As previously stated, Colgan’s vice president of administration indicated that, if the company had known about the captain’s complete history of FAA checkride failures, then he would have been dismissed from the company. Also, Colgan did not obtain a signed consent statement from the first officer when she was a pilot applicant, even though she was hired after AC 120-68D had been issued. As a result, the NTSB concludes that Colgan Air did not use all available sources of information on the flight crew’s qualifications and previous performance to determine the crew’s suitability for work at the company. 2.8 Airspeed Selection Procedures Bombardier specified procedures for the use of the ref speeds switch in the Q400 AFM, which is an FAA-required document. The AFM’s procedures for use of the ref speeds switch were included in a section about ice protection features. As discussed in sections 1.17.2.2 and 2.2.2, the procedures indicated that the ref speeds switch was to be turned to the increase position before entering icing conditions or upon initial detection of icing and was to be turned to the off position when the airplane was aerodynamically clean (that is, all ice was removed from the visible leading edges of the wing and wing tips). For a flaps 15 landing with the ref speeds switch in the increase position, pilots needed to increase airspeeds by 20 knots. Q400 operators were responsible for developing their own procedures for the use of the ref speeds switch that were consistent with the AFM and approved by the FAA. Colgan’s procedures for the Q400 were summarized in its CFM, which provided the normal procedures and checklists for flight crews. However, the only direct or indirect references in the Q400 CFM regarding how and when to use the ref speeds switch were the following: • In the expanded portion of the after start checklist, which is accomplished before takeoff, a caution note stated, “Ensure the REF SPEEDS switch is set to OFF. If REF SPEEDS switch is set to INCR, the stick shaker may activate on takeoff.” • An item on the expanded portion of the climb checklist was “ice protection – as req’d,” with the remark, “make sure de-icing and anti-icing switches are set as required for the ambient conditions.” • An item on the cruise checklist was “24-hr ice protection test – as req’d.” (As previously indicated, the ref speeds switch was one of the items to be checked.) 123

NTSB Aircraft Accident Report 124 During postaccident interviews, Colgan pilots indicated that they were familiar with the function and operation of the ref speeds switch. However, some company pilots expected to be able to turn off the switch before the approach and landing flight phases, as the airplane descended out of icing conditions. For example, one pilot stated that he had turned the ref speeds switch to the off position after descending out of icing conditions but had planned to “mentally” add 20 knots to the airspeed if ice had resumed on final approach. The captain of the BTV stick shaker event stated that she had briefed the landing speeds based on the expectation that the ref speeds switch would be turned to the off position before the beginning of the approach, but she had forgotten to turn the switch to off, and the first officer had not noticed the position of the switch. Even though the ref speeds switch is relatively uncommon among air carrier airplanes,268 it is still important for the switch to be properly matched to the airspeed bugs on those airplanes with the switch installed. In the Q400, airspeed bugs are set by pilots using a rotary knob on their outboard forward panel. Two bugs are available for landing, but the AFM does not require their use or specify how they should be set. The NTSB found that Q400 operators used different bug speeds for landing. One operator, which had operated the airplane for 10 years, instructed its pilots to set the two available bugs to Vref and Vref (ice) for every approach to prevent confusion or the need to reset bugs during an approach if conditions were to change. Another operator, whose director of flight operations was previously a Q400 certification test pilot, had its pilots set the landing bugs to Vref and Vga partly because landings accomplished with the higher (icing) reference speed were rare. This operator found that, even when operating during wintertime in a northern climate, most conditions at 1,000 feet agl were such that the landing could be conducted at normal reference speeds. Colgan chose to have its pilots set either Vref or Vref (ice) and Vga as the landing bugs. If Vref had been set and icing conditions were encountered, or if Vref (ice) had been set and the airplane was no longer in icing conditions, each pilot was expected to manually reset the airspeeds. Colgan’s guidance on setting landing bugs was contained in the CFM expanded approach checklist. The guidance indicated that pilots were to determine the landing weight and airspeeds and then set the solid blue bug to Vref or Vref (ice) and the open blue bug to Vga. Both flight crewmembers were to verify this action by responding “set.” This procedure did not mention cross-referencing the airspeed bug settings with the ref speeds switch position (which are independent of each other) and did not include information about the early stall warning that could result from setting normal Vref speeds with the ref speeds switch in the increase position. After the accident, Colgan issued two operations bulletins pertaining to the ref speeds switch and airspeed settings.269 The first bulletin, 09-001, included two warnings and two cautions under the heading, “ref speeds switch.” The warnings prohibited (1) moving the ref

268 The NTSB is not aware of any air carrier airplanes that have a ref speeds switch besides the Q400, which is operated by two other U.S air carriers in addition to Colgan. 269 The first bulletin was issued before the BTV event, and the second one was issued after the event.

NTSB Aircraft Accident Report 125 speeds switch to the increase position below 1,000 feet agl during takeoff and (2) changing the position of the ref speeds switch below 1,000 feet agl during landing. The cautions indicated that (1) if airspeed is within 20 knots of the low-speed cue, then the airspeed must be increased before the ref speeds switch is selected to the increase position, or a stall warning might occur, and (2) if Vref is used for landing, then the ref speeds switch must be selected to the off position, or a stall warning might occur at an airspeed higher than Vref. The bulletin also added a specific response to any ice protection system checklist item and required both flight crewmembers to respond, and it reiterated the proper icing terminology to use with the ACARS system (“icing” or “eice”)270 to ensure that the proper ice speeds were received (from AeroData) for Vref and Vga. The second bulletin, 09-003, added a specific line item to the approach checklist, “ref speeds switch – as req’d,” with both crewmembers responding. It also provided guidance to flight crews, including a requirement to decide on the position of the switch before the initial approach phase, a prohibition against changing the switch position below 1,000 feet agl, a requirement to use only Vref (ice) and Vga (ice) with the ref speeds switch set to the increase position, and a statement that the speed bugs could be reset to Vref and Vga if the ref speeds switch was turned to the off position above 1,000 feet agl. A reference to the switch was added to the takeoff profile, and the approach profiles were changed to require a minimum airspeed of 180 knots before lowering the landing gear. Colgan’s flight crew training on the use of the ref speeds switch was incorporated into its ground school curriculum. An examination of the company’s slides used during Q400 initial training showed that the function of the ref speeds switch was described in the module on the ice and rain protection system. However, the actual use of the ref speeds switch was not included in the modules on AeroData, ACARS, line-oriented flight training, situational awareness and safety, or winter operations.271 Colgan’s training manual, which contained the syllabus for Q400 upgrade and transition training, did not specifically mention the ref speeds switch in ground school subject matter sections, including the one on ice and rain protection. Also, the simulator training modules described in the manual made no direct reference to the use of the ref speeds switch. Thus, it is unlikely that crews were appropriately trained on the use the ref speeds switch, especially during simulator training, when it is important for pilots to demonstrate an understanding of the need to match the approach speed bug settings to the position of the ref speed switch. The NTSB acknowledges Colgan’s efforts after the accident to educate its flight crews, through CFM operations bulletins, about the relationship between the ref speeds switch and airspeed bug settings. However, training in this area would further emphasize this relationship. The NTSB concludes that Colgan Air’s procedures and training at the time of the accident did not specifically require flight crews to cross-check the approach speed bug settings in relation to

270 Before the accident, the CFM showed these terms, which could be used in the optional remarks field of the landing condition screen, but the manual did not elaborate on the effect that the entries would have on the airspeed and landing distances received. Also, the CFM did not mention the need to cross-reference the position of the ref speeds switch when requesting landing performance data using either of the terms. 271 Colgan’s ground school training included slides on ACARS and winter operations. However, specific information about entering icing terminology into ACARS and the relationship of these entries to the stall warning and the ref speeds switch were not discussed.

NTSB Aircraft Accident Report 126 the ref speeds switch position; such awareness is important because a mismatch between the bugs and the switch could lead to an early stall warning. Therefore, the NTSB recommends that the FAA direct Part 121, 135, and 91K operators of airplanes equipped with a ref speeds switch or similar device to (1) develop procedures to establish that, during approach and landing, airspeed reference bugs are always matched to the position of the switch and (2) implement specific training to ensure that pilots demonstrate proficiency in this area. 2.9 Stall Training During training for private and commercial certificates, pilots perform recoveries from fully developed stalls. Even though these stall recoveries are typically accomplished in small trainer-type airplanes, the sensations and lessons from this training usually remain with a pilot. However, as pilots transition to larger, autopilot-equipped, transport-category airplanes, they rarely, if ever, receive reinforcement of how actual stalls feel and how they are to be handled because air carrier training does not require pilots to practice recoveries from fully developed stalls. The airline transport pilot practical test standards provide explicit guidance regarding how airline pilots should enter, induce, and recover from an impending stall (known as an approach to stall) but not a full aerodynamic stall. The approach-to-stall maneuvers require strict adherence to precise airspeed, altitude, and heading control and continuous smooth positive control. Colgan’s training manual referenced the practical test standards in its procedures for stall training, and training records indicated that the accident pilots had met these standards during their Q400 training.272 The practical test standards currently require pilots to recover from an approach to stall with minimal altitude loss. This recovery procedure can be effective as long as an airplane is not fully stalled. However, altitude loss standards are not an appropriate method for determining if a pilot can recognize and properly respond to a fully developed stall. Once a stall has occurred, an airplane cannot be recovered until the wing’s AOA is reduced, which will necessitate a loss of altitude. At stall AOAs, drag is high, and the thrust available may not be sufficient to overcome the drag. The nose of the airplane must be pitched down using the elevators. The amount of altitude loss during the recovery depends on several variables, including how slow the airplane is flying and how quickly the airplane is pitched down. Section 2.6.3.1 of the Airplane Upset Recovery Training Aid states, “to recover from a stall, angle of attack must be reduced below the stalling angle—apply nose down pitch control and maintain it until stall recovery.” Current air carrier training emphasizes the need to maintain altitude through the use of power during a stall recovery, and most turbine-powered aircraft can be flown nearly to a stall and recovered primarily with the application of full power (and pitch control inputs as required

272 The captain’s stall training at GIA was consistent with the training that he received at Colgan. The BE-1900 AFM contained a warning to avoid the pitch excursions that can happen as power is increased during an approach- to-stall recovery. The stall profiles for the clean, takeoff, and landing configurations included the following comment: “With stall warning indication the aircraft will have approximately 10° nose up pitch. During recovery DO NOT lower or allow the nose to fall. Allow the aircraft to fly out of the stall.”

NTSB Aircraft Accident Report 127 to counter any power-induced pitch changes). Colgan Q400 pilots indicated that, with approach- to-stall recoveries, the application of full power would typically require some nose-down pressure on the control column but that little change in pitch was required. The pilots stated that they were trained to use a balance of forward and aft column pressure to obtain the desired pitch during a recovery (rather than use a pronounced push forward) so that the airplane could regain a flying AOA and airspeed.273 Even though air carrier pilots are trained to use power to maintain altitude during approach-to-stall recoveries, positive nose-down control force is the necessary first step that a pilot must take once an actual aerodynamic stall has occurred. Because the application of power by itself will not recover a stalled airplane, approach-to-stall training may negatively affect a pilot’s actions if a full stall were to develop. Although the accident captain responded as trained when he applied power in an apparent attempt to maintain altitude, he did not apply full power (the engine power levers were advanced to about 70°, but the rating detent was 80°), and he responded inappropriately to the stall warning by applying back pressure on the control column. The NTSB identified three possible reasons related to Colgan’s Q400 approach-to-stall simulator training to explain why he was apparently startled and confused by the stall warning. First, Colgan’s simulator training did not include the use of the ref speeds switch set to the increase position. Thus, the training had not prepared the flight crew to recognize the early activation of the stick shaker as a result of the ref speeds switch being set to the increase position. Second, the simulator training was performed as a preplanned proficiency maneuver (the approach-to-stall maneuvers to be performed are well known by pilots in advance of their training) rather than as a maneuver with an element of surprise. However, a fully developed stall is an unplanned, emergency situation in which the airplane’s nose must be pushed down to reduce the AOA. Third, the simulator training was hand flown by pilots. During the accident flight, the autopilot had been engaged until the onset of the stick shaker, at which time the autopilot disconnected automatically. Although autopilot disconnect needs to occur for a stall recovery maneuver to be accomplished, the captain (and the first officer) had not been trained to experience the sudden transition from automated to manual flight with an active stall warning. The NTSB has investigated other accidents in which pilots applied inappropriate nose-up pitch control inputs during an attempted stall recovery. For example, on October 14, 2004, Pinnacle Airlines flight 3701, a Bombardier CRJ-200, was on a repositioning flight when the airplane stalled at 41,000 feet. FDR data showed that the flight crew moved the control column aft after the first stick shaker activation and moved the column aft with increasing magnitude after three subsequent activations of the stick pusher.274

273 During Q400 simulator observations, the NTSB found that initial nose-up pitch attitudes of 7° to 10° were needed to recover from approaches to stalls with a minimal altitude loss compared with the greater nose-down pitch attitudes that are typically needed for stall recoveries in small trainer-type aircraft with the minimal loss of altitude appropriate for the airplane. 274 FDR data showed that the stick shaker activated five times and that the stick pusher activated four times.

NTSB Aircraft Accident Report 128 Also, on December 22, 1996, an Airborne Express DC-8-63 was on a postmodification functional evaluation flight when it crashed in Narrows, Virginia.275 The flight crew failed to apply positive nose-down control inputs in response to a stall at 14,000 feet. (The stall protection system was inoperative during the flight.) After the airplane stalled, the crew applied power to recover but did not establish nose-down control inputs. Another such accident involved West Caribbean Airways flight 708, an MD-82, near Machiques, Venezuela, on August 16, 2005. FDR data showed that the horizontal stabilizer reached its full nose-up position as the airplane descended from 31,000 feet. The CVR recorded the aural warning “stall, stall” and the continuous sound of the stick shaker for 1 minute 46 seconds before impact.276 The NTSB has continued to advocate for flight crew training in the post-stall flight regime because of multiple accidents in which flight crews did not apply appropriate recovery procedures. For example, in a letter dated May 7, 2009, the NTSB commented on an NPRM titled, “Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers,” which proposed to amend the regulations for training programs for flight and cabin crewmembers and dispatchers. The NTSB indicated that stall recovery training should go beyond approaches to stall to include recoveries from a full stall condition and that available flight data from flight tests, accidents, and incidents should be used to model stall behavior to facilitate training beyond the initial stall warning. If the approach-to-stall training that the flight crew received had been properly applied, then the crew should have recovered the airplane from the stall warning and the pitch excursion. However, the NTSB concludes that the current air carrier approach-to-stall training did not fully prepare the flight crew for an unexpected stall in the Q400 and did not address the actions that are needed to recover from a fully developed stall. Therefore, the NTSB recommends that the FAA require Part 121, 135, and 91K operators and Part 142 training centers to develop and conduct training that incorporates stalls that are fully developed; are unexpected; involve autopilot disengagement; and include airplane-specific features, such as a ref speeds switch. 2.9.1 Stick Pusher Training The NTSB has investigated prior accidents in which pilots have responded incorrectly to the stick pusher. As previously indicated, the NTSB found that the flight crew of Pinnacle Airlines flight 3701 had responded to the stick pusher activations by pulling back on the control column, which caused the airplane to enter an aerodynamic stall. As a result, the NTSB issued Safety Recommendation A-07-4, which asked the FAA to do the following: 277

275 During the flight, a stall series was being performed to verify that the airspeeds at which the airplane experienced stick shaker activation and stall indication were in accordance with precalculated values for the airplane. 276 The investigation of this accident is being conducted by the Comite de Investigación de Accidentes Aéreos of Venezuela. 277 The NTSB notes that it issued a related safety recommendation, A-94-173, to the FAA after the United Express flight 6291 accident. This recommendation is discussed in section 1.18.1.6.

NTSB Aircraft Accident Report 129 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 stick pusher systems, and, if warranted, establish training requirements for stick pusher-equipped airplanes based on the findings of this panel. On April 13, 2007, the FAA stated that it planned to ask the working group that developed the Airplane Upset Recovery Training Aid to reconvene and develop materials for this issue. On January 22, 2008, the NTSB classified this recommendation “Open—Acceptable Response.” In November 2008, the revised Airplane Upset Recovery Training Aid was published. However, the revised guidance does not explicitly address the need for, or methods to accomplish, stick pusher familiarization training. The NTSB is concerned that classroom training of this important system is incomplete because the training does not familiarize pilots with the forces associated with stick pusher activation or provide them with experience in learning the magnitude of the airplane’s pitch response. In addition, the FAA has not taken any other actions to meet the intent of Safety Recommendation A-07-4. During the public hearing for this accident, a Bombardier test pilot stated that company pilots receive a stick pusher demonstration during training because pilots need to see and experience the tactile feel associated with the pusher’s operation. Also, a NASA research scientist remarked that such training would help make the stick pusher’s operation “somewhat less astonishing” if the pusher were to activate during flight, which could help in a situation similar to the one faced by the accident flight crew. The NTSB recognizes, however, that pusher familiarization training needs to be done correctly and provided in a context that does not lead to negative training. When he flew the Saab 340, the captain received exposure to the stick pusher during ground checks before the first flight of the day,278 and, as indicated in section 2.2.3, he might have received simulator training on the pusher. However, stick pusher training was not consistently provided to Colgan’s Q400 pilots, and a check airman stated that about 75 percent of pilots who were shown the pusher in the simulator would try to recover by overriding the pusher. After the accident, the company implemented stick pusher familiarization training for its fleets. The NTSB concludes that the circumstances of this and other accidents in which pilots have responded incorrectly to the stick pusher demonstrate the continuing need to train pilots on the actions of the stick pusher during flight and the airplane’s initial response to the pusher. Therefore, the NTSB recommends that the FAA require all Part 121, 135, and 91K operators of stick pusher-equipped aircraft to provide their pilots with pusher familiarization simulator training. In addition, because the Airplane Upset Recovery Training Aid published in 2008 did not address the intent of Safety Recommendation A-07-4 and no other FAA action has met the

278 First-flight-of-the-day checks are not substitutes for stick pusher familiarization training in a simulator. In addition, there may be negative transfer during these checks because of a tendency for pilots to hold some pressure against the pusher.

NTSB Aircraft Accident Report 130 recommendation’s intent, Safety Recommendation A-07-4 is reclassified “Closed— Unacceptable Action/Superseded.” 2.9.2 Simulator Fidelity Flight training simulators contain computer-coded aerodynamic, engine, flight control, and other models to calculate the forces and moments on the airplane, which are then used to simulate the airplane’s motion. The FAA’s acceptance of flight training simulator devices had been guided by AC 120-40B, “Airplane Simulator Qualification,” until May 30, 2008, when 14 CFR Part 60 became effective. Part 60 governs the initial and continuing qualification and use of flight simulation training devices and outlines the maneuvers and the tolerances to be used when comparing simulators and flight test time history data. According to Part 60, approval of full flight simulators (levels A through D) depends on passing a series of objective tests that compare the response of the simulator with the response of an airplane during a flight test. Part 60 applies more rigorous standards for all flight simulators than those described in AC 120-40B. For example, the regulation requires that full flight simulator stall characteristics be tested “for full stall and initiation of recovery.” One of the simulator tests, “Stall Characteristics,” states the following requirement, which must be met during the second segment climb, approach, or landing configuration: Time histories data must be recorded for full stall and initiation of recovery. The stall warning signal must occur in the proper relation to buffet/stall … FFSs [full flight simulators] of airplanes exhibiting a sudden pitch attitude change or ‘g break’ must demonstrate this characteristic. The NTSB notes that the stall fidelity testing required under Part 60 is a significant improvement compared with the testing under AC 120-40B, which required only that the stall warning signal occur in the proper relation to stall. However, the NTSB also notes that Part 60 contains no bank tolerance requirement for speeds below stick shaker, no pitch tolerance requirement for any speed, and no requirements to address power-on or turning flight stalls.279 In addition, because Part 60 applies only to simulators qualified after May 30, 2008, most training simulators currently in operation may not meet the regulation’s requirements. Flight crew training on full stalls and recoveries had not previously been included in simulator training partly because of industry concerns about the lack of simulator aerodynamic model fidelity in the post-stall flight regime. However, the NTSB believes that advances in technology can allow post-stall aircraft behavior to be modeled in simulators. In the late 1990s, a government/industry commercial aviation safety team found that loss of control was among the top three causes of all worldwide fatal commercial aircraft accidents and was the second highest cause of passenger fatalities between 1988 and 1997. In its final

279 The Part 60 requirements for stall characteristics are based on idle power, wings-level stalls at deceleration entry rates of 1 knot or less per second.

NTSB Aircraft Accident Report 131 report, the team identified several intervention strategies to reduce loss-of-control accidents,280 including the following: To mandate stall recognition and recovery training, regulators must modify the appropriate regulations. Airlines/operators should develop and implement a ground school and simulator training program to train pilots to handle post stall recovery as part of advanced maneuver training. Regulators should mandate the implementation of a ground school and simulator training program to train pilots to handle post stall recovery as part of advanced maneuver training. The team’s final report also noted, “several of the interventions address the need for upset recovery, stall and post-stall recovery training. To accomplish this training, improved aerodynamic modeling near the limits of the flight envelope (high angles of attack and/or sideslip)[ ] 281 is necessary for appropriate simulator fidelity.” In response to this work, NASA, along with Boeing, conducted a study beginning in the late 1990s to increase simulator model fidelity beyond the data envelope that existed at the time. This study used rotary balance and conventional wind tunnels to develop an aerodynamic model for the higher AOA and sideslip ranges that are required to simulate stall upsets in large transport-category airplanes. This enhanced upset recovery aerodynamic model was validated using certification flight test maneuver data, including stalls, and accident data. NASA and Boeing reported that simulations involving the enhanced upset recovery aerodynamic model were able to reasonably reproduce the results of stall flight tests, unlike the baseline simulation used in flight training at the time. According to a 2005 paper that summarized findings from the NASA and Boeing study, this research demonstrated that simulation fidelity could be significantly improved and that the useful data envelope for upset training could be expanded. The paper concluded, “results from NASA/Boeing research conducted to date have led to a recommendation to re-examine the potential uses of simulators that are specifically designed for upset training. This research has demonstrated that simulation fidelity can be significantly improved such that the useful envelope for upset training may be expanded.”282 Similarly, a 2009 paper on aerodynamic modeling for upset training concluded the following:

280 Joint Safety Analysis Team, Loss of Control, Commercial Aviation Safety Team Approved Final Report, December 15, 2000. 281 Sideslip is the lateral angle between the longitudinal axis of the airplane and the direction of motion (flightpath or relative wind). Sideslip is normally produced by rudder forces, yawing motion resulting from asymmetrical thrust, or lateral gusts. 282 J.V. Foster, K. Cunningham, et al., “Dynamics Modeling and Simulation of Large Transport Airplanes in Upset Conditions,” American Institute of Aeronautics and Astronautics, Report No. AIAA-2005-5933, 2005.

NTSB Aircraft Accident Report 132 Much work has been performed in the modeling and simulation of flight dynamics in ‘extreme’ conditions. Through this work, a process has been established that yields [a] model that [has] very good predictive capability and subsequent correlation with flight test data. Although most of the work in this area has focused on highly maneuverable military aircraft, the concepts for data collection and reduction are well suited for use in the civil arena, as was proven during two effort[s] sponsored by NASA in the past decade.283 In June 2009, the Royal Aeronautical Society284 hosted a flight simulation conference, titled “Flight Simulation: Towards the Edge of the Envelope.” Participants at the conference discussed the need for upset recovery training, training strategies, the role of motion cues in upset recovery training,285 and aerodynamic modeling for upset recovery training. The aerodynamic modeling presentations indicated that extended envelope modeling (higher AOA and sideslip data ranges) was now possible for civil aircraft simulators and pointed out that military aircraft simulators already included such modeling.286 Also, a paper presented at the flight simulator conference indicated that Boeing was testing a higher-data-range simulator that incorporated lessons learned from the NASA and Boeing study.287 According to the paper, several pilots who were tested in this higher-data-range simulator were typically able to complete upset training maneuvers without exceeding the simulator’s validated flight envelope. Boeing’s testing, however, did not evaluate pilot performance in upset recoveries with fully developed stall scenarios. The NTSB notes that among the contributing causes to the Airborne Express/Narrows accident (previously discussed in section 2.9) was the company’s DC-8 flight training simulator’s inadequate fidelity in reproducing the airplane’s stall characteristics. Specifically, the stalls practiced by the flight crew in the training simulator resulted in a high sink rate at a nose- high attitude without the large roll excursions and uncommanded pitch-down experienced by the accident airplane. As a result, on July 29, 1997, the NTSB issued Safety Recommendation A-97-47, which asked the FAA to do the following: Evaluate the data available in the stall characteristics of airplanes used in air carrier service and, if appropriate, require the manufacturers and operators of flight simulators used in air carrier pilot training to improve the fidelity of these

283 D.R. Gingras and J.N. Ralston, “Aerodynamic Modeling for Training on the Edge,” Proceedings of the Spring 2009 Flight Simulation Conference, Royal Aeronautical Society, 2009. 284 According to its website, the Royal Aeronautical Society, headquartered in London, England, is a multidisciplinary professional institution dedicated to the global aerospace community. 285 Higher-level flight simulators consist of a simulated cab on a motion platform to provide pilots with onset motion cues. Such cues provide a vestibular/kinetic sense of the aircraft’s motion, which is coupled with the motion of the visual scene. 286 As a result of the conference, the Royal Aeronautical Society chartered an international committee for aviation training in extended flight envelopes. The committee’s goals are to define best practices for upset recovery, training scenarios for these best upset recovery practices, and methods to validate simulator responses in training these scenarios. 287 David C. Carbaugh, Robert A. Curnutt, et al., “Simulator Upset Recovery Training,” Proceedings of the Spring 2009 Flight Simulation Conference, Royal Aeronautical Society, 2009.

NTSB Aircraft Accident Report 133 simulators in reproducing the stall characteristics of the airplanes they represent to the maximum extent that is practical; then add training in recovery from stalls with pitch attitudes at or below the horizon to the special events training programs of air carriers. On June 9, 1999, the FAA stated that an aircraft in an aerodynamic stall might handle and perform differently than the programming in the simulator might indicate for an identical circumstance and that the acquisition of data in this flight condition would have questionable accuracy and would be costly and dangerous to acquire. On November 19, 1999, the NTSB stated that the ability of simulators to replicate an airplane’s actions in some stall and stall recovery regimes could be improved and that the FAA’s lack of action to improve simulator fidelity in reproducing stall characteristics was disappointing. As a result, Safety Recommendation A-97-47 was classified “Closed—Unacceptable Action.” As previously discussed, advances in post-stall modeling have occurred since the FAA’s June 1999 response to Safety Recommendation A-97-47. However, during this and other accidents (including the Airborne Express/Narrows and the West Caribbean Airways flight 708 accidents), the pilots did not apply appropriate recovery controls after the airplane entered a sustained stall,288 and the AOA might have exceeded the AOA validated for the full stall and initiation of recovery required by Part 60. In addition, statistics from the government/industry commercial aviation safety team for 1999 through 2008 showed that loss of control had become the leading cause of all worldwide fatal commercial aircraft accidents and the leading cause of passenger fatalities. Operators should be aware of the possibility of negative effects when conducting stall training in flight regimes that exceed the validated flight envelope. If the full stall training requested in Safety Recommendation A-10-22 would be accomplished in a simulator, then it is essential that the simulator be approved for this training beyond the fully developed stall AOA. Simulator improvements to the high AOA flight characteristics will reduce the likelihood of negative training. The NTSB concludes that pilots could have a better understanding of an airplane’s flight characteristics during the post-stall flight regime if realistic, fully developed stall models were incorporated into simulators that are approved for such training. Therefore, the NTSB recommends that the FAA define and codify minimum simulator model fidelity requirements to support an expanded set of stall recovery training requirements, including recovery from stalls that are fully developed. These simulator fidelity requirements should address areas such as required AOA and sideslip angle ranges, motion cueing, proof-of-match with post-stall flight test data, and warnings to indicate when the simulator flight envelope has been exceeded.

288 During a sustained stall, the airplane can reach AOAs beyond those that occur when an appropriate and a timely stall recovery technique is used. The flight characteristics of such sustained stalls are different from those of an unstalled airplane. Timely recognition of sustained stall characteristics could represent the last chance for a pilot to lower the AOA and recover the airplane.

NTSB Aircraft Accident Report 2.9.3 Tailplane Stall Training The accident flight crew had seen a NASA-produced video, titled “Icing for Regional and Corporate Pilots,” during winter operations training in initial, transition, and recurrent ground school. The video was intended to enhance a pilot’s ability to assess hazardous icing conditions and understanding of icing effects on an airplane. The video also discussed tailplane stalls and wing stalls as a result of icing conditions. In addition, the video stated that pilots needed to properly diagnose icing problems (while maintaining airspeed awareness) because the differences between a wing and a tailplane stall were subtle but the recovery techniques were different. As previously indicated in section 2.2.3.1, the video indicated that tailplane stalls were most likely to occur with ice accumulation on the horizontal stabilizer and that symptoms of tailplane stalls included lightening of the controls, pitch excursions, difficulty in pitch trim, buffeting of the controls, and sudden nose-down pitching. The tailplane stall recovery procedure discussed in the video required pilots to pull back on the control column; reduce flap setting; and, for some aircraft, reduce power. However, the tailplane stall recovery procedure presented in the video was the opposite of the recovery procedure for a conventional wing stall, which requires lowering the nose and adding power. Postaccident interviews with Colgan pilots about tailplane stalls produced varying responses. One captain stated that the video about tailplane icing made a big impression on him, and another captain stated that the video got his attention. Some pilots indicated that they would apply the tailplane stall procedure if they had clearly identified the symptoms of a tailplane stall, whereas other pilots stated that it would be difficult to determine if the airplane was in a conventional wing stall or a tailplane stall. Some pilots thought that the Q400 might be susceptible to a tailplane stall, some pilots were not sure about the airplane’s susceptibility, and one pilot (a check airman) stated that the possibility of a tailplane stall in the Q400 had “never crossed [his] mind.” Colgan’s manuals and training materials (except for the NASA icing video) made no reference to tailplane stalls or tailplane stall recovery techniques. Further, the company’s director of flight standards indicated that the company did not teach pilots tailplane stall recovery techniques, and no procedures for tailplane stalls were included in the company’s CFM or the Q400 AFM. During the public hearing for this accident, officials from Bombardier testified that the Q400 was not susceptible to tailplane stalls. For example, the Bombardier principal engineering test pilot for the DHC-8 series stated that, during Q400 testing, the airplane showed no tailplane stall tendencies, and a Bombardier engineering manager stated that the company did not have a tailplane stall recovery procedure because the airplane was demonstrated to be free from tailplane stalls under all conditions. The engineering manager also stated that he was not aware of any formal document to Q400 operators indicating that the airplane was not susceptible to tailplane stalls. Also during public hearing testimony, the FAA’s manager of air carrier training stated his belief that no airplanes currently being operated by Part 121 air carriers were susceptible to 134

NTSB Aircraft Accident Report 135 tailplane stalls. He recalled that the early versions of two airplanes, the Saab 340 and the Jetstream J31, had tailplane stall tendencies but stated that these tendencies were corrected by airworthiness directives and manufacturing changes. The FAA manager further indicated that training programs should not lead to negative training or possible miscues regarding how flight crews are to handle a full wing stall. As stated in section 2.2.3.1, it is unlikely that the captain was deliberately attempting to perform a tailplane stall recovery in response to the stick shaker activation. Nevertheless, the NTSB concludes that the inclusion of the NASA icing video in Colgan Air’s winter operations training may lead pilots to assume that a tailplane stall might be possible in the Q400, resulting in negative training. Therefore, the NTSB recommends that the FAA identify which airplanes operated under Part 121, 135, and 91K are susceptible to tailplane stalls and then (1) require operators of those airplanes to provide an appropriate airplane-specific tailplane stall recovery procedure in their training manuals and company procedures and (2) direct operators of those airplanes that are not susceptible to tailplane stalls to ensure that training and company guidance for the airplanes explicitly states this lack of susceptibility and contains no references to tailplane stall recovery procedures. 2.10 Federal Aviation Administration Oversight Oversight of the Colgan certificate and the Q400 program were provided by a POI and a Q400 APM. The POI was based at the Washington FSDO, which was near the company’s headquarters at the time of the accident, and the Q400 APM was based at the Teterboro FSDO, which was near the EWR base. The investigation of this accident found that FAA records of oversight activities at Colgan showed no deficiencies related directly to the circumstances of the accident. The investigation also found that, between February 2007 and February 2008, Colgan underwent a period of substantial growth. During this time, the Q400 was introduced into the company’s operations, a relatively large number of pilots (“a couple of hundred,” according to the company’s vice president of administration) was hired, and a new Q400 base of operations was established at EWR.289 In addition, Colgan had to outsource Q400 flight crew training (with FlightSafety International in Toronto) until the company could become fully qualified to conduct its own Q400 flight crew training (which occurred in July 2008). FAA Order 8900.1, “Flight Standards Information Management System,” notes that POIs must determine when surveillance retargeting is required based on, among other things, significant changes in an air carrier’s operating environment, including changes in the scope and scale of operations (that is, growth or downsizing).290 The order indicated that such changes could affect a carrier’s ability to balance its resources, size, and organizational structure with

289 The 15 Q400 airplanes that Colgan purchased and the pilots hired to fly the airplanes represented about a 30-percent increase in the size of the company. 290 FAA Order 8900.1 also states that surveillance retargeting is required for other triggering events, such as accidents or incidents.

NTSB Aircraft Accident Report 136 operational requirements. The investigation of this accident did not find any evidence that surveillance retargeting had occurred. For example, no evidence showed that the size of the certificate management team changed despite the significant growth that Colgan was experiencing. The POI stated, during a postaccident interview, that the only other aviation safety inspector on his staff (besides the Q400 APM) was an APM for the Saab 340. Also, neither the POI nor the previous Q400 APM (who was in the position from March 2007 to February 2008) was qualified on the Q400 at the time that it was initially incorporated into Colgan’s fleet. The POI received his Q400 training in October and November 2007, which was the same time that Colgan line pilots were being initially trained on the airplane. Also, he and the previous APM were responsible for overseeing proving flights291 for the Q400, even though they were not completely familiar with the airplane. The current Q400 APM was assigned to the certificate in March 2008, after Q400 revenue service had begun, and received his Q400 training in May 2008. Although both FAA aviation safety inspectors were experienced pilots,292 they were responsible for overseeing the newly introduced service of an airplane for which they were not previously qualified and had not flown except during simulator training. As a result, the inspectors had to continue to become familiar with the airplane while they were conducting their day-to-day management of the certificate. In December 2009, Colgan moved its headquarters from the Washington, D.C., area to Memphis, but the Colgan certificate remained with the Washington FSDO. Thus, the POI is providing oversight of operations at Colgan headquarters and the company’s training center (also located in Memphis) from a remote location. However, during its investigation of the December 2007 Air Wisconsin Airlines flight 3758 accident in Providence, Rhode Island, the NTSB found that providing remote oversight was difficult for the company’s POI, assistant POI, and APM, who were not located near the company’s primary training center and crew bases.293 FAA Order 8900.1 also states that rapid expansion or growth of an air carrier could affect its training programs. In October 2007, during Colgan’s rapid growth period, the captain was disapproved for a Saab 340 airline transport pilot certificate and type rating on his initial attempt to upgrade to captain. (He received the airline transport pilot certificate and type rating later that month on a subsequent attempt.) This disapproval was the captain’s second failed checkride since beginning work for Colgan; he had also been previously graded “train to proficiency” during another checkride. Because of his continued weaknesses in basic aircraft control and attitude instrument flying, the captain was a candidate for remedial training. However, the POI did not recommend that the company provide remedial or another type of supplemental training to the captain or other pilots with persistent training deficiencies, even though SAFO 06015,

291 Before revenue service can be operated, proving flights have to be conducted as part of compliance with a new aircraft process document, which directs the activities and provides guidance for aviation safety inspectors during the addition of a new aircraft make and model to an air carrier’s operations. 292 During postaccident interviews, the POI stated that he was type rated on the Bombardier CRJ-200, the Jetstream 31, and an early model DHC-8, and the APM stated that he was type rated on the DHC-8 and a variant of the Dassault Falcon. Both the POI and APM had accumulated more than 8,000 hours total flight time. 293 The inspectors were located in Chicago, Illinois; the company’s primary training center was located in Charlotte, North Carolina; and the crew bases were in Philadelphia, Pennsylvania, Washington, D.C., and Norfolk.) Additional information about this accident, NTSB case number DCA08FA018, is available on the NTSB’s website.

NTSB Aircraft Accident Report 137 issued in 2006, recommended the implementation of such training. (During the public hearing for this accident, the POI for Colgan stated that he was not aware of the SAFO.) Even though Colgan’s training and checking programs were approved by the FAA, the FAA aviation safety inspectors could only conduct a small number of the training and checking events at the airline because of their other responsibilities. As a result, the inspectors had to rely on company aircrew program designees (under the aircrew designated examiner program) for airline transport pilot certifications and type ratings and check airmen for proficiency and line checks. The POI was responsible for operations within the aircrew designated examiner program, and the Q400 APM supported the POI by providing surveillance of program activities associated with that specific airplane type. The APM was also responsible for recommending candidate aircrew program designees to the POI, who made the selections, and for qualifying each designee in the conduct of airman certification. In addition, the APM was responsible for overseeing check airmen and ensuring that they maintained high standards when conducting proficiency and line checks. FAA Order 8900.1 further states, “air carrier expansion or growth can also raise potential safety and quality concerns, and influence the likelihood of noncompliance with existing processes and controls.” Because of the 15 new Q400 airplanes in its inventory, Colgan needed to upgrade pilots to Q400 captains and train newly hired (and low-time) pilots as Q400 first officers. This situation warranted additional FAA oversight of Colgan’s check airmen and aircrew program designees to ensure that training and checking standards were not affected by pressures to qualify these pilots. The NTSB notes that this focused oversight was also needed because of the lack of detail in Colgan’s electronic pilot training records and the lack of previous Part 121 experience of some company Q400 check airmen and aircrew program designees.294 Available Q400-qualified aviation safety inspectors from all FAA regions and from Part 142 training centers could have augmented the certificate’s inspectors and provided quality assurance over Colgan’s aircrew program designees. In addition, the International Air Transport Association (IATA) and the Department of Defense (DOD) conducted independent audits of Colgan in 2007. Both of the audits contained findings that necessitated corrective actions by Colgan. The corrective actions taken by Colgan in response to the audit findings were accepted by IATA in September 2007 and DOD in April

1. The Colgan POI stated that he was aware of these audits but did not get a copy of the

reports, which prevented him from having a comprehensive understanding of the reports’ findings. For example, the POI believed that IATA’s findings were minor295 and that a DOD issue was not within the scope of his responsibilities because it was not mandated by the FAA. One finding from the audits involved Colgan’s internal evaluation program (IEP),296 which is not required by FAA regulations. As stated in section 2.7.2, the NTSB found significant

294 After the accident, the NTSB interviewed five company Q400 check airmen and two company Q400 aircrew program designees. The NTSB learned that none of the check airmen or aircrew program designees had any previous Part 121 experience before their employment with Colgan. 295 The NTSB has made no determination to characterize the audit findings. 296 As stated in AC 120-59, “Air Carrier Internal Evaluation Programs.” IEPs are voluntary self-monitoring and auditing programs adopted by most Part 121 air carriers.

NTSB Aircraft Accident Report 138 problems with Colgan’s pilot training records. These problems would likely have been prevented by a sound IEP, which did not exist at the time of the audits and during Colgan’s period of rapid growth.297 However, the issues with Colgan’s IEP were subsequently corrected to the satisfaction of the auditing organizations. Although the NTSB recognizes that the POI needed to perform his duties in accordance with stated regulations and procedures, use of evaluation tools, such as these audits, might have alerted him to items that required close review.

On December 20, 1996, the NTSB issued Safety Recommendation A-96-163 as a result of its investigation of the December 1995 Tower Air flight 41 accident in Jamaica, New York. Safety Recommendation A-96-163 asked the FAA to do the following: Develop, by December 31, 1997, standards for enhanced surveillance of air carriers based on rapid growth, change, complexity, and accident/incident history; then revise national flight standards surveillance methods, work programs, staffing standards, and inspector staffing to accomplish the enhanced surveillance that is identified by the new standards. On November 24, 2004, the NTSB stated that the FAA had briefed NTSB staff in March 2004 about programs related to oversight and surveillance of air carriers, including ATOS and the Surveillance and Evaluation Program.298 The NTSB indicated that, during this briefing, the FAA had stated that the risk indicators used by the Surveillance and Evaluation Program for targeting surveillance resources included rapid growth or expansion, new or major program changes, complexity of aircraft or new aircraft types, and accident and incident history. Because the FAA had developed these surveillance standards, the NTSB classified Safety Recommendation A-96-163 “Closed—Acceptable Action.” Since that time, the NTSB has investigated several accidents in which inadequate FAA oversight was a factor and issued several recommendations to address these inadequacies. For example, Safety Recommendation A-05-8, issued as a result of the Air Sunshine flight 527 accident (see section 1.18.1.8), asked the FAA in part to review the procedures used during its oversight of the company, including those for the Surveillance and Evaluation Program, to determine why the inspections failed to ensure that the operational and maintenance issues that existed at the company were corrected.299 Colgan’s substantial growth came at a time when the air carrier was transitioning from, according to the Q400 APM, a “mom and pop,” or startup, airline. Also, the POI for Colgan stated that the safety culture at the company was “more reactive than I’d like … not quite as proactive.” As a result, additional resources for enhanced FAA oversight of the certificate were needed but were not provided. This situation is problematic because, according to a Pinnacle Airlines third quarter 2009 financial report, 30 additional Q400s have been ordered for Colgan

297 At that time, the program was in its early stages of development. 298 According to the FAA, as part of the Surveillance and Evaluation Program, tools were developed for principal inspectors to assess the overall risk situation of a carrier, document and analyze their observations, and refocus the surveillance program toward those areas for which the highest risks were perceived. 299 Safety Recommendation A-05-8 was classified “Closed—Acceptable Action” on August 27, 2009.

NTSB Aircraft Accident Report 139 (15 of which will be delivered beginning in 2010), continuing the company’s expansion and rapid growth. A June 2005 report by the Department of Transportation’s Office of Inspector General found that, at five Part 121 air carriers that were experiencing rapid growth, FAA inspectors were not able to effectively use oversight systems (ATOS and the Surveillance and Evaluation Program) to monitor the rapidly occurring changes.300 The NTSB concludes that the current FAA surveillance standards for oversight at air carriers undergoing rapid growth and increased complexity of operations do not guarantee that any challenges encountered by the carriers as a result of these changes will be appropriately mitigated. Therefore, the NTSB recommends that the FAA develop more stringent standards for surveillance of Part 121, 135, and 91K operators that are experiencing rapid growth, increased complexity of operations, accidents and/or incidents, or other changes that warrant increased oversight, including the following: (1) verify that inspector staffing is adequate to accomplish the enhanced surveillance that is promulgated by the new standards, (2) increase staffing for those certificates with insufficient staffing levels, and (3) augment the inspector staff with available and airplane-type-qualified inspectors from all FAA regions and Part 142 training centers to provide quality assurance over the operators’ aircrew program designee workforce. 2.11 Company Policies 2.11.1 Flight Operational Quality Assurance FOQA is a voluntary safety program in which an air carrier collects, deidentifies, and analyzes actual in-flight data from a QAR or an FDR to identify potential operational risks and implement corrective actions. According to the FAA, as of October 30, 2009, 19 of the 82 Part 121 certificate holders had FAA-approved FOQA programs.301Although Colgan had received FAA approval for its FOQA implementation and operations plan in October 2008, the FOQA program was not fully implemented and was not providing useful information at the time of the accident. The FAA manager for voluntary safety programs reported that FOQA implementation could take about 1 year and that Colgan’s implementation efforts were hindered by unanticipated issues affecting the installation of FOQA hardware. In October 2009, Colgan stated that QAR data analysis was projected to begin by the end of January 2010.

300 Department of Transportation, Safety Oversight of an Air Carrier Industry in Transition, Report Number AV-2005-062 (Washington, DC: DOT/OIG, 2005). 301 FOQA programs are not required to be approved by the FAA. However, an advantage of having an FAA- approved FOQA program is participation in the FAA’s Aviation Safety Information Analysis and Sharing (ASIAS) system. According to the FAA’s director of aviation safety analytical services, ASIAS is a government-industry partnership that brings together safety information in a protected forum, allowing queries and analysis of multiple databases. This director stated that, as of July 2009, 21 air carriers with FAA-approved FOQA programs were participating in ASIAS. Although ASIAS has been used to analyze events such as tail strikes and wrong runway departures, it has not yet been used to analyze stick shaker or stall warning events.

NTSB Aircraft Accident Report 140 Colgan’s voluntary reporting systems, including ASAP, did not include any reports of stall warnings. However, it is possible that a stall warning resulting from a mismatch between the ref speeds switch and the airspeed bugs may be a more common occurrence than currently realized, given the circumstances of the accident flight and the BTV event. The frequency and circumstances of stall warnings could be examined as part of a FOQA program because, in developing FOQA programs, operators select the recorded flight parameters to be analyzed and one available parameter is the in-flight activation of the stall warning system.302 Any information learned from analysis of FOQA program data could result in revised company procedures, checklists, and training and could be shared with the FAA and others in the aviation industry. the two other U.S. operators of the Q400 are both regional airlines without FOQA programs. d whether newer aircraft, including the Q400, were included in FOQA data monitoring efforts. cess to implement a FOQA program could be greatly simplified for operators of these airplanes. Recommendation A-07-11 was classified “Closed—Acceptable Action” on January 22, 2008. operators participated in FOQA. The recommendation asked the FAA to “strongly encourage”

Even though Colgan did not have a functioning FOQA program at the time of the accident, the company might have benefited from other air carriers’ information about the Q400, including stall warnings. However, Most of the operators with FOQA programs were established major airlines, which had a significant amount of data about the operation of the aircraft in their fleet. At the time of the accident, the FAA made no systematic attempt to determine whether newer or smaller airlines, including regional airlines, were participating in FOQA programs an Not all airplanes are capable of supporting a FOQA data recording. Those airplanes that are currently able to support these recordings are equipped with a data bus that allows information to be transmitted in digital format from multiple data sensors to QARs. The FAA has not done a survey of the Part 121 air carrier fleet to determine how many airplanes are QAR capable. However, operators of those airplanes that are capable of supporting a QAR recording might still need a supplemental type certificate for a QAR retrofit, which could be expensive and time-consuming. Some new aircraft have QAR capability already installed, so the pro On January 23, 2007, the NTSB issued Safety Recommendation A-07-11, which asked the FAA to strongly encourage and provide assistance to all regional air carriers to implement an approved ASAP and a FOQA program. As indicated in section 1.18.1.9, on April 13, 2007, the FAA stated that it took several actions in response to this recommendation, including participation at Regional Airline Association conferences to increase awareness of ASAP and FOQA and the issuance of AC 120-92, which identified FOQA as an integral part of an SMS. As a result of these actions, Safety Also in its response to Safety Recommendation A-07-11, the FAA recognized that there was significant participation in ASAP among regional operators but that only a few regional

302 The accident airplane’s FDR recorded stick shaker and stick pusher parameters once every 4 seconds. In contrast, a QAR might be designed to record hard-target FOQA parameters at higher sample rates to yield a high- confidence analysis of stall warning events in the Q400 fleet.

NTSB Aircraft Accident Report regional air carriers to voluntarily implement a FOQA program, yet only three regional airlines had FOQA programs either planned or underway as of July 2009. As indicated in AC 120-82, FOQA programs provide objective safety information that would not otherwise be obtainable. Also, FOQA was established as a worldwide standard by ICAO in 2005, but U.S. air carriers are not required to conform with this standard because FOQA is currently a voluntary program. During his December 2009 testimony before the U.S. Senate, the FAA Administrator stated that he had asked operators without a FOQA program to implement this program and develop data analysis processes to ensure effective use of program information. The NTSB concludes that mandatory FOQA programs would enhance flight safety because all operators would have readily available data to identify operational risks and use in developing corrective actions. Therefore, the NTSB recommends that FAA require all Part 121, 135, and 91K operators to (1) develop and implement FOQA programs that collect objective flight data, (2) analyze these data and implement corrective actions to identified systems safety issues, and (3) share the deidentified aggregate data generated through these analyses with other interested parties in the aviation industry through appropriate means. The NTSB recognizes that, as indicated in AC 120-82, FOQA is built upon the provisions of 49 United States Code 40123 and 14 CFR Part 193, which establish protection of voluntarily submitted information. The FAA states in AC 120-82 that maintaining confidentiality of FOQA information among operators is important for providing a cooperative environment. If FOQA data were required to be provided to the FAA, these data would no longer fall under the protections provided by 49 United States Code 40123 and 14 CFR Part 193. The NTSB concludes that the viability of FOQA programs depends on the confidentiality of the data, which would currently not be guaranteed if operators were required to implement these programs and were required to share the data with the FAA. Therefore, the NTSB recommends that the FAA seek specific statutory and/or regulatory authority to protect data that operators share with the FAA as part of any FOQA program. In addition, Colgan had previously proposed including, as part of its FOQA program, a sample of CVR recordings from routine line operations. The company indicated that the sample CVR recordings could be used to determine, among other information, how well pilots adhered to sterile cockpit and standard operating procedures, which could help to prevent accidents. The company asserted that its use of the CVR for FOQA purposes would ensure pilots’ confidentiality. The NTSB has recognized the benefits of using flight recorder information for safety purposes. For example, on October 1, 2009, the NTSB issued Safety Recommendation A-09-99, which asked helicopter emergency medical services operators to “establish a structured flight data monitoring program that incorporates routine reviews of all available sources of information to identify deviations from established norms and procedures and other potential safety issues.” Aircraft operators would benefit from similar reviews of available safety information sources that are downloaded as part of a company’s FOQA program. The NTSB concludes that the systematic monitoring of all available safety data, as part of a flight operational quality assurance program, could provide operators with objective information regarding the manner in which flights are conducted and that a periodic review of this information would enhance flight safety 141

NTSB Aircraft Accident Report 142 by assisting operators in detecting and correcting deviations from standard operating procedures. Therefore, the NTSB recommends that the FAA require Part 121, 135, and 91K operators to (1) routinely download and analyze all available sources of safety information, as part of their FOQA program, to identify deviations from established norms and procedures; (2) provide appropriate protections to ensure the confidentiality of the deidentified aggregate data; and (3) ensure that this information is used for safety-related and not punitive purposes. 2.11.2 Use of Personal Portable Electronic Devices on the Flight Deck The NTSB has identified hazards associated with the use of mobile phone technology (including texting) in rail and highway accidents and has issued recommendations to restrict the use of this technology by transport operators.303 Also, in 2008, the NTSB added, to its Most Wanted List, the need to restrict cellular telephone use by commercial drivers of school buses and motorcoaches, except in emergencies. During the taxi phase of the accident flight, the first officer sent a text message on her personal cell phone about 2113, which was about 5 minutes 30 seconds before ATC cleared the flight for takeoff. (Evidence indicated that the airplane was not moving at the time that she used her mobile phone.) However, AC 91.21-1B, “Use of Portable Electronic Devices Aboard Aircraft,”304 which was issued on August 25, 2006, indicated that cell phones were not to be used while an aircraft was taxiing for departure after leaving the gate. The AC further stated that cell phones should be turned off and properly stored so that the aircraft could be prepared for takeoff. Although Colgan’s policy on the use of mobile phones on the flight deck was consistent with the guidance contained in AC 91.21-1B, the company’s pilot checklists did not address turning off cell phones in preparation for departure. Colgan also stated that it considered the use of cell phones by flight crewmembers to be covered as part of sterile cockpit procedures. On February 4, 2009, the FAA published SAFO 09003, “Cellular Phone Usage on the Flight Deck.” The purpose of this SAFO was to alert all Part 121 and 135 operators to the potential hazards associated with flight crewmembers leaving their cellular phones on during critical phases of flight. The SAFO was the result of an inspector’s observation of a ring tone/warbling sound coming from a first officer’s cellular phone during a takeoff roll just before reaching the airplane’s takeoff decision speed. The SAFO stated that the ring tone was a

303 For example, on November 30, 2006, the NTSB issued Safety Recommendation H-06-27, which asked the Federal Motor Carrier Safety Administration to “publish regulations prohibiting cellular telephone use by commercial driver’s license holders with a passenger-carrying or school bus endorsement, while driving under the authority of that endorsement, except in emergencies.” The recommendation is currently classified “Open— Acceptable Response.” Also, on June 13, 2003, the NTSB issued Safety Recommendation R-03-1, which asked the Federal Railroad Administration to “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.” The recommendation was classified “Closed—Acceptable Alternate Action” on September 17, 2009. 304 According to the AC, portable electronic devices are personal devices that include, for example, mobile telephones; computers with wireless network capabilities; and other wireless-enabled devices, such as personal digital assistants. Such devices are not provided by an operator for use in supporting flight operations. Electronic flight bags or laptop computers used for landing performance calculations would thus not be considered personal portable electronic devices.

NTSB Aircraft Accident Report 143 distraction to the flight crew and could have resulted in an unnecessary rejected takeoff. The FAA found that the company’s guidance did not prohibit flight crewmembers from leaving phones on while on the flight deck and that the company’s checklists did not address turning off cell phones in preparation for departure. The SAFO recommended that directors of operations of all Part 121 and 135 certificate holders review guidance to determine if procedures are in place to remind flight crews to turn off phones while on the flight deck. The SAFO also recommended a review and evaluation of the operator’s indoctrination and recurrent training curriculums concerning cell phone use and the sterile cockpit concept. On October 21, 2009, Northwest Airlines flight 188, an Airbus A320, N374NW, became a “NORDO” (no radio communications) flight at 37,000 feet. The flight was operating under 14 CFR Part 121 from San Diego, California, to Minneapolis-St. Paul International/Wold- Chamberlain Airport (MSP) with 5 crewmembers and 144 passengers on board. The flight was NORDO for about 1 hour 17 minutes. During that time, the airplane flew past MSP and continued northeast for about 100 miles. When the flight crew and the MSP center controller reestablished communications, the first officer stated, “we got distracted and we’ve overflown MSP. We are overhead Eau Claire [Wisconsin] and would like to make a 180 [degree turn] and do an arrival from Eau Claire.” About 5 minutes later, the controller asked the first officer to explain what had caused the situation, and he replied, “just cockpit distraction, that’s all I can tell you.” During interviews with the Northwest flight crew, the NTSB learned that the distraction involved the use of personal laptop computers during the discussion of new flight crew scheduling software and procedures. However, Delta Air Lines policy (which governed Northwest operations as a result of a merger with the company),305 prohibited the use of personal computers and other personal electronic devices on the flight deck.306 Although the Colgan first officer’s use of her personal cell phone during the taxi phase of the accident flight was not directly associated with the accident, the event described in SAFO 09003 illustrates the potential for such devices to create a hazardous distraction during a critical phase of flight. In addition, the Northwest event showed that the use of a personal computer during cruise flight could severely affect flight crew situational awareness. The NTSB concludes that distractions caused by personal portable electronic devices affect flight safety because they can detract from a flight crew’s ability to monitor and cross-check instruments, detect hazards, and avoid errors. Therefore, the NTSB recommends that the FAA require all Part 121, 135, and 91K operators to incorporate explicit guidance to pilots, including checklist reminders as appropriate, prohibiting the use of personal portable electronic devices on the flight deck.

305 Delta’s website indicated that the airline had acquired ownership of Northwest and was in the process of fully integrating Northwest into Delta’s operations. 306 For more information about this incident, see DCA10IA001 on the NTSB’s website.

NTSB Aircraft Accident Report 144 2.12 Safety Alerts for Operators According to FAA Order 8000.87A, SAFOs “contain important safety information that is often critical.” SAFOs are intended for FAA inspectors; air carrier directors of safety, operations, and maintenance; fractional ownership program managers; training center managers; repair station managers; and others as applicable. Although FAA inspectors are among the intended audience, the order states, “SAFOs do not burden FAA inspectors with additional responsibilities not included in their work programs and not processed in accordance with the agreement between the FAA and its inspectors’ bargaining unit.” At the public hearing for this accident, the FAA’s manager of air carrier operations asserted that this language was included in the order because FAA inspectors are heavily tasked. As previously noted, the FAA had issued SAFOs concerning issues identified in this investigation, including SAFO 06004, “Approach and Landing Accident Reduction: Sterile Cockpit, Fatigue,” dated April 28, 2006, and SAFO 06015, “Remedial Training for Part 121 Pilots,” dated October 27, 2006 (see sections 1.18.1.1 and 1.18.1.7, respectively). The recommended actions discussed in these SAFOs included increased emphasis on sterile cockpit discipline, fatigue countermeasures and operator fatigue management, and additional training and oversight for pilots who have experienced multiple training and checking failures. FAA Order 8000.87A stated that operators are responsible for implementing the actions recommended in a SAFO. However, no evidence showed that Colgan had initiated any of the recommended actions in these SAFOs. The FAA does not routinely track whether the recommended actions included in SAFOs have been adopted,307 citing inspector workload as a reason. The FAA order states that SAFOs are “especially valuable” to air carriers in meeting their statutory duty to operate with the highest degree of safety. The NTSB recognizes the importance of an air carrier’s statutory responsibility to provide safe transportation. However, the FAA has a statutory responsibility to provide effective oversight of the aviation industry. Assessing an operator’s need to implement action on “important safety information that is often critical” and measuring the resulting change is an inherent responsibility of FAA inspectors and must be considered part of their workload. Delegating the responsibility for these actions solely to an operator may not produce the desired outcome. SAFOs may be an appropriate method for disseminating routine or initial information to operators in a timely manner. However, when safety-critical information, which often requires a change in industry practices or procedures, needs to be distributed, SAFOs are not the appropriate format because no requirement exists for the FAA to measure whether the SAFO achieved its intended result. The FAA uses an SMS approach to structure its oversight processes, but transmitting critical safety information to operators without measuring results is inconsistent with the basic principles of this system.

307 The FAA has undertaken tracking efforts for some SAFOs to determine whether the desired safety benefit has been realized. For example, FAA Notice 8900.71 was issued on April 23, 2009, in response to the NTSB’s March 2009 request for an assessment of industry actions taken in response to SAFOs 06015 and 06005 (the latter of which discussed bounced landing training).

NTSB Aircraft Accident Report 145 The FAA’s manager of air carrier operations testified at the public hearing that the agency was considering the establishment of a new transmittal method for safety-critical information, referred to as an operational directive, which would be similar to an airworthiness directive. Thus, operators would be responsible for complying with the operational directive, and FAA inspector surveillance would be required to determine whether the recommended actions had been accomplished. The NTSB is encouraged that the FAA is considering this new method for transmitting safety-critical information. The same safety benefit could be achieved if the FAA revised Order 8000.87A so that the SAFO process would incorporate FAA followup. The NTSB concludes that the current use of SAFOs to transmit safety-critical information is not effective because oversight and documentation of an operator’s response are not required and critical safety issues may not be effectively addressed. Therefore, the NTSB recommends that the FAA implement a process to document that all Part 121, 135, and 91K operators have taken appropriate action in response to safety-critical information transmitted through the SAFO process or another method. 2.13 Preflight Weather Documents and Icing Terminology As previously stated, no evidence showed that the icing conditions that existed before the accident were abnormal for wintertime operations in the BUF area. However, the NTSB’s investigation of this accident identified two weather-related safety issues—preflight weather documents provided to Part 121 flight crews and icing terminology used in the Aeronautical Information Manual (AIM)—that warranted changes. These issues are discussed in sections 2.13.1 and 2.13.2, respectively. 2.13.1 Preflight Weather Documents Chapter 26 of FAA Order 8900.1, Aviation Weather Information Systems for Air Carriers, section 3-2094, “Operational Requirements—Flightcrews,” states the following regarding weather information provided to flight crews: Flightcrews need accurate weather information to determine the present and forecast weather conditions on any planned operation. For example, for adequate flight planning, flightcrews should know existing and expected weather conditions at the departure airport, along the planned route of flight, and at destination, alternate, and diversionary airports. The section also provides a list of the numerous weather products that flight crews need to consider in operational preflight planning decisions. Chapter 26 of the order, section 3-2096, “Adverse Weather Phenomena Reporting and Forecasting Requirements,”308 states that any weather information system used in Part 121

308 According to section 3-2096, adverse weather phenomena are meteorological conditions that could affect safety if encountered during flight or ground operations. Examples of such phenomena include surface winds

NTSB Aircraft Accident Report 146 operations must include an FAA-approved adverse weather phenomena reporting and forecasting subsystem. Such subsystems allow operators to monitor weather reports from various sources to quickly and accurately identify adverse weather phenomena and predict their effects on flight and ground operation safety. The subsystems are required to include forecasting capabilities that are at least equal to those of government weather forecasting systems.309 Even though the subsystems are automated, dispatch personnel are responsible for (1) programming the subsystems to ensure that they capture specific weather products during specific time periods for the arrival and alternate airports for each flight and (2) providing weather documents containing this information to flight crews. In this case, the Colgan director of dispatch was responsible for programming the company’s FAA-approved private weather contractor subsystem to capture specific weather products for the route of flight between EWR and BUF (and from EWR to ROC, the alternate airport). The weather document for the accident flight was issued about 1800. The NTSB’s review of this document revealed that it was missing pertinent information. For example, the weather document did not contain relevant AIRMETs, even though they are among the in-flight weather advisories that flight crews need to determine present and forecast weather conditions for an operation. One of the missing AIRMETs relevant to the accident flight extended over the flight route and alerted pilots to expect moderate rime icing below 8,000 feet. Another missing and relevant AIRMET extended over a larger region in the northeast, including the accident site, and alerted pilots to expect occasional moderate icing below 18,000 feet. The icing conditions in both of these AIRMETs were expected to last from 2145 to 0400 the next day.310 The NTSB’s investigation of this accident verified the conditions detailed in the AIRMETs. The only icing information included in the weather document for the accident flight was the reports and forecast of snow at BUF and two PIREPs indicating light-to-moderate rime icing in the BUF area between 3,000 and 14,000 feet. Even though the minimal aircraft performance degradation resulting from ice accumulation did not affect the flight crew’s ability to fly and control the airplane, the NTSB is concerned that pertinent preflight information regarding icing along the flight route was not relayed to the crew. The AIRMETs relevant to the accident flight that were not included in the weather document would have provided the crew with additional information about icing and, accordingly, would have increased situational awareness. However, this increased situational awareness would not likely have affected the outcome of the flight for the reasons previously discussed in section 2.2. On August 15, 1996, the NTSB issued Safety Recommendation A-96-48 as a result of its investigation of the American Eagle flight 4184 accident in Roselawn, Indiana (see section

exceeding 30 knots, active thunderstorms, moderate or severe in-flight icing, severe or extreme turbulence, and meteorological conditions causing runway surface contamination. 309 According to 14 CFR 121.101, “each certificate holder conducting domestic or flag operations shall adopt and put into use an approved system for obtaining forecasts and reports of adverse weather phenomena, such as clear air turbulence, thunderstorms, and low altitude wind shear, that may affect safety of flight on each route to be flown and at each airport to be used.” 310 Other AIRMETs in effect at the time described IFR conditions and turbulence over the BUF area. These AIRMETs were also not included in the weather document.

NTSB Aircraft Accident Report 147 1.18.1.13). Safety Recommendation A-96-48 recognized the importance of AIRMETs and Center Weather Advisories (CWAs)311 in flight planning and asked the FAA to do the following: Direct principal operations inspectors (POIs) to ensure that all 14 Code of Federal Regulations (CFR) Part 121 air carriers require their dispatchers to provide all pertinent information, including airman’s meteorological information (AIRMETs) and Center Weather Advisories (CWAs), to flightcrews for preflight and in-flight planning purposes. On April 24, 1997, the FAA stated that it issued Flight Standards Information Bulletin for Air Transportation 97-03 on March 17, 1997, which directed POIs to ensure that air carriers require dispatchers to provide pertinent information, including AIRMETs and CWAs, when appropriate, for preflight and in-flight planning purposes. The FAA also stated that the information in the bulletin would be incorporated into FAA Order 8400.10, “Air Transportation Operations Inspector’s Handbook.”312 On August 20, 1997, the NTSB stated that the flight standards information bulletin addressed the intent of Safety Recommendation A-96-48 and classified it “Closed—Acceptable Action.” However, this accident demonstrates that, even though the FAA took actions to address this safety issue, weather documents are still missing pertinent information, including AIRMETs. In addition, the NTSB’s review of the weather document for the accident flight revealed that some of the information was outdated. For example, the weather document included three CWAs, but they were not valid at the time of the accident flight.313 Also, the wind and temperature aloft forecast for BUF, which was issued about 1300 and was valid between 1200 and 1600, had expired before the accident flight. This outdated information should not have been part of the weather document but was included in it because of programming limitations of Colgan’s weather contractor subsystem. Problems with weather documents have also been found at other Part 121 air carriers. For example, on April 12, 2007, Pinnacle Airlines flight 4712, a Bombardier/Canadair Regional Jet CL600-2B19, N8905F, departed the end of the runway while landing at Cherry Capital Airport, Traverse City, Michigan (see section 1.18.1.5). None of the 3 crewmembers and 49 passengers was injured; the airplane was substantially damaged. The accident flight’s weather document, which was prepared by the Pinnacle Airlines dispatcher, did not include any NWS in-flight weather advisories. However, NWS AIRMETs for icing, turbulence, and IFR conditions were valid for the area at the time of the accident. Also, on December 25, 2007, Alaska Airlines flight 464, a McDonnell Douglas DC-9-83, N943AS, encountered severe turbulence during the descent for landing at Ontario International

311 A CWA is an aviation warning for conditions that are meeting or approaching national in-flight advisory criteria (for example, AIRMETs, SIGMETs, or Convective SIGMETs) and are impacting the respective airspace. These short-term warnings are typically valid for 2 hours. 312 FAA Order 8400.10 has been superseded by FAA Order 8900.1. 313 Two CWAs for low-level windshear, issued by the New York Air Route Traffic Control Center, had expired at 1320. A CWA for scattered thunderstorms, issued by the Cleveland Center, expired about 1630.

NTSB Aircraft Accident Report 148 Airport, Ontario, California.314 Two flight attendants sustained serious injuries during the turbulence encounter, and the third flight attendant, the two flight crewmembers, and the 109 passengers were not injured. During its investigation of this accident, the NTSB determined that two NWS Significant Meteorological Information (SIGMET) advisories were not included in the weather document for the flight. The SIGMETs were issued before the flight’s departure as a result of occasional severe turbulence for the Ontario area. The NTSB determined the probable cause of this accident was the lack of turbulence forecast information available to the flight crew, which resulted in the flight attendants not being seated when the flight encountered the severe turbulence. Contributing factors to the accident included the failure of the company that provided the flight’s weather briefing information to forecast severe turbulence and the failure of the airline dispatcher to provide the SIGMETs to the flight crew.315 Flight crews need to be provided with an operationally useful weather document containing all relevant weather information, including AIRMETs and SIGMETs, for each flight so that they can make sound safety-of-flight decisions based on that information. Such documents must contain up-to-date information so that flight crews do not have to sort through outdated or unrelated information for their flight. The NTSB concludes that weather documents missing key weather products or containing products that are no longer valid prevent flight crewmembers from having relevant, readily available weather-related safety information for preflight and in-flight decision-making. Therefore, the NTSB recommends that the FAA require Part 121, 135, and 91K operators to revise the methodology for programming their adverse weather phenomena reporting and forecasting subsystems so that the subsystem-generated weather document for each flight contains all pertinent weather information, including AIRMET, SIGMET, and other NWS in-flight weather advisories, and omits weather information that is no longer valid. The NTSB further recommends that the FAA require POIs of Part 121, 135, and 91K operators to periodically review the weather documents generated for their carriers to verify that those documents are consistent with the information requested in Safety Recommendation A-10-32. 2.13.2 Icing Terminology Chapter 7 of the AIM, Safety of Flight, section 7-1-21, describes the effects of ice on an aircraft and provides terminology for pilots to use when describing icing conditions to ATC. However, during its investigation of this accident, the NTSB found that the definitions for reportable icing intensities in the July 2008 version of the AIM had not been updated to reflect the definitions published in December 2007 in AC 91-74A, “Pilot Guide: Flight in Icing Conditions.” Table 4 shows the differences in terminology between AIM section 7-1-21(b) and AC 91-74A.

314 Additional information about this accident, NTSB case number SEA08LA050, is available on the NTSB’s website. 315 The NTSB discussed these weather-related issues with Alaska Airlines, which added NWS products to the weather subsystem used to generate its weather documents.

NTSB Aircraft Accident Report Table 4. Icing Definitions

Icing intensity Aeronautical Information Manual definition Advisory Circular 91-74A definition Trace Ice becomes perceptible. Rate of accumulation is slightly greater than sublimation. Deicing/anti-icing equipment is not utilized unless encountered for an extended period of time (over 1 hour). Ice becomes noticeable. The rate of accumulation is slightly greater than the rate of sublimation. A representative accretion rate for reference purposes is less than 1/4 inch (6 mm) per hour on the outer wing. The pilot should consider exiting the icing conditions before they become worse. Pilots should be aware that any ice, even in trace amounts, could be potentially hazardous. Light The rate of accumulation may create a problem if flight is prolonged in this environment (over 1 hour). Occasional use of deicing/anti-icing equipment removes/prevents accumulation. It does not present a problem if the deicing/anti-icing equipment is used. The rate of ice accumulation requires occasional cycling of manual deicing systems to minimize ice accretions on the airframe. A representative accretion rate for reference purposes is 1/4 inch to 1 inch (0.6 to 2.5 cm) per hour on the outer wing. The pilot should consider exiting the condition. Moderate The rate of accumulation is such that even short encounters become potentially hazardous and use of deicing/anti-icing equipment or flight diversion is necessary. The rate of ice accumulation requires frequent cycling of manual deicing systems to minimize ice accretions on the airframe. A representative accretion rate for reference purposes is 1 to 3 inches (2.5 to 7.5 cm) per hour on the outer wing. The pilot should consider exiting the condition as soon as possible. Heavy None. The rate of ice accumulation requires maximum use of the ice protection systems to minimize ice accretions on the airframe. A representative accretion rate for reference purposes is more than 3 inches (7.5 cm) per hour on the outer wing. Consider immediate exit from the conditions. Severe The rate of accumulation is such that deicing/anti-icing equipment fails to reduce or control the hazard. Immediate flight diversion is necessary.

The rate of ice accumulation is such that ice protection systems fail to remove the accumulation of ice, and ice accumulates in locations not normally prone to icing, such as areas aft of protected surfaces and any other areas identified by the manufacturer. Immediate exit from the condition is necessary. Note: AC 91-74A also states that deicing or anti-icing systems are expected to be activated and operated continuously in the automatic mode, if available, at the first sign of ice accumulation or as directed in the AFM and that occasional and frequent cycling refers to manually activated systems. The AC further states that accretion rates can be measured by an icing rate meter.

As shown in table 4, three main differences exist between the icing terminology in the AIM and AC 91-74A. First, the AC provides an accretion rate for each icing definition, which can help pilots evaluate and accurately describe the icing conditions. Second, the AC contains a fifth icing category—heavy—to explain the environment that occurs between moderate and severe icing, providing additional icing information for pilots to consider. Last, the AC includes more detailed guidance than the AIM for pilot actions in icing conditions, providing pilots with further information for addressing specific icing situations. The light-to-moderate icing terminology used in the two PIREPs that were included in the weather document for the accident flight had likely portrayed accurate conditions at the time 149

NTSB Aircraft Accident Report of the flight. Nevertheless, the NTSB is concerned that pilots transmitting airframe icing PIREPs may not be using the most updated definitions in determining and reporting the severity of icing. Although the AC is advisory only, it is important that the icing definitions and accretion rates in the AC be incorporated into the AIM because that publication is the FAA’s official guide for basic flight information and ATC procedures. The NTSB concludes that detailed icing definitions that include accretion rates and recommended pilot actions would help pilots more accurately determine the icing conditions to report in airframe icing PIREPs and more effectively respond to those conditions. Therefore, the NTSB recommends that the FAA update the definitions for reportable icing intensities in the AIM so that the definitions are consistent with the more detailed intensities defined in AC 91-74A. 150

NTSB Aircraft Accident Report

1. Conclusions
2. 1

Findings

1. The flight crew was properly certificated and qualified in accordance with applicable Federal

regulations.

1. The airplane was properly certified, equipped, and maintained in accordance with Federal

regulations.

1. The recovered components showed no evidence of any preimpact structural, engine, or

system failures, including no indications of any problems with the airplane’s ice protection system.

1. The air traffic controllers who were responsible for the flight during its approach to Buffalo-

Niagara International Airport performed their duties properly and responded immediately and appropriately to the loss of radio and radar contact with the flight.

1. This accident was not survivable.
2. The captain’s inappropriate aft control column inputs in response to the stick shaker caused

the airplane’s wing to stall.

1. The minimal aircraft performance degradation resulting from ice accumulation did not affect

the flight crew’s ability to fly and control the airplane.

1. Explicit cues associated with the impending stick shaker onset, including the decreasing

margin between indicated airspeed and the low-speed cue, the airspeed trend vector pointing downward into the low-speed cue, the changing color of the numbers on the airplane’s indicated airspeed display, and the airplane’s excessive nose-up pitch attitude, were presented on the flight instruments with adequate time for the pilots to initiate corrective action, but neither pilot responded to the presence of these cues.

1. The reason the captain did not recognize the impending onset of the stick shaker could not be

determined from the available evidence, but the first officer’s tasks at the time the low-speed cue was visible would have likely reduced opportunities for her timely recognition of the impending event; the failure of both pilots to detect this situation was the result of a significant breakdown in their monitoring responsibilities and workload management.

1. The flight crew did not consider the position of the reference speeds switch when the stick

shaker activated. 151

NTSB Aircraft Accident Report 152

1. The captain’s response to stick shaker activation should have been automatic, but his

improper flight control inputs were inconsistent with his training and were instead consistent with startle and confusion.

1. The captain did not recognize the stick pusher’s action to decrease angle-of-attack as a

proper step in a stall recovery, and his improper flight control inputs to override the stick pusher exacerbated the situation.

1. It is unlikely that the captain was deliberately attempting to perform a tailplane stall

recovery.

1. No evidence indicated that the Q400 was susceptible to a tailplane stall.
2. Although the reasons the first officer retracted the flaps and suggested raising the gear could

not be determined from the available information, these actions were inconsistent with company stall recovery procedures and training.

1. The Q400 airspeed indicator lacked low-speed awareness features, such as an amber band

above the low-speed cue or airspeed indications that changed to amber as speed decrease toward the low-speed cue, which would have facilitated the flight crew’s detection of the developing low-speed situation.

1. An aural warning in advance of the stick shaker would have provided a redundant cue of the

visual indication of the rising low-speed cue and might have elicited a timely response from the pilots before the onset of the stick shaker.

1. The captain’s failure to effectively manage the flight (1) enabled conversation that delayed

checklist completion and conflicted with sterile cockpit procedures and (2) created an environment that impeded timely error detection.

1. The monitoring errors made by the accident flight crew demonstrate the continuing need for

specific pilot training on active monitoring skills.

1. Colgan Air’s standard operating procedures at the time of the accident did not promote

effective monitoring behavior.

1. Specific leadership training for upgrading captains would help standardize and reinforce the

critical command authority skills needed by a pilot-in-command during air carrier operations.

1. Because of the continuing number of accidents involving a breakdown of sterile cockpit

discipline, collaborative action by the Federal Aviation Administration and the aviation industry to promptly address this issue is warranted.

1. The flight crewmembers’ performance during the flight, including the captain’s deviations

from standard operating procedures and the first officer’s failure to challenge these deviations, was not consistent with the crew resource management (CRM) training that they had received or the concepts in the Federal Aviation Administration’s CRM guidance.

NTSB Aircraft Accident Report

1. The pilots’ performance was likely impaired because of fatigue, but the extent of their

impairment and the degree to which it contributed to the performance deficiencies that occurred during the flight cannot be conclusively determined.

1. All pilots, including those who commute to their home base of operations, have a personal

responsibility to wisely manage their off-duty time and effectively use available rest periods so that they can arrive for work fit for duty; the accident pilots did not do so by using an inappropriate facility during their last rest period before the accident flight.

1. Colgan Air did not proactively address the pilot fatigue hazards associated with operations at

a predominantly commuter base.

1. Operators have a responsibility to identify risks associated with commuting, implement

strategies to mitigate these risks, and ensure that their commuting pilots are fit for duty.

1. The first officer’s illness symptoms did not likely affect her performance directly during the

flight.

1. The captain had not established a good foundation of attitude instrument flying skills early in

his career, and his continued weaknesses in basic aircraft control and instrument flying were not identified and adequately addressed.

1. Remedial training and additional oversight for pilots with training deficiencies and failures

would help ensure that the pilots have mastered the necessary skills for safe flight.

1. Colgan Air’s electronic pilot training records did not contain sufficient detail for the

company or its principal operations inspector to properly analyze the captain’s trend of unsatisfactory performance.

1. Notices of disapproval need to be considered along with other available information about

pilot applicants so that air carriers can fully identify those pilots who have a history of unsatisfactory performance.

1. Colgan Air did not use all available sources of information on the flight crew’s qualifications

and previous performance to determine the crew’s suitability for work at the company.

1. Colgan Air’s procedures and training at the time of the accident did not specifically require

flight crews to cross-check the approach speed bug settings in relation to the reference speeds switch position; such awareness is important because a mismatch between the bugs and the switch could lead to an early stall warning.

1. The current air carrier approach-to-stall training did not fully prepare the flight crew for an

unexpected stall in the Q400 and did not address the actions that are needed to recover from a fully developed stall.

1. The circumstances of this and other accidents in which pilots have responded incorrectly to

the stick pusher demonstrate the continuing need to train pilots on the actions of the stick pusher and the airplane’s initial response to the pusher. 153

NTSB Aircraft Accident Report

1. Pilots could have a better understanding of an airplane’s flight characteristics during the

post-stall flight regime if realistic, fully developed stall models were incorporated into simulators that are approved for such training.

1. The inclusion of the National Aeronautics and Space Administration icing video in Colgan

Air’s winter operations training may lead pilots to assume that a tailplane stall might be possible in the Q400, resulting in negative training.

1. The current Federal Aviation Administration surveillance standards for oversight at air

carriers undergoing rapid growth and increased complexity of operations do not guarantee that any challenges encountered by the carriers as a result of these changes will be appropriately mitigated.

1. Mandatory flight operational quality assurance programs would enhance flight safety

because all operators would have readily available data to identify operational risks and use in developing corrective actions.

1. The viability of flight operational quality assurance programs depends on the confidentiality

of the data, which would currently not be guaranteed if operators were required to implement these programs and were required to share the data with the Federal Aviation Administration.

1. The systematic monitoring of all available safety data, as part of a flight operational quality

assurance program, could provide operators with objective information regarding the manner in which flights are conducted, and a periodic review of this information would enhance flight safety by assisting operators in detecting and correcting deviations from standard operating procedures.

1. Distractions caused by personal portable electronic devices affect flight safety because they

can detract from a flight crew’s ability to monitor and cross-check instruments, detect hazards, and avoid errors.

1. The current use of safety alerts for operators to transmit safety-critical information is not

effective because oversight and documentation of an operator’s response are not required and critical safety issues may not be effectively addressed.

1. Weather documents missing key weather products or containing products that are no longer

valid prevent flight crewmembers from having relevant, readily available weather-related safety information for preflight and in-flight decision-making.

1. Detailed icing definitions that include accretion rates and recommended pilot actions would

help pilots more accurately determine the icing conditions to report in airframe icing pilot reports and more effectively respond to those conditions. 154

NTSB Aircraft Accident Report 155 3.2 Probable Cause The National Transportation Safety Board determines that the probable cause of this accident was the captain’s inappropriate response to the activation of the stick shaker, which led to an aerodynamic stall from which the airplane did not recover. Contributing to the accident were (1) the flight crew’s failure to monitor airspeed in relation to the rising position of the low- speed cue, (2) the flight crew’s failure to adhere to sterile cockpit procedures, (3) the captain’s failure to effectively manage the flight, and (4) Colgan Air’s inadequate procedures for airspeed selection and management during approaches in icing conditions.

NTSB Aircraft Accident Report

1. Recommendations
2. 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 14 Code of Federal Regulations Part 121, 135, and 91K operators to review their standard operating procedures to verify that they are consistent with the flight crew monitoring techniques described in Advisory Circular (AC) 120-71A, “Standard Operating Procedures for Flight Deck Crewmembers”; if the procedures are found not to be consistent, revise the procedures according to the AC guidance to promote effective monitoring. (A-10-10) Require that airspeed indicator display systems on all aircraft certified under 14 Code of Federal Regulations Part 25 and equipped with electronic flight instrument systems depict a yellow/amber cautionary band above the low-speed cue or airspeed indicator digits that change from white to yellow/amber as the airspeed approaches the low-speed cue, consistent with Advisory Circular 25-11A, “Electronic Flight Displays.” (A-10-11) For all airplanes engaged in commercial operations under 14 Code of Federal Regulations Parts 121, 135, and 91K, require the installation of low-airspeed alert systems that provide pilots with redundant aural and visual warnings of an impending hazardous low-speed condition. (A-10-12) (Supersedes Safety Recommendations A-03-53 and -54 and is classified “Open—Unacceptable Response”) Issue an advisory circular with guidance on leadership training for upgrading captains at 14 Code of Federal Regulations Part 121, 135, and 91K operators, including methods and techniques for effective leadership; professional standards of conduct; strategies for briefing and debriefing; reinforcement and correction skills; and other knowledge, skills, and abilities that are critical for air carrier operations. (A-10-13) Require all 14 Code of Federal Regulations Part 121, 135, and 91K operators to provide a specific course on leadership training to their upgrading captains that is consistent with the advisory circular requested in Safety Recommendation A-10-13. (A-10-14) Develop, and distribute to all pilots, multimedia guidance materials on professionalism in aircraft operations that contain standards of performance for professionalism; best practices for sterile cockpit adherence; techniques for 156

NTSB Aircraft Accident Report assessing and correcting pilot deviations; examples and scenarios; and a detailed review of accidents involving breakdowns in sterile cockpit and other procedures, including this accident. Obtain the input of operators and air carrier and general aviation pilot groups in the development and distribution of these guidance materials. (A-10-15) (Supersedes Safety Recommendation A-07-8) Require all 14 Code of Federal Regulations Part 121, 135, and 91K operators to address fatigue risks associated with commuting, including identifying pilots who commute, establishing policy and guidance to mitigate fatigue risks for commuting pilots, using scheduling practices to minimize opportunities for fatigue in commuting pilots, and developing or identifying rest facilities for commuting pilots. (A-10-16) Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to document and retain electronic and/or paper records of pilot training and checking events in sufficient detail so that the carrier and its principal operations inspector can fully assess a pilot’s entire training performance. (A-10-17) Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to include the training records requested in Safety Recommendation A-10-17 as part of the remedial training program requested in Safety Recommendation A-05-14. (A-10-18) Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to provide the training records requested in Safety Recommendation A-10-17 to hiring employers to fulfill their requirement under the Pilot Records Improvement Act. (A-10-19) Develop a process for verifying, validating, auditing, and amending pilot training records at 14 Code of Federal Regulations Part 121, 135, and 91K operators to guarantee the accuracy and completeness of the records. (A-10-20) Direct 14 Code of Federal Regulations Part 121, 135, and 91K operators of airplanes equipped with a reference speeds switch or similar device to (1) develop procedures to establish that, during approach and landing, airspeed reference bugs are always matched to the position of the switch and (2) implement specific training to ensure that pilots demonstrate proficiency in this area. (A-10-21) Require 14 Code of Federal Regulations Part 121, 135, and 91K operators and 14 Code of Federal Regulations Part 142 training centers to develop and conduct training that incorporates stalls that are fully developed; are unexpected; involve autopilot disengagement; and include airplane-specific features, such as a reference speeds switch. (A-10-22) Require all 14 Code of Federal Regulations Part 121, 135, and 91K operators of stick pusher-equipped aircraft to provide their pilots with pusher familiarization simulator training. (A-10-23) (Supersedes Safety Recommendation A-07-4) 157

NTSB Aircraft Accident Report Define and codify minimum simulator model fidelity requirements to support an expanded set of stall recovery training requirements, including recovery from stalls that are fully developed. These simulator fidelity requirements should address areas such as required angle-of-attack and sideslip angle ranges, motion cueing, proof-of-match with post-stall flight test data, and warnings to indicate when the simulator flight envelope has been exceeded. (A-10-24) Identify which airplanes operated under 14 Code of Federal Regulations Part 121, 135, and 91K are susceptible to tailplane stalls and then (1) require operators of those airplanes to provide an appropriate airplane-specific tailplane stall recovery procedure in their training manuals and company procedures and (2) direct operators of those airplanes that are not susceptible to tailplane stalls to ensure that training and company guidance for the airplanes explicitly states this lack of susceptibility and contains no references to tailplane stall recovery procedures. (A-10-25) Develop more stringent standards for surveillance of 14 Code of Federal Regulations (CFR) Part 121 135, and 91K operators that are experiencing rapid growth, increased complexity of operations, accidents and/or incidents, or other changes that warrant increased oversight, including the following: (1) verify that inspector staffing is adequate to accomplish the enhanced surveillance that is promulgated by the new standards, (2) increase staffing for those certificates with insufficient staffing levels, and (3) augment the inspector staff with available and airplane-type-qualified inspectors from all Federal Aviation Administration regions and 14 CFR Part 142 training centers to provide quality assurance over the operators’ aircrew program designee workforce. (A-10-26) Require all 14 Code of Federal Regulations Part 121, 135, and 91K operators to (1) develop and implement flight operational quality assurance programs that collect objective flight data, (2) analyze these data and implement corrective actions to identified systems safety issues, and (3) share the deidentified aggregate data generated through these analyses with other interested parties in the aviation industry through appropriate means. (A-10-27) Seek specific statutory and/or regulatory authority to protect data that operators share with the Federal Aviation Administration as part of any flight operational quality assurance program. (A-10-28) Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to (1) routinely download and analyze all available sources of safety information, as part of their flight operational quality assurance program, to identify deviations from established norms and procedures; (2) provide appropriate protections to ensure the confidentiality of the deidentified aggregate data; and (3) ensure that this information is used for safety-related and not punitive purposes. (A-10-29) Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to incorporate explicit guidance to pilots, including checklist reminders as 158

NTSB Aircraft Accident Report appropriate, prohibiting the use of personal portable electronic devices on the flight deck. (A-10-30) Implement a process to document that all 14 Code of Federal Regulations Part 121, 135, and 91K operators have taken appropriate action in response to safety-critical information transmitted through the safety alert for operators process or another method. (A-10-31) Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to revise the methodology for programming their adverse weather phenomena reporting and forecasting subsystems so that the subsystem-generated weather document for each flight contains all pertinent weather information, including Airmen’s Meteorological Information, Significant Meteorological Information, and other National Weather Service in-flight weather advisories, and omits weather information that is no longer valid. (A-10-32) Require principal operations inspectors of 14 Code of Federal Regulations Part 121, 135, and 91K operators to periodically review the weather documents generated for their carriers to verify that those documents are consistent with the information requested in Safety Recommendation A-10-32. (A-10-33) Update the definitions for reportable icing intensities in the Aeronautical Information Manual so that the definitions are consistent with the more detailed intensities defined in Advisory Circular 91-74A, “Pilot Guide: Flight in Icing Conditions.” (A-10-34) 4.2 Previously Issued Recommendations Reiterated in This Report The NTSB reiterates the following recommendations to the Federal Aviation Administration: Require all Part 121 and 135 air carriers to obtain any notices of disapproval for flight checks for certificates and ratings for all pilot applicants and evaluate this information before making a hiring decision. (A-05-1) Require all 14 Code of Federal Regulations Part 121 air carrier operators to establish training programs for flight crewmembers who have demonstrated performance deficiencies or experienced failures in the training environment that would require a review of their whole performance history at the company and administer additional oversight and training to ensure that performance deficiencies are addressed and corrected. (A-05-14) 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) 159

NTSB Aircraft Accident Report 4.3 Previously Issued Recommendations Reclassified in This Report Safety Recommendation A-07-13 is reclassified “Open—Unacceptable Response” in section 2.3.1 of this report. Safety Recommendations A-03-53 and -54 are reclassified “Closed—Unacceptable Action/Superseded” in section 2.3.3 of this report. The recommendation is superseded by Safety Recommendation A-10-12. Safety Recommendation A-07-8 is reclassified “Closed—Unacceptable Action/Superseded” in section 2.4.2 of this report. The recommendation is superseded by Safety Recommendation A-10-15. Safety Recommendation A-05-1 is reclassified “Open—Unacceptable Response” in section 2.7.3 of this report. Safety Recommendation A-07-4 is reclassified “Closed—Unacceptable Action/Superseded” in section 2.9.1 of this report. The recommendation is superseded by Safety Recommendation A-10-23. BY THE NATIONAL TRANSPORTATION SAFETY BOARD DEBORAH A.P. HERSMAN ROBERT L. SUMWALT Chairman Member

CHRISTOPHER A. HART

Vice Chairman

Adopted: February 2, 2010

160

NTSB Aircraft Accident Report 161 Board Member Statements Chairman Hersman, Vice Chairman Hart, and Member Sumwalt filed the following concurring statements.

Notation 8090A Chairman Hersman, Concurring:

This accident refocuses much needed attention on many long-standing issues of concern to the Safety Board – issues such as flight crew monitoring, pilot performance and training, sterile cockpit rules, FAA oversight, and the use of personal electronic devices, among others. I commend our staff for holding a public hearing and completing a thorough investigation in advance of the one-year anniversary of the accident. Their accomplishment was significant and had a tremendous impact on identifying critical concerns in the aviation industry.

I voted in support of the findings, the probable cause and the recommendations and, along with my colleagues, supported the adoption of the final report. However, during the public Board meeting, I submitted a proposal to the Board to amend the probable cause by adding fatigue as a fifth contributing factor, specifically that the flight crew members’ fatigue contributed to the accident because they did not obtain adequate rest before reporting to duty. After open discussion, the Board rejected the amendment 2 to 1. While I would have preferred for fatigue to be included in the probable cause, that in no way diminishes my support for the Board’s final product which I believe advances aviation safety.

Let me explain why I think fatigue, an issue that has been on our Most Wanted List of Transportation Safety Improvements since its inception in 1990, was a factor in this accident. Numerous accident investigations, research data and safety studies show that operators, like the flight crew in this accident, who are on duty but have not obtained adequate rest present an unnecessary risk to the traveling public. Fatigue results from continuous activity, inadequate rest, sleep loss or nonstandard work schedules. The effects of fatigue include slowed reaction time, diminished vigilance and attention to detail, errors of omission, compromised problem solving, reduced motivation, decreased vigor for successful completion of required tasks and poor communication, and generally results in performance deficiencies like those present during this accident flight. As we conclude in the accident report, the flight crews’ errors, including the captain’s inappropriate response to the activation of the stick shaker and the flight crews’ failure to monitor air speed, adhere to sterile cockpit procedures and adequately monitor the flight, were the causal and contributing factors of this accident. But I also believe that these errors are consistent with fatigue.

According to the FAA, operator fatigue is one of the most persistent hazards in all travel modes, including commercial aviation.1 The Safety Board has examined operator fatigue in its safety studies on flight crew errors,2 commuter airlines,3 and aviation safety in Alaska.4 In the flight crew study, the Board found that crews, comprised of captains and first officers whose time since awakening was above the median for their crew position, made more errors overall. In the study on commuter airline safety, the Board found that self-reports from commuter airline pilots indicated that most pilots had flown while fatigued. In the study on aviation in Alaska, the Board concluded that the consecutive, long duty days, permitted by Title 14 Code of Federal Regulations (14 CFR) Part 135.261 for commuter airline and air taxi flight crews                                                             1 Federal Aviation Administration, SAFO 06004; Approach and Landing Accident Reduction: Sterile Cockpit, Fatigue. 04/28/06.  2 National Transportation Safety Board,1994. A Review of Flightcrew-Involved, Major Accidents of U.S. Air Carriers, 1978 Through 1990. Safety Study NTSB/SS-94/01.  3 National Transportation Safety Board, 1994. Commuter Airline Safety. Safety Study NTSB/SS-94/02.   4 National Transportation Safety Board, 1995. Aviation Safety in Alaska. Safety Study NTSB/SS-95/03.  1   

in Alaska, can contribute to fatigue and are a detriment to safety.5 A 1999 NASA study found that 80% of regional airline pilots said they had nodded off during a flight,6 and fatigue continues to show up in reports in NASA’s Aviation Safety Reporting System.7

The question is why, after more than 40 years of documentation and investigation of the hazards of fatigue, so little has changed in our identification of fatigue as a causal or contributing factor in accidents. I would like to contrast how we have addressed fatigue with two other human factors issues that have matured in the last four decades -- alcohol impairment and adherence to standard operating procedures (SOPs).

Today, the impairing effects of alcohol are well understood and accepted by NTSB investigators and society at-large. However, this has not always been the case. Early in the Safety Board’s history, the prevailing view was that an individual could be under the influence with a blood alcohol content above today’s legal limit, and still not be considered drunk. For example, we investigated the 1967 collision in Baker, California, between a car travelling the wrong way on the highway and a bus which resulted in 20 fatalities and 11 injuries.8 The NTSB calculated that at the time of the collision, the driver of the car had a blood-alcohol level of between .15 and .19 (or higher). Nonetheless the accident report states that “there is a difference between being "under the influence" of alcohol and varying degrees of drunkenness. In the common acceptance of the term, "drunkenness" is taken to mean that a person is in a helpless state of immobility.” The report goes on to determine that the driver was not “drunk” because prior to the accident he successfully traveled around town by car, talked with friends and “therefore, it is logical to believe that he was able to read, comprehend and respond to traffic control devices, although probably not as well or as quickly as if he were sober.” In the report, alcohol was not cited as one of the probable cause factors; it was listed as a contributing factor. The Safety Board concluded that because the driver was not immobilized by the alcohol, alcohol was not a causal factor. The use of alcohol, to a certain extent, was tolerated in the transportation industry and by society in general if an impaired individual could still function at some level.

Fortunately, we have advanced beyond this limited viewpoint. Alcohol testing is now a routine component of our accident investigations, and society has placed stricter limits on alcohol use. Today, safety-sensitive transportation employees are subject to random and post-accident drug and alcohol testing, and every state now has impaired driving laws with an .08 or higher breath or blood concentration legal limit. Federal regulations establish an even lower .04 limit for transportation professionals.

Fatigue-impaired performance is not unlike alcohol-impaired performance. For example, a 2003 study demonstrated that sleep loss is at least as potent as ethanol in its performance-impairing effects and two hours of sleep loss equates to a breath ethanol concentration of approximately .05%.9 Other studies establish that prolonged wakefulness significantly impairs speed and accuracy, hand–eye coordination,                                                             5 Evaluation of U.S. Department of Transportation Efforts in the 1990s to Address Operator Fatigue, NTSB/SR- 99/01, May 1999.  6 Co, E.L, et al. Crew Factors in Flight Operations XI: A survey of fatigue factors in regional airline operations. NASA/TM report no.199-208799.  7Michael B. Mann, Deputy Associate Administrator, NASA, Hearing on Pilot Fatigue, Aviation Subcommittee of the Committee on Transportation and Infrastructure, United States House of Representatives, August 3, 1999.  8 National Transportation Safety Board, Interstate Bus Automobile Collision on Interstate Route 15, Baker, California, March 7, 1968.  9 Roehrs T; Burduvali E; Bonahoom A et al. Ethanol and sleep loss: a “dose” comparison of impairing effects. Sleep 2003; 26(8):981-5.  2   

decision making, and memory,10 and one study, in fact, correlates prolonged wakefulness with impairment, such that being awake for 16 hours is equivalent to a .05 BAC.11

We have successfully identified the problem of impairment due to alcohol and drugs in the workplace, and the regulators and industry have devised rules, testing and treatment countermeasures to address the problem. The challenge we face now is creating an environment in which to identify the impairing effects of fatigue. Whether it is using predictive scheduling tools, technology such as eye or voice assessment, administering self tests to quickly assess fatigue or even coming up with a blood test to identify the extent to which fatigue is affecting an individual’s ability to be vigilant, react quickly and avoid both lapses of attention and response errors – we need to address this critical problem.12

Another example of the progress we have made during the Safety Board’s four decades-long investigations of human factors is adherence to Standard Operating Procedures, such as the sterile cockpit rule (prohibiting extraneous conversation below 10,000 feet). We have made the connection between violating the sterile cockpit rule and creating a lax environment in the cockpit that results in crews not being attentive to the task at hand. Today, for sterile cockpit violations to be cited in the probable cause, crews do not have to be engaged in a conversation at the time the accident sequence commences; the conversation just has to be present at some point during the flight.

An example of how far this concept has advanced was brought to my attention a few years ago in a petition for reconsideration for a 1967 mid-air collision of Piedmont Airlines flight 22, a Boeing 727, with a twin engine Cessna 310. The 727 was departing Asheville Regional Airport in North Carolina and the Cessna was on approach to the same airport. All 82 people aboard both aircraft were killed. The petition for reconsideration raised three points, one of which was that the NTSB report made no mention of a fire in a cockpit ashtray that preoccupied the Piedmont crew in the final 35 seconds before the collision. The time that lapsed from take-off to collision was only about 2 minutes and 37 seconds, however, the final accident report’s only reference to the crew’s recorded cockpit conversation stated that it was “concerned primarily with the operation of the aircraft and nothing was found of a probative value to the investigation.” As difficult as it is to believe, the crew’s preoccupation with the fire was not mentioned in the final report.

We have certainly come a long way. Today, extraneous conversation in the cockpit while under 10,000 feet is an unacceptable safety hazard and has regularly been cited as a causal or contributing accident factor. Like with fatigue, we do not have a test to demonstrate the degree to which a sterile cockpit violation affects a crew’s performance. We similarly do not require that any causal or contributing factor equate to a percentage or share of the cause of an accident. Nonetheless, the Safety Board recognizes that a sterile cockpit violation can be a contributing factor for an accident, as was the case in this accident. In this accident, the crew was not behind in their checklists and had not violated the sterile cockpit rule in the two minutes prior to the upset. However the Board did believe that the sterile cockpit violation earlier in the flight created an “environment” where errors were not detected or recognized. Consequently, the sterile cockpit violation was one of four contributing factors to the accident. The exact same logic should be applied to our determination of fatigue; we can demonstrate that the crew was fatigued at the time of the accident and consistent with research, data and science, fatigue results in performance deficiencies that were displayed by the crew. Thus, fatigue should be included as a contributing factor.

                                                            10 Babkoff et al., 1988; Florica et al., 1968; Gillberg et al., 1994; Linde and Bergstrom, 1992; Mullaney et al., 1983.  11 Dawson D, Reid K: Fatigue, alcohol and performance impairment. Nature 1997; 388: 235.   12 Fatigue Management in Transportation Operations. 2009 International Conference; http://depts.washington.edu/uwconf/fmto/FatigueManagementAbstracts.pdf.  3   

Just as the aviation industry, including the NTSB, has addressed alcohol use and adherence to SOPs, it must also address the issue of fatigue. Unlike many of our complex, technical or cutting edge findings that require further explanation to the public to show why we made the finding, I believe this situation is one that requires an explanation of why we did not reach a conclusion – that is, why we did not identify fatigue in the probable cause determination. Anyone who has attempted to overnight in a crew lounge, an office or an airport waiting room, or has tried to get a night’s sleep on a red-eye flight from Seattle to Newark will tell you, this type of sleep in not recuperative, and the data and science support this. Anyone who has a new baby at home or is caring for an ill relative can tell you that interrupted sleep is not restorative sleep, and studies support this. Any employee who is asked to remain awake throughout the day and be prepared for the most demanding portion of their workday at 10pm after they have been awake for at least 15 consecutive hours would likely acknowledge that they are not at peak performance, and research supports this. Safety Board studies indicate that the duration of the most recent sleep period, the amount of sleep during the previous 24 hours, and split or fragmented sleep patterns are among the most critical factors leading to fatigue-related accidents.13

The failure of the Safety Board to include fatigue as one of the contributing factors in this accident is symptomatic of the Board’s inconsistent approach to addressing fatigue in transportation accidents. We have developed a methodology to be used by our investigators in our on-going efforts to address fatigue in accident investigations through a fatigue checklist.14 It is not necessary for fatigue to be the sole cause of an accident, but it should be included as a factor when it is present and performance deficiencies consistent with fatigue are identified. In 1999 the NTSB recognized that, “[a]lthough generally accepted as a factor in transportation accidents, the exact number of accidents due to fatigue is difficult to determine and likely to be underestimated. The difficulty in determining the incidence of fatigue-related accidents is due, at least in part, to the difficulty in identifying fatigue as a causal or contributing factor in accidents. There is no comparable chemical test for identifying the presence of fatigue as there is for identifying the presence of drugs or alcohol; hence, it is often difficult to conclude unequivocally that fatigue was a causal or contributing factor in an accident. In most instances, one or more indirect or circumstantial pieces of evidence are used to make the case that fatigue was a factor in the accidents.”15

There is consensus at the Safety Board that the flight crew in this accident was likely fatigued, and our accident report makes this conclusion. The factual information in the docket establishes the presence of fatigue for both of these crew members.16 The captain spent the night before the accident sleeping in the company crew room, where he obtained, at best, 8 hours of interrupted sleep as evidenced by multiple log-ins to the CrewTrac system at 2151, then 0310 and again at 0726. At worst, it was poor-quality, interrupted sleep of a shorter duration. NASA and other studies show that even in an onboard rest facility with beds available for long haul flight crews, pilots might get three hours of sleep and the quality does not approach 'home' sleep.17 So, conservatively, the captain in this accident obtained 2 fewer hours sleep than his usual sleep and perhaps, significantly less based on the quality of sleep. In addition to this acute                                                             13 National Transportation Safety Board, Factors That Affect Fatigue in Heavy Truck Accidents, Highway Safety Study NTSB/SS-95/01 (Washington, D.C.: NTSB, 1995).  14 http://www.ntsb.gov/info/fatigue_checklist_V%202_0.pdf.  15 SR99-01 - Evaluation of U.S. Department of Transportation Efforts in the 1990s to Address Operator Fatigue  16 National Transportation Safety Board, Aircraft Accident Report: Crash on Approach to Airport Colgan Air, Inc. Operating as Continental Connection Flight 3407 Bombardier DHC-8-400, N200WQ Clarence Center, New York, Feb. 12, 2009, Human Performance Group Chairman Factual Report, Docket No. SA-531, and Addendum 1 DCA09MA027.  17 Rosekind, M.R., Gregory, K.B., Miller, D.L., Co, E.L. (2000). Crew factors in flight operations XII: A survey of sleep quantity and quality in on-board crew rest facilities. (Technical Memorandum 2000-20961). Moffett Field, CA: NASA and Rosekind, M. R., Gregory, K. B., Miller, D. L., Oyung, R. L., Neri, D. F., & Dinges, D. F. Sleep quantity and quality of augmented long-haul flight crews in on-board crew rest facilities. Sleep Research, 1997, 26:41.  4   

sleep loss, he had a cumulative sleep debt of between 6 and 12 hours, which reflected the 2 to 4 hours of sleep debt he accumulated over the course of each of the preceding three nights, two of which were spent in the crew lounge. At the time of the accident, he had been awake at least 15 hours – 3 hours more than the level at which the 1994 NTSB study identified performance degradation in accident flight crews. Finally, the accident occurred at the time of day when the captain would normally go to sleep.

The first officer was similarly not properly rested. The night before the accident, she commuted from Seattle to Newark, changing planes shortly after midnight in Memphis, and arriving in Newark at 0630, which was 0300 Seattle time. While she may not have experienced cumulative sleep debt, she likely had some acute sleep loss and, in the preceding 34 hours, had only gotten a maximum of 8.5 total hours of sleep – 3.5 hours of which were while traveling overnight cross-country (1 ½ hours from Seattle and 2 hours from Memphis to Newark), and the remaining 5 while resting in the company crew room. However, based on information contained in the docket including an interview of a flight attendant who had a conversation with the first officer during the 1100 hour, the 5 hours of rest in the crew lounge between 0800 and 1300 are questionable. Again, it is not likely that she obtained recuperative sleep in a busy, well-lit crew room.

Reflective of these facts, the Safety Board accident report concludes that “[t]he pilots’ performance was likely impaired because of fatigue…” However, the report diminishes the significance of this finding when it states that “[sic] the extent of their impairment and the degree to which [fatigue] contributed to the performance deficiencies that occurred during the flight cannot be conclusively determined.” More simply, the report concludes that while fatigue likely impaired the pilots’ performance, because we could not assign fatigue a percent or number, we discount it as a contributing factor of the accident.

This approach is not consistent with our determinations in other accident investigations. For example in the collision between a truck and an Amtrak train in Bourbonnais,18 the Safety Board stated that “despite the fact that the truck driver was suffering from fatigue at the time of the accident, investigators could not determine the extent to which fatigue accounted for his performance” (analysis page 55). However, that did not prevent the Board from citing in the probable cause for the accident the truck driver’s “inappropriate response to the grade crossing warning devices and his judgment, likely impaired by fatigue.” Similarly, in a collision between two trains in Macdona, Texas,19 the Safety Board concluded that “neither the engineer nor the conductor of the Union Pacific Railroad train made effective use of the time that was available to them to obtain rest.” In that accident, the Safety Board identified fatigue as the cause of the crew’s inappropriate response to wayside signals governing the movement of their train. Contributing to the crewmembers’ fatigue was their failure to obtain sufficient restorative rest prior to reporting for duty because of their ineffective use of off-duty time and the company scheduling practices which inverted their sleep cycles. In the 1989 grounding of the U.S. tank ship Exxon Valdez, many recall the intoxication of the ship’s Captain, but this was also a significant fatigue accident. Fatigue was identified as a major contributor that, subsequently, was given serious national and international attention when the Board stated that “there were no rested deck officers on the Exxon Valdez available to stand the navigation watch when the vessel departed from the Alyeska Terminal.”20 Fatigue was cited in the probable cause of the accident.                                                             18 National Transportation Safety Board, Collision of National Railroad Passenger Corporation (Amtrak) train 59 with a loaded truck-semitrailer combination at a highway/rail grade crossing in Bourbonnais, Illinois, March 15, 1999.  19 National Transportation Safety Board, Collision of Union Pacific Railroad Train MHOTU-23 With BNSF Railway Company Train MEAP-TUL-126-D With Subsequent Derailment and Hazardous Materials Release; Macdona, Texas; June 28, 2004; RAR0603.  20 National Transportation Safety Board, Grounding of U.S. Tank ship Exxon Valdez on Bligh Reef, Prince William Sound Near Valdez, Alaska, March 04 1989. NTSB/ MAR-90/04, Washington D.C.: NTSB.   5   

In other more recent Safety Board aviation accident investigations, the Board concluded that fatigue – even if unquantifiable – caused or contributed to the accident. For example, in the Shuttle America accident in Cleveland in 200721, the Board determined that fatigue was one of four contributing factors, such that the captain’s fatigue affected his ability to effectively plan for and monitor the approach and landing. Also in 2007, in our investigation of the Pinnacle, Traverse City accident,22 the Board found that poor decision making by the pilots likely reflected the effects of fatigue produced by a long, demanding duty day. In another case, the 2004 Kirksville, Missouri accident,23 the Board found that the pilots’ fatigue likely contributed to their degraded performance. It is important to note that similar to this accident, in the CVR transcripts for both the Shuttle America and Kirksville accidents, the crewmembers are engaged in conversation throughout the flight, chatting about various topics, and in the Kirksville accident their sterile cockpit violation is also cited in the probable cause. In each of these investigations, the Safety Board determined that fatigue caused or contributed to the accident. We should be making a similar determination here.

Presently, we do not have the tools to conclusively determine the degree to which a person is fatigued. We cannot pinpoint whether fatigue results in 20% memory reduction, 50% degraded decision-making ability, 25% slower reaction time, or some other value for each individual. This difficulty, however, does not mean we cannot – or should not – find that fatigue contributed to the accident. Making a determination that fatigue is a contributing factor does not detract from this accident report’s other determinations, nor is it an all-or-nothing proposition. A captain can be a poor performer and also be fatigued. The crew may violate the sterile cockpit rules and be fatigued. A first officer may not adhere to standard operating procedures and also be fatigued.

The issue of fatigue challenges us to periodically adjust our lens and take a fresh look to ensure that the aviation industry and the crews who fly our skies report to work rested and fit for duty. Fatigue is complex and multifaceted. During my time at the Board, we have issued recommendations about sleep disorders, flight and duty time revisions, fatigue management systems, education and training. I suggest that our failure to identify fatigue as a factor in this accident is not just a missed opportunity, but also turns a blind eye to a situation that even the average person can recognize. We are never going to change the debate on fatigue unless we face it head on. That means dealing with all aspects of fatigue – from revising the hours of service to sleep disorders to personal responsibility to commuting.

Flight crew commuting is particularly challenging. A regional flight crew’s home base changes often, and to offset the disruption of frequent relocations, pilots may commute from a home location. The Colgan Air pilots were commuting pilots. Both pilots were based in ERW but the captain lived in Florida and the first officer in Seattle. During the previous 14 months, the first officer lived in Phoenix (when hired by the company), then expected to be based in Houston before being sent to Norfolk, Virginia and then at the time of the accident, was based in Newark, New Jersey but lived in Seattle, Washington. Flight crew salaries are also problematic. It is financially challenging for pilots, whether earning $60,000 or $16,000, to regularly relocate their families or hold down multiple residences. When the FAA convened the fatigue                                                             21 National Transportation Safety Board, Aircraft Accident Report: Runway Overrun During Landing Shuttle America, Inc. Doing Business as Delta Connection Flight 6448 Embraer ERJ-170, N862RW Cleveland, Ohio February 18, 2007. AAR-08-01  22 National Transportation Safety Board, Aircraft Accident Report: Runway Overrun During Landing Pinnacle Airlines Flight 4712 Bombardier/Canadair Regional Jet CL600-2B19, N8905F Traverse City, Michigan April 12, 2007, AAR-08-02.  23 National Transportation Safety Board, Aircraft Accident Report: Collision with Trees and Crash Short of Runway, Corporate Airlines Flight 5966, British Aerospace BAE-J3201, N875JX, Kirksville, Missouri, October 19, 2004. AAR-06-01.  6   

7    ARC in the summer of 2009, they took commuting off the table, and neither Colgan, nor ALPA addressed the issue of commuting in their accident submission documents, even though 70% of the pilots based in Newark commute and 20% commute from over 1000 miles away. I recognize that an objective analysis of commuting will be a difficult, and perhaps, uncomfortable discussion. But we should not be afraid to confront this issue in the context of understanding fatigue and its effect on pilot performance.

The one constant throughout this discussion is that the causes of fatigue among pilots are fairly well- defined and that the results of fatigue, namely accidents of varying degrees, are well-known. Unfortunately, in the aviation industry, fatigue-related decisions – such as minimum crew hires, flight crew schedules and commuting – are decisions that too often reflect the economics of the industry, rather than the data and science of fatigue and human performance.

The tragedy in this accident report is that what we uncovered in the investigation, we already knew. The FAA talks about safety being their highest priority. Colgan Air’s slogan was never to compromise safety. The pilots want a safe profession. Yet, if we are serious about safety, we must establish an aviation system that minimizes pilot fatigue and ensures that flight crews report to work rested and fit for duty. Flying tired is flying dangerously, and it is a practice that needs to end.

Notation 8090C  Concurring Statement by Vice‐Chairman Christopher A. Hart    In concurring with the report and decision regarding this tragic accident, I commend the staff for such a  thorough and detailed investigation and report, and I commend the Board for bringing the benefit of  various viewpoints and perspectives to help address some very complex and difficult issues, including  several issues on which reasonable people can differ.  I also commend the staff for recommending that  two issues of industry‐wide significance be treated in an industry‐wide manner, rather than solely in  relation to this accident – (a) pilot professionalism, and (b) the impact upon safety of code‐sharing  arrangements between major and regional carriers.  In this concurring statement, I would like briefly to  address the first of those two issues as well as FOQA.    Pilot Professionalism  In the sunshine meeting I stated my concern that our commercial aviation system is experiencing a  declining percentage of airline pilots who have the benefit of military pilot training, and our system is  not adequately responding to the challenges that are being created by that decline.  Not only is military  training world‐class, but the military has a long history of effectively weeding out those who simply lack  “the right stuff.”    This is not to say that pilots cannot get world‐class training in our civilian system; but that system needs,  among other things, a more effective weeding process.  Currently the pilot licensing process is based  upon passing various written and flight tests – but there is no distinction between those who pass the  first time, versus those who don’t pass until the third time, versus those who don’t pass until the ninth  time.   Most of what most attorneys do is not potentially life‐threatening for their clients, yet some  states limit the number of times that lawyers‐to‐be can fail the bar exam.  In addition, I am aware of at  least one mode of transportation in which failure to pass a critical written test the second time results in  dismissal from the program, and passing the test requires a score of 100.     Similarly, there is no distinction in our civilian system between those who pass flight tests the first time  versus those, such as the captain in this accident, who failed the first attempt in several different flight  tests.      Moreover, written tests largely measure knowledge, and flight tests largely measure “stick and rudder”  skills.”  Other crucial attributes are not generally measured by either of these tests, such as discipline     

2    and judgment – two attributes for which the effectiveness of military training is also well known, but  that have also been shown lacking in this and other recent commercial aviation accidents and incidents.     Our civilian system needs to address the challenge of systematically continuing to provide the world‐ class pilot training that the military has provided for so many years, and the system particularly needs a  better way to keep out those who should not begin or continue flying passengers for hire.       Flight Operational Quality Assurance (FOQA)  Before coming to the NTSB I was involved in developing and facilitating various proactive information  programs at the FAA, and in doing so, I have frequently stated my opposition to mandating FOQA  programs.  Voluntary FOQA programs in the US provided much of the crucial information that the  industry safety processes used to decrease the US fatal accident rate by 65% from 1997 to 2007 –  amazing enough in and of itself, but even more so given that the industry was already generally  considered to be very safe in 1997.  Mandating FOQA in the wake of that success story could be viewed  as “punishing” those who did the right thing, and runs the risk of making the perfect, i.e., 100%  implementation of FOQA, the enemy of the good.    In a world in which FOQA programs are not as widely implemented as they are in the US, I certainly  understand why ICAO wants them mandated; but in the US, where voluntary implementation is so  widespread – the vast majority of passengers in the US are carried on airlines with FOQA programs – the  need for a mandate is not so apparent.    One of my major concerns about mandating FOQA is that a mandate could result in a loss of the  protection that FOQA information currently has when it is shared with the FAA.  When the proposal was  offered not to require sharing of the information with the FAA unless and until legislation is obtained  that protects information that is shared with the FAA, I felt that it would be better for the safety of the  system to concur with a mandate recommendation, as so modified, rather than having the mandate  recommendation be adopted by majority vote, over my dissent, as it was originally proposed. 

NTSB Aircraft Accident Report

1. Appendixes

Appendix A Investigation and Hearing Investigation The National Transportation Safety Board was notified of this accident about 2230 on February 12, 2009. A go-team launched early the next morning. Accompanying the team to Buffalo was former Board Member Steven Chealander. The following investigative teams were formed: Operations, Human Performance, Structures, Systems, Powerplants, Air Traffic Control, Meteorology, Aircraft Performance, Maintenance Records, and Pipeline. Also, specialists were assigned to conduct the readout of the flight data recorder and transcribe the cockpit voice recorder at the NTSB’s laboratory in Washington, D.C. Parties to the investigation were the Federal Aviation Administration (FAA), Colgan Air, Air Line Pilots Association (ALPA), National Air Traffic Controllers Association, and United Steelworkers Union (Flight Attendants). In accordance with the provisions of Annex 13 to the Convention on International Civil Aviation, the Transportation Safety Board of Canada (TSB) participated in the investigation as the representative of the State of Design and Manufacture (Airframe and Engines), and the Air Accidents Investigation Branch of the United Kingdom (AAIB) participated in the investigation as the representative of the State of Design and Manufacture (Propellers). Transport Canada, Bombardier, and Pratt & Whitney Canada participated in the investigation as technical advisors to the TSB, and Dowty Propellers participated in the investigation as a technical advisor to the AAIB, as provided in Annex 13. Public Hearing A public hearing was held from May 12 to 14, 2009, in Washington, D.C. Former Acting Chairman Mark Rosenker presided over the hearing; Board Member and current Chairman Deborah Hersman, former Board Member Kathryn Higgins, and Board Member Robert Sumwalt also participated in the hearing. The issues presented at the hearing were the effect of icing on airplane performance, cold weather operations, sterile cockpit rules, flight crew experience, fatigue management, and stall recovery training. The technical panel comprised investigators from the NTSB and the TSB. Parties to the public hearing were the FAA, Colgan Air, ALPA, and Bombardier. 174

NTSB Aircraft Accident Report 175 Appendix B Cockpit Voice Recorder The following is a transcript of the Honeywell model 6022 SSCVR 120 cockpit voice recorder, serial number 97896, installed on a Bombardier DHC-8-400, N200WQ, operated by Colgan Air, Inc., as Continental Connection flight 3407, which crashed into a residence in Clarence Center, New York, while on an instrument approach to Buffalo-Niagara International Airport, Buffalo, New York, on February 12, 2009:

LEGEND

CAM Cockpit area microphone voice or sound source

HOT Flight crew audio panel voice or sound source

INT Interphone voice or sound source

PA Public address sound source

RDO Radio transmissions from N200WQ

RAMP Radio transmission from Newark Ramp controller

GND Radio transmission from Newark Ground controller

TWR Radio transmission from the Newark Tower controller

DEP Radio transmission from New York Departure controller

ZNY Radio transmission from the New York Center controller

ZOB Radio transmission from the Cleveland Center controller

APP Radio transmission from the Buffalo Approach controller

OPS Radio transmission from the Colgan Buffalo Operations ground controller

-A First controller at identified ATC facility

-B Second controller at identified ATC facility

-C Third controller at identified ATC facility

-1 Voice identified as the captain

-2 Voice identified as the first officer

-3 Voice identified as the flight attendant

-? Voice unidentified

Unintelligible word Expletive

@ Non-pertinent word

( ) Questionable insertion

[ ] Editorial insertion Note 1: Times are expressed in Eastern Standard Time. 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.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 176 20:15:48 START OF RECORDING START OF TRANSCRIPT

20:16:03.4 HOT-1

heard somebody on the— on the phone earlier today before I saw you for the first time this morning. I believe it was— yeah yeah it was before that. that uh was talking about you know possibly getting Qs later this year.

20:16:11.0 HOT-2

uh-huh… oh yeah?

20:16:23.3 HOT-1

so there's been some scuttlebutt...uh...

20:17:30.3 RAMP

Colgan thirty four oh seven monitor ground on point eight. he'll be with you in about uh five minutes.

20:17:35.7 RDO-2

over to ground Colgan thirty four zero seven.

20:17:43.2 HOT-2

yeah I've heard so many things and people say this and people say that.

20:17:47.3 HOT-1

yeah.

20:17:47.6 HOT-2

I'm just— I'm surprised at how calmly— I usually don't do very well with not knowing what's happening. I like to know exactly what it's going to be you know in my future for the next day the next week the next month. and I'm just— now that I'm commuting from Seattle I'm thinking you know it really doesn't matter where you know I would— if it went anywhere else I'd put in a bid to go anywhere but Newark. I can't get farther away from Seattle really...well so much I like Florida but I just have never heard any of those rumors.

20:18:20.8 HOT-1

no I haven't either.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 177 20:18:22.1 HOT-2

or Atlanta.

20:18:22.8 HOT-1

actually the the the Saab would do pretty well as long as they weren't on uh they would never go on derivative power. [sound of throat clearing] they have a derivative uh— oh man DC ten. or an MD eleven. one of the two.

20:18:36.2 HOT-2

**.

20:18:41.3 HOT-1

FedEx. oh you know those guys. that was like a carrier landing to them.

20:18:45.2 HOT-2

yeah.

20:18:49.1 HOT-1

um anyway uhhh— what was I gonna say...oh the Saab.

20:18:57.1 HOT-2

yeah.

20:18:57.3 HOT-1

they have a derivative engine program that uhh you know when the engine starts producing less then then rated power you know they— then we go into a derivative situation. the only time it hurts which would really hurt in Florida obviously is when it's hot and heavy.

20:19:05.7 HOT-2

uh-huh...yeah.

20:19:16.8 HOT-1

you know it doesn't climb for beans. but but as far as— I flew the nineteen hundred in in Florida and to go down there in the summertime in the afternoon when the thunderstorms are all developing and everything that nineteen hundred gets tossed around pretty good.

20:19:35.5 HOT-2

yeah.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 178 20:19:36.1 HOT-1

but the uh the three forty is pretty solid. it it uh it bounces around but it it's so much heavier than the nineteen hundred it doesn't— it doesn't do too bad.

20:19:47.3 HOT-2

yeah I was flying in Flagstaff and the density in Arizona— the density altitude of I think it's like eleven thousand five hundred.

20:19:56.8 HOT-1

uh-huh.

20:19:58.5 HOT-2

and that I was just in like an Arrow— a Piper Arrow. but the runway slopes a little bit and you can't climb faster than the runway slopes like you'll take off and then the runway slopes up a little bit— Sedona does the same thing and I was there around the same week when it was just horrible density altitude. and you'd take off and my students would try to pull the nose up and I'd push it right back down and you know you'd hit the runway again before you can get enough speed to actually get up and off the ground. it's really not a very comfortable feeling.

20:20:24.5 HOT-1

wow.

20:20:27.5 HOT-2

but when it's a hundred and twenty down in Phoenix and you get a little bit higher in the mountains and you know it's still it's cooled down to a hundred and five but you're at you know seven thousand feet altitude.

20:21:22.9 HOT-2

I was in one of those this morning.

20:21:25.4 HOT-1

yeah.

20:21:26.1 HOT-2

I was in one of those this time last night.

20:21:41.2 HOT-1

ohhh heavens.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 179 20:22:23.7 HOT-1

you know the bad thing is is uh because they you know cancelled the Rochester round trip— or wherever we were going— was it Rochester? yeah I think it was.

20:22:33.7 HOT-2

yeah. now this doesn't mean anything.

20:22:35.7 HOT-1

this doesn't mean anything. you know you can't uh make a dime off of this.

20:22:41.0 HOT-2

yeah although I'm still excited about flight time so. [sound of laughter] I'm glad you know the more flight time I get the better.

20:23:14.1 HOT-?

[sound of sniffle]

20:23:14.5 HOT-2

no and they— I told you that they dropped a four day trip from my PC check.

20:23:18.8 HOT-1

yeah yeah yeah.

20:23:19.4 HOT-2

yeah so I think I'm at like sixty five hours or so anyways. it it would take a lot of over to get me up there.

20:23:33.1 HOT-2

did you see the lines for next month?

20:23:35.3 HOT-1

shew. yeah I saw them. not good for me. [sound of throat clearing]

20:23:39.4 HOT-2

ohhh. I printed them out I didn't look at them.

20:23:43.2 HOT-1

I'll be in the back. just a sec.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 180 20:23:44.7 HOT-2

I got one.

20:23:46.7 PA-1

folks from the flight deck just to keep you updated. uh we're we're gonna be sitting here just for a few more minutes uh... we did have some taxi delays out there obviously because of the uh the weather. uh planes are moving right now we're about number twenty uh for takeoff so it'll be uh it'll probably be another forty minutes. forty to forty five minutes before we're airborne. I appreciate your patience.

20:24:15.2 HOT-1

[sound of throat clearing]

20:24:30.3 HOT

[sound of double chime]

20:24:34.9 INT-1

what's up?

20:24:35.3 INT-2

hi. passengers would like to know if they can use cell phones. they all need to do some calls.

20:24:39.5 INT-1

oh I I figured as much. I thought about that right whenever uh I got done.

20:24:46.1 INT-3

that be okay?

20:24:46.7 INT-1

and I was just waiting for the call. I knew you were gonna call. I was just you know I was surprised you didn't call fifteen seconds earlier.

20:24:49.1 INT-3

[sound of laughter]

20:24:55.2 INT-3

and were gonna go ahead and give ‘em some water. is that okay?

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 181 20:24:58.2 INT-1

uh yeah but be careful because I may be moving up here just you know in just a little while just to a different place.

20:25:03.8 INT-3

okay. okay that's fine.

20:25:05.3 INT-1

and if you guys want to be up and uh do some water or something that'll be good.

20:25:07.2 INT-3

yeah yeah just in case we can't do any service in the air. ‘cause I have to tell you a lot of them are not very happy so we'll try to get them happy. [sound of laughter]

20:25:15.7 INT-1

okay that sounds wonderful. okay thanks.

20:25:16.8 INT-3

thanks. alright.

20:25:30.0 PA-3

ladies and gentlemen if you need to use your cellphones I have asked the captain and he said that it would be okay. thank you.

20:25:39.5 HOT-?

[sound of sniffle]

20:25:49.1 HOT-1

ohh heavens...I am glad I came over to the uh Q. my— my whole deal with uh you know comin' over even though I'm kind of getting screwed on the on the schedules.

20:26:05.6 HOT-2

yeah.

20:26:06.0 HOT-1

and I'll you how uh what it will do is if these things go to Houston in six months or nine months or whatever I'm already in the Q.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 182 20:26:16.5 HOT-2

yeah.

20:26:19.3 HOT-1

uh there are a lot of guys in Houston right now that have more seniority than I do uh um that refuse to go to the Q until it gets to Houston.

20:26:31.3 HOT-2

yeah.

20:26:32.1 HOT-1

so I figured well you know I'll go ahead and jump in the Q.

20:26:36.5 HOT-2

yeah.

20:26:37.0 HOT-1

uh maybe I'll be able to uh take another day off.

20:26:39.7 HOT

[sound of double chime]

20:26:41.2 HOT-1

I'll get it.

20:26:43.1 INT-1

yes?

20:26:43.5 INT-3

what about using the lav? we've got a couple of people that are a little annoyed because we're telling them they can't use the lav.

20:26:51.3 INT-1

uh well you know as long as I'm sittin' here uh let me know whenever they're seated because I I don't know when they're gonna— when they're gonna release us to uh to move. uh but go ahead and just keep us updated for each and every person that gets up to go to the lav I need to know when they're seated. when they're seated.

20:27:09.1 INT-3

oh okay.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 183 20:27:09.7 HOT-1

okay?

20:27:10.4 INT-3

alright.

20:27:11.1 INT-1

alright.

20:27:11.5 INT-3

alright.

20:27:11.8 INT-1

tell them to piss off early.

20:27:14.9 HOT-2

[sound of laughter]

20:27:17.7 HOT-2

[sound of throat clearing]

20:27:30.8 HOT-1

anyway. um you know I jumped on this thing. I figured you know I was busting my butt on the on the Saab.

20:27:39.2 HOT-2

yeah.

20:27:39.8 HOT-1

um my philosophy is it's all about the pay credit.

20:27:44.3 HOT-2

uh-huh.

20:27:44.6 HOT-1

'kay that's what I live and breath by but uh I mean I had one month last summer uh July or August. had a hundred forty seven hours of pay credit.

20:27:59.0 HOT-2

yeah...that's nice.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 184 20:27:59.4 HOT-1

that was sweet. and and I you know I never did but I thought man if I— if I was on the Q—.

20:28:05.5 HOT

[sound of double chime]

20:28:07.3 HOT-2

that'd be so much more.

20:28:08.3 HOT-1

yeah oh gosh yeah.

20:28:09.2 INT-2

howdy.

20:28:10.3 INT-3

I have someone in the lav right now and then there'll be another person going in and I'll let you know when they're out and seated. okay?

20:28:17.1 INT-1

alright.

20:28:17.5 INT-3

alright thanks.

20:28:19.9 HOT-1

um but you know once I get down there it's gonna take a month month and a half for everybody to go through you know how ever many they take at a time.

20:28:27.9 HOT-2

yeah.

20:28:30.4 HOT-1

once it gets down there. plus there's also a bunch of other guys that are here that uh—.

20:28:36.6 HOT-2

[sound of sneeze]

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 185 20:28:37.4 HOT-1

bless you. that want to uh go back to Houston.

20:28:41.9 HOT-2

yeah.

20:28:42.9 HOT-1

a bunch.

20:28:45.4 HOT-2

there's a ton of em.

20:28:48.8 HOT-1

there's uh there's even a few that uh have never been to Houston [sound of laughter] that want to get the heck out of Newark.

20:28:54.5 HOT-2

that's that's me.

20:28:55.8 HOT-1

so—.

20:28:56.8 HOT-2

I'll go. I'll put in a bid for wherever this thing goes. I figured they— if it went to Houston there might be some more FOs that would want to transition over but they'd let me go down before they transition other guys over wouldn't they? yeah.

20:29:08.1 HOT-1

oh sure oh sure. because they would let you go as the openings are available and your seniority dictates.

20:29:14.4 HOT-2

yeah yeah.

20:29:16.3 HOT-1

uh once you get down there and and this would be very similar to me.

20:29:20.8 HOT-2

yeah.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 186 20:29:21.1 HOT-1

uh—.

20:29:22.7 HOT-2

they can't kick me out once they allowed me down there though can they?

20:29:25.1 HOT-1

oh no no.

20:29:25.9 HOT-2

yeah.

20:29:26.6 HOT-1

but it but it would happen the exact same thing with me as it would with you.

20:29:31.8 HOT-2

yeah.

20:29:32.4 HOT-1

we get down there shew we get this schedule this schedule this schedule and as they kept as they keep transitioning people over our schedules get worse and worse and worse.

20:29:36.3 HOT-2

yeah yeah worse and worse and worse.

20:29:43.8 HOT-1

but uh you know that's that's in the future we'll see what happens.

20:29:44.5 HOT-2

[sound of sniffle]

20:29:49.0 HOT-2

yeah.

20:29:50.0 HOT-1

but even on the Saab uh I was able to make about uh gross about sixty thousand last year so—.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 187 20:30:02.4 HOT-2

I made gross fifteen thousand eight hundred. I got here in January. aww.

20:30:03.0 HOT-1

but I— yeah no I know no I know. I I understand. I was on the on the uh FO uh welfare—.

20:30:12.9 HOT-2

you were there when it was nineteen an hour weren't you?

20:30:15.4 HOT-1

no I never was on nineteen. no.

20:30:16.3 HOT-2

[sound of sniffle] oh. that's good.

20:30:20.1 HOT-2

I'm just lucky 'cause I have a husband that's working.

20:30:22.2 GND

Colgan thirty four zero seven you're at romeo mike correct?

20:30:25.4 RDO-2

uh romeo hotel Colgan thirty four zero seven.

20:30:27.6 GND

okay Colgan thirty four zero seven out of romeo hotel roger. you're gonna give way to Delta from the left and then taxi via bravo and hold short of kilo.

20:30:37.8 RDO-2

give way to Delta then bravo short of kilo for Colgan thirty four zero seven.

20:30:41.8 HOT-2

[sound of sniffles]

20:30:42.8 HOT-1

alright give way to Delta then I'm sorry.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 188 20:30:44.5 HOT-2

bravo short of kilo.

20:30:45.6 HOT-1

bravo short of kilo.

20:30:46.8 HOT-2

I don't see a Delta.

20:30:48.0 HOT-1

right here. this uh plane here.

20:30:50.0 HOT-2

oh gotcha.

20:30:51.9 HOT

[sound of double chime]

20:30:55.6 HOT-1

[sound of throat clearing]

20:30:56.8 INT-3

hello?

20:30:57.9 INT-1

hey are they are they back?

20:30:58.6 INT-3

I still have another one in the bathroom and another one waiting. do you need—.

20:31:02.6 INT-1

no I uh I uh we need to go.

20:31:04.9 INT-3

okay uh.

20:31:05.1 INT-1

so the one waiting has to wait and I I'm gonna have to coordinate to uh.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 189 20:31:05.8 INT-3

okay okay. one in there right now as soon as she comes out I'll—.

20:31:14.7 INT-1

alright well this is— I was afraid of this. alright thanks.

20:31:16.3 INT-3

okay okay alright.

20:31:25.5 HOT-2

she might get out in time.

20:31:30.0 HOT-1

God.

20:31:34.4 CAM

[sound similar to door closing]

20:31:35.4 HOT-2

there you can hear her getting out now.

20:31:36.8 HOT-1

yeah.

20:31:42.4 HOT-2

totally lose our spot you can hear him.

20:31:49.3 HOT-2

here I go.

20:31:49.7 HOT

[sound of double chime]

20:31:50.4 INT-2

that it?

20:31:51.3 INT-3

okay we're good.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 190 20:31:55.6 HOT-?

[sound of sniffle]

20:32:15.2 HOT-1

I hate to make people wait. I understand needs and all that kind of stuff but uh.

20:32:17.4 HOT-2

oh I know but if it means us taking off and us three people later in line.

20:32:48.3 HOT-1

alright bravo short of kilo.

20:33:05.6 HOT-1

yeah we're on ground now right?

20:33:08.8 HOT-2

yeah.

20:33:10.0 HOT-?

[sound of sniffle]

20:34:02.1 HOT-?

[sound of sniffle]

20:34:06.5 GND

Colgan thirty four zero seven Newark Ground two two right at whiskey continue juliet at romeo follow JetBlue.

20:34:14.4 RDO-2

juliet at romeo follow JetBlue Colgan thirty four zero seven.

20:34:18.5 HOT-1

yeah JetBlue's right behind uh the bent wing pencil jet.

20:34:25.7 HOT-2

[sound of laughter]

20:34:27.0 HOT-1

looked like a bent wing maybe it's not.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 191 20:34:31.2 HOT-2

what's that mean?

20:34:31.8 HOT-1

it's just a lawn dart.

20:34:33.0 HOT-2

oh I've never heard the term bent wing.

20:34:37.3 HOT-1

bent wing is winglet.

20:34:39.1 HOT-2

oh oh gotcha.

20:35:16.7 HOT-2

come on JetBlue. I didn't realize JetBlue came in to here. I wonder where they go from.

20:35:22.7 HOT-1

they have uh one flight to Tampa they have uh couple flights to Fort Lauderdale and uh three or four flights to Orlando.

20:35:30.7 HOT-2

out of Newark?

20:35:31.9 HOT-1

out of Newark.

20:35:33.6 HOT-2

oh okay well that doesn't help me at all. 'cause JetBlue does a ton— there's like four flights from Seattle to JFK a day and I decided I figured it out that'd be you know if I'm only doing it a couple times a week or a couple times a month or like once a month. that's only— I think there's a twenty five dollar shuttle.

20:35:51.1 HOT-1

yeah.

20:35:52.1 HOT-2

that's not so bad.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 192 20:35:53.9 HOT-1

they have free TV. live TV.

20:35:55.7 HOT-2

on the shuttle?

20:35:57.1 HOT-1

on uh JetBlue.

20:35:57.7 HOT-2

oh on JetBlue.

20:35:58.8 HOT-1

you got to pay for your for your movies though. if you ever— if you fly Continental if they fly seven fives or the uh seven three nine hundreds the ones that are equipped you got free movies.

20:36:13.2 HOT-2

that's cool.

20:36:13.4 GND

Lufthansa four one three heavy at juliet follow the Continental Express Embraer— make that the Continental uh Dash eight Q four hundred series.

20:36:19.6 HOT-2

Q four hundred.

20:36:33.0 GND

Colgan thirty four zero seven you follow JetBlue that's your sequence about number sixteen. monitor the tower.

20:36:39.8 RDO-2

follow JetBlue and monitor tower Colgan thirty four zero seven.

20:36:48.2 HOT-?

[sound of sniffles]

20:37:11.4 PA-3

ladies and gentlemen at this time once again if you'd be so kind and turn off your cell phones. thank you.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 193 20:37:17.8 HOT-2

you think they'd just be launching us off two two since all these planes have circle to land two nine...you'd think they'd be using the right and the left. [sound of sniffle] well I guess never mind because then you've got spacing going to the—.

20:37:35.5 HOT-1

yeah the spacing off the arrivals still because uh until they break.

20:37:37.4 HOT-2

yeah. that's right I forget about all that.

20:37:59.9 HOT

[sound of master caution chime]

20:38:00.7 HOT-?

[sound of sniffle]

20:38:03.4 HOT

[sound of double chime]

20:38:05.4 INT-3

hello?

20:38:06.1 INT-1

hey if that one would like to go to the restroom now go ahead.

20:38:09.1 INT-3

oh okay thank you.

20:38:10.6 INT-1

and let me know if anybody else is in need uh after that one.

20:38:14.1 INT-3

okay thank you. buh-bye.

20:38:14.7 INT-1

okay thanks.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 194 20:38:19.3 HOT-1

oh let's see. what was I gonna tell— I was gonna tell you something. I didn't want to really say it off of uh in front of the ramp guys.

20:38:28.1 HOT-2

oh you didn't have your FOPP. [Flight Operations Policies and Procedures Manual]

20:38:29.6 HOT-1

oh yeah yeah yeah yeah yeah yeah uh you know @ right?

20:38:34.3 HOT-2

yeah.

20:38:34.9 HOT-1

um he was doing his PC check today.

20:38:37.4 HOT-2

uh-huh.

20:38:38.0 HOT-1

he came up last night and he's you know he's always been real good you know as far as just uh seems like a top notch guy.

20:38:45.9 HOT-2

yeah.

20:38:46.3 HOT-1

and he came in and he just— uh it just looked like his face was drained you know all the blood out of it and everything. he just came in told me he was headed to his PC check today. and he said he got on the plane he went to pull it out to uh to study.

20:39:05.5 HOT-2

he was using it to study yeah.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 195 20:39:07.6 HOT-1

and he said it was not in his bag. says that was the first time he uh uh he figured out that he didn't have it. he left it at home. he says I've been with the company I forget what he said five or six years this is— this is the first time he's ever done that. I said dude it happens to the best of us. I said let's see if we can help you out so I gave him mine I said yeah I just got to make sure my FO has it you know tomorrow. we ha— we have to have one in the—.

20:39:36.8 HOT-2

yeah I've got mine.

20:39:37.9 HOT-1

and so that's all we have to have. but uh made sure it was up to date um which it was and uh he took it down there.

20:39:51.1 HOT-2

that was nice of you.

20:39:52.9 HOT-1

and he was he was coming in from Saint Lou— uh coming in from Saint Louis. he was gonna try to and make the one thirty flight today to get in at five oh clock.

20:40:03.0 HOT-2

to Saint Louis?

20:40:04.3 HOT-1

in. one thirty out of Saint Louis in here at five oh clock.

20:40:07.8 HOT-2

oh yeah?

20:40:08.3 HOT-1

and that flight was delayed until five thirty so he wasn't going to be in until uh about— what time is it now? eight oh clock it's eight forty yeah it's uh it's due in about any time.

20:40:20.0 HOT-2

yeah...yeah.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 196 20:41:31.1 HOT-?

[sound of sniffle]

20:41:34.5 HOT-2

oh I'm ready to be in the hotel room.

20:41:38.2 HOT-1

I feel feel feel bad for you as far as feeling **.

20:41:44.2 HOT-2

well this is one of those times that if I felt like this when I was at home there's no way I would have come all the way out here. but now that I'm out here.

20:41:51.7 HOT-1

you might as well.

20:41:52.7 HOT-2

I mean if I call in sick now I've got to put myself in a hotel until I feel better. you know we'll see how how it feels flying. if the pressure's just too much I you know I could always call in tomorrow at least I'm in a hotel on the company's buck but we'll see. I'm pretty tough.

20:42:09.3 HOT-?

[sound of sniffle]

20:42:15.3 HOT-1

oh that Airborne may help out a little bit.

20:42:18.4 HOT-2

yeah.

20:42:19.1 HOT-1

you could kill it with uh you know a bunch of OJ or a bunch of vitamin C.

20:42:24.1 HOT-2

yeah I've got um got ‘em to give me a a carton of orange juice to take home with me.

20:42:51.6 HOT-1

is that a triple seven? for TAP? oh nope it's an Airbus three thirty.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 197 20:42:55.7 HOT-2

no it's an Airbus.

20:43:00.8 HOT-?

[sound of sniffle]

20:43:10.2 HOT-2

so what did you do before you started flying for Colgan?

20:43:13.6 HOT-1

oh I I'd been in the airline industry for a while. I worked for uh the original Piedmont Airlines merged with US Airways. watched two companies— two profitable companies with two completely different cultures uh merge together and turn to a pile of crap.

20:43:33.5 HOT-2

oh that's too bad.

20:43:34.8 HOT-1

and I lost my job in the— in the merger.

20:43:39.0 HOT-2

how'd you lose your job?

20:43:40.5 HOT-1

uh they took the position that I was doing— um do you have any napkins over there by chance?

20:43:45.6 HOT-2

oh yeah I've got a whole load of them in my thing.

20:43:48.6 HOT-1

[sound of coughing]

20:43:50.2 HOT-1

thanks. uh they made my— well I I I guess I could— don't mean to say I lost my job but uh they gave me a a very poor choice to make.

20:44:03.3 HOT-2

yeah.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 198 20:44:03.8 HOT-1

or a very poor alternative.

20:44:06.6 HOT-2

what was that?

20:44:07.1 HOT-1

uh I was in a management position— well I was temporarily in a management position. and because I was temporarily in that management position for longer than thirty days they considered me part of that department although I was not being paid the full management salary I was just getting a little uh...

20:44:10.2 HOT-2

[sound of sniffle] uh-huh...yeah.

20:44:33.1 HOT-1

...whatever you want to call it. uh a little add on. and anyway so uh they turned that position into a clerical position.

20:44:37.1 HOT-2

[sound of sniffle]

20:44:49.7 HOT

[sound of double chime]

20:44:54.4 INT-3

yes sir.

20:44:54.9 INT-1

hey is everyone down?

20:44:56.4 INT-3

yeah.

20:44:57.3 INT-1

okay thanks.

20:44:57.9 INT-3

okay.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 199 20:44:59.7 HOT-1

um so they gave us uh an alternative uh an option to stay with the job it was going to a clerical position. we would lose approximately sixty five percent of our salary.

20:45:14.6 HOT-2

whoa.

20:45:15.8 HOT-1

um or you know sayonara so I went sayonara.

20:45:23.9 HOT-2

yeah I would too.

20:45:26.6 HOT-1

and then I worked for American Express for a while as a contract— a contract employee with RJ Reynolds tobacco company.

20:45:36.0 HOT-2

oh yeah.

20:45:36.6 HOT-1

and uh did a lot of travel packages hospitality events driver appearances

20:45:42.6 HOT-2

oh that's cool.

20:45:43.5 HOT-1

uh for uh for NASCAR uh NHRA track racing AMA superbikes unlimited hydroplane. that was— that was probably the best job I've ever had. probably the best one ever. just the most fun. it was challenging at times yet it was very rewarding you get to go to to the events and all that kind of stuff.

20:46:04.0 HOT-2

oh I bet. why'd you leave there?

20:46:07.8 HOT-1

uh the uh political uh arena with uh the tobacco companies and smoking in in general and that stuff.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 200 20:46:14.8 HOT-2

oh.

20:46:18.4 HOT-1

uh the biggest thing that I ever learned in a business law class is uh US domestic laws are dictated by social acceptance. had a textbook about this thick.

20:46:28.7 HOT-2

yeah.

20:46:29.4 HOT-1

that was one sentence out of the— one of the chapters.

20:46:33.3 HOT-2

uh-huh.

20:46:33.6 HOT-1

that has stuck with me ever ever since I took that business law class.

20:46:37.7 HOT-2

oh that's funny.

20:46:38.4 HOT-1

and it is so true.

20:46:39.7 HOT-2

yeah.

20:46:40.3 HOT-1

uh I mean there's just so many examples that you could use. and and and look back and say that's true as true could be. but uh so they were cut back— oh and I did the sweepstakes stuff too. uh that was a whole messload of fun.

20:46:58.8 HOT-2

oh yeah?

20:46:59.0 HOT-1

they'd have different sweepstakes for their different uh cigarette brands.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 201 20:47:01.8 HOT-2

uh-huh.

20:47:02.0 HOT-1

and like they'd have the uh uh Salem cigarettes their menthol brand. uh Salem's fortieth anniversary when the did uh they did forty winners for a three night cruise in the Bahamas.

20:47:20.0 HOT-2

oh that's cool.

20:47:21.0 HOT-1

so uh they gave me— basically they— uh I develop a package uh wrote all the little fine print went through legal with that made sure I was okay and uh then I just waited. waited until they had the drawing and they gave me a list of forty names. it wasn't just myself uh I was— I was the main contact point but uh I had two other people that uh helped me out with that and we had a whole a blast of fun. I mean we'd contact the winners and say you know this is so and so from American Express Travel on behalf of RJ Reynolds Tobacco Company and uh we have your name and we'll do your travel. uh and this is what's planned. this is you know all kinds of things to do. so anyway I did that as well.

20:47:26.9 HOT-2

yeah...yeah.

20:48:12.7 HOT-1

but uh just with all the political mumbo jumbo they uh they were cutting back on their brand promotions and sweepstakes and everything.

20:48:20.5 HOT-2

yeah.

20:48:20.8 HOT-1

so uh uh I transferred with American Express and went down— back down to Tampa er back down to Florida. I was in Orlando to get my **. but uh after that I worked for Verizon for a little while.

20:48:28.4 HOT-2

yeah....Horizon?

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 202 20:48:39.5 HOT-1

Verizon.

20:48:41.1 HOT-2

oh Verizon. oh okay.

20:48:41.2 HOT-1

Veri— yeah. uh worked in the uh high speed internet uh division.

20:48:45.6 HOT-2

okay.

20:48:46.3 HOT-1

uh sold DSL and all the peripherals that go along with it. DSL and dial up and helped uh I was on the beta team for uh uh their FTTP is what we call just the FTTP FTTP program which is fiber tooth the premise is now called Verizon FIOS.

20:49:06.6 HOT-2

yeah okay.

20:49:10.0 HOT-1

and FIOS is out in uh would be out in the Seattle areas— some of the Seattle areas uh—.

20:49:17.1 HOT-2

they just did that in the apartments that I was at in the Chesapeake I think.

20:49:20.7 HOT-1

yeah yeah they go in and do uh you know like uh like an exclusive arrangement with a— with a community whether it's a you know a housing community a development or something like that or a condo community or you know apartments or whatever. they'll go in and do like an exclusive arrangement for x number of years and then go in and sell it to everybody give them a good price. but uh we developed all the the policies and procedures the setup. all that kind of stuff.

20:49:21.8 HOT-2

yeah.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 203 20:49:26.7 HOT

[sound of master caution chime consistent with parking brake application]

20:49:56.3 HOT-2

oh that's neat.

20:50:01.1 HOT-1

so that was neat. they— they gave they gave a big package to management employees. it was geared toward the old uh technology people in management positions. uh but they extended it— extended it to everybody except wireless. and I wasn't in you know I wasn't part of wireless so I I took the package and left and went flying.

20:50:32.7 HOT-2

okay.

20:50:32.9 HOT-1

I went through Gulfstream's program 'cause uh you know it was just the best program for for my needs and and what I needed you know the timeframe that I had. you know how fast I wanted to get into the one twenty one environment and all that. so it really uh really worked out well for me.

20:50:56.9 HOT-2

that's good.

20:50:58.3 HOT-1

got hired with Colgan right after that.

20:51:01.5 HOT-2

you've been here you said four years?

20:51:03.4 HOT-1

what's that?

20:51:04.7 HOT-2

you said you've been here four years?

20:51:06.1 HOT-1

uh almost four years. about eh three and a half years.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 204 20:51:17.9 HOT-1

silly old Gulfstream they uh— I even had an interview with Pinnacle to go fly uh the RJs because they had a preferential program with uh Gulfstream preferential— preferential interview process.

20:51:29.3 HOT-2

oh yeah?

20:51:32.1 HOT-1

and uh I turned down the job because at that time they weren't they weren't paying anything for training.

20:51:40.6 HOT-2

oh yeah?

20:51:46.6 HOT-1

they just at that at that point in time I just like well if the company can't even invest in their employees as they go through training you know some sort of uh stipend or or something like that. fifty dollar a day per diem or—.

20:52:02.6 HOT-2

yeah. oh they weren't giving anything?

20:52:05.6 HOT-1

no.

20:52:05.9 HOT-2

oh.

20:52:07.4 HOT-1

nope they weren't giving anything.

20:52:09.0 HOT-2

jeez.

20:52:10.5 HOT-1

I mean I had a place to stay but you know I'dve still been out of out of uh income for about ten weeks is what they were calling for.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 205 20:52:18.5 HOT-2

yeah that's— that's really tough.

20:52:34.2 HOT-?

[sound of sniffles]

20:52:39.7 PA-1

folks from the flight deck just to uh give you another update. we're getting a little bit closer. we're still about number ten for departure. and we'll be airborne just uh shortly and just to kind of uh pass on a little bit more information from uh other pilots who have taken off earlier uh the turbulence has uh decreased uh quite a bit but uh there's still gonna be some bumps on the climbout so make sure those seatbelts are fastened tightly. thanks.

20:53:16.7 HOT-2

they're calling winds three hundred at fifteen.

20:53:19.6 HOT-1

three hundred at fifteen.

20:53:43.7 HOT-1

interviewed with Colgan and and uh they gave me the choice of either going on the nineteen hundred or the Saab. I told them I've flown the nineteen hundred and it would be a pretty easy transition just learning the the particular you know profiles and callouts for Colgan as opposed to Gulfstream. I said but I'd rather have the the Saab so I could learn you know a little bit more CRM because they have a flight attendant and also uh I liked the bases better that the Saab had to offer.

20:54:12.1 HOT-2

yeah...yeah.

20:54:23.1 HOT-1

and uh I I was interviewing— have you ever flown with @?

20:54:28.0 HOT-2

nope.

20:54:28.4 HOT-1

do you know who he is?

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 206 20:54:29.3 HOT-2

I know who he is.

20:54:31.1 HOT-1

he uh he was interviewing me along with uh @.

20:54:32.1 HOT-2

**.

20:54:37.0 HOT-2

oh okay.

20:54:37.8 HOT-1

and uh I asked him after the interview. I said you know that's I mean that was an honest answer but I'd be more challenged in the in the Saab. he said no man that was a perfect answer. so.

20:54:49.7 HOT-2

oh that's good. well they asked me what I wanted. I said I wanted the Q. I didn't know much buh difference between the Saab and the Q but um and they said well tough you can't have it. [sound of laughter] so I was like why did you ask me if you told me I can't have it? so then they put me in the Saab I got everything ready we were all set cause we wanted— me and my husband I mean we lived in Phoenix for a few years we don't have kids we don't have any commitments. we just you know we wanted to experience living in different places before we settled back down in Seattle so we were geared up ready to move to Houston.

20:55:08.7 HOT-1

yeah...yeah go ahead.

20:55:14.9 TWR

attention all aircraft. current altimeter two niner six one.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 207 20:55:20.7 HOT-2

uh six one's the altimeter. uh geared up ready to move to Houston. and then the day before I was supposed to go to training @ called and basically begged me to switch to the Q and that pushed me back a week in training and I waited a week and I asked my husband I said look when I upgrade like thirteen dollars an hour more. it's a bigger plane. I'd rather fly this plane than the Saab. he says hey we haven't signed anything we haven't— so we just like switched our whole gears up to Virginia.

20:55:46.6 HOT-1

wow.

20:55:48.9 HOT-2

if they'd told us that all those outstations were gonna close and we'd come to Newark but but we're ready to be back in Seattle anyway.

20:55:56.1 HOT-1

are you from that area originally?

20:55:58.5 HOT-2

yeah all my family's there. all my husband's family is there. we both grew up in Seattle. so we want to settle— we want to buy a house with the market the way it is and I mean it's hard to pass up buying a house right now.

20:56:06.2 HOT-1

yeah.

20:56:15.0 HOT-2

we * get you know my sister bought a house last year. she thought she was buying in the bottom of the market and her house has already decreased thirty thousand dollars in value.

20:56:19.7 HOT-1

uh-huh...dohhh wow.

20:56:24.8 HOT-2

yeah. and we know that that might happen to us too but we're not gonna— we're not looking to sell in a year or two. we're looking to buy settle down and live there for you know five to ten years.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 208 20:56:30.0 HOT-1

yeah...it's it's gonna take about that before it uh comes back up. yeah.

20:56:36.8 HOT-2

picks back up.

20:56:40.7 HOT-1

but it's it's got to be close to the bottom if not at the bottom at this point in time.

20:56:45.8 HOT-2

yeah.

20:56:51.3 HOT-1

yeah I I think— I don't know if it were me if I were buying at this point in time I think I would start looking about halfway through the year.

20:56:59.7 HOT-2

yeah.

20:57:00.6 HOT-1

halfway or you know into August September time frame.

20:57:04.0 HOT-2

yeah well we're helping my grandpa right now is—. he is a hundred and he's losing— he doesn't— he's losing his memory. he he can't function. somebody has to be with him twenty four hours a day. he's not so bad— I mean if he if he could just— if he couldn't remember who people were all the time we'd put him in a home.

20:57:23.1 HOT-1

right.

20:57:23.9 HOT-2

but in the morning he's really sharp and then in the afternoon he's got what's called Sundowner’s it's like part time Alzheimer's.

20:57:29.2 HOT-1

okay.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 209 20:57:29.3 HOT-2

like in the afternoon he starts to go a little- he can't remember. and so my parents have been going insane. they live next door. they've been having to be there all the time and my aunts are having to be there. it's so hard so— while my husband finds a job we've been kind of staying between my parents house and his house helping out to give them a break. and then that gives us a break. we're not stuck in a lease for when we find a house.

20:57:50.7 HOT-1

uh-huh...right.

20:57:54.4 HOT-2

and it— you know it's really nice because everything we're saving goes straight to a down payment so.

20:58:00.4 HOT-?

[sound of sniffle]

20:58:04.3 HOT-1

yeah I've got a cousin that flies for UPS. he uh flies uh seven fives seven sixes right seat.

20:58:11.6 HOT-2

yeah.

20:58:11.8 HOT-1

he's in his tenth— or well past his tenth year so he's now in his eleventh year.

20:58:15.6 HOT-2

yeah.

20:58:18.4 HOT-1

and uh they just sold their house bout uh bout a year ago and they just bought another house uh and moved into it just at the end of this past year.

20:58:32.4 HOT-2

yeah.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 210 20:58:33.1 HOT-1

so he he was kind of— he— they sold kind of as the market was going down.

20:58:38.7 HOT-2

that's good though.

20:58:38.8 HOT-1

they got— they got you know uh something decent out of it. he said he didn't get quite as much as he could have it he would have sold it you know six or eight months before.

20:58:49.7 HOT-2

yeah.

20:58:50.1 HOT-1

but um they they didn't lose any money by any means.

20:58:54.8 HOT-2

oh that's good.

20:58:55.7 HOT-1

and uh he got uh it was a house that he said he he had uh put an offer on and somebody else had already put an offer on which was a lot more money. and he he said well he could you know it just wasn't worth it to him.

20:59:14.0 HOT-2

no point in getting into a bidding war in today's market.

20:59:17.8 HOT-1

yeah exactly. and uh the guy's financing did not go through.

20:59:24.1 HOT-2

oh that's nice.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 211 20:59:25.4 HOT-1

and uh you know it's still for sale still for sale still for sale and my cousin said he called and asked if it you know if it was still for sale or was it still pending. he said no the financing had had fallen through. so he offered— uh offered him forty or fifty thousand dollars lower than what they had offered him at first.

20:59:49.4 HOT-2

yeah.

20:59:49.8 HOT-1

and theirs was already the low offer.

20:59:51.6 HOT-2

yeah.

20:59:51.6 HOT-1

and they got— and they took it.

20:59:53.5 HOT-2

that sucks. oh I mean it's great for your cousin but.

20:59:56.4 HOT

[sound of master caution chime consistent with parking brake application]

20:59:56.5 HOT-1

yeah yeah yeah I mean it sucks for them exactly.

20:59:57.7 HOT-2

yeah.

20:59:59.1 HOT-1

because they were trying— they were trying to get out it. and they were obviously trying to get the best they could.

21:00:03.0 HOT-2

no of course.

21:00:04.0 HOT-1

just like everybody else does.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 212 21:00:05.4 HOT-2

yeah.

21:00:09.6 HOT-1

ohh wow that guy is— oh we'll see how close this is.

21:00:13.2 HOT-2

ooo...that's not gonna happen.

21:00:23.0 HOT-1

that's a seven two seven just landed. oh that's not too bad. okay.

21:00:28.0 HOT-2

oh yeah 'cause now he just got a thirty knot headwind.

21:00:28.9 HOT-1

*.

21:00:38.2 HOT-2

that wasn't very * it looked a lot closer.

21:00:40.4 HOT-1

yeah it did. it really did.

21:01:11.2 HOT-2

everybody's five.

21:01:29.1 HOT-2

Cargojet?

21:01:31.1 HOT-1

yeah that was that seven two that just—.

21:01:32.3 HOT-2

yeah.

21:01:34.1 HOT-1

Cargojet whoever that is.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 213 21:01:35.4 HOT-2

yeah.

21:02:46.2 HOT-1

Continental fifty. going to Frankfurt.

21:02:59.1 HOT-1

have you guys done very much travelling?

21:03:01.1 HOT-2

um-hmm.

21:03:01.7 HOT-1

oh good.

21:03:02.9 HOT-2

yeah we— my husband goes to— he was going to Phoenix almost every month. when he drilled there. he drilled once a month there.

21:03:10.2 HOT-1

uh-huh.

21:03:10.9 HOT-2

and uh he just got based back in Seattle which is nice because he make more in one weekend of drill than I make in an entire pay cycle here.

21:03:19.6 HOT-1

that sucks. what branch is he with?

21:03:20.3 HOT-2

well he's army.

21:03:23.1 HOT-1

army.

21:03:23.1 HOT-2

uh that'll hopefully change now I— the next paycheck that comes should have my five dollar raise on it.

21:03:30.3 HOT-1

good.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 214 21:03:30.8 HOT-2

I thought the last one should because I got hired January sixteenth. but apparently the sixteenth through the thirtieth they said that you don't get your raise until the pay period after.

21:03:39.3 HOT-1

it would be the twentieth.

21:03:40.7 HOT-2

yeah that made me— but but no— but my but my pay from the sixteenth to the thirtieth didn't have the raise in it.

21:03:46.1 HOT-1

uh-huh.

21:03:47.6 HOT-2

and I got hired on the sixteenth.

21:03:48.8 HOT-1

that's okay. it'll it'll be retroed back.

21:03:50.8 HOT-2

no no she said it wouldn't. I called and asked.

21:03:53.1 HOT-1

why wouldn't it be retroed back?

21:03:54.1 HOT-2

because she says that your raise doesn't take effect until the first pay period— the first full pay period after you got hired. so I got hired on the sixteenth and the pay period started on the sixteenth. so from the sixteenth to the thirtieth that my raise wasn't in effect until after that. I'm thinking that's like two hundred buck— two hundred bucks to an FO is a lot of money.

21:04:12.6 HOT-1

ohhh I think I'd question that.

21:04:15.0 HOT-2

I did. and she— and I called payroll and they said that that's just how policy is.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 215 21:04:23.7 HOT-2

so I talked to two different people. I talked to payroll and they gave me someone from HR and that's what it— both of them said that and I thought that was a load of crap.

21:04:30.0 HOT-1

okay oh that's not the way they used to do it. that may be how Pinnacle does it.

21:04:35.1 HOT-2

yeah but.

21:04:36.7 HOT-1

that's not how Colgan used to do it.

21:04:39.1 HOT-2

no but I'll be getting an extra two hundred dollars each paycheck. now I'll be making more than he does in a weekend but.

21:04:45.1 HOT-1

[sound of laughter]

21:04:45.5 HOT-2

[sound of laughter] that's good.

21:04:50.6 HOT-2

oh.

21:04:54.1 HOT-1

what was it?

21:04:55.2 HOT-2

is it a Bell?

21:04:56.3 HOT-1

I don't know. kind of looked like it didn't it.

21:04:58.5 HOT

[sound of master caution chime consistent with parking brake application]

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 216 21:04:59.4 HOT-2

yeah.

21:05:01.0 HOT-1

well this isn't an elephant so I'm not scared of it.

21:05:03.9 HOT-2

yeah that's for sure. no but we uh we travelled to Phoenix a lot and 'cause we used to live there and he went down to— we went to Disneyworld and now that we're back in Seattle— we've got two dogs. so now that we're back in Seattle with all of our family it's a lot easier to just take off and you know my sister can wake up in the morning and find two extra dogs in her backyard. [sound of laughter]

21:05:24.7 HOT-1

right.

21:05:36.0 HOT-?

[sound of sniffle]

21:05:37.2 HOT-1

that's what uh my wife and I did before we— you know settled down and had you know bought a house and had you know started a family and all that kind of stuff. we uh wanted to get to know each other more and more and you know just enjoy the time between the two of us. because you know obviously when you start a family and everything and it's just not the same. it's just you're closing one chapter or one book and opening another.

21:05:53.8 HOT-2

yeah...exactly.

21:05:58.7 HOT

[sound of master caution chime]

21:06:05.1 HOT-1

uh but we I mean we always fit our children into our schedule and uh you know and also you know focused on their schedules too to make a compromise. it wasn't all one sided. it wasn't all for the kids it wasn't all for us but uh we didn't let their lives run ours.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 217 21:06:19.3 HOT-2

yeah...that's good.

21:06:31.9 HOT-1

and you know that's that's the big thing that I'd I'd recommend to any young couple that's that's out there just unsolicited advice you know just you know don't get in a big hurry.

21:06:43.5 HOT-2

yeah. no we're not. we want to give it— we want to do a lot more travelling. although gosh I'm so freaking mad. I feel like Colgan walks all over me. this company treats me like crap so much. I've been assigned my vacation in March. and I have been— I have sent four emails and I've made a dozen calls saying I do not want vacation in march I never requested that. that was assigned to me. here are ten different other weeks that I'd like vacation that are open on the vacation slot and she won't give it to me. she won't give it to me. I've called @. she's the one dealing with it. I've left her voicemails she won't call me back. I've sent her emails she won't call me back. she won't change my vacation. it still even has me in Norfolk she won't change it. and I think I've got like two more days before I'm within the forty five days and they can't change it. and I know she's going to screw me over and I'm going to be so freaking mad if they make me take my vacation in march cause I can't— I don't want to take vacation when my husband can't take vacation because we want to go somewhere.

21:07:17.2 HOT-1

sh— um...right right.

21:07:39.4 HOT-1

um now that she she looks at it on the tenth of every month and then posts it right after that so take a look.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 218 21:07:46.1 HOT-2

but I— I did I did she just emailed me she said you can't have Christmas off. and I said but what about the other ten weeks I asked for off you know and she did— she wouldn't email me back and it's just like— I if I only get to bid one week every month the entire year's gonna go by without me being able to get a bid in. because if somebody else higher than me wants that week off and she she and she won't respond back the fact that I'm in Newark now and I had to wait until I was in Newark to make my bid that's what I waited ‘til uh two months ago is when I started you know getting to do it. she won't do anything to help me and it's like I don't know what to do and I'm just gonna get screwed into having— I mean I literally have sent like several emails made several phone calls—.

21:07:58.1 HOT-1

ah.

21:08:27.1 HOT-1

go to @. that's what he's there for.

21:08:29.7 HOT-2

is it?

21:08:30.1 HOT-1

yeah oh hell yeah. oh yeah.

21:08:32.1 HOT-2

because I just— you know I can't get walked on anymore.

21:08:35.6 HOT-1

oh no. go to @ and just say look you know.

21:08:38.6 HOT-2

I don't want— yeah.

21:08:40.1 HOT-1

you know you don't want to piss anybody off. you don't want to make— you don't—.

21:08:42.1 HOT-2

no and I have been very polite about it. I haven't— I haven't gotten angry. I haven't you know—.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 219 21:08:47.9 HOT-1

just just like you just told me. you feel like you're getting walked all over.

21:08:51.5 HOT-2

oh yeah.

21:08:52.1 HOT-1

and there's no reason for it. and you looked on the on the spreadsheet and there's weeks available and everything?

21:08:56.3 HOT-2

and I sent her— and there's weeks available. and I sent her like— I sent I want you know I said if I can't have Christmas what about— I said I want Christmas I know that ones probably full. I'd like then the week after and then if that one's full the week before Christmas. if that one's full then Thanksgiving and then I went through I said if I can't have any of that I would like any week available after may. and she wouldn't give me any— there's got to be a week available after May.

21:09:19.3 HOT-1

well you can check and see if there's weeks available.

21:09:21.5 HOT-2

I did and all those weeks that I said— the only week that was filled was Christmas week. the week after was open. the week before was open and she wouldn't give me any of those. she only— she only responded saying that Christmas week was full. she didn't respond to any of the other— I can't get her to respond to me. she wouldn't tell me that any of the other weeks were full. she wouldn't sign me up for any of the other weeks and I'm still scheduled for vacation in March.

21:09:41.9 HOT-1

okay uhh.

21:09:44.9 HOT-2

but I'll give her a call again tomorrow and I haven't checked any of my emails.

21:09:47.6 HOT-1

but she's— yeah she's not gonna look at uh vacation again basically until the tenth of next month.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 220 21:09:53.5 HOT-2

so that that means I'm screwed and I just have to have it in march 'cause the tenth of March.

21:09:57.4 HOT-1

no no go to @.

21:09:59.1 HOT-2

yeah I mean that's the thing I told her you know like if she waits ‘til the tenth of march that's gonna be after you know after March bids are already— they'll have you know they'll have already given me vacation for March.

21:10:14.8 HOT-1

oh yeah yeah I see what you're saying.

21:10:17.0 HOT-2

so I can't you know I can't wait ‘til—.

21:10:19.8 HOT-1

okay yeah go to @.

21:10:21.3 HOT-2

yeah.

21:10:23.5 HOT-1

it it's been— what I would do before you go to @ is look up your FO vacation spreadsheet. print it.

21:10:31.7 HOT-2

um-hum...yeah yeah.

21:10:33.3 HOT-1

and say okay well you know this is— and and if you still have a copy of your email. print it. this is what I've done so far and highlight the the spaces that are still available and and it doesn't matter whether you're based in Newark or Norfolk or or Albany.

21:10:35.3 HOT-2

yeah...um-hum...yeah...well sh— well if I was based—.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 221 21:10:50.9 HOT-1

cause every— everything on the Q is on the Q. everything on the Saab is on the Saab.

21:10:57.1 HOT-2

um-hum.

21:10:58.2 HOT-1

they don't do it by base anymore.

21:11:00.3 HOT-2

oh I thought— that what she emailed me back. she said only two FOs per base can have each week off. but then there are some weeks—.

21:11:07.6 HOT-1

well that's funny 'cause there's five captains that uh that are you know that out of five captains four of them are from Newark one's from Norfolk *.

21:11:19.8 HOT-2

exactly.

21:11:21.2 HOT-1

you know it's like *.

21:11:23.4 HOT-2

and then if they do it that way then who doesn't get vacation? because there's more than fifty two FOs.

21:11:28.9 HOT-1

because— and here's another thought. or here's another 'nother deal with that—.

21:11:32.7 HOT-2

or a hundred four FOs.

21:11:34.2 HOT-1

um then then you should have been given the vacation of your choice if you're based in Norfolk if they're if they're separating it.

21:11:43.6 HOT-2

yeah.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 222 21:11:43.7 HOT-1

and the only people that you'd be competing with would be Norfolk based FOs.

21:11:47.6 HOT-2

yeah but now I'm—.

21:11:48.6 HOT-1

likewise Albany and stuff like that.

21:11:51.5 HOT-2

yeah.

21:11:53.6 HOT-1

but uh yeah I would just uh I would go to @ at this point.

21:11:59.0 HOT-2

yeah cause I can't wait— I mean I tried— I sent her very polite very nice emails. I haven't been like this upset at her. I just— you know I've sent her nice polite emails. I cannot wait. I do not want to have vacation in march. I've been telling you this for two months. I don't want my vacation in march. I do not want to get stuck with having it— having to take it. ‘cause it's not within forty five days.

21:12:20.8 HOT-1

right.

21:12:21.7 HOT-2

I mean I've never had a company be like this before with vacations.

21:12:38.7 HOT-2

why can't we take off two two right?

21:13:47.1 HOT-?

[sound of sniffle]

21:13:48.1 HOT-2

my husband look at my email. I haven't looked for two days. I emailed her and then I— and then it was two days before—.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 223 21:14:27.0 HOT-1

not much on the departure roll.

21:14:29.6 HOT-2

what?

21:14:30.3 HOT-1

said not much on the departure roll. he ain't rollin' too fast.

21:14:33.5 HOT-2

uh-uh.

21:14:37.3 HOT-1

**.

21:15:00.5 HOT-1

wow.

21:15:50.8 HOT-1

let's do a taxi checklist.

21:15:52.3 HOT-2

alrighty. taxi checklist. takeoff data briefing set complete.

21:15:55.4 HOT-1

set complete.

21:15:56.1 HOT-2

condition levers max?

21:15:57.3 HOT-1

max.

21:15:57.8 HOT-2

trims three set.

21:15:58.9 HOT-1

three set.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 224 21:15:59.4 HOT-2

and takeoff warning?

21:16:00.4 HOT-1

test.

21:16:00.8 HOT-2

taxi check complete.

21:16:06.5 HOT-2

and we're following JetBlue.

21:16:09.4 HOT-1

well for the time being anyway.

21:16:11.0 HOT-2

yeah *.

21:16:12.1 HOT-1

unless they cut us off...which is entirely possible.

21:16:23.4 HOT-1

slide right. leave a little room.

21:16:25.3 HOT-2

what?

21:16:25.9 HOT-1

** give these guys a little room here.

21:16:28.6 HOT-2

yeah.

21:16:29.3 HOT-1

JIC. just in case.

21:16:31.7 HOT

[sound of master caution chime]

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 225 21:16:50.6 HOT-1

well.

21:16:58.2 HOT-1

I'll take it.

21:17:00.3 HOT-2

yeah me too.

21:17:05.9 PA-2

folks it looks like we're number two for departure. should be pretty quick here. like to have the flight attendants please take their seats. thank you.

21:17:22.6 TWR

Colgan thirty four oh seven on uh departure you're gonna turn— fly heading two seven zero maintain two thousand now.

21:17:30.1 RDO-1

two seven zero maintain two thousand Colgan thirty four oh seven.

21:17:30.7 HOT-2

oh.

21:17:38.3 HOT-1

alright heading two seven zero.

21:17:41.8 HOT-2

and it's still five thousand?

21:17:42.9 HOT-1

and two thousand.

21:17:44.0 TWR

Colgan thirty four oh seven runway two two right at whiskey. position and hold.

21:17:47.2 RDO-2

position and hold Colgan thirty four oh seven.

21:17:49.9 HOT-1

alright pos and hold. before takeoff checklist.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 226 21:17:55.7 HOT-2

uh before takeoff checklist. watch your legs. FA notification received transponder TCAS on ALT flight control checked free radar terrain off. flight taxi flight. cabin PA complete. external lights on. before takeoff checklist complete.

21:18:18.9 HOT-2

okay.

21:18:22.8 TWR

and Colgan thirty four oh seven runway two two right at whiskey winds three zero zero at one niner cleared for takeoff.

21:18:27.7 RDO-2

cleared for takeoff Colgan thirty four zero seven.

21:18:30.3 HOT-1

alright cleared for takeoff it's mine up to two thousand heading two seven zero after departure. here we go.

21:18:35.4 CAM

[sound of increasing engine rpm]

21:18:42.3 HOT-1

check power.

21:18:44.6 HOT-2

and power checked.

21:18:48.8 HOT-2

eighty knots.

21:18:50.1 HOT-1

eighty.

21:18:55.0 HOT-2

V one.

21:18:56.2 HOT-2

rotate.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 227 21:19:01.6 HOT-2

positive rate.

21:19:02.3 HOT-1

gear up.

21:19:03.0 CAM

[sound similar to landing gear handle movement]

21:19:07.5 CAM

[sound similar nose gear uplock and door closing]

21:19:10.4 TWR

Colgan thirty four oh seven turn right heading two seven zero maintain two thousand contact New York Departure.

21:19:15.0 RDO-2

right two seventy two thousand and over to departure Colgan thirty four zero seven.

21:19:20.7 RDO-2

Departure Colgan thirty four oh seven is seven hundred for two thousand heading two seventy.

21:19:26.5 DEP-A

Colgan uh thirty four oh seven New York radar contact. climb maintain one zero ten thousand.

21:19:31.6 HOT

[sound similar to altitude alert]

21:19:32.5 RDO-2

up to ten thousand Colgan thirty four zero seven.

21:19:35.5 HOT-2

ten thousand.

21:19:36.4 HOT-1

ten thousand alt sel flaps zero. set indicated airspeed two ten. climb checklist.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 228 21:19:44.3 HOT-2

alrighty.

21:19:45.4 CAM

[sound similar to decreasing propeller rpm]

21:20:08.9 DEP-A

Colgan thirty four oh seven proceed direct COATE.

21:20:11.5 RDO-2

direct COATE Colgan thirty four zero seven.

21:20:13.9 HOT-2

direct COATE.

21:20:14.2 HOT-1

direct COATE.

21:20:19.5 HOT-1

and NAV for me.

21:20:20.2 HOT-2

NAV selected.

21:20:39.9 HOT-1

wee this is fun.

21:20:41.7 HOT-2

yeah.

21:20:43.0 HOT-1

okay almost.

21:20:46.6 DEP-A

Colgan thirty four oh seven contact departure one one eight one seven. eighteen seventeen.

21:20:50.9 RDO-2

eighteen seventeen Colgan thirty two— thirty four zero seven.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 229

21:21:00.9 RDO-2

[sound of mic click]

21:21:10.0 RDO-2

departure Colgan thirty four zero seven five point seven for ten thousand.

21:21:14.2 DEP-B

Colgan thirty four zero seven New York Departure roger.

21:22:27.0 HOT-2

and climb checklist complete. I don't know if I said it or not.

21:22:31.0 PA-3

ladies and gentlemen for your continued safety we do ask that you keep your seatbelts securely fastened even if the captain turns off the fasten seatbelt sign. we would like to add a special welcome to our One Pass members. you'll be earning valuable miles for your trip today. if you are not already a member of the One Pass program you can enroll online at Continental dot com...Continental Connection is pleased to provide you with a complimentary copy of Sky Mall catalogue and Continental Magazine both located in your seat pocket.

21:22:31.6 HOT-1

autopilot's engaged.

21:22:33.5 HOT-2

alright.

21:22:39.2 HOT-1

it's probably a good thing.

21:22:43.7 HOT

[sound similar to altitude alert]

21:22:44.9 HOT-1

nine ten alt sel.

21:22:45.7 HOT-2

ten alt sel.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 230 21:23:08.7 HOT

[sound of double chime]

21:23:14.1 PA-2

we're through ten thousand feet.

21:23:24.3 PA-3

ladies and gentlemen the use of approved portable electronic devices is now permitted.

21:23:56.6 DEP-B

Colgan thirty four zero seven climb maintain one two twelve thousand. proceed direct COATE.

21:24:01.4 RDO-2

twelve thousand direct COATE Colgan thirty four zero seven.

21:24:04.6 HOT-1

twelve alt sel.

21:24:05.4 HOT-2

twelve alt sel.

21:24:18.4 HOT-?

[sound of sniffle]

21:24:47.2 HOT-1

eleven twelve alt sel.

21:24:47.3 HOT

[sound similar to altitude alert]

21:24:48.6 HOT-2

eleven twelve alt sel.

21:25:14.2 HOT-1

have you ever looked at the logbook very much as far as uh like putting your times and stuff in?

21:25:19.8 HOT-2

um-hum.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 231 21:25:20.7 HOT-1

• okay. I kinda * you just haven't done like writeups?

21:25:25.2 HOT-2

yeah I just haven't written anything in it but I've looked at it and looked up crew writeups.

21:26:18.0 HOT-1

well I didn't write any numbers down so.

21:26:21.8 HOT

[sound of double chime]

21:26:23.6 HOT-1

uh.

21:26:24.8 INT-2

hello.

21:26:25.6 INT-3

hi what do you think about doing service?

21:26:29.0 INT-1

actually I think if you could uh do something fairly quick I think we might be okay. I don't have a whole lotta cloud cover up here.

21:26:36.4 INT-3

okay.

21:26:37.1 INT-1

uh just be careful.

21:26:38.8 INT-3

okay.

21:26:39.1 INT-1

if we hear of anything—.

21:26:40.7 INT-3

give us a buzz.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 232 21:26:41.2 INT-1

we will.

21:26:41.9 INT-3

alright thanks.

21:27:08.1 DEP-B

Colgan thirty four zero seven contact New York Center one tree two point six good day.

21:27:12.6 RDO-2

one three two point six Colgan thirty four zero seven.

21:27:22.4 RDO-2

departure Colgan thirty four zero seven twelve thousand direct COATE.

21:27:29.3 HOT-1

geez.

21:27:30.7 HOT-1

this I **.

21:27:31.5 ZNY-A

Colgan thirty four zero seven New York Center you should be with the New York Center on one three two point six.

21:27:40.8 RDO-2

alrighty we'll try them thirty four zero seven thanks.

21:28:12.9 RDO-2

Center Colgan thirty four zero seven twelve thousand direct COATE.

21:28:16.8 ZNY-B

Colgan thirty four zero seven New York Center roger. Wilkes-Barre altimeter two nine six seven.

21:28:22.3 RDO-2

six seven thanks.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 233 21:28:25.1 HOT-2

six seven.

21:28:25.6 HOT-1

sixty seven set crosscheck.

21:28:27.4 HOT-2

set crosschecked.

21:28:30.1 HOT-1

alright.

21:28:42.0 HOT-1

today's the twelfth right?

21:28:43.5 HOT-2

yup.

21:28:47.0 HOT-2

at least that's what you told me earlier.

21:28:50.2 HOT-1

well that's my story and I'm sticking to it.

21:28:52.2 HOT-2

alright.

21:28:58.5 HOT-1

well that's good.

21:29:19.7 HOT-1

so where's this page here? I don't see any writing on it.

21:29:32.6 HOT-1

interesting.

21:29:46.0 HOT-?

[sound of throat clearing]

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 234 21:29:50.1 HOT-1

alright I'll give that to you.

21:29:52.8 HOT-2

alright.

21:29:53.7 HOT-1

fill out what you can...I'll sign it **.

21:30:31.1 HOT-2

it's Zulu time is the in and out right?

21:30:34.3 HOT-1

uh that's in Zulu time but we want it local time.

21:30:36.3 HOT-2

yeah local okay.

21:30:38.5 HOT-1

on here. so just minus five. sooooo let's see.

21:30:45.4 HOT-2

so nineteen forty five.

21:30:47.5 HOT-1

seven forty five yeah nineteen forty five...wow an hour and a half taxi.

21:30:53.7 HOT-2

yeah. **.

21:30:57.8 HOT-1

oh that just— that just stinks...we can't reap the benefit.

21:31:04.3 HOT-2

I know.

21:31:18.1 RDO-1

blocked.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 235

21:31:44.6 ZNY-B

Colgan thirty four zero seven climb to flight level— correction climb to one six thousand.

21:31:50.0 RDO-2

one six thousand Colgan thirty four zero seven.

21:31:53.0 HOT-2

sixteen.

21:31:53.5 HOT-1

sixteen alt sel.

21:31:54.9 HOT-2

alt sel.

21:32:08.4 HOT-1

oops. you didn't feel that.

21:32:11.0 HOT-2

no I didn't feel that.

21:32:13.0 HOT-2

they didn't do a twenty four hour ice protection test.

21:32:15.4 HOT-1

yeah I just did.

21:32:16.5 HOT-2

you did?

21:32:17.2 HOT-1

yup.

21:32:20.5 HOT-1

that's why I was looking back on all those pages.

21:32:22.8 HOT-2

yeah.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 236 21:32:23.2 HOT-1

it said it was miss— er uh you know.

21:32:27.3 HOT-2

yeah.

21:32:28.0 HOT-1

there uh there was one page there wasn't anything on it. so it's like they they tore it out in error.

21:32:34.1 HOT-2

oh yeah.

21:32:35.4 HOT-1

so.

21:32:58.1 HOT-2

just twenty four ice test complete? or write—.

21:33:02.0 HOT-1

yeah I'd— I'd put twenty four hour uh check's complete.

21:33:19.1 HOT-2

alrighty.

21:33:20.9 ZNY-B

Colgan thirty four zero seven contact New York Center one tree tree point tree five.

21:33:25.8 RDO-2

one three three point three five Colgan thirty four zero seven.

21:33:31.8 HOT-1

there we go.

21:33:32.9 RDO-2

thirty four zero seven fourteen point one for sixteen thousand.

21:33:37.3 ZNY-C

Colgan thirty four zero seven New York Center roger. Wilkes-Barre altimeter two niner six seven.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 237

21:33:42.4 RDO-2

six seven thank you thirty four oh seven.

21:33:48.0 HOT-2

I'm assuming we're only gonna land once.

21:33:51.6 HOT-1

yeah.

21:33:56.8 HOT-1

the only thing that um I would not do— well the type of flight— I don't know if you can see it here. I'll show you.

21:34:03.8 HOT-2

I see. oh yeah I didn't know what to—.

21:34:05.9 HOT-1

if if you don't know the type of flight it is it's— it's down here on the bottom.

21:34:08.1 HOT-2

uh-huh. oh oh okay.

21:34:10.2 HOT-1

just a regular revenue flight—.

21:34:11.4 HOT

[sound similar to altitude alert]

21:34:12.3 HOT-1

fifteen sixteen alt sel. regular revenue flight is type one.

21:34:15.2 HOT-2

okay.

21:34:17.3 HOT-1

unless it's a reposition or special ferry or whatever it's something else.

21:34:21.0 HOT-2

[sound of sneeze]

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 238 21:34:21.6 HOT-1

bless you.

21:34:22.2 HOT-2

excuse me. okay.

21:34:24.0 HOT-1

um a— and this is just my little deal and it is what I was taught and everything. and and it makes sense to me.

21:34:31.9 HOT-2

sure.

21:34:32.7 HOT-1

um on your two.

21:34:35.6 HOT-2

uh-huh.

21:34:36.3 HOT-1

what happens if we have to divert to an alternate?

21:34:39.0 HOT-2

oh yeah that's true.

21:34:40.0 HOT-1

um I was told it was their little uh uh like superstition.

21:34:46.3 HOT-2

oh.

21:34:46.6 HOT-1

you don't put— you don't put it until you land there.

21:34:49.3 HOT-2

right right. no that makes sense.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 239 21:34:49.7 HOT-1

uh but well okay. well you can take it that far. I don't care. but it makes sense that if you have to divert someplace at least you're not scratching through and doing all that kind of stuff. uh but I still do the one landing and however many starts we have and fill the rest of it out.

21:34:59.3 HOT-2

yeah.

21:35:06.5 HOT-2

yeah.

21:35:07.9 HOT-1

but uh other than that that's all there is to it. on your writeups—.

21:35:15.0 HOT-2

I've written— I mean I've written other planes up before. just not from— with Colgan.

21:35:18.1 HOT-1

okay alright so you know like the one P or the two P as you write ‘em up like that?

21:35:20.6 HOT-2

uh-huh. yeah.

21:35:23.7 HOT-1

write it up. uh and if you're doing one twenty one ops you obviously know as short sweet to the point as you possibly can um.

21:35:36.0 HOT-2

give em all the details that you need to give.

21:35:38.2 HOT-1

yeah but but also don't get too wordy with it.

21:35:42.4 HOT-2

right.

21:35:44.0 HOT-1

um and what I try to do is— is I'd look up in the MEL book.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 240 21:35:54.7 HOT-2

uh-huh.

21:35:55.3 HOT-1

to begin with before I write things up.

21:35:58.0 HOT-2

so you know yeah.

21:35:59.0 HOT-1

that way if I screw up and write it up one way and it grounds the airplane but it's not— it's not exactly or I could write it up slightly different to get an MEL to get it back to where you can do maintenance type of deal.

21:36:15.1 HOT-2

yeah.

21:36:16.3 HOT-1

it's it's a judgment call by all means.

21:36:19.7 HOT-2

yeah.

21:36:21.2 HOT-1

you you definitely want to write the proper thing up. um you know I try to uh uh get em to fix— I uh on the Saab we don't have glass we uh we had EFIS screens.

21:36:37.7 HOT-2

right.

21:36:40.1 HOT-1

but uh you had a EHSI and uh a EADI.

21:36:45.5 HOT-2

uh-huh.

21:36:46.2 HOT-1

I wrote up the course selector. course one selector.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 241 21:36:49.0 HOT-2

uh-huh.

21:36:50.7 HOT-1

uh because it wouldn't move. it was stuck on one particular course setting.

21:36:55.9 HOT-2

uh-huh.

21:36:56.7 HOT-1

and uh wrote it up totally explained exactly what it was and they uh at the time there were four planes down. two getting line checks and then my airplane and another one uh that had something wrong with it. they only had four mechanics on duty at the time. so they were all trying to do something. er I'm sorry they had four down I was the fifth one.

21:37:20.1 HOT-2

oh okay.

21:37:21.1 HOT-1

so they tried to MEL the uh the uh the autopilot system uh because of the heading selector.

21:37:32.0 HOT-2

yeah.

21:37:32.6 HOT-1

I you know I wouldn't be able to turn. and it's like wait a minute. it doesn't even apply.

21:37:36.4 HOT-2

yeah.

21:37:37.4 HOT-1

so uh you got to be careful about that.

21:37:40.5 HOT-2

yeah.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 242 21:37:41.2 HOT-1

just don't— you know understand the MELs that they uh they try to put on it make sure it applies to what you're doing.

21:37:48.3 HOT-2

yeah.

21:37:48.7 HOT-1

and the problem you're having. and I I called ‘em back and told ‘em uh that it doesn't have anything to do with the autopilot. well I mean doesn't it do this this this? no it's— this is what's wrong or this is what I told them before. ohhhhhh.

21:38:03.6 HOT-2

yeah.

21:38:04.6 HOT-1

ehh well can we just go ahead with that MELed we'll uh get it—. well I'll tell you we could go with that MEL but I can't sign the release. I guess we'll have to get somebody to fix it then won't we. well I guess we will.

21:38:18.9 HOT-2

[sound of laughter]

21:38:19.5 HOT-1

took em twenty minutes to fix it. they just had to pop out a panel uh little component put in another component.

21:38:25.2 HOT-2

yeah.

21:38:26.1 HOT-1

and it took em all of twenty minutes. it's just the fact that they were shorthanded.

21:38:29.2 HOT-2

oh yeah.

21:38:29.7 HOT-1

they were trying to uh uh—.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 243 21:38:31.9 HOT-2

save a minute here.

21:38:32.7 HOT-1

yeah save a minute here. get us out back and then they would have time to do it.

21:38:36.8 HOT-2

yeah.

21:38:41.1 HOT-1

but of course that turned into a fiasco. we were going to Alexandria Louisiana that night.

21:38:46.3 HOT-2

oh yeah.

21:38:46.7 HOT-1

and uh let's do a cruise checklist.

21:38:49.8 HOT-2

oh cruise checklist.

21:38:51.2 HOT-1

yeah.

21:38:52.4 HOT-2

altimeters two niner six seven set crosscheck.

21:38:54.9 HOT-1

two niner six seven set crosscheck.

21:38:57.5 HOT-2

power set seatbelt sign on lights set cabin pressure check. and well cabin pressure. what's Buffalo at?

21:39:07.0 HOT-1

uh not too much. uh seven twenty eight.

21:39:08.7 HOT-2

seven hundred.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 244 21:39:12.7 HOT-2

cabin pressure check and twenty four hour ice protection test complete. cruise checklist complete. um-huh.

21:39:17.2 HOT-1

thanks. yeah we uh after they fixed it so— we were already delayed. they fixed it we were delayed a little bit more. no big deal.

21:39:24.0 HOT-2

yeah.

21:39:24.2 HOT-1

get in uh start up number two and we're doing the paperwork and all of a sudden we get bing. look— it looked— it was engine lookup light. I went oh crap that's not good. I looked up it was chip detect. right chip detect.

21:39:43.3 HOT-2

what's that?

21:39:43.7 HOT-1

what— what that— what that's doing is detecting chips of metal in the engine.

21:39:48.4 HOT-2

oh.

21:39:50.2 HOT-1

and uh we were thinking aww crap. so I said grab the checklist real quick and let's just go through it. well in the chip detect abnormal checklist there's nothing pertaining to on the ground. it's all pertaining to in the air so I said okay shut it down. called maintenance they came over they cleaned out a little filter screen. they said it was probably carbon built up blah blah blah.

21:40:05.3 ZNY-C

two eight charlie golf climb and maintain flight level two two zero.

21:40:09.8 N28CG

two zero zero for two two zero two eight charlie golf.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 245

21:40:12.1 ZNY-C

and how would you describe the icing?

21:40:16.8 HOT-2

yeah.

21:40:17.4 HOT-1

they fel— uh cleaned out this little carbon screen. did uh a runup check observation. I kept everybody on the plane. told em what was going on. man their eyes were you know they're all over here watching what they were doing. but it was either that or they'd have to get bussed around get out and bout the time that they'd get out they would bus em back around.

21:40:18.3 N28CG

yeah we'll call it about light to moderate rime.

21:40:36.7 HOT-2

yeah.

21:40:37.2 HOT-1

anyway we started up ops check good. so filling out filling out the paperwork. got the door closed and everything. it's got a little whiskey hatch over here.

21:40:45.4 HOT-2

uh-huh.

21:40:46.0 HOT-1

I'm handing the paperwork out. ding. #. right chip detect— chip detect again.

21:40:51.8 HOT-2

ohh.

21:40:52.8 HOT-1

so I shut it down told everybody yeah we're gonna have to get another airplane. they had another airplane it was on a Saturday so they had extra— they had spares because of the schedule and everything.

21:41:01.9 HOT-2

yeah.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 246 21:41:04.4 HOT-1

um so uh twenty minutes later we launch and get about halfway up there uh over this one VOR and uh all of a sudden oh and uh uh I'll back up a half a step. I was telling the—telling the FO this was like— I don't know a month after I upgraded to captain.

21:41:29.7 HOT-2

oh geez.

21:41:30.6 HOT-1

I said you know uh uh all this stuff is just happening to me. and it's— you know hell the only thing I haven't had is is an air return.

21:41:39.8 HOT-2

oh God.

21:41:40.8 HOT-1

so we get over this VOR headed to Alexandria. ding ding ding. that's not a caution light that's a master warning.

21:41:48.5 HOT-2

yeah.

21:41:50.5 HOT-1

and uh looked up avionics smoke detector.

21:41:56.2 HOT-2

ohh.

21:41:58.2 HOT-1

I'm going @ my FO cool as #. man should I get my uh smoke goggles on and everything. said yeah gimme— gimme the memory items. I'm— I'm over here. I don't smell anything. the avionics bay is right behind the captain's seat.

21:42:15.9 HOT-2

yeah.

21:42:17.1 HOT-1

there's a little uh fire bottle. little uh rubber kind of cover thing that you can stick the fire bottle into and blow it if you need to if you're actually on fire.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 247 21:42:21.1 HOT-2

uh-huh...uh-huh.

21:42:28.2 HOT-1

I reach back in here and find it and uh I open it up because it's— it's kind of like a drainer in a sink.

21:42:35.5 HOT-2

yeah.

21:42:35.9 HOT-1

like over a garbage disposal. it's just kinda like this. and it's rubber and you can push.

21:42:40.2 HOT-2

uh-huh.

21:42:40.5 HOT-1

so I pushed it. man man I don't smell anything. called the flight attendant. @ hey do you smell any smoke back there? no. why? should I?

21:42:53.3 HOT-2

[sound of laughter]

21:42:55.5 HOT-1

well no you shouldn't. I'm glad you don't. thanks for playing the game. and— and I just cut her off. good *. [sound of laughter]

21:43:04.3 HOT-2

nice.

21:43:05.9 HOT-1

she calls back well uh what— what do you want me to do? I said naw man uh I said I think it's just a false alarm. but uh I was just checking. we just— we've got a light up here that went off. I said I don't think there's anything to it. so anyway she— she was good with that. and uh we didn't have ACARS— we don't have ACARS in the Saabs. so I called uh Manassas on ARINC. I said uh so uh what do you want me to do? go back to Houston? continue on or what? call us when you get on the ground in Alexandria. hey no problem. so they're gonna do a road trip and change the smoke detector out.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 248 21:43:23.7 HOT-2

yeah...yeah.

21:43:48.5 HOT-1

and uh sure enough by the next morning— we were taking it out the next morning they had— they had come— they did a road trip from Houston. changed the deal out. away we went. of course after that day uh we all went to the uh steakhouse. we ate a steak baked potato and drank a messload of beer.

21:44:09.4 HOT-2

yeah.

21:44:10.2 HOT-1

it was just one of those— one of those days. yeah.

21:44:12.1 HOT-2

one of those days where you have to have a few beers at the end.

21:44:16.4 HOT-1

that was that was a good time. I like flying the Saab. if— if you upgrade to the Saab— I mean if you have the opportunity to upgrade to Saab versus the Q and you want to get your PIC time.

21:44:29.2 HOT-2

um-huh.

21:44:29.5 HOT-1

and uh you know and if that's uh you know a goal for you I guess go ahead and do it.

21:44:34.0 HOT-2

yeah. um-huh.

21:44:35.8 HOT-1

that a neat airplane to fly. it's not like this.

21:44:38.2 HOT-2

yeah right.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 249 21:44:40.1 HOT-1

I mean it's taking five steps backwards but you're in the left seat.

21:44:46.2 HOT-2

yeah.

21:44:46.5 HOT-1

it's— it's like moms SUV or minivan. you know the soccer van uh you don't have to fly with your hands and your feet. you just fly with your hands.

21:44:59.2 HOT-2

yeah.

21:44:59.5 HOT-1

once you— once you flip the auto— uh the yaw damp on and autopilot on it's solid as a rock.

21:45:05.2 HOT-2

works the rudders for you.

21:45:07.1 HOT-1

yeah it works rudders for you. it's all coordinated.

21:45:09.9 HOT-2

I think it's fun flying with— with captains. not so much any— lately but right at first that came from the Saab and they'd see— they'd see the rudder and they'd— aww # and kick it really hard and fling the plane back and forth.

21:45:23.8 HOT-1

kind of like I did a little while ago.

21:45:25.4 HOT-2

yeah kind of but uh at first I flew— I flew with some captains that were doing it really bad.

21:45:30.5 HOT-1

really.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 250 21:45:30.9 HOT-2

like knock the flight attendants down in the back.

21:45:32.7 HOT-1

[sound of laughter]

21:45:34.5 HOT-2

like I'd see the flight attendants afterwards and they're like um who was flying.

21:45:39.8 HOT-1

that would be that bonehead captain.

21:45:42.8 HOT-2

[sound of laughter]

21:45:44.0 HOT-1

you know what? yeah I tell you I'm getting a lot more used to it. uh I'm not saying I like it any better but I am getting used to it.

21:45:51.0 HOT-2

yeah.

21:45:55.6 HOT-2

yeah I don't know what I want to do with the upgrade. I'm not entirely in like a big rush to upgrade. um it would depend on where I'm based. just because having to commute to be the bottom of the list is gonna suck. and—.

21:46:07.0 HOT-1

true and— and you know like you were talking about as far as uh right now your wanting to buy a house and wanting to have—.

21:46:13.6 HOT-2

exactly if I hold off— you know if it's a matter of holding on a few months well then I'll be making a substantial amount more money in the— in the Q than I would in the Saab.

21:46:22.0 HOT-1

right.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 251 21:46:22.9 HOT-2

depending you know how— how long would it be to make that worth my while. would it— would I make more money upgrading into the Saab right away or would I make more money if I waited for the Q for a little while.

21:46:32.6 HOT-1

well think of it this way uh if you— if you stayed on the on the Q obviously you're gonna— you're not making the captain rate.

21:46:42.0 HOT-2

right.

21:46:42.5 HOT-1

but you may have a better quality of life to begin with uhh with regards to buying a house and having a schedule to where you you know you could work around and you could be—.

21:46:55.3 HOT-2

exactly.

21:46:55.6 HOT-1

you know home with your husband to to take care of all that kind of stuff.

21:46:59.6 HOT-2

exactly yeah it's just gonna depend where we're at when that happens. but I— I mean I'm not— I'm not in such a hurry to upgrade. I've got very very very good connections at Alaska.

21:47:10.4 HOT-1

oh cool.

21:47:11.2 HOT-2

Alaska's the only major I'd want to go to.

21:47:13.2 HOT-1

yeah.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 252 21:47:13.5 HOT-2

just because I don't want to commute my whole life...so um once I do upgrade you know once once Alaska starts hiring I don't— I mean I don't necessarily have to have a thousand hours PIC. I need to have some PIC.

21:47:25.7 HOT-1

you don't have to with uh Alaska?

21:47:26.8 HOT-2

um it it depends. you you you do and on paper you do but it just— it it depends who you know. if you know people then you can kind of sneak away with it a little bit. I definitely need to have you know the proper experience you need to be qualified. but if I have—.

21:47:36.6 HOT-1

huh...sure.

21:47:40.4 HOT-2

you know if at about five hundred hours they said to to go and interview and then I can interview and they can say we want you to have a thousand hours. so once you get a thousand hours um we're gonna put you into ground school. they'll say stuff like that.

21:47:53.9 HOT-1

okay.

21:47:54.3 HOT-2

so I mean it depends and I don't even know if that's the route I want to go anymore...you know the more I think about it. I wouldn't I wouldn't mind flying for FedEx or UPS.

21:48:09.3 HOT-1

FedEx is still big on military time and the uh and the internal recommendations so those two things— I mean that knocks me out of FedEx for sure.

21:48:10.5 HOT-2

yeah...yeah.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 253 21:48:18.0 HOT-1

but uh UPS like I said I got my cousin that uh flies seven fives seven six. he's based in Ontario.

21:48:26.3 HOT-2

yeah.

21:48:27.2 HOT-1

uh not too far from where he lives. but uh.

21:48:36.3 HOT-2

yeah I wouldn't mind— you know I could even see myself doing like I mean for quality of life I could see myself doing cargo stuff and just I mean like small stuff like there's a company that flies right out of my hometown to Spokane Washington and back every night.

21:48:36.7 HOT-1

that's just—.

21:48:49.5 HOT

[tones similar to ACARS message reception]

21:48:51.2 HOT-2

and I'd do that three nights a week and be home. I could have kids and raise a family. and I think that that might be more worth my while. something like that.

21:48:58.5 HOT-1

yeah yeah.

21:48:59.6 HOT-2

and it just depends. I don't even know. I'm I'm so in limbo right now it's actually kind of kind of interesting. like I don't know where I'll be in a year. I don't know where I'll be in—.

21:49:05.4 HOT-1

well just keep your eyes open you know and and keep you know keep listening uhh and and something will come across er you know you'll know whenever it's time.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 254 21:49:18.2 HOT-2

yeah.

21:49:18.3 HOT-1

I've gotta do this. I've gotta— I'm ready to move on. um [sound similar to yawn] excuse me. it's kind of like me. you know I started this this little gig late in life.

21:49:28.7 HOT-2

yeah.

21:49:28.9 HOT-1

oh it's like it's a second career for me basically because I— I was able to take that package with Verizon.

21:49:34.1 HOT-2

yeah.

21:49:35.5 HOT-1

but uh...you know it's...you know do I— g— at this point do I go to a major and you know not be able to be there for very long.

21:49:48.8 HOT-2

yeah be an FO the rest of your life or...

21:49:51.8 HOT-1

uhh which— that may not be a bad thing as long as I would be able to progress and and uh and be a lifetime FO if you will.

21:50:02.9 HOT-2

yeah yeah.

21:50:03.4 HOT-1

uh and just and and dwell upon the quality of life part of it or do I stay here with Colgan and uh...

21:50:11.8 HOT-2

[sound of sneeze] excuse me.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 255 21:50:15.2 HOT-1

and you know likewise do the quality of life. I don't have to make two hundred thousand dollars a year er a hundred fifty thousand dollars a year whatever you know I could—.

21:50:20.7 HOT-2

exactly.

21:50:23.8 HOT-1

I can certainly be comfortable on on a hundred thousand. um you got traffic out there just it's crossing left to right.

21:50:32.9 HOT-2

uh in sight.

21:50:35.4 HOT-1

but uh—.

21:50:41.8 HOT-2

um winds are at two fifty at fifteen gusting twenty three they're using runway—.

21:50:45.0 ZNY-C

Colgan three four zero seven contact Cleveland Center one two four point three two.

21:50:48.8 RDO-2

one two four point three two Colgan three four zero seven.

21:50:53.1 HOT-2

one two four thirty two.

21:50:58.5 RDO-2

Cleveland Center Colgan thirty four zero seven sixteen thousand.

21:51:02.1 ZOB

Colgan thirty four zero seven Cleveland Center roger.

21:51:05.4 HOT-2

alright so it's the winds are at two five zero fifteen gusting twenty three and they're using three two and two three. do you want to use uh—.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 256 21:51:11.7 HOT-1

uh two three.

21:51:12.5 HOT-2

two three.

21:51:13.2 HOT-1

yeah.

21:51:13.7 HOT-2

okay.

21:51:13.8 HOT-?

[sound of sniffle]

21:51:16.3 HOT-1

and flaps fifteen.

21:51:18.3 HOT-2

okay.

21:51:21.7 HOT-2

uh it's runway two three.

21:51:23.8 HOT-1

ouch.

21:51:26.1 ZOB

Southwest six fifteen cleared direct to the Buffalo airport.

21:51:35.8 HOT-2

that us?

21:51:37.0 HOT-1

nope.

21:51:37.4 HOT-2

I didn't think so.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 257 21:51:38.6 HOT-1

yeah.

21:51:39.1 HOT-2

[sound of laughter] I just heard direct Buffalo.

21:51:42.0 HOT-2

uh does this look good to you? um...we've got TRAVA ILS two three TRAVA KLUMP runway two three.

21:51:43.3 HOT-?

[sound of sniffle]

21:51:50.7 HOT-1

yeah TRAVA.

21:51:51.9 HOT-2

yeah here you go. and the EOA is in there.

21:51:53.0 HOT-?

[sound of sniffle]

21:51:59.4 HOT-1

thirty three.

21:52:03.7 HOT-?

[sound of sniffle]

21:52:05.1 HOT-1

try not to be dyslexic.

21:52:07.8 HOT-2

[sound of laughter]

21:52:08.2 HOT-1

last time I flew in here two thirty uh— two thirty three's the uh inbound course. I put two twenty three.

21:52:14.2 HOT-2

oh geez. two thirty thirty three— no * it's runway— oh it is two thirty three?

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 258 21:52:19.6 HOT-1

it's two thirty three.

21:52:21.3 HOT-2

runway two three. oh yeah no that makes sense. now you got me confused.

21:52:26.2 HOT-1

well I— well I didn't mean to confuse you now. two three three.

21:52:29.9 HOT-2

two three three.

21:52:31.0 HOT-1

and I'll brief it that way too.

21:52:32.6 HOT-2

alright it's two three three. [sound of laughter] we're good.

21:52:34.2 HOT-1

that's two three three.

21:52:53.2 HOT-?

[sound of sniffle]

21:52:57.2 HOT-2

alrighty and for the rest of that weather uh three miles. it's snowing with some mist.

21:53:03.5 HOT-1

alright.

21:53:05.7 HOT-2

it didn't give me an RVR.

21:53:07.5 HOT-1

good...it's good.

21:53:10.9 HOT-2

that means it's far enough right?

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 259 21:53:13.9 HOT-1

yeah.

21:53:20.3 HOT-2

runway five then what do we have? one two nine two five.

21:53:30.4 HOT-?

[sound of sniffle]

21:53:40.2 HOT-2

alrighty your numbers. for flaps fifteen runway two three are eighteen and fourteen.

21:53:43.1 HOT-?

[sound of sniffle]

21:53:47.5 HOT-1

alrighty eighteen and fourteen.

21:53:49.7 HOT-2

we have to go around it's gonna be twenty five and forty five.

21:54:05.5 HOT-?

[sound of sniffle]

21:54:06.7 HOT-2

alrighty. I don't think we had any specials did we?

21:54:12.0 HOT-1

uh I don't believe we did.

21:54:13.6 HOT

[sound of double chime]

21:54:16.9 INT-3

hello.

21:54:17.2 INT-2

hey any specials?

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 260 21:54:18.6 INT-3

uh no we don't.

21:54:19.8 INT-2

no specials.

21:54:20.6 INT-3

nope.

21:54:20.8 INT-2

we should be there in about twenty twenty five minutes.

21:54:23.0 INT-3

fantastic.

21:54:23.9 INT-2

alright

21:54:24.1 INT-3

thanks bye.

21:54:58.5 HOT-2

yeah I kind of like that I'm so flexible with what I'm doing.

21:55:01.3 CAM

[sound similar to seat track movement]

21:55:03.0 HOT-2

• I have goals but I have such a wide range of goals I don't know exactly

what I want. 21:55:05.3 HOT

[sound similar to double chime]

21:55:25.0 ZOB

Colgan thirty four zero seven Cleveland.

21:55:28.1 RDO-2

thirty four zero seven go ahead.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 261

21:55:30.2 ZOB

Colgan thirty four zero seven reset your transponder. squawk seven— er uh two seven six two.

21:55:35.6 RDO-2

two seven six two Colgan thirty two— thirty four zero seven.

21:55:39.9 HOT-2

oops I think I had two seven six two I think I put half and half. two seven six two yeah. twenty five and then I switched that one. oops.

21:55:56.8 HOT-?

[sound of sniffle]

21:56:08.0 HOT-1

it's just like we're in I don't know just just a light haze or type cloud. I don't know just we can see things out in front of us.

21:56:17.4 HOT-2

do you want to go down?

21:56:18.6 HOT-1

huh? ohh. I was thinking about that.

21:56:26.4 HOT-2

might be easier on my ears if we start going down sooner.

21:56:28.9 HOT-1

yeah we could do it. that's fine.

21:56:31.6 RDO-2

and Center Colgan thirty four zero seven.

21:56:35.6 ZOB

Colgan thirty four zero seven uh say again?

21:56:35.9 HOT-1

get discretion to twelve.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 262

21:56:38.7 RDO-2

oh yeah just can we get PD down to twelve thousand for Colgan thirty four zero seven.

21:56:42.6 ZOB

uhh standby.

21:56:44.9 HOT-1

I got your standby.

21:56:46.5 HOT-2

[sound of laughter]

21:56:49.5 HOT-?

[sound of sniffle]

21:57:07.1 HOT-1

we may have to wait for separation on this guy over here.

21:57:10.0 HOT-2

yeah.

21:57:10.8 ZOB

Colgan thirty four zero seven cross BENEE at maintain one one thousand.

21:57:15.7 RDO-2

BENEE at one one eleven thousand Colgan thirty four zero seven.

21:57:20.5 HOT-2

BENEE at eleven.

21:57:21.3 HOT-1

tooo what was it?

21:57:23.2 HOT-2

BENEE.

21:57:23.4 HOT-1

oh BENEE.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 263 21:57:25.4 HOT-1

BENEE at one one thousand.

21:57:27.2 HOT-2

yes sir.

21:57:34.9 HOT-1

yeah that works.

21:58:28.0 HOT-?

[sound of sniffle]

21:58:31.1 HOT-1

you know we had a a controller down in Houston. uh he was known as Mister Happy.

21:58:37.7 HOT-2

oh yeah.

21:58:38.4 HOT-1

guy was just he was— had a perfect personality for the being a controller. he never let anything rattle him. and he just all just all bubbly type a type a guy. he retired— just to let you know how he— how well respected he was um he retired and he had they published where his retirement party was. there was pilots from Continental Colgan pilots Chautauqua Expressjet you know the main carriers there in Houston.

21:58:56.8 HOT-?

[sound of sniffles]

21:59:09.2 HOT-2

oh that's cool.

21:59:12.3 HOT-1

they all went to go see you know Mister Happy and everything but but that's where I got the bent wing pencil jet.

21:59:19.6 HOT-2

it's where what?

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 264 21:59:20.6 HOT-1

that's where I got the bent wing pencil jet uh name from.

21:59:24.7 HOT-2

he calls them that?

21:59:26.4 HOT-1

yeah it was uh Jet Lincoln instead of Jetlink. called em Jet Lincoln and we were Cold One.

21:59:29.0 HOT-2

uh-huh...oh.

21:59:32.4 HOT-1

Cold One nintey five sixty five you'll be following a bent wing pencil jet at your one oh clock. two miles or whatever it was.

21:59:40.9 HOT-2

that's funny.

21:59:42.1 HOT-1

either that or you're following the lawn dart today. let's see uh if it was a CRJ we're following the Barbie Jet.

21:59:45.6 HOT-2

[sound of laughter]

21:59:52.2 HOT-2

the Barbie Jet.

21:59:59.5 HOT-1

or he would say you're following Chi-tak-wa.

22:00:03.3 HOT-1

[sound of laughter]

22:00:04.1 HOT-2

[sound of laughter]

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 265 22:00:05.9 HOT-2

the guys that have fun and enjoy their jobs are so much more pleasant to work with.

22:00:09.4 HOT-1

oh yeah.

22:00:10.8 HOT-2

yeah.

22:00:14.6 HOT-?

[sound of sniffle]

22:00:16.2 HOT-1

College Station Texas was a a contract control tower.

22:00:23.0 HOT-2

yeah.

22:00:23.2 HOT-1

had a guy that worked in there. had an odd accent to begin with. and uh College Station Airport is uh owned and operated by the university— uh the Texas A and M university.

22:00:37.8 ZOB

Mesaba thirty forty five contact Cleveland Center one two zero point six.

22:00:39.7 HOT-2

uh-huh.

22:00:43.2 RDO-2

one two zero point six Colgan thirty four zero seven.

22:00:46.2 ZOB

nope Colgan thirty four zero seven you stay here. that was for Mesaba.

22:00:49.8 HOT-2

oh.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 266 22:00:51.7 HOT-2

I'm not doing very good by * tonight.

22:00:52.7 HOT-1

it's alright.

22:00:54.0 ZOB

Colgan thirty four zero seven you still here?

22:00:56.3 RDO-2

yes sir thirty four zero seven.

22:00:59.5 HOT-1

sorry about that. oh anyway he would say Eeeeeeeeastwood information echo.

22:01:08.9 HOT-2

[sound of laughter]

22:01:11.3 HOT-1

and he'd give us he'd give us same type of uh clearance to Houston. Colgan ninety five twenty six you're cleared to the George Herbert Walker er yeah George Herbert Walker Bush Intergalactical Airport.

22:01:27.6 HOT-2

[sound of laughter]

22:01:28.1 HOT-1

instead of Intercontinental. Intergalactical Airport via the College Station zero seven six. baaaseball Rice won. climb maintain seven thousand. departure frequency is Houston Center one two three point seven. squawk whatever you know.

22:01:36.8 HOT-2

[sound of laughter]

22:01:47.6 HOT-2

yeah.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 267 22:01:48.0 HOT-1

and I would try to read it back exactly the same way. went in there I don't know you know about three or four months before I left and he was just all calm and quiet. you know I could tell it was him said hey man what happened to that Eeeeeeastwood Airport information echo. he said yeah they clipped my wings.

22:02:09.7 HOT-2

oh no. they didn't like him doing that?

22:02:12.3 HOT-1

I said well uh if if you need uh if you need any help on that one you just let me know who to call and I'll uh be glad to put in a good word for ya. and he he chuckled. he said uh he said awww let it blow over for a little while and I'll be back I'll be back to my regular self later.

22:02:32.1 HOT-2

[sound of laughter]

22:02:32.9 HOT-1

yeah.

22:02:36.4 HOT-1

I just like the flying down there a whole lot better.

22:02:39.1 HOT-2

yeah.

22:02:39.6 HOT-1

see and and in the Saab in the northeast uh you * there's no FMS there's no glass.

22:02:46.9 HOT-2

yeah.

22:02:47.5 HOT-1

and you're you're asses and elbows all the time.

22:02:51.5 HOT-2

yeah.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 268 22:02:52.4 HOT-1

uh because uh you're flying the the victor airways. the uh the VORs are so close together and you're having to go to intersections.

22:03:00.3 HOT-2

yeah.

22:03:00.7 HOT-1

cross radials and all that kind of stuff. and uh it's it's hard work.

22:03:04.8 HOT-2

yeah.

22:03:05.3 HOT-1

down in Houston y— you're more spread out. uh the flying is a whole lot nicer down there the controllers are a whole lot nicer. in Florida the same way.

22:03:18.6 HOT-2

yeah Phoenix is like that.

22:03:20.3 HOT-?

[sound of sniffle]

22:03:21.2 HOT-1

man I— it's just all the pressure of all the the congestion and the the volume and weather and anything and everything. the the controllers uh they just it's like they uh constantly have their—.

22:03:38.1 ZOB

Colgan thirty four zero seven contact Buffalo Approach one two six point one five.

22:03:41.8 HOT

[sound similar to altitude alert]

22:03:42.7 RDO-2

one two six one five Colgan thirty four zero seven.

22:03:45.4 HOT-1

twelve eleven alt sel.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 269 22:03:46.5 HOT-2

twelve eleven alt sel.

22:03:50.0 HOT-?

[sound of sniffle]

22:03:53.0 RDO-2

Buffalo Approach Colgan thirty four zero seven twelve for eleven thousand with romeo.

22:03:59.2 APP

Colgan forty four zero seven Buff Approach good evening. Buffalo altimeter's two niner eight zero. plan ILS approach runway two three.

22:04:05.1 RDO-2

two niner eight zero and ILS two three Colgan thirty four zero seven.

22:04:09.1 HOT-2

*.

22:04:09.3 HOT-1

two niner eight zero.

22:04:11.6 HOT-2

eight.

22:04:12.4 HOT-1

and we'll expect two three.

22:04:15.1 HOT-2

yup.

22:04:15.5 HOT-1

and if you've got your charts handy I'll brief it real quick.

22:04:17.7 HOT-2

IIII do.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 270 22:04:19.4 HOT-1

**. alright it's uh gonna be the ILS to uh runway two three at Buffalo. chart eleven two twenty April oh seven.

22:04:28.9 HOT-2

yes sir.

22:04:29.7 HOT-1

got uh eleven three's the frequency set both sides. two thirty three set on my side I saw you set yours. uh glideslope uh final approach fix uh glideslope intercept is at the—.

22:04:39.9 APP

Colgan thirty four zero seven proceed direct TRAVA.

22:04:43.2 RDO-2

direct TRAVA Colgan thirty four zero seven.

22:04:45.8 HOT-2

direct—.

22:04:46.2 HOT-1

direct TRAVA.

22:04:50.6 HOT-1

oooh let's see I forget. do I do the do the first one?

22:04:54.8 HOT-2

I did the first one. it doesn't matter you could do either one. there's no hold in there so—.

22:05:00.6 APP

Colgan thirty four zero seven descend and maintain six thousand.

22:05:03.8 RDO-2

sorry about that down to six thousand Colgan thirty four zero seven.

22:05:08.2 HOT-2

cranky old guy.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 271 22:05:08.9 HOT-1

six thousand alt sel. that's something I you in in the Saab whoever if the autopilot's engaged you know the pilot flying manipulates that #.

22:05:17.0 HOT-2

yeah...oh yeah.

22:05:20.7 HOT-1

I don't know why we don't do that here but we don't.

22:05:23.2 HOT-2

yeah.

22:05:24.3 HOT-1

alright well if you don't mind I'm gonna go ahead and push her on down at a thousand feet a minute.

22:05:27.0 HOT-2

oh that's okay.

22:05:29.5 HOT-1

uh continuing on glideslope intercept's the outer marker twenty two oh six that's fourteen uh seventy eight above the ground. DA's nine twenty eight we'll put nine thirty in...it's also two hundred above the ground. touchdown zone elevation is seven twenty eight. highest MSA's south of the outer marker at thirty nine hundred north of the marker is twenty seven. and ALSF two lighting uh missed approach is up to twenty three hundred climbing right turn to three thousand via three hundred heading uh on the uh two six seven radial to BUF VOR. and er outbound on VOR out to WELLA uh which is DME twenty three point one uh hold uh this thing'll probably do a parallel entry. uh we got the weather. bugs are set eighteen fourteen flaps fifteen. uh off of twenty three I forget let me look it up.

22:06:05.0 HOT-?

[sound of sniffles]

22:06:31.0 HOT-2

left.

22:06:32.6 HOT-1

oh sure. I'll do it left turn.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 272 22:06:36.9 HOT-2

left turn.

22:06:37.6 HOT-1

first available.

22:06:38.7 HOT-2

I think so.

22:06:39.9 HOT-1

can I make echo?

22:06:41.3 HOT-2

um I think so.

22:06:42.9 HOT-1

okay.

22:06:45.3 HOT-1

we'll do it. oh #.

22:06:48.7 HOT-2

[sound of laughter]

22:06:50.5 HOT-1

going too far off.

22:06:55.6 HOT-2

yeah you can make echo.

22:06:55.8 HOT-1

*.

22:07:14.2 HOT-2

[sound similar to yawn] alright I'm gonna call in range. I'll be off one for a second.

22:07:16.8 HOT-1

I got one.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 273 22:07:18.3 HOT-2

• two five right? yup.

22:07:21.2 HOT-?

[sound of sniffle]

22:07:22.1 RDO-2

Ops Colgan thirty four zero seven's in range.

22:07:29.9 HOT-?

[sound of sniffle]

22:07:30.6 OPS

thirty four zero seven go for Buffalo ops.

22:07:33.4 RDO-2

yeah we're just letting you know we're in range. uh let's see here looks like we're ten maybe fifteen minutes out.

22:07:39.2 OPS

we'll see you in about ten fifteen minutes. gate twenty six. um we do actually have another Colgan turn we're trying to get out uh because they have the adapter we need to meet you guys. um so it might be just a couple minutes when you get here before we can actually bring the jetbridge up to ya.

22:07:54.2 RDO-2

alrighty uh thirty four zero seven we'll be we'll be ready for that thanks.

22:07:58.6 OPS

thank you see you then.

22:07:59.9 HOT-1

is the other Colgan in?

22:08:02.3 HOT-2

the other Colgan's there right now. and they're trying to turn him and we may have to sit and wait for them to turn him.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 274 22:08:07.4 HOT-1

yeah.

22:08:08.4 HOT-2

that's what she said.

22:08:09.1 HOT-1

how'd they beat us?

22:08:11.8 HOT-2

I don't— they must have taken runway two niner. 'cause they— we we sat there for like forty five minutes without anybody taking off two two.

22:08:26.4 HOT-?

[sound of sniffle]

22:08:27.5 HOT-1

alrighty.

22:08:37.4 HOT-?

[sound of sniffle]

22:08:41.0 HOT-2

alrighty **.

22:08:41.4 APP

Colgan thirty four zero seven descend and maintain five thousand.

22:08:45.0 RDO-2

five thousand Colgan thirty four zero seven.

22:08:47.9 HOT-1

five thousand alt sel.

22:08:48.9 HOT-2

five thousand alt sel I'm off one.

22:08:50.2 HOT-1

I've got one.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 275 22:08:51.1 PA-2

folks from the flight deck your first officer speaking uh it looks like at this time we're about ten maybe fifteen minutes outside of Buffalo. weather in Buffalo is uh pretty foggy. uh snowing a little bit there it's not too terribly cold uh but uh at this time I'd like to make sure everybody remains in their seats so the flight attendants can prepare the cabin for arrival. thank you.

22:09:10.6 HOT-2

[sound of sniffles] alrighty I'm back on one.

22:09:12.1 APP

Colgan thirty four zero seven descend and maintain four thousand.

22:09:15.6 RDO-2

and four thousand Colgan thirty four zero seven.

22:09:15.9 PA-3

ladies and gentlemen in preparation for landing in Buffalo please be certain your seatback is straight up and your seatbelt is fastened. please pass any remaining service items and unwanted reading materials to us as we pass through the cabin. please turn off all portable electronic devices and stow them until we have reached the gate. after landing Continental Connection allows passengers to use cell phones. I will make an announcement when it is safe to use this device. if you plan to use your cell phone please ensure it's accessible since personal items must be stowed until we reach the gate.

22:09:17.8 HOT-1

four thousand alt sel.

22:09:18.8 HOT-2

four thousand.

22:09:26.0 HOT-1

how's the ears?

22:09:27.3 HOT-2

uh they're stuffy.

22:09:31.6 HOT-1

are they poppin?

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 276 22:09:32.7 HOT-2

yeah.

22:09:33.3 HOT-1

okay. that's a good thing.

22:09:35.7 HOT-2

yeah I wanna make em pop. [sound of laughter]

22:10:20.6 HOT-?

[sound of sniffle]

22:10:22.6 HOT-2

is that ice on our windshield?

22:10:25.6 HOT-1

got it on my side. you don't have yours?

22:10:28.7 HOT-1

• [sound of whistle]

22:10:29.2 HOT-?

[sound of sniffle]

22:10:30.5 CAM

[sound of click]

22:10:32.3 HOT-2

oh yeah oh it's lots of ice.

22:10:39.5 HOT-?

[sound of sniffle]

22:10:47.5 HOT-1

oh yeah that's the most I've seen— most ice I've seen on the leading edges in a long time. in a while anyway I should say.

22:10:51.4 HOT-2

oh *.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 277 22:10:56.8 HOT-?

[sound of sniffle]

22:10:57.7 HOT-2

yeah that's another thing. all the guys— @ came in to our when we interviewed and he said oh yeah you'll all be upgraded in six months into the Saab and blah ba blah ba blah and I'm thinking you know what. flying in the northeast I've sixteen hundred hours. all of that in Phoenix how much time do you think actual I had or any in in ice. I had more actual time on my first day of IOE than I did in the sixteen hundred hours I had when I came here.

22:11:14.8 HOT-?

[sound of sniffle]

22:11:21.0 HOT-1

[sound of laughter]

22:11:22.2 HOT-2

I'm not even kidding. the first day.

22:11:25.7 HOT-1

well that sounds— well I mean I didn't have sixteen hundred hours.

22:11:27.5 HOT

[sound similar to altitude alert]

22:11:28.9 HOT-1

five for four alt sel.

22:11:29.8 HOT-2

five four alt sel.

22:11:31.1 HOT-?

[sound of sniffle]

22:11:31.5 HOT-1

but uh as a matter of fact I got hired with about six hundred and twenty five hours here.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 278 22:11:37.6 HOT-2

oh wow.

22:11:39.4 HOT-1

uh.

22:11:39.9 HOT-2

that's not much for uh back when you got hired.

22:11:42.5 HOT-1

no but uh out of that six and a quarter two hundred fifty hours was uh part one twenty one turbine. multi engine turbine.

22:11:50.0 HOT-2

oh that's right yeah.

22:11:54.3 HOT-2

no but all these guys are complaining they're saying you know how we were supposed to upgrade by now and they're complaining I'm thinking you know what? I really wouldn't mind going through a a winter in the northeast before I have to upgrade to captain.

22:12:04.0 HOT-1

no no.

22:12:05.0 HOT-2

I've never seen icing conditions. I've never deiced. I've never seen any— I've never experienced any of that. I don't want to have to experience that and make those kinds of calls. you know I'dve freaked out. I'dve have like seen this much ice and thought oh my gosh we were going to crash.

22:12:17.7 APP

Colgan thirty four oh seven descend and maintain two thousand three hundred.

22:12:21.8 RDO-2

okay down to two thousand three hundred Colgan thirty four zero seven.

22:12:25.1 HOT-2

um two three alt sel.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 279 22:12:27.4 HOT-2

I've got you in pitch pitch hold. I don't know if that's what you want.

22:12:27.6 HOT-1

two three alt sel.

22:12:29.6 HOT-1

yeah that's alright. let's uh— we'll do vertical speed back.

22:12:33.3 HOT-2

but I'm glad to have seen oh— you know now I'm so much more comfortable with it all.

22:12:37.6 HOT-1

yeah uh I I spent the first three months in uh Charleston West Virginia and uh flew—.

22:12:43.5 APP

Colgan thirty four zero seven turn left heading three three zero.

22:12:47.0 RDO-2

left heading three three zero Colgan thirty four zero seven.

22:12:49.3 HOT-1

left three three zerooo. we're in heading mode now. go to blue needles.

22:13:01.2 HOT-1

but I— first couple of times I saw the amount of ice that that Saab would would pick up and keep on truckin'.

22:13:05.9 HOT-2

yeah.

22:13:06.7 HOT-?

[sound of sniffle]

22:13:08.0 HOT-1

saw it out on the spinner. ice comin' out about that far my eyes about that big around. I'm going gosh. I mean Florida man— barely a little you know out of Pensacola.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 280 22:13:09.3 HOT-2

yeah.

22:13:14.2 HOT-2

holy cow...oh my gosh...oh yeah.

22:13:18.0 HOT

[sound similar to altitude alert]

22:13:21.4 HOT-1

that's uh thirty three for twenty three alt sel.

22:13:24.1 HOT-2

thirty three for twenty three alt sel.

22:13:24.8 HOT-1

let's do a descent checklist please.

22:13:25.9 HOT-2

do a descent checklist. altimeters two niner eight zero set crosschecked.

22:13:29.1 HOT-1

twenty nine eighty set crosschecked.

22:13:30.8 HOT-2

fuel balance check. pressurization set and cabin PA complete. descent checklist complete.

22:13:35.7 HOT-1

alright if you want to go ahead we can do the approach checklist along with it.

22:13:37.4 HOT-2

yeah sure. um approach checklist approach and landing brief complete.

22:13:41.6 HOT-1

uh complete.

22:13:42.3 HOT-2

bugs set.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 281 22:13:43.3 HOT-1

set.

22:13:44.3 HOT-2

GPWS landing flaps selected fifteen degrees. fuel transfer off hydraulic pressure and quantity check. caution warning lights check seatbelt sign on and external lights on. approach checklist complete.

22:13:54.5 HOT-2

[sound of sniffle]

22:13:54.7 HOT-1

rock and roll.

22:13:58.4 HOT-2

oh yeah— I'm so glad. I would've— I w— I mean—. I would've been been fine. I would have survived it. there wasn't— we n— never had to make decisions that I wouldn't have been able to make but...now I'm more comfortable.

22:14:08.5 APP

Colgan thirty four zero seven turn left heading three one zero.

22:14:12.1 RDO-2

left heading three one zero for Colgan thirty four zero seven.

22:14:12.7 CAM

[sound similar to engine power increase]

22:14:14.6 HOT-1

three one zero.

22:14:16.6 HOT-2

yeah.

22:14:21.9 HOT-?

[sound of sniffles]

22:14:22.6 HOT-1

alright let's see if I can get this seat...siteated...that's alright there.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 282 22:14:24.7 CAM

[sound similar to seat track movement]

22:14:32.7 HOT-1

still trying to find that sweet spot I guess there *.

22:14:39.8 CAM

[sound similar to engine power increase]

22:14:56.7 HOT-?

[sound of sniffle]

22:15:06.3 HOT-1

flaps five. [covered by background radio transmissions]

22:15:08.1 HOT-2

what?

22:15:08.8 HOT-1

flaps five please.

22:15:10.0 HOT-2

oh *.

22:15:11.2 CAM

[sound similar to flap handle movement]

22:15:13.2 HOT-?

[sound of sniffle]

22:15:13.5 APP

Colgan thirty four zero seven three miles from KLUMP turn left heading two six zero maintain two thousand three hundred until established localizer. cleared ILS approach runway two three.

22:15:22.2 RDO-2

left two sixty two thousand three hundred 'til established and cleared ILS two three approach Colgan thirty four zero seven.

22:15:31.7 HOT-1

alright approach is armed.

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 283 22:15:32.8 HOT-2

roger.

22:15:38.8 HOT-?

[sound of sniffle]

22:15:59.5 CAM

[sound similar to decrease in engine power]

22:16:04.1 HOT-1

gear down...loc's alive.

22:16:06.2 CAM

[sound similar to landing gear handle movement]

22:16:06.4 APP

Colgan thirty four zero seven contact tower one two zero point five. have a good night.

22:16:07.4 CAM

[sound similar to landing gear deployment]

22:16:11.5 RDO-2

over to tower you do the same thirty four zero seven.

22:16:14.9 HOT

[sound of two double chimes]

22:16:19.2 HOT-?

[sound of sniffle]

22:16:21.2 HOT-2

gear's down.

22:16:23.5 HOT-1

flaps fifteen before landing checklist.

22:16:26.0 CAM

[sound similar to flap handle movement]

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 284 22:16:26.6 HOT-2

uhhh.

22:16:27.4 CAM

[sound similar to stick shaker lasting 6.7 seconds]

22:16:27.7 HOT

[sound similar to autopilot disconnect horn repeats until end of recording]

22:16:27.9 CAM

[sound of click]

22:16:31.1 CAM

[sound similar to increase in engine power]

22:16:34.8 HOT-1

Jesus Christ.

22:16:35.4 CAM

[sound similar to stick shaker lasting until end of recording]

22:16:37.1 HOT-2

I put the flaps up.

22:16:40.2 CAM

[sound of two clicks]

22:16:42.2 HOT-1

[sound of grunt] *ther bear.

22:16:45.8 HOT-2

should the gear up?

22:16:46.8 HOT-1

gear up oh #.

22:16:50.1 CAM

[increase in ambient noise]

NTSB Aircraft Accident Report

INTRA-AIRCRAFT COMMUNICATION AIR-GROUND COMMUNICATION TIME and

TIME and SOURCE CONTENT SOURCE CONTENT 285 22:16:51.9 HOT-1

we're down.

22:16:51.9 CAM

[sound of thump]

22:16:52.0 HOT-2

we're [sound of scream]

22:16:53.9 END OF TRANSCRIPT END OF RECORDING

FD07373 ｜ 2010_美国_AAR1002.pdf

分类：06_境外及港澳台调查报告 ｜ 年份：2010 ｜ 地域： ｜ 严重程度： ｜ 场所： ｜ 起火原因： ｜ 来源格式：pdf

Runway Overrun During Rejected Takeoff  Global Exec Aviation  Bombardier Learjet 60, N999LJ  Columbia, South Carolina  September 19, 2008          Accident Report NTSB/AAR-10/02 PB2010-910402

National Transportation Safety Board

NTSB/AAR-10/02 PB2010-910402 Notation 8061B Adopted April 6, 2010

Aircraft Accident Report Runway Overrun During Rejected Takeoff Global Exec Aviation Bombardier Learjet 60, N999LJ Columbia, South Carolina September 19, 2008

National Transportation Safety Board

490 L’Enfant Plaza, S.W. Washington, D.C. 20594

National Transportation Safety Board. 2010. Runway Overrun During Rejected Takeoff, Global Exec Aviation, Bombardier Learjet 60, N999LJ, Columbia, South Carolina, September 19, 2008. Aircraft Accident Report NTSB/AAR-10/02. Washington, DC.

Abstract: This report describes the September 19, 2008, accident involving a Bombardier Learjet Model 60 (Learjet 60), N999LJ, which overran runway 11 during a rejected takeoff at Columbia Metropolitan Airport, Columbia, South Carolina, while operating as a 14 Code of Federal Regulations Part 135 unscheduled passenger flight. The captain, the first officer, and two passengers were killed; two other passengers were seriously injured.

The safety issues discussed in this report include the criticality of proper aircraft tire inflation; maintenance requirements and manual revisions for tire pressure check intervals; tire pressure monitoring systems; airplane thrust reverser system design deficiencies; inadequate system safety analyses by the Federal Aviation Administration (FAA) and Learjet; inadequate level of safety in the certification of changed aeronautical products; flight crew training for tire failure events; flight crew performance, including the captain’s action to initiate an rejected takeoff after V1, the captain’s experience, and crew resource management techniques; and considerations for tire certification criteria. Safety recommendations concerning these issues are addressed to the FAA.

The National Transportation Safety Board (NTSB) 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 NTSB 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 Internet at http://www.ntsb.gov. Other information about available publications also may be obtained from the website or by contacting:

National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, SW Washington, DC 20594 (800) 877-6799 or (202) 314-6551

NTSB publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2010-910402 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 NTSB reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

NTSB Aircraft Accident Report Contents Contents .......................................................................................................................................... i  Figures ........................................................................................................................................... iv  Acronyms and Abbreviations .......................................................................................................v  Executive Summary ................................................................................................................... viii 

1. Factual Information ...................................................................................................................1 
2. 1 History of Flight .........................................................................................................................1 
3. 2 Injuries to Persons ......................................................................................................................3 
4. 3 Damage to Airplane ...................................................................................................................3 
5. 4 Other Damage ............................................................................................................................3 
6. 5 Personnel Information ................................................................................................................3 
7. 5.1 Captain .............................................................................................................................4 
8. 5.2 First Officer .....................................................................................................................5 
9. 5.3 Flight Crew’s 72-Hour History ........................................................................................6 
10. 6 Airplane Information .................................................................................................................7 
11. 6.1 Main Landing Gear Tires .................................................................................................7 
12. 6.2 Engine Power Control and Thrust Reverser System Control ..........................................9 
13. 6.2.1 Commanding Forward Thrust ..........................................................................11 
14. 6.2.2 Commanding Reverse Thrust ..........................................................................11 
15. 6.2.3 Thrust Reverser System Logic Criteria............................................................12 
16. 7 Meteorological Information .....................................................................................................12 
17. 8 Aids to Navigation ...................................................................................................................12 
18. 9 Communications ......................................................................................................................13 
19. 10 Airport Information ................................................................................................................13 
20. 11 Flight Recorders .....................................................................................................................13 
21. 12 Wreckage and Impact Information ........................................................................................14 
22. 13 Medical and Pathological Information ...................................................................................14 
23. 14 Fire .........................................................................................................................................15 
24. 15 Survival Aspects ....................................................................................................................15 
25. 15.1 Survivors’ Descriptions of Crew-Provided Safety Information ..................................16 
26. 15.2 Survivors’ Descriptions of Exiting the Airplane .........................................................16 
27. 15.3 Postaccident Examination of Airplane Exits ...............................................................17 
28. 16 Tests and Research .................................................................................................................17 
29. 16.1 Sound Spectrum Study ................................................................................................17 
30. 16.1.1 Engine N1 ......................................................................................................17 
31. 16.1.2 Airplane Ground Speed..................................................................................18 
32. 16.2 Airplane Performance Study and Map Overlay ...........................................................19 
33. 16.3 Main Landing Gear Tires .............................................................................................21 
34. 16.3.1 Basic Design and Function ............................................................................21 

i

NTSB Aircraft Accident Report 1.16.3.2 Reconstruction and Examination of Accident Airplane’s Main Landing Gear Tires and Wheels ............................................................................................21  1.16.3.3 Tire Pressure Data Collected from In-Service Airplanes ..............................23  1.16.4 Thrust Reverser System ...............................................................................................24  1.16.4.1 Ground Tests and Engineering Review .........................................................24  1.16.4.2 Accidents and Incident Involving Thrust Reverser System Anomalies ........25  1.16.4.3 Approved Modifications After 2001 Landing Accident ................................26  1.16.5 Certification of the Learjet 60 as a Changed Aeronautical Product ............................27  1.16.5.1 Thrust Reverser Control Design ....................................................................28  1.16.5.2 Protection of Equipment in Wheel Wells ......................................................29  1.16.6 Comparison of Certification Criteria for Learjet 45 and Learjet 60 ............................29  1.16.6.1 Thrust Reverser System Design .....................................................................30  1.16.6.2 Protection of Equipment in Wheel Wells ......................................................30  1.17 Organizational and Management Information .......................................................................30  1.17.1 Main Landing Gear Tire Maintenance and Checks .....................................................31  1.17.2 Pilot Training and Standard Operating Procedures .....................................................31  1.17.2.1 Rejected Takeoff ............................................................................................32  1.17.2.2 Pretakeoff Passenger Briefing ........................................................................33  1.17.2.3 Airplane Weight and Balance Calculations ...................................................34  1.17.3 Federal Aviation Administration Oversight ................................................................34  1.18 Additional Information ..........................................................................................................35  1.18.1 Takeoff Safety Training Aid ........................................................................................35  1.18.2 Postaccident Safety Action ..........................................................................................36  1.18.2.1 Learjet Tire Servicing Advisory Wire ...........................................................36  1.18.2.2 Federal Aviation Administration Safety Alert for Operators ........................36  1.18.2.3 Learjet Revisions to Flight and Maintenance Manuals ..................................37  1.18.2.3.1 Temporary Flight Manual Change, Revised Procedures ..................... 37  1.18.2.3.2 Temporary Revision to Maintenance Manual ...................................... 37  1.18.2.4 Federal Aviation Administration Legal Interpretation That Learjet 60 Tire Pressure Checks Are Preventive Maintenance ...............................................38  1.18.3 Previously Issued Safety Recommendations ...............................................................38  1.18.3.1 Learjet 60 Thrust Reverser System Recommendations Resulting From This Accident Investigation ....................................................................................38  1.18.3.2 Ongoing Assessment of Safety-Critical Systems ..........................................40  1.18.3.3 Crew Resource Management .........................................................................41  1.18.3.4 Onboard Flight Recorder Systems .................................................................42  1.18.4 Current Airworthiness Requirements and Guidance for the Certification of Changed Aeronautical Products .................................................................................................43  1.18.5 Tire Pressure Monitoring Systems in Aircraft Applications .......................................43  1.18.6 Tire Load Certification Requirements .........................................................................44  1.18.6.1 Learjet 60 Tire Selection ................................................................................45  1.18.6.2 Effect of Tire Camber Angle on Tire Sidewall Loads ...................................45  1.18.7 Takeoff Accident and Incident Data ............................................................................46  1.18.7.1 High-Speed Rejected Takeoffs ......................................................................46  1.18.7.2 Airplane Types Involved in Tire-Related Events ..........................................46  1.18.7.3 Pilot Accounts of Real and Simulated Tire Failure Events ...........................46  ii

NTSB Aircraft Accident Report

1. Analysis .....................................................................................................................................48 
2. 1 General .....................................................................................................................................48 
3. 2 Accident Sequence ...................................................................................................................49 
4. 2.1 Captain’s Initiation of Rejected Takeoff After V1 .........................................................49 
5. 2.2 Uncommanded Forward Thrust Emergency ..................................................................51 
6. 3 Airplane Issues .........................................................................................................................53 
7. 3.1 Tire Failures ...................................................................................................................53 
8. 3.1.1 Operator’s Tire Maintenance Practices ............................................................54 
9. 3.1.2 Maintenance Manual References to Tire Pressure Check Intervals ................54 
10. 3.1.3 Lack of Tire Pressure Information for Flight Crews .......................................56 
11. 3.2 Thrust Reverser System Deficiencies ............................................................................56 
12. 3.3 Safety of Changed Aeronautical Products .....................................................................60 
13. 4 Flight Crew Performance .........................................................................................................62 
14. 4.1 Lack of Training for Tire-Related Events .....................................................................62 
15. 4.2 Captain’s Experience in the Learjet 60 and as Pilot-in-Command ................................63 
16. 4.3 Crew Resource Management .........................................................................................65 
17. 4.4 Medication Use and Rest Opportunities ........................................................................66 
18. 5 Occupant Survivability ............................................................................................................67 
19. 6 Other Safety Issues ..................................................................................................................68 
20. 6.1 Tire Certification and Testing Considerations ...............................................................68 
21. 6.2 Flight Recorders .............................................................................................................69 
22. Conclusions ...............................................................................................................................71 
23. 1 Findings....................................................................................................................................71 
24. 2 Probable Cause.........................................................................................................................73 
25. Recommendations ....................................................................................................................74 
26. 1 New Recommendations ...........................................................................................................74 
27. 2 Previously Issued Recommendations Resulting From This Accident Investigation and

Classified in This Report ........................................................................................................76 

1. Appendixes ...............................................................................................................................78 

Appendix A: Investigation and Hearing ........................................................................................78  Appendix B: Cockpit Voice Recorder Transcript ..........................................................................79 

iii

NTSB Aircraft Accident Report Figures Figure 1. Learjet factory technician checking inboard tire pressure (left image) and outboard tire pressure (right image). .....................................................................................................................9  Figure 2. Captain's side view of Learjet 60 thrust levers (at idle) and thrust reverser (piggyback) levers. To illustrate lever movement, one thrust reverser lever is in the stowed position, and the other is lifted to command reverse thrust (arrow shows direction lever moves when lifted from the stowed position). ........................................................................................................................9  Figure 3. Learjet 60 with thrust reversers deployed. The dotted yellow lines show the stowed position for the doors. ....................................................................................................................10  Figure 4. Engine N1 calculated as a function of elapsed time into the takeoff roll (time of the start of the loud rumbling sound is shown). ...................................................................................18  Figure 5. Airplane ground speed calculated as a function of elapsed time into the takeoff roll (time of the start of the loud rumbling sound is shown). ...............................................................19  Figure 6. Map of Columbia Metropolitan Airport showing integrated sound spectrum data, cockpit voice recorder comments, and wreckage locations plotted. ..............................................20  Figure 7. Reconstruction of the right outboard main landing gear tire showing outboard sidewall damage. Arrows depict the generally uniform location of the damage. ........................................22  Figure 8. Inboard aft corner of the left main landing gear wheel well for the Learjet 45 (left) and the inboard after corner of the right main landing gear wheel well for the Learjet 60 (right). ......30  iv

NTSB Aircraft Accident Report Acronyms and Abbreviations AC advisory circular AFM airplane flight manual AMM aircraft maintenance manual ARFF aircraft rescue and firefighting ARP aerospace recommended practice ASRS Aviation Safety Reporting System ATIS automatic terminal information service ATP airline transport pilot AW advisory wire CAE Columbia Metropolitan Airport CAM cockpit area microphone CFR Code of Federal Regulations CRM crew resource management CSN cycles since new CVR cockpit voice recorder DER designated engineering representative EEC electronic engine control EUROCAE European Organization for Civil Aviation Equipment FAA Federal Aviation Administration v

NTSB Aircraft Accident Report FADEC full authority digital electronic control FBO fixed-base operator FDR flight data recorder FR Federal Register FSI FlightSafety International KIAS knots indicated airspeed kts knots MLG main landing gear msl mean sea level N1 engine fan speed NPRM notice of proposed rulemaking NTSB National Transportation Safety Board P/N part number PIC pilot-in-command POI principal operations inspector psi pounds per square inch QRH quick reference handbook QTR qualification test report RSA runway safety area RTO rejected takeoff vi

NTSB Aircraft Accident Report RVDT rotary variable differential transformer S/N serial number SAFO safety alert for operators SB service bulletin SIC second-in-command SIR special investigation report SMS safety management system TC type certificate TCDS type certificate data sheet TEB Teterboro Airport TFM temporary flight manual TLA thrust lever angle TPMS tire pressure monitoring system TR temporary revision TSO technical standard order V1 takeoff decision speed V2 takeoff safety speed Vr rotation speed VOR very high frequency omnidirectional radio range

vii

NTSB Aircraft Accident Report viii Executive Summary On September 19, 2008, about 2353 eastern daylight time, a Bombardier Learjet Model 60, N999LJ, owned by Inter Travel and Services, Inc., and operated by Global Exec Aviation, overran runway 11 during a rejected takeoff at Columbia Metropolitan Airport, Columbia, South Carolina. The captain, the first officer, and two passengers were killed; two other passengers were seriously injured. The nonscheduled domestic passenger flight to Van Nuys, California, was operated under 14 Code of Federal Regulations Part 135. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed. The National Transportation Safety Board determines that the probable cause of this accident was the operator’s inadequate maintenance of the airplane’s tires, which resulted in multiple tire failures during takeoff roll due to severe underinflation, and the captain’s execution of a rejected takeoff (RTO) after V1, which was inconsistent with her training and standard operating procedures. Contributing to the accident were (1) deficiencies in Learjet’s design of and the Federal Aviation Administration’s (FAA) certification of the Learjet Model 60’s thrust reverser system, which permitted the failure of critical systems in the wheel well area to result in uncommanded forward thrust that increased the severity of the accident; (2) the inadequacy of Learjet’s safety analysis and the FAA’s review of it, which failed to detect and correct the thrust reverser and wheel well design deficiencies after a 2001 uncommanded forward thrust accident; (3) inadequate industry training standards for flight crews in tire failure scenarios; and (4) the flight crew’s poor crew resource management (CRM). The safety issues discussed in this report focus on criticality of proper aircraft tire inflation; maintenance requirements and manual revisions for tire pressure check intervals; tire pressure monitoring systems; airplane thrust reverser system design deficiencies; inadequate system safety analyses by the FAA and Learjet; inadequate level of safety in the certification of changed aeronautical products; flight crew training for tire failure events; flight crew performance, including the captain’s action to initiate an RTO after V1, the captain’s experience, and CRM; and considerations for tire certification criteria. Safety recommendations concerning these issues are addressed to the FAA.

NTSB Aircraft Accident Report 1

1. Factual Information
2. 1 History of Flight

On September 19, 2008, about 2353 eastern daylight time,1 a Bombardier Learjet Model 60 (Learjet 60),2 N999LJ, owned by Inter Travel and Services, Inc., and operated by Global Exec Aviation, overran runway 11 during a rejected takeoff (RTO)3 at Columbia Metropolitan Airport (CAE), Columbia, South Carolina. The captain, the first officer, and two passengers were killed; two other passengers were seriously injured. The nonscheduled domestic passenger flight to Van Nuys, California, was operated under 14 Code of Federal Regulations (CFR) Part 135. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed. Review of the cockpit voice recorder (CVR) transcript revealed that the flight crew received clearance instructions from the CAE ground controller at 2347:04 to taxi from the northeast fixed-base operator’s (FBO) parking ramp to runway 11. After a short discussion with the first officer about which way to turn,4 the captain, who was the pilot flying, turned the airplane left onto taxiway U. The controller provided an amended taxi clearance after noticing that the airplane had turned the wrong way.5 The flight crew followed the amended taxi clearance, which involved back-taxiing the airplane on runway 11 and performing a 180° turn on the runway to position the airplane for takeoff. At 2351:22, the captain briefed the RTO procedure and stated, “we’ve got plenty of runway so we’ll abort for anything below eighty knots [kts] after V-one and before V-two[6] engine failure fire malfunction loss of directional control all the big things after V-two we’ll go

1 All times in this report are eastern daylight time unless otherwise noted and based on a 24-hour clock. 2 Learjet engineering and certification documents refer to the airplane as Learjet Model 60 or L60. For brevity and consistency, this report refers to the Learjet Model 60 as “Learjet 60.” 3 An RTO may also be referred to as an aborted takeoff in some publications. 4 The clearance was to taxi via taxiway U and cross the approach end of runway 23 to taxiway N, then taxiway A. The first officer replied to the controller, “okay Uniform November Alpha ah to one one.” The captain stated to the first officer, “and hold short of two two I think it was,” and the first officer replied, “I think he said…we could cross it.” The captain stated, “oh did he?” and then asked, “and we’re going right outta here, correct?” The first officer replied, “ah well I think we have to go left outta here don’t we?” 5 The controller stated that construction at the airport made it confusing for pilots to taxi. He indicated that the accident flight crew’s initial taxi clearance would have required the crew to turn the airplane away from the takeoff runway, which the controller stated went “against normal.” 6 According to 14 CFR 1.2, V1 is the maximum speed in the takeoff at which the pilot must take the first action (such as applying brakes, reducing thrust, or deploying speed brakes) to stop the airplane within the accelerate-stop distance, which is a calculated distance defined in 14 CFR 25.109. V1 is also the minimum speed in the takeoff at which, after a failure of an airplane’s critical engine, the pilot can continue the takeoff and achieve the required height above the takeoff surface within the takeoff distance. According to 14 CFR 25.107, V2 is the takeoff safety speed that must provide at least a minimum specified climb gradient in the event of a loss of power in one engine.

NTSB Aircraft Accident Report 2 ahead and take it into the air treat it as an in-flight emergency.”7 The first officer replied, “correct.” The captain asked if the first officer had any questions, and the first officer asked, “reference the ah between eighty and ah V-one you’re only ah aborting for the fire failure loss of directional control?” The captain replied, “yes,” then added, “or an inadvertent thrust-, ah, T-R [thrust reverser] deployment.” The first officer then stated, “that will ah cause the loss of directional control I guess,” to which the captain replied, “exactly hah they go together.” The first officer later stated, “well eh if the runway is long I abort but if it’s short I kinda do different briefing depending on what the length of the runway is but we’re pretty heavy so it’s probably not a bad idea.” The CVR transcript indicated that the flight crew continued performing pretakeoff checklist items and that the captain requested wind information.8 The captain initiated the takeoff roll, and, at 2355:00.1,9 the first officer stated, “eighty knots. Crosscheck,” to which the captain replied, “check.” At 2355:10.5, the first officer reported, “V-one.” About 1.5 seconds later, the CVR captured the beginning of a loud rumbling sound. Postaccident sound spectrum and airplane performance studies10 indicated that the airplane’s position on the runway at the onset of the loud rumbling sound corresponded with the location where the first main landing gear (MLG) tire fragments were found. Four-tenths second after the beginning of the loud rumbling sound, the first officer stated, “go,” the captain stated something unintelligible, and, at 2355:13.0, the first officer stated, “go go go.” The CVR recorded a sound similar to a metallic click, and, at 2355:14.0, the captain stated, “go?” Postaccident sound spectrum and airplane performance studies estimated that, about this time, the airplane’s ground speed reached a peak of about 144 kts. The first officer then stated, “no? ar- alright. Get ah what the [expletive] was that?” The CVR recorded another metallic click sound, and, at 2355:17.0, the captain stated, “I don’t know. We’re not goin’ though.” At 2355:18.4, another metallic click sound was recorded, and, at 2355:19.5, the captain stated, “full out.” Postaccident performance studies indicated that the airplane was decelerating. Within 1 second, the CVR captured a sound consistent with the application of wheel braking, and, at 2355:21.6, the CVR captured a sound consistent with the nosewheel steering disconnect warning tone. Postaccident performance studies indicated that the airplane had then accelerated. About 7 seconds later, the first officer stated, “shut ’em off,” and, at 2355:32.4, the first officer stated, “they’re shut off they’re shut off.” At 2355:36.0, the first officer made a radio transmission on the CAE tower control frequency, saying, “roll the equipment we’re goin’ off the end.” The CVR recording ended at 2355:41.1. A controller in the CAE tower who observed the airplane’s takeoff roll reported that the beginning of the takeoff roll appeared normal but that, when the airplane was part way down the runway, sparks appeared that seemed to be coming from the airplane’s right MLG. One of the

7 The captain’s briefing of the RTO criteria was inconsistent with Global Exec Aviation’s training manual, which is discussed in section 1.17.2.1. 8 At 2354:27, the captain asked the first officer to request a wind check from the controller. The controller stated, “wind zero seven zero at eight gust one four.” The captain asked the first officer, “zero one zero at eight?” The first officer replied, “ah huh.” The captain then stated, “’kay so pretty much straight down.” Runway 11 has a magnetic heading of 110°. 9 Times related to the takeoff sequence are reported to tenths of 1 second because of the speed at which events occurred. 10 For further information, see sections 1.16.1 and 1.16.2.

NTSB Aircraft Accident Report two surviving passengers stated that, during the takeoff roll, the airplane was shifting and swaying back and forth all the way down the runway and that the airplane felt “out of control” from the start. The other surviving passenger reported that the airplane felt as if it blew a tire and that the airplane leaned to the right “almost like a wing had touched the ground.” The controller observed that the airplane went straight off the end of the runway. The airplane passed through the 1,000-foot runway safety area (RSA), struck airport lighting and navigation antennas, and descended a steep downhill slope before striking a lighting pole and the perimeter fence. The airplane then struck a concrete highway marker post, crossed a five-lane road, and struck a second concrete post and an embankment on the far side of the road. The controller stated that, when the airplane struck the hill, the airplane stopped and exploded into a fireball. Both passengers stated that the nose of the airplane went up and down at least twice before final impact. Debris from all four MLG tires was found on the runway. 1.2 Injuries to Persons Table. Injury Chart Injuries Flight Crew Cabin Crew Passengers Other Total Fatal 2 0 2 0 4 Serious 0 0 2 0 2 Minor 0 0 0 0 0 None 0 0 0 0 0 Total 2 0 4 0 6 1.3 Damage to Airplane The airplane was destroyed by impact forces and the postcrash fire. 1.4 Other Damage Damage to airport property included some of the runway approach lighting, a localizer antenna array, and the airport perimeter fence. Concrete roadway right-of-way markers and a five-lane asphalt road were also damaged. 1.5 Personnel Information The captain was hired by Global Exec Aviation on January 4, 2008, and the first officer was hired on August 8, 2008. According to Global Exec Aviation’s director of operations, the accident flight was the crewmembers’ second flight of the day, and they had previously flown together twice. 3

NTSB Aircraft Accident Report 4 1.5.1 Captain The captain, age 31, held an airline transport pilot (ATP) certificate for multiengine land airplanes with type ratings for Cessna CE-500 (issued on June 18, 2005), Learjet 60 (issued on October 25, 2007), and Cessna CE-650 (issued on January 19, 2008) airplanes.11 She held a first-class airman medical certificate issued April 29, 2008, with the limitation, “holder shall wear corrective lenses.” According to Global Exec Aviation employment records, the captain had accumulated about 3,140 hours total flight time, including about 2,040 hours pilot-in-command (PIC) time. She had accumulated about 35 hours in the Learjet 60 (about 8 hours of which were as PIC) and about 118 hours in the Cessna CE-650 (which were accumulated at Global Exec Aviation). Before the 2-day trip pairing that included the accident flight, the captain’s most recent experience as PIC of a Learjet 60 was on August 16, 2008. In the 30 days before the accident, the captain had accumulated about 19 hours as second-in-command (SIC) in the Learjet 60 and about 15 hours as PIC in the Cessna CE-650. In the 90 days, 30 days, and 24 hours preceding the accident, the captain had logged about 67, 36, and 1.5 hours, respectively. The captain completed Global Exec Aviation’s initial new-hire training on January 4,

1. Global Exec Aviation’s director of operations stated that the captain came to the company

with excellent references and had flown with and been recommended by a previous Federal Aviation Administration (FAA) principal operations inspector (POI) for the company. The director of operations stated that, because of the captain’s references, the company did not give the captain a checkride in a simulator, even though the company typically gave a checkride to other potential new hires. The captain’s most recent recurrent simulator training was completed at a FlightSafety International (FSI) training facility on August 13, 2008, and her most recent recurrent ground training was completed on August 16, 2008. The captain’s most recent line check was completed on May 6, 2008, and her most recent Learjet 60 proficiency check was completed on August 14,

1. The evaluator who conducted the Learjet 60 proficiency check stated that the captain

performed “very much” within standards and that the outcome of the checkride was never in doubt. He stated that the captain displayed good crew resource management (CRM) skills and had good command of the airplane. Another Learjet 60 instructor who provided recurrent ground and simulator training to the captain at FSI described her as meticulous with good organizational skills. He recalled that, during training, the captain told him that she had not been in the Learjet 60 for some time; he stated that her first day of simulator training was a little rough during basic air work but that, by the end of that session, the captain was doing well. The instructor reported that the captain’s second and third day of training went very well. He stated that his notes for the second day indicated “excellent CRM” and that he does not give that rating to many people. He stated that

11 She also held second-in-command privileges for Cessna CE-560XL airplanes; a flight instructor certificate for instrument, single-engine, and multiengine land airplanes; commercial privileges for single-engine land airplanes; private privileges for single-engine seaplanes; and an aircraft dispatcher certificate.

NTSB Aircraft Accident Report 5 the training included such abnormal scenarios as V1 cuts and RTOs with an engine failure or a thrust reverser unlock. Global Exec Aviation’s director of operations, who had trained with the captain and had flown about 30 hours with her, described the captain as “laid back,” which he considered “typical of a less experienced captain.” He described her decision-making skills as excellent and conservative. He stated that he would work with her on being more vocal in her command authority but that she was “above normal” for a new captain. A review of FAA records found no previous accidents, incidents, or enforcement actions. FAA records indicated that the captain received a notice of disapproval on August 11, 2006, for a practical test for the ATP certificate because of unsatisfactory performance in the nonprecision approach and circle-to-land procedures. She retested the same day and passed. On April 11, 1997, when the captain was a private pilot with about 192 total flight hours, she received a notice of disapproval for the practical test for the airplane instrument rating because of unsatisfactory performance of partial-panel very high frequency omnidirectional radio range (VOR) instrument approach procedures and instrument landing system instrument approach procedures. She was retested on April 14, 1997, and received a second notice of disapproval because of unsatisfactory performance of partial-panel VOR instrument approach procedures. She was retested on May 28, 1997, and passed. On November 14, 1997, when the captain had accrued about 252 total flight hours, she received a notice of disapproval for a practical test for the commercial airplane multiengine land certificate because of unsatisfactory knowledge of the national airspace system and airplane performance and limitations. (She subsequently passed the checkride for private pilot privileges for multiengine land airplanes on December 6, 1997, and she passed the checkride for the commercial certificate for multiengine land airplanes on September 1, 2004.12) 1.5.2 First Officer The first officer, age 52, held an ATP certificate for multiengine land airplanes with type ratings for Learjet 60 (issued on March 1, 2007) and Cessna CE-500 airplanes.13 He held a first-class airman medical certificate issued July 18, 2008, with the limitations “must wear corrective lenses” and “possess glasses for near/intermediate vision.” According to employment records from Global Exec Aviation and estimates from another employer14 and a previous employer, the first officer had accumulated about 8,200 hours total flight time, including about 7,500 hours PIC time and about 300 hours in Learjet 60 airplanes (about 108 hours of which were as SIC). In the 90 days, 30 days, and 24 hours preceding the accident, the first officer logged about 42, 34, and 1.5 hours, respectively.

12 According to the captain’s résumé, in 1997, she was attending college and was not working in an aviation field that would require a commercial multiengine certificate. She subsequently gained flight experience and worked as a flight instructor in the years before her successful retest in 2004. 13 He also held commercial privileges for single-engine land airplanes, rotorcraft/helicopters, and instrument helicopters. 14 The first officer also began flying for another operator in August 2008. Global Exec Aviation’s director of operations stated that he thought that the first officer had accepted a full-time position with another operator but that he was unsure of which one.

NTSB Aircraft Accident Report 6 The first officer completed Global Exec Aviation’s initial new-hire training on August 8,

1. His previous employer, also a Part 135 operator, provided him with Learjet 60 flight

training and his most recent Learjet 60 proficiency check, which was completed on March 13, 2008.15 Global Exec Aviation’s director of operations stated that the first officer was hired as a part-time pilot. A review of FAA records found no previous accidents, incidents, enforcement actions, or notices of disapproval. Global Exec Aviation’s director of operations had flown about 5 hours with the first officer and described him as a well-experienced pilot with excellent piloting skills. He stated that the first officer had good CRM skills and had no problem speaking up but that he was not overly assertive. 1.5.3 Flight Crew’s 72-Hour History Review of airline travel, cellular telephone, hotel, and company records provided information about the captain’s and the first officer’s nonwork activities during the 72 hours before the accident. These records revealed that, on Wednesday, September 17, 2008, both the captain and the first officer were passengers aboard a commercial flight that departed Long Beach, California, about 1238 Pacific daylight time en route to New York. They checked into hotel rooms in Secaucus, New Jersey, about 2200, and each requested hotel wake-up calls for about 0800 the next morning. Based on their respective telephone records, the captain had the potential for 6 hours of sleep, and the first officer had the potential for 7 hours of sleep, that night. The first officer’s wife, who had communicated with him via telephone and text messaging, recalled that he had told her that noise at the hotel made it difficult to sleep. On Thursday, September 18, 2008, both pilots left the hotel about 1000, taking the hotel shuttle to Teterboro Airport (TEB), Teterboro, New Jersey, where the accident airplane was parked. About 1200, they conducted a 48-minute test flight in the accident airplane to ensure that maintenance on a high-pressure bleed valve was effective.16 About 1400, both the captain and the first officer checked into their rooms at a different hotel in Secaucus and were off duty until the next day. Based on their respective cellular telephone records, the captain had the potential for 7.5 to 9.5 hours of sleep, and the first officer had the potential for 9.75 hours of sleep, during the night before the accident. On Friday, September 19, 2008 (the day of the accident), telephone activity for the captain showed numerous telephone calls and text messages, leaving three 1-hour uninterrupted periods. Telephone activity for the first officer indicated that he had one 1-hour and one 2-hour periods of uninterrupted time. Both the captain and the first officer checked out of the hotel about 2018 and traveled to TEB. They departed TEB in the accident airplane about 2142 and arrived at the Columbia Aviation ramp at CAE about 2310 to pick up the passengers.

15 Global Exec Aviation and the FAA accepted the training performed under his previous employer because both companies used the same training program and facility. The FAA can accept such training instead of training provided by the current employer if the FAA determines that the previous training was sufficient. 16 The accident airplane had been at TEB since September 12, 2008, for maintenance after the valve became stuck in the open position during a flight.

NTSB Aircraft Accident Report 7 1.6 Airplane Information The accident airplane was powered by two Pratt & Whitney Canada PW305A high-bypass turbofan engines, each of which was rated at a maximum 4,600 pounds of thrust with a maximum nontransient forward engine fan speed (N1) of 10,820 rpm, or 102 percent. The airplane’s initial airworthiness certificate was dated December 14, 2006, and the airplane was configured with a seating capacity for two crewmembers and eight passengers. The accident airplane’s empty weight was 14,755 pounds, its maximum ramp weight was 23,750 pounds, and its maximum takeoff weight was 23,500 pounds. According to performance calculations provided by Bombardier Learjet, given the accident flight conditions, V1 would have been 136 kts indicated airspeed (KIAS),17 Vr (rotation speed) would have been 145 KIAS, and V2 would have been 153 KIAS. According to logbook information dated September 16, 2008, the airplane had accumulated 106 hours and 121 cycles since new (CSN). At the time of the accident, the airplane had accumulated an estimated 108.5 hours and 123 CSN. 1.6.1 Main Landing Gear Tires The airplane was equipped with dual wheel and tire assemblies at each MLG position. Each MLG tire was a Goodyear Flight Eagle, part number (P/N) 178K43-1, size 17.5 x 5.75-8.18 For use on the Learjet 60, the rated tire inflation pressure19 was 220 pounds per square inch (psi). Applicable tire certification requirements are specified in 14 CFR 25.733 and FAA Technical Standard Order (TSO) TSO-C62c.20 TSO-C62c specified various tire performance criteria, one of which was a maximum allowable air pressure loss of 5 percent per day for an airplane tire under normal operating circumstances. According to the Goodyear Qualification Test Report (QTR) 461B-3044-TL, the Goodyear Flight Eagle tire documented a daily pressure loss of about 2.2 percent. Maintenance logs indicated that all four MLG tires were new when installed in December 2007 and had accumulated a total of 20 landings at the time of the accident. Flight history records showed that the airplane had flown 5 days during the 12-day period that preceded the accident. Interviews with personnel from all facilities that handled the accident airplane during that time period revealed that none had serviced or received a request to service the MLG tires. Global Exec Aviation’s director of maintenance estimated that the tire pressures may not have been checked for about 3 weeks before the accident.

17 KIAS refers to the airplane’s speed as shown on the airspeed indicator. 18 For the purpose of this report, “Goodyear Flight Eagle tire” refers to tire P/N 178K43-1, size 17.5 x 5.75-8, as specified for the Learjet 60. 19 Rated pressure is the maximum inflation pressure to match the tire’s load rating. Aircraft tire pressures are given for an unloaded tire; when the rated load is applied to the tire, the pressure increases by 4 percent as a result of a reduction in air volume. According to Learjet data, the allowable MLG tire pressure range for the Learjet 60 (based on its maximum takeoff weight of 23,500 pounds) would be 209 to 219 pounds per square inch gauge (gauge pressure). 20 TSO-C62c was in effect at the time of certification; the current version is TSO-C62e, issued on September 29, 2006.

NTSB Aircraft Accident Report The Learjet 60 Aircraft Maintenance Manual (AMM) contained the minimum maintenance requirements for continued airworthiness in accordance with applicable regulations. Chapter 5 of the AMM, the contents of which related to the intervals for scheduled inspections, stated that the Learjet inspection program “also contains other inspections and individual stand-alone inspection checks, which must be accomplished at the specified intervals.” Chapter 5 referenced tire pressure inspections under “Inspection Phase A5.” The A5 inspection, which is due at 300-hour intervals, included Inspection Reference Number P1210055, which stated, “Nose and Main Tires – Check for proper inflation. (Refer to [chapter] 12-10-05).” The contents of chapter 12 of the AMM related to technical specifications and descriptions of how to perform various maintenance tasks. Chapter 12-10-05, pages 301 and 302, contained the following guidance: Important inflation practices and tips are as follows: … Measure the cold tire pressure before the first flight of every day or every 10 day[s] on in-service tires [that] are not in use.… Do not underinflate the tire. An underinflated tire generally cannot be detected visually. The AMM indicated that a tire should be replaced if found to have operated at an inflation pressure loss of 15 percent. Other guidance calling for daily or regular checks of tire pressure was contained in a Learjet maintenance publication, Aircraft Tire Care and Maintenance, dated September 2001; a Learjet product support publication, Everyday Maintenance of Tires and Brakes, dated April 10, 2007; FAA Advisory Circular (AC) AC 20-97B, Aircraft Tire Maintenance and Operational Practices; and several Goodyear publications, including Goodyear Information Report 97001, Learjet Tire Maintenance, dated January 9, 1997, and an operator letter dated March 1999 referring to the availability of Goodyear’s Comprehensive Guide to Aircraft Tire Care and Maintenance. As shown in figure 1 below, to check tire pressures on the Learjet 60, the person performing the check must crouch or crawl under the wing of the airplane to gain access to the MLG tire pressure valves. The landing gear doors may conceal the valves for the outboard tires, requiring a person to lie on the ground to gain access. 8

NTSB Aircraft Accident Report Figure 1. Learjet factory technician checking inboard tire pressure (left image) and outboard tire pressure (right image). 1.6.2 Engine Power Control and Thrust Reverser System Control The Learjet 60’s control levers for commanding engine power for forward thrust are located on the cockpit pedestal. The level of engine power (measured as N1) commanded by the pilot’s positioning of the thrust levers for forward thrust is communicated electronically to the engine control components mounted on each engine. The Learjet 60 has no mechanical or cable-actuated connection between the cockpit thrust levers and the engines. The airplane’s thrust reverser system, which is designed to help stop the airplane on the ground, is also electronically controlled. The thrust reverser system responds to the pilot’s positioning of the thrust reverser levers (also known as “piggyback” levers because they are located on top of the thrust levers) by using electronic signals to command reverse thrust functions. See figure 2 (at right) for the captain’s side view of Learjet 60 thrust levers and thrust reverser levers. reverser system responds to the pilot’s positioning of the thrust reverser levers (also known as “piggyback” levers because they are located on top of the thrust levers) by using electronic signals to command reverse thrust functions. See figure 2 (at right) for the captain’s side view of Learjet 60 thrust levers and thrust reverser levers. The Learjet 60’s thrust reversers are designed with two half-shell doors on each engine that form the engine’s aft nacelle when stowed (forward thrust configuration). When deployed (reverse thrust configuration), the thrust reverser doors redirect the flow of engine fan air and exhaust gases forward to provide a The Learjet 60’s thrust reversers are designed with two half-shell doors on each engine that form the engine’s aft nacelle when stowed (forward thrust configuration). When deployed (reverse thrust configuration), the thrust reverser doors redirect the flow of engine fan air and exhaust gases forward to provide a Figure 2. Captain's side view of Learjet 60 thrust levers (at idle) and thrust reverser (piggyback) levers. To illustrate lever movement, one thrust reverser lever is in the stowed position, and the other is lifted to command reverse thrust (arrow shows direction lever moves when lifted from the stowed position). 9

NTSB Aircraft Accident Report 10 deceleration force to assist with ground braking. (See figure 3 below, which depicts a Learjet 60 with thrust reversers deployed.) Although the use of reverse thrust can reduce the distance needed to stop the airplane, most of the stopping power is provided by the wheel brakes.21 Both the thrust levers and the thrust reverser (piggyback) levers share some common mechanical components in the cockpit pedestal that move whenever a pilot manipulates either the thrust levers or the thrust reverser levers. The shared components depend on microswitches to detect which levers the pilot is using for commanding either forward or reverse thrust. (The following two sections describe the shared components and the basic system functions for forward and reverse thrust during normal operations; section 1.6.2.3 describes the fail-safe logic criteria and system responses to detected anomalies.)

21 The FAA’s master minimum equipment list for the Learjet 60 (upon which operators’ minimum equipment lists are based) allows an operator to fly the airplane with inoperative thrust reversers for up to 10 days, during which time a maintenance lockout pin is installed in the reversers to prevent use. Figure 3. Learjet 60 with thrust reversers deployed. The dotted yellow lines show the stowed position for the doors.

NTSB Aircraft Accident Report 11 1.6.2.1 Commanding Forward Thrust To command forward thrust, a pilot positions the cockpit thrust levers (one per engine) to a desired engine power setting (such as takeoff, maximum continuous thrust, or cruise power). As the pilot moves the thrust levers, a mechanical linkage on each thrust lever rotates the input shaft on a rotary variable differential transformer (RVDT) in the cockpit pedestal for each lever. As the RVDTs’ input shafts rotate, each RVDT electronically provides information about the changing thrust lever angle (TLA) to the electronic engine control (EEC) computer for the corresponding engine. The EECs interpret the TLA information and provide corresponding electronic signals to each engine’s full authority digital electronic control (FADEC) components.22 Based on the signals received from the EECs, the FADEC components, which perform functions including thrust management and compressor surge control, regulate engine output to provide the level of engine power commanded by the pilot. In the case in which the EECs provide the logic signals that forward thrust has been commanded, the FADEC components regulate engine power according to the forward thrust power schedule. 1.6.2.2 Commanding Reverse Thrust To command reverse thrust, a pilot positions the engine power levers to idle power, then lifts the thrust reverser (piggyback) levers to the deploy position. When the thrust reverser levers are lifted to the deploy position, a mechanical linkage on each lever (the same linkage used by each thrust lever when forward thrust is commanded) rotates the input shaft on each respective RVDT; microswitches (one for each thrust reverser lever) detect that the reverser levers are lifted and send an electronic request for the thrust reversers to deploy. While the thrust reverser doors on both engines begin to move from stowed toward the deployed position, balk solenoids in the throttle quadrant (one for each lever) momentarily prevent the pilot from moving the thrust reverser levers further until the thrust reversers fully deploy. Once the doors are fully deployed, each balk solenoid releases, allowing the pilot to further lift the thrust reverser levers to command increased reverse thrust. The EECs respond to the pilot’s movement of the thrust reverser levers by signaling the FADEC components to set engine power in accordance with the reverse thrust power schedule. The reverse thrust power schedule is a function of both TLA (set by the pilot through positioning of the reverse thrust levers to command any amount of reverse thrust up to full reverse thrust) and the airplane’s indicated airspeed when less than 100 kts. Slower indicated airspeed will result in less thrust.23

22 According to Pratt & Whitney Canada, the FADEC is a dual-channel system made of several components to control the engine’s thrust. The main control system components are the thrust lever, EEC, and the hydromechanical fuel metering unit. The FADEC system regulates each engine’s high-pressure rotor speed (N2) and low-rotor (fan) speed (N1) in response to the pilot-operated TLA, ambient conditions, other pilot-selected inputs, and aircraft discrete inputs. 23 According to the Pratt & Whitney Canada PW305 Customer Training Manual, engine power provided for reverse thrust for an airplane traveling at 100 kts would be about 85 percent of takeoff N1, whereas engine power for an airplane traveling 0 to 40 kts would be about 50 percent of takeoff N1.

NTSB Aircraft Accident Report 12 1.6.2.3 Thrust Reverser System Logic Criteria The thrust reverser system requires specific input from various sensors on the airplane, which provide input into the logic control functions that prevent certain operations when specific criteria are not met. The thrust reverser system logic criteria are designed to protect against inadvertent thrust reverser deployment during flight and to prevent the engines from producing high levels of thrust while the reverser doors are in transit. For the thrust reverser doors on each engine to fully deploy when commanded and to remain deployed, the EECs must receive input from the squat switches, which are sensors mounted on each MLG assembly, signaling that the airplane is on the ground.24 In addition, each engine’s thrust reverser doors must fully open to change the electrical state of the switches for the balk solenoids to release the thrust reverser levers. In addition, the thrust reverser levers’ microswitches (located in the cockpit pedestal with each respective RVDT) must indicate that the reverser levers are lifted before the EECs will signal the FADEC components to use the reverse thrust engine power schedule. In the event of a scenario in which almost any of the thrust reverser logic requirements are not met, the thrust reversers are designed to stow. Learjet engineering personnel indicated that the uncommanded stowage of the thrust reversers in the event of any system loss or malfunction is part of a fail-safe design that ensures that a system anomaly cannot result in a thrust reverser deployment in flight, which could adversely affect the airplane’s controllability. The design is intended to reduce the pilot’s emergency procedures workload and prevent potential mistakes that could exacerbate an abnormal situation.25 1.7 Meteorological Information Automatic terminal information service (ATIS) information V (victor) was current at the time of the accident. According to the CVR transcript, the first officer advised the ground controller before taxi that the crew had obtained ATIS V, which indicated that winds were from 060° at 10 kts, visibility was 10 miles with clear skies below 12,000 feet above mean sea level (msl), the temperature was 21° C, the dew point was 13° C, and the altimeter setting was 30.23 inches of mercury. 1.8 Aids to Navigation No deficiencies with navigational aids were noted.

24 The squat switches signal “ground mode” upon sensing that the MLG is partially compressed to support the airplane’s weight. 25 Both Learjet and FAA personnel noted that designing the thrust reversers to fail to the stow position prevents a pilot from having to perform the procedures of isolating which engine had a faulty thrust reverser, correctly increasing thrust on the opposing engine to counteract the other’s reverse thrust, and then shutting down the engine with the faulty thrust reverser. In multiengine airplanes, numerous accidents have occurred when pilots identified and shut down the wrong engine.

NTSB Aircraft Accident Report 13 1.9 Communications No ground or airplane communications equipment deficiencies were noted. 1.10 Airport Information CAE is located about 5 miles southwest of Columbia at an elevation of about 236 feet msl. Runway 11/29, which has a grooved asphalt surface, is 8,601 feet long and 150 feet wide. The RSA beyond the departure end of runway 11 is 1,000 feet long and 500 feet wide. At the time of the accident, several taxiways and runway 5/23 were closed for construction. Runway and taxiway closure information was available in Notice to Airmen 08-75 and was included in the ATIS V broadcast. CAE is certificated under 14 CFR Part 139 and maintains aircraft rescue and firefighting (ARFF) capabilities at index C.26 At the time of the accident, CAE had four firefighting personnel on duty 24 hours a day and three ARFF vehicles (Redbird 6, 9, and 10). Each vehicle was a 1500-series crash truck that carried at least 1,500 gallons of water and 200 gallons of foam concentrate. Redbird 10 also carried 700 pounds of dry chemical agent. 1.11 Flight Recorders The airplane was equipped with a Universal model 1603-02-12 CVR, which is a solid-state unit that records 2 hours of digital audio information. Examination of the CVR showed structural and fire damage on the outer case. Removal of the damaged outer case exposed the inner crash-protected memory case, which showed no structural or fire damage. Download of the digital information at the National Transportation Safety Board’s (NTSB) laboratory in Washington, D.C., revealed that the CVR captured both a two-channel recording of the last 2 hours of operation and a separate four-channel recording of the last 30 minutes of operation. The 2-hour recording captured one channel of poor-quality27 audio information from the cockpit area microphone (CAM) and one channel of good-quality28 audio information from the captain’s and the first officer’s audio panels combined. The 30-minute recording captured good-quality audio information from the captain and the first officer and

26 CAE is an index C airport based on five or more average daily departures of aircraft having a length of at least 126 feet but less than 159 feet. To meet index C capabilities, two or three ARFF vehicles are required that contain a total of 3,000 gallons of water and commensurate quantities of aqueous film-forming foam. In addition, ARFF apparatus must carry either 500 pounds of sodium-based dry chemical, halon 1211, clean agent, or 450 pounds of potassium-based dry chemical agent. 27 The NTSB uses five categories to classify the levels of CVR recording quality: excellent, good, fair, poor, and unusable. A poor-quality recording is characterized by fragmented phrases and conversations, and extensive passages of conversations may be missing or unintelligible. 28 A good-quality recording is characterized by crew conversations that are easily and accurately understandable with only a few words that are unintelligible.

NTSB Aircraft Accident Report 14 poor-quality information from the CAM (each on separate channels).29 The airplane was not equipped with a flight data recorder (FDR).30 1.12 Wreckage and Impact Information Examination of the debris path from the runway to the main wreckage site revealed that the initial wreckage debris on the runway consisted of fragments from the right outboard MLG tire. In immediate proximity following the initial tire debris (along the airplane’s direction of travel), tire skid marks and gouging on the runway surface crossed the runway centerline at an angle from left to right before generally realigning with the runway heading and continuing straight off the departure end into a swath of ground scars and debris that extended to the main wreckage. The identified debris extended down the runway in the following order (with some overlap): right outboard MLG tire (some fragments of which were found coated with hydraulic fluid), airplane landing light, airplane pieces, right inboard MLG tire, left inboard MLG tire, and left outboard MLG tire. Fragments of the MLG wheel sets were found strewn along the debris path with few tire fragments attached; all four MLG wheel and brake assemblies showed grinding and friction damage on the bottom, with the most severe damage evident on the right outboard wheel. The left and right squat switches were found in the grass at the end of the runway, separated from their respective MLG struts. The airplane came to rest on a 25° to 30° embankment on the east side of a five-lane road. The top and right side of the fuselage were burned away to about the level of the cabin floor. The aft fuselage forward of the vertical stabilizer was mostly consumed by fire, particularly beneath the fuselage fuel tank location. Both engines and their mounting structures were fire damaged. The left engine’s thrust reverser doors were in the stowed position. Remnants of the thrust reverser door actuating mechanism from the right engine (which sustained more fire damage than the left) were in locations consistent with the stowed position. Postaccident examination of the engines revealed that their combustor sections contained organic debris; thermal damage to the airplane’s engine diagnostic system precluded memory data extraction. 1.13 Medical and Pathological Information The Lexington County, South Carolina, Office of the Coroner performed autopsy examinations on the captain, the first officer, and two passengers. The cause of death for both the captain and the first officer was reported as smoke and fume inhalation and thermal injuries, and a contributing factor for both was blunt force trauma. The cause of death for the two passengers was reported as injuries resulting from blunt force trauma. The two survivors received second- and third-degree burns.

29 The fourth channel did not contain (and was not required to contain) any audio information. 30 According to 14 CFR 135.152(a), the requirement for an FDR does not apply to multiengine, turbine-powered airplanes configured with fewer than 10 passenger seats, excluding any required crewmember seat.

NTSB Aircraft Accident Report 15 The FAA’s Civil Aerospace Medical Institute performed toxicology testing on samples from the captain and the first officer. The toxicology reports for the captain and the first officer indicated that the samples tested negative for ethanol and a wide range of drugs, including major drugs of abuse (marijuana, cocaine, phencyclidine, amphetamines, and opiates). Twenty percent carboxyhemoglobin saturation (carbon monoxide), 1.8 (μg/mL) cyanide,31 and 0.03 (μg/mL, μg/g) diphenhydramine32 were detected in the captain’s blood.33 Diphenhydramine was also detected in her liver. Twenty-five percent carboxyhemoglobin saturation, 2.07 (μg/mL) cyanide, and 0.036 (μg/mL, μg/g) diphenhydramine were detected in the first officer’s blood. Diphenhydramine was also detected in his liver and urine, and ibuprofen34 was detected in his urine. 1.14 Fire According to statements from the passengers and witnesses, a fire erupted in and around the airplane when it came to rest at final impact. CAE ARFF responders received the alert of the accident via the crash phone and radio from the airport communication center. All three ARFF vehicles and all four ARFF personnel on duty arrived at the scene within 5 minutes of notification and found that the entire length of the airplane and sections of the highway were on fire. The fire was under control about 10 minutes after the first ARFF crews arrived. Mutual aid response was provided by Lexington County and the Town of Cayce. Burn lines consistent with a fuel fire extended downhill from the wing and fuselage fuel tanks, across the road toward the airport fence, and along the gutter of the road. 1.15 Survival Aspects The captain was seated in the left cockpit seat, and the first officer was seated in the right cockpit seat. According to the two surviving passengers, the two fatally injured passengers were seated in the forward cabin, one in the forward-facing seat on the left and the other on the side-facing divan on the right. The two survivors were seated in the aft forward-facing seats. The captain’s seat five-point restraint system buckle was found with four of the five buckles fastened; the crotch-strap buckle was not located in the wreckage. The first officer’s five-point restraint system buckle was found with all five buckles fastened. None of the identified seat belt buckles from the cabin were found fastened (not all buckle components from the cabin were located).

31 Carbon monoxide and cyanide levels can result from smoke inhalation. 32 Diphenhydramine is an over-the-counter antihistamine with sedative effects that is often used to treat allergy symptoms (commonly known by the trade name Benadryl®) or as a sleep aid (commonly known by the trade name Unisom®). 33 The condition and specific anatomical sources of the blood samples from both the captain and the first officer were not reported. 34 Ibuprofen is an over-the-counter pain reliever and fever reducer commonly known by the trade name Motrin®.

NTSB Aircraft Accident Report 1.15.1 Survivors’ Descriptions of Crew-Provided Safety Information The passenger who was seated in the aft forward-facing seat on the right recalled that, before the airplane taxied, the captain asked the passengers if they knew where the seatbelts were and told them that the fire extinguisher and the snacks were in the back. The passenger stated that he did not hear the “usual” safety briefing but noted that the captain told them where the exits were and stated, “you have all done this before.” He stated that he did not think that the captain’s briefing sounded very professional. He recalled that he fastened his seatbelt but indicated that he did not notice what the other passengers did with their seatbelts. He stated that he assumed that they used them because he was familiar with their travel habits, and they typically used their seatbelts on every flight. The other surviving passenger, who was seated in the aft forward-facing seat on the left, stated that the pilots did not provide a safety briefing and that he did not remember hearing any specific language about the location of the exits. He recalled that one of the pilots made a comment that he interpreted to mean that the pilot considered the passengers to be frequent fliers who were familiar with safety briefings. He stated that he fastened his seatbelt but not very tightly. 1.15.2 Survivors’ Descriptions of Exiting the Airplane The passenger in the aft right seat stated that, as soon as the airplane came to a stop, fire erupted in the cabin. He stated that he remembered being told that there was an exit near him and that he turned around went to the aft exit door (on the right) and “did what it said to do.” He stated that he did not remember if there were instructions or arrows on the exit that showed how to open it but stated that he opened it without difficulty and jumped out onto the wing of the airplane. He recalled that he went through more fire outside the airplane; ran away from the airplane; and saw, within 5 seconds, the airplane burst into bigger flames. He stated that, as he ran, he pulled off his burning clothes. The passenger in the aft left seat stated that the airplane went up and back down “hard” and that, before the airplane’s final “very, very hard” impact, he saw something or someone fly up and hit the ceiling in the forward cabin. He stated that he may have been unconscious for a few seconds but that he saw the other passenger get up and yell, “we gotta go! We gotta go!” He indicated that he did not know that there was an exit behind him but that the other passenger “went right to it,” opened it, and leapt “straight out into a wall of flames.” He stated that he went to the exit, stayed to the left to try to avoid the fire, and jumped out. He indicated that, when he landed on the ground, he was on fire and began rolling to put out the fire himself. 16

NTSB Aircraft Accident Report 17 1.15.3 Postaccident Examination of Airplane Exits The airplane’s main passenger boarding door, a type I exit of a clamshell design with upper and lower doors,35 was located at the left forward cabin. The exterior handle and the interior lower handle were found at the accident site in the closed/locked position, and the door pins were found in the extended/locked position. The fuselage was deformed at the aft bottom area of the door frame, and the lower door could not be opened; the upper door latch was operable with effort. A type III escape hatch was located in the lavatory area in the rear cabin on the right, above the lavatory’s seat.36 The lavatory and escape hatch area were separated from the cabin by two wooden partitions (extending from floor to ceiling) on each side of the airplane with a sliding, wooden “pocket” door in the middle that, when open, stowed into the left partition. The charred remains of this pocket door were found consistent with it having been in the open (stowed) position; the hatch and the surrounding fuselage were destroyed by fire. The escape hatch handle and one pin-type latch were found in the debris in the open (unlatched) position. 1.16 Tests and Research 1.16.1 Sound Spectrum Study The NTSB performed a sound spectrum study to examine a 50-second segment of audio (from 2354:42 to 2355:32) captured on the CVR by the CAM in the near-final moments on the recording. The sound spectrum study used the audio signals as a basis for calculating the accident airplane’s engine N1 and ground speed. 1.16.1.1 Engine N1 The calculated engine N1 values were used to plot a curve of the airplane’s N1 as a function of time, as shown in figure 4 on the following page. Breaks in the curve indicate times during which clearly discernible engine sounds were absent, which likely resulted from other sounds obscuring the engine sound signal.

35 A type I exit, according to 14 CFR 25.807(a)(1), is a floor-level exit with a rectangular opening of not less than 24 inches wide by 48 inches high, with 8-inch maximum corner radii. 36 A type III exit, per 14 CFR 25.807(a)(3), is a rectangular opening of not less than 20 inches wide by 36 inches high, with 7-inch maximum corner radii and with a step-up inside the airplane of 20 inches or less. The step-down outside the airplane may not exceed 27 inches for exits located over the wing.

NTSB Aircraft Accident Report

Figure 4. Engine N1 calculated as a function of elapsed time into the takeoff roll (time of the start of the loud rumbling sound is shown). As shown in figure 4, from 2354:42, the calculated engine N1 increased to a peak within 10 seconds and then remained constant near that peak level (about 93 percent) for the next 20 seconds until 2355:12, when a distinct noise burst (corresponding with the beginning of a loud rumbling sound) was recorded. After the noise burst, from 2355:14 to 2355:16, there was noticeable wavering of engine N1; during this 2-second period, N1 decreased from about 93 percent to about 84 percent and then increased back up to about 88 percent before finally decreasing below about 76 percent, at which point engine noises became only intermittently discernible. At 2355:19, engine N1 was about 68 percent. In the final 4 seconds of analyzed audio (beginning at 2355:28), discernible engine noises corresponded with an N1 rising through about 86 percent to about 93 percent before decreasing again to about 83 percent. 1.16.1.2 Airplane Ground Speed The data derived from the sound spectrum analysis for the sound produced by the tires rolling over the runway grooves (the spacing of which was measured) were used in calculating airplane ground speed. These calculated ground speed values were used to plot a curve of the airplane’s ground speed as a function of time, as shown in figure 5 on the following page. Breaks 18

NTSB Aircraft Accident Report in the curve indicate times during which clearly discernible tire-rolling sounds were absent, which likely resulted from other sounds obscuring the tire sound signal.

Figure 5. Airplane ground speed calculated as a function of elapsed time into the takeoff roll (time of the start of the loud rumbling sound is shown). As shown in figure 5, the airplane’s ground speed increased from about 5 kts about 8 seconds into the recording (at 2454:50) to about 138 kts at the time that the rumbling sound began at 2355:12. The sound spectrum analysis of airplane ground speed ends a few seconds later; tire-rolling sounds beyond that time were not clearly discernible. The analysis indicated a peak ground speed of about 144 kts. 1.16.2 Airplane Performance Study and Map Overlay The airplane’s position on the runway at the time that the CVR began recording usable sound spectrum data is not precisely known; however, radio communications and wreckage debris locations on the runway provided a basis for estimating the airplane’s initial position. Plotting this estimated position on a map of CAE provided an initiation point. Other time-stamped information, such as calculated ground speed, engine N1 values (in rpm), and flight crew comments, was then correlated with the airplane’s position plots on the CAE map, and 19

NTSB Aircraft Accident Report mapped wreckage debris information was added. The result provided a graphical depiction of the relative progression of events throughout the takeoff roll to impact, a segment of which is shown in figure 6.

Figure 6. Map of Columbia Metropolitan Airport showing integrated sound spectrum data, cockpit voice recorder comments, and wreckage locations plotted. The sound spectrum study speed analysis ends at 2355:14 (when sound signatures are no longer clearly discernible); information derived from the integration of that portion of the sound spectrum is shown in pink. CVR comments, engine N1, and ground speed from the same timeframe are shown in yellow text. For the purpose of positioning the remaining CVR comments in the approximate locations where they occurred, the airplane performance study further extrapolated the airplane’s ground speed to 2255:31 through a visual examination of the sound spectrum illustration. This extrapolated information is shown in red text. Wreckage and tire debris found on the runway are also shown as marked. 20

NTSB Aircraft Accident Report 21 1.16.3 Main Landing Gear Tires 1.16.3.1 Basic Design and Function Transport-category aircraft tires, such as those installed on the Learjet 60, operate at high inflation pressures37 and have a thick-walled construction made up of three main materials: rubber, fabric (primarily the flexible nylon ply material that gives tires their strength), and the steel bead wires. Transport-category aircraft tires are designed to withstand intermittent (taxi, takeoff, and landing) operations in severe operating conditions, such as under the airplane’s heavy load requirements and at high speeds. Each intermittent use of the tires is typically brief and followed by lengthy periods of relief from the loads and/or high speeds while the aircraft is in flight or parked. When an aircraft tire is in use, both heavy weight and high speed contribute to the strong forces that act on it. An aircraft tire in use can generate high temperatures within its structure in part because of the amount that the materials can flex in response to inflation pressure and loading. Aircraft tires perform properly only when they have the correct inflation pressure and are not overloaded. Proper inflation and loading result in an acceptable amount of sidewall deflection. Sidewall overdeflection occurs when a tire is operated while underinflated or overloaded. When a tire’s sidewalls overdeflect at the bottom of each rotation, the excessive flexing of the rubber can result in fatigue of the reinforcing fibers and the generation of higher internal temperatures at a faster rate than would be generated in a properly inflated, properly loaded tire. High temperatures can degrade the physical properties of the tire’s rubber compounds and melt the nylon threads in the plies; such damage can lead to tire failure. 1.16.3.2 Reconstruction and Examination of Accident Airplane’s Main Landing Gear Tires and Wheels Pieces of the right outboard tire, which were the first debris found on the runway, were identified as fragments of the tire’s sidewall. About 80 percent of the tire was reconstructed. Both sidewalls showed damage around the entire circumference of the tire; the damage had a ragged appearance and was located at a generally uniform distance from the wheel rim, as shown in figure 7 on the following page. Both the inboard right tire and the inboard left tire showed similar sidewall damage (on one sidewall each). The outboard left tire, fragments of which were the farthest down the runway, had a more torn and shredded appearance than the other three tires and showed extensive tearing through its layers. One fragment of this tire, about 19 inches in circumferential length, showed sidewall damage.

37 In contrast, the tires used on many single-engine general aviation airplanes are not of a high-pressure tire design; those tires carry a load that is about proportionate to what automotive tires carry and have inflation pressures and wall thicknesses similar to the tires used in automotive applications.

NTSB Aircraft Accident Report 22

The characteristics of the sidewall damage observed on all four of the accident airplane’s tires were consistent with a photograph in a Goodyear publication showing typical heat damage sustained from sidewall overdeflection and flexing fatigue.38 Goodyear engineers and the Goodyear publication noted that previous tire testing found that aircraft tire sidewall damage from flexing fatigue is predominantly consistent with taxi-cycle operations while the tire is

38 Aircraft Tire Care and Maintenance, The Goodyear Tire & Rubber Company Publication 700-862-931-538 (Akron, Ohio: The Goodyear Tire & Rubber Company, 2002, rev. 10/2004), http://www.goodyearaviation.com/resources/tirecare.html (accessed February 15, 2010). Figure 7. Reconstruction of the right outboard main landing gear tire showing outboard sidewall damage. Arrows depict the generally uniform location of the damage.

NTSB Aircraft Accident Report 23 underinflated; Goodyear testing showed that as little as 5-percent underinflation greatly reduces the fatigue life of transport-category aircraft tires. Because either underinflation or overloading can result in tire sidewall overdeflection, tire testing data for both scenarios were reviewed. According to estimated static load deflection charts created during the investigation for the accident tires, the amount of underinflation needed for a loaded tire to produce the type of overdeflection damage observed on the accident airplane’s tires (specifically, the damage location on the sidewall) would be about 36-percent underinflation. Alternatively, testing data showed that the amount of overload needed for a properly inflated tire to produce the amount of overdeflection consistent with the sidewall damage observed on each of the accident airplane’s tires would be about 12,200 pounds. Other damage observed on fragments from each of the accident airplane’s tires included blue to purple heat discoloration indicative of moderate to severe heat damage. According to the Goodyear publication, blue tinting appears at temperatures from 210° to 230° F. Microscopic examination of fragments from all four tires revealed that the tires’ nylon fibers (which are generally soft and fabric-like when undamaged) had melted and resolidified into single strands that had a stiffness resembling that of broom bristles. The Goodyear publication noted that the melting point of nylon is greater than 400° F. Rubber reverts to an uncured state and loses strength and adhesion at temperatures from 280° to 320° F, then becomes hard and dry at temperatures from 355° to 390° F. Fragments from all four tires showed abrasion and rub marks on the inner liner and heat damage to the rubber and nylon fibrous cord materials. Goodyear engineering personnel and investigators experienced in tire failure examinations noted that, although heat and rolling distance could affect the start of wrinkling, they were not aware of wrinkling or liner damage ever occurring in aircraft tires that had been properly inflated. The tires showed no evidence of impact, puncture, or adhesive-separation damage. Examination of the wheels and brakes showed no evidence of overheating or brake lock-up,39 and none of the wheels’ eutectic fuse plugs, which are designed to melt if the wheel temperature reaches about 390° F, leaked when tested. The right outboard wheel assembly had no flanges remaining, and the left outboard wheel assembly retained nearly full height on the outboard flange. The threaded tire inflation valve bodies on two of the wheels (left inboard and right outboard) could be removed by finger torque (the specification for installation required 190 inches-pounds); the inflation valve bodies of the other two wheels were found more tightly secured. The internal mechanisms of the four tire inflation valves did not leak when tested. 1.16.3.3 Tire Pressure Data Collected from In-Service Airplanes The average daily pressure loss for Learjet 60 tires reported in the QTR, which is within the 5 percent allowed by TSO-C62c, is comparable to the daily loss rate for tires on many other

39 Evidence indicated that the wheel brakes stopped rotating after sustaining mechanical damage associated with runway contact.

NTSB Aircraft Accident Report 24 transport-category airplanes. The NTSB reviewed tire pressure information collected from various sources for the purpose of gaining insight into industry practices related to tire pressures and maintenance for in-service transport-category airplanes. The information included historical data from 2005 to 2009 and tire pressure and maintenance practice information collected from two FBOs and eight commercial operators. The data collection was not intended (or sufficient) for performing statistical analyses. The collected data showed that most of the tires sampled were inflated to within 10 percent of their rated pressure, which was typically within maintenance limits. However, some tires were operated at inflation values well below the limits that the respective AMMs specified for tire replacement. During the data collection, nearly all maintenance providers interviewed mentioned that use of the AMM was required by each operator’s FAA-approved operations specifications. One FBO operator indicated that some AMMs do not call for mandatory tire pressure checks as part of scheduled maintenance and that he believed that weekly tire pressure checks were generally good practice. A review of AMMs for the Cessna CE-650 and the Dassault Falcon 50 (airplane types also operated by Global Exec Aviation) found that the AMMs were organized similar to the Learjet 60 AMM; the reference to daily tire pressure checks was found in chapter 12 of each. The Dassault airplane flight manual (AFM) for pilots also contained a reference to chapter 12 of the AMM for tire pressure check information. 1.16.4 Thrust Reverser System 1.16.4.1 Ground Tests and Engineering Review The Learjet 60 is equipped with cockpit annunciator lights that indicate the status of the thrust reverser system to the pilots. Ground tests were performed using a Learjet 60 that was specially equipped to simulate possible anomalies that could affect the thrust reverser system’s logic functions, and the test airplane’s cockpit annunciator lights were monitored throughout the testing. In the cockpit, the thrust reverser system has a total of six annunciators (two columns of three annunciator lights each, with one column per engine). The annunciators for each engine include the green TR ARM light, which illuminates when the thrust reverser system is armed and available for use if commanded;40 the amber TR UNLOCK light, which illuminates when the thrust reverser doors are unlocked and in transit; and the white TR DEPLOY light, which illuminates when the thrust reverser doors are in the fully deployed position. When the thrust reverser doors on each engine are fully deployed, the amber TR UNLOCK lights extinguish.

40 The TR ARM lights remain illuminated when the airplane is on the ground at idle engine power and any time that the TR UNLOCK or TR DEPLOY lights are illuminated. During taxi operations, the green TR ARM lights extinguish when the engine power levers are moved to a position greater than the idle-thrust position.

NTSB Aircraft Accident Report 25 During one test, the airplane was on the ground (with squat switches in ground mode) with the thrust reversers deployed and at idle thrust. While the airplane remained on the ground, the test equipment switched the squat switch status to air mode, thus creating a situation in which the logic requirements to maintain thrust reverser deployment were no longer being met. As a result, the thrust reverser doors stowed, the TR DEPLOY light extinguished, the TR UNLOCK light illuminated, and the TR ARM light flashed for less than 2 seconds before all thrust reverser system annunciators extinguished. The EECs, upon receiving the input that the thrust reversers were stowed and that the squat switches were signaling air mode, shifted logic and signaled the FADEC components to change the engine thrust output from the reverse thrust power schedule to the forward thrust power schedule. (In the test airplane’s configuration, the thrust changed from ground idle speed to flight idle speed.) In this situation, the EECs would transition from the reverse thrust power schedule to the forward thrust power schedule during about a 2-second transition through idle power. During the entire sequence, the thrust reverser levers in the cockpit would remain in the reverse thrust idle position (as selected by the pilot) while the engines produced forward thrust. Because both the thrust reverser levers and the forward thrust levers share common RVDTs (one for the left engine and one for the right engine), the EECs, which receive TLA information from the RVDTs, would signal the engines to produce a level of forward thrust that generally corresponds with the level of reverse thrust commanded; that is, a pilot commanding full reverse thrust (for maximum deceleration of the airplane) would instead receive high levels of forward thrust (accelerating the airplane) according to the forward thrust power schedule.41 To reduce the forward thrust in such a situation in a Learjet 60, a pilot would need to move the thrust reverser levers out of the commanded reverse thrust position and place them in the stowed position, consistent with the “Inadvertent Stow of Thrust Reverser After a Crew-Commanded Deployment” procedure described in section 1.16.4.3. 1.16.4.2 Accidents and Incident Involving Thrust Reverser System Anomalies April 1994 accident during landing (Learjet 60 prototype test flight) On April 6, 1994, a prototype Learjet 60 airplane (a modified Learjet 55) was involved in a landing accident during a test flight. After the airplane landed with a suspected flat tire, the pilot’s application of the thrust reversers produced no deceleration, and the airplane went off the end of the runway. Postaccident examination found that both right MLG tires were flat and that the right MLG strut was damaged. June 1998 incident during rejected takeoff In June 1998, a Learjet 60 was involved in an incident during an RTO at Washington Dulles International Airport, Chantilly, Virginia. According to the pilot’s report submitted to the National Aeronautics and Space Administration’s Aviation Safety Reporting System (ASRS), both right MLG tires failed during the takeoff roll, and tire and brake assembly damage led to

41 For any given TLA, the forward thrust power schedule results in higher engine power than the reverse thrust schedule, and the maximum possible reverse TLA is less than full forward TLA.

NTSB Aircraft Accident Report 26 severed hydraulic brake lines and squat switch wiring. The airplane’s thrust reversers stowed during the attempted RTO, and the airplane went off the left side of the 11,500-foot runway near the end. During interviews with Learjet 60 pilots, one pilot provided contact information for another captain that he believed had experienced a thrust reverser incident; a 2009 interview with that captain revealed that he was involved in the 1998 incident that was recorded in the ASRS. During the interview, the captain recalled that the airplane had four new MLG tires just installed and that he had completed two uneventful flights in the airplane on the day of the incident. He recalled that, for the incident takeoff, the airplane was loaded to near maximum takeoff weight and that the taxi route for takeoff was long. He stated that, fairly early in the takeoff roll and well before V1, he heard a loud bang that he felt certain was a blown tire because he had experienced a blown tire before. He described the event as a “very violent explosion” that created holes in the flaps and damage to the right side of the fuselage. January 2001 accident during landing On January 14, 2001, a Learjet 60 went off the end of a runway after a collision with deer during landing at Troy Municipal Airport, Troy, Alabama.42 The pilots, who were critically injured, reported that the thrust reversers failed to operate. The airplane’s thrust reversers were found stowed, and the squat switch on the left MLG showed damage and evidence of deer impact. An NTSB sound spectrum study performed on the airplane’s CVR recording revealed that, after the airplane touched down, N1 increased to a speed higher than what could be achieved on the reverse thrust power schedule. 1.16.4.3 Approved Modifications After 2001 Landing Accident On November 20, 2003, Learjet issued an AFM revision that changed the name of the “Inadvertent Stow of Thrust Reverser During Landing Rollout” abnormal procedure to “Inadvertent Stow of Thrust Reverser After a Crew-Commanded Deployment” and moved it to the emergency procedures section. In addition, on February 21, 2005, Learjet issued Service Bulletin (SB) 60-78-7 (the latest revision of which was dated May 1, 2006), which advised Learjet 60 owners and operators of a modification that Learjet was installing on in-production airplanes (including the accident airplane) and that could be retrofitted to in-service airplanes.43 The SB noted that the purpose of the modification, which incorporated the airplane’s existing wheel speed detection system into the thrust reverser logic,44 was “to reduce the possibility of inadvertent stowing during thrust reverser operation.” The SB modification was not required by the FAA.

42 The report for this accident, NTSB case number ATL01FA021, is available at the NTSB’s website at http://www.ntsb.gov/ntsb/query.asp. 43 The SB applied to airplanes with serial numbers (S/N) 60-002 through -276. New-production airplanes, starting with S/N 60-277, were equipped with the modification. The accident airplane was S/N 60-314. 44 The wheel speed sensors were already installed on the airplane as part of the autospoiler system. The wiring for both the wheel speed sensors and the squat switches is routed along the MLG struts.

NTSB Aircraft Accident Report 27 The modification added the wheel speed sensor input to the thrust reverser logic, thus providing a redundant ground signal intended to help ensure that the thrust reversers would remain deployed in the event of the loss of a squat switch ground signal after landing. The wheel speed sensor signal would provide redundancy after the airplane’s squat switches had been in air mode for at least 2 minutes, beginning within 50 seconds of the ground/air transition. 1.16.5 Certification of the Learjet 60 as a Changed Aeronautical Product The Learjet 60 was certificated on January 15, 1993, under 14 CFR Part 25 (the airworthiness standards for transport-category airplanes). The Learjet 60 was added as the most recent model in a series of derivative models (or “changed aeronautical products”) that were approved and added to Learjet type certificate (TC) A10CE, which was originally issued for the Learjet 24 on March 17, 1966. Performance and basic specifications for the models on TC A10CE vary widely. The Learjet 24 has maximum gross takeoff weight of 13,000 pounds, can be configured for up to 8 people (2 crew and 6 passengers), a maximum altitude of 41,000 feet, and a maximum range of 1,266 miles; in comparison, the Learjet 60 has nearly twice the maximum gross takeoff weight, a configuration option for up to 10 people (2 crew and 8 passengers), a maximum altitude of 51,000 feet, and a maximum range of 2,768 miles. The Learjet 60 also has a different wing and fuselage than earlier models and includes a large fuel tank in the aft fuselage. All but two Learjet models (the Learjet 23 and the Learjet 45) were certificated using TC A10CE. The certification basis for changed aeronautical products allows an aircraft manufacturer to introduce a derivative model as a design update on a previously certificated aircraft and add the changed product onto an existing TC. The FAA approves such changes if it finds that the changes are not significant enough to warrant application for a new TC. This process enables a manufacturer to introduce derivative aircraft models without having to resubmit the entire aircraft design for certification review. The manufacturer can use the results of some of the analyses and testing from the original type certification to demonstrate compliance, in which case the regulations that were in effect on the date of the original TC apply. Title 14 CFR 21.101 specifies the requirements for demonstrating airworthiness compliance for changed aeronautical products; the current revision of the regulation differs from the one that applied to the certification of the Learjet 60.45 According to the revision of 14 CFR 21.101, which became effective on September 16, 1991, the certification basis for the Learjet 60 required, at the discretion of the FAA, compliance with either the regulations cited in the original TC (issued in 1966) or applicable regulations in effect on the date of the application. The exceptions related to compliance with different versions of and amendments to the regulations are specified on the Learjet 60’s type certificate data sheet (TCDS).46

45 See section 1.18.4 for the current requirements. 46 Specifically, the Learjet 60 is certificated under 14 CFR Part 25, effective February 1, 1965, as amended by amendments 25-1 through -73, with specified exceptions. The TCDS specifies sections of the regulation and amendment levels that apply.

NTSB Aircraft Accident Report 28 The Learjet 60’s certification basis did not require compliance with some of the regulatory revisions for aircraft certification that were in effect in 1993 (when the Learjet 60 was introduced), which would apply to new aircraft models certificated on new TCs. For example, the Learjet 60’s compliance with 14 CFR 25.1309, which related to failures of equipment, systems, and installations, was based primarily on the original version of the regulation.47 A revised and more extensive version of 14 CFR 25.1309, including amendment 25-41, (which became effective September 1, 1977, for newly certificated aircraft) did not fully apply to the Learjet 60.48 According to Learjet and FAA personnel, during the changed product certification process, Learjet informs the FAA about proposed design changes from the initial concept and throughout the design’s progress. As Learjet develops the design change, company senior engineers, recognized by the FAA as designated engineering representatives (DERs), review the change. FAA certification engineers in Wichita, Kansas, meet regularly with Learjet engineering staff, and the final design must be approved by the FAA. During a 1981 certification review of the Learjet 25,49 the FAA provided comments about the practice of applying the original certification basis to derivative airplanes. The FAA noted that the original certification basis for fail-safe criteria of flight critical systems, defined in 14 CFR 25.629, requires that the criteria address “only reasonably probable single failures and malfunctions,” whereas the revised requirements of 14 CFR 25.629 and 25.1309 require the analyses to address all single and other combinations of failures not shown to be “extremely improbable.” The FAA concluded that “it is necessary that flight critical systems meet these more stringent requirements to ensure safety.” The FAA stated that “the current regulations in the system installation area (14 CFR 25.672, 25.1303, and 25.1309) should be applied to all new model airplane certifications and derivative certification airplanes where equivalent safety is not ensured by the application of the old regulations.” 1.16.5.1 Thrust Reverser Control Design The Learjet 60 was the first Learjet model to be equipped with a fully electronic thrust reverser control. Learjet incorporated the electronic control system on the Learjet 60 to take advantage of design improvements made possible by computer control of the engines. In this design, the pilots could move the power levers to detents for specific modes of flight, such as takeoff and cruise. The microprocessor controls could then make continual adjustments to reduce fuel consumption and pilot workload.

47 The original version of 14 CFR 25.1309 states that equipment, systems, and installations must be designed and installed to ensure that they perform their intended functions under any foreseeable operating conditions and to prevent hazards to the airplane if they malfunction or fail. 48 According to the Learjet 60’s TCDS, only the airplane’s electronic flight instrument system was required to comply with this revised version of the regulation. 49 None of the Learjet 25 design characteristics under FAA review were related to the systems examined in this investigation. For more information, see FAA. Type Certification Decision Document, Learjet Special Certification Review, Supplement 1, April 30, 1981 (Kansas City, Missouri: FAA Central Region, Office of the Regional Counsel).

NTSB Aircraft Accident Report The fail-safe concept for the Learjet 60 thrust reverser system design was intended to protect against deployment of thrust reversers in flight. To achieve this protection, the logic criteria were such that any system failures or anomalies would result in the stowage of the thrust reversers. An uncommanded stowage of the thrust reversers in the Learjet 60 does not result in a corresponding movement of the cockpit thrust reverser levers. Such lever movement is not a regulatory requirement but was inherent in older Learjet models (also on TC A10CE) and most other airplanes that are equipped with mechanical thrust reverser control systems. With mechanical systems, cables physically connect the cockpit thrust reverser levers to the thrust reversers and engine power control units; thus, any uncommanded stowage of the thrust reverser doors would result in a corresponding movement of the levers in the cockpit and a corresponding reduction in engine thrust. Certification and test flights for the Learjet 60 were conducted without the use of thrust reversers (and without the reverser credit for calculating takeoff and landing runway length). 1.16.5.2 Protection of Equipment in Wheel Wells According to 14 CFR 25.729, any equipment that is essential to safe operation of the airplane and that is located in wheel wells “must be protected from the damaging effects of … a bursting tire, unless it is shown that a tire cannot burst from overheat, and … a loose tire tread, unless it is shown that a loose tire tread cannot cause damage.” The Learjet 60’s compliance with this requirement is recorded on a checklist that referenced a report that had originated during development of the Learjet 54. That report stated that two fuse plugs are installed in each main wheel to prevent overheating explosions and that tire burst tests had been conducted to demonstrate results for adjacent structure. The investigation found that two hydraulic lines in each wheel well of the Learjet 60 did not have the protection of a restrictor, making it possible to lose the hydraulic supply if those tubes were breached. In addition, a review of Learjet service history found that tire bursts in some airplanes resulted in extensive damage, both in the wheel well and beyond the MLG tires’ plane of rotation. 1.16.6 Comparison of Certification Criteria for Learjet 45 and Learjet 60 The Learjet 45 was certificated on a new TC (T00008WI) on September 22, 1997, under 14 CFR Part 25, as amended by amendments 25-1 through -77. The Learjet 45’s compliance with 14 CFR 25.1309 is based on amendment 25-41, effective September 1, 1977 (unlike the Learjet 60, for which compliance is based primarily on the original version of the regulation). The more recent revision to the regulation, as applicable to the Learjet 45, states that airplane equipment, systems, and installations must be designed to ensure that they perform their intended functions under any foreseeable operating condition and that any failure that would prevent the continued safe flight and landing of the airplane is extremely improbable. The regulation also states that warning information must be provided to alert pilots to unsafe system operating conditions and to enable them to take appropriate corrective action. Compliance with the design criteria must be shown by analysis that considers possible modes of failure, including damage from external sources and the probability of multiple or undetected failures. 29

NTSB Aircraft Accident Report 30 1.16.6.1 Thrust Reverser System Design The Learjet 45 is equipped with a fully electronic thrust reverser control. The Learjet 45’s system is designed to electronically duplicate the thrust reverser lever movement and engine power reduction inherent in the older mechanical systems. Specifically, the Learjet 45’s thrust reverser control electronically triggers the cockpit thrust reverser levers to move to the stowed position and the engine thrust to idle if an abnormal condition results in the stowage of reverser doors while the cockpit thrust reverser levers are raised. 1.16.6.2 Protection of Equipment in Wheel Wells With the exception of the Learjet 45, the MLG is similar throughout the series of Learjet airplane models and is based on similarities to the initial 1960s models that had been certificated before more stringent regulatory requirements existed. Components in the wheel wells of the Learjet 45 have protective plating and revised routing that provide more protection. Differences in the Learjet 45’s and the Learjet 60’s protection of system components in the MLG well, for which 14 CFR 25.1309 applies, are illustrated in figure 8 below, which shows protection in the inboard aft corner of the MLG wheel well for each airplane. Notable is the white shield that protects the Learjet 45’s hydraulic and electrical system components, whereas components in the Learjet 60 are more exposed. 1.17 Organizational and Management Information Global Exec Aviation, based in Long Beach, California, was established in 2002 to provide on-demand charter services using managed airplanes. At the time of the accident, the company operated nine airplanes: two Gulfstream GIVs, three Gulfstream GIIIs, a Falcon 50, a CE-650, the accident airplane, and a Cessna 441.50 Global Exec Aviation began operating the

50 At the time of the accident, the Cessna 441 was grounded by a supplemental inspection document. Figure 8. Inboard aft corner of the left main landing gear wheel well for the Learjet 45 (left) and the inboard after corner of the right main landing gear wheel well for the Learjet 60 (right).

NTSB Aircraft Accident Report accident airplane, which was listed on the company’s operations specifications, under 14 CFR Part 135 for on-demand charter flights in August 2008 after having previously managed the airplane for its owner for 14 CFR Part 91 flights. Global Exec Aviation had 20 employees, including 11 full-time pilots. The company also used part-time pilots for some flight operations. 1.17.1 Main Landing Gear Tire Maintenance and Checks According to its operations specifications, Global Exec Aviation was required to comply with the Learjet AMM, and the company’s director of maintenance stated that he referred to the AMM when determining what scheduled maintenance needed to be performed and when. He stated that he did not know how often the Learjet 60’s tire pressures were supposed to be checked. He indicated that there is no requirement to record tire pressure checks and that the company does not document them. Global Exec Aviation’s director of operations stated that Learjets occasionally blow tires just like any other jet and that Bombardier Challenger jets have a requirement for daily pressure checks in the AFM but that the Learjet does not. He stated that the pilots never check the tire pressures and are not trained to do so and that no such procedures are in place. At the time of the accident, the exterior preflight procedure indicated that the flight crew should “check” the MLG wheels, tires, and brakes. The airplane’s AFM indicated that the crew should check the “condition” of those components. The director of maintenance indicated that, if pilots suspected any problem with a tire while on a trip, they would call him as they would with any other maintenance issue. The Learjet 60 pilots and instructors interviewed stated that preflight tasks involved visually inspecting the tires for general condition, such as excessive wear, sidewall bulges, or visible tire cord. All but one pilot interviewed stated that tire underinflation would be difficult to determine visually (one thought that “significant” underinflation could be visually detected). All but one of the Learjet 60 pilots and instructors interviewed stated that checking tire pressure was a maintenance function and that they were neither trained nor expected to check tire pressure at any time. 1.17.2 Pilot Training and Standard Operating Procedures Global Exec Aviation provided its pilots with company indoctrination training; all other ground training, simulator training, and checks were provided by FSI in Tucson, Arizona. Global Exec Aviation pilots received the same FAA-approved Basic Bombardier Learjet 60 Training Program that FSI provided to other operators; Global Exec Aviation did not have any additional operator-specific training. Flight crew procedure checklists for the Learjet 60 are published in the Bombardier Learjet 60 AFM, which is an FAA-approved manual that contains the normal, abnormal, and emergency procedures for the airplane. The Learjet 60 Crew Checklist and the Quick Reference Handbook (QRH) list the procedures in a cockpit-ready reference checklist format. 31

NTSB Aircraft Accident Report 1.17.2.1 Rejected Takeoff According to Global Exec Aviation’s operations manual, the pilot flying is responsible for conducting a takeoff briefing before each takeoff. The manual stated, in part, that the briefing may be “full” or “abbreviated” at the discretion of the pilot in command: Generally, a full briefing will be conducted for the first flight of the day for a particular crew pairing. A full briefing will include the following: a. abort procedure prior to V1, b. procedure to be followed in case of a problem after V1, c. minimum safe altitude for flap retraction / running checklists, d. emergency return plan, e. and the normal takeoff plan (initial departure procedure, altitude, squawk, and departure frequency). An abbreviated briefing will include the words “standard brief” and will include letters c through e above. Global Exec Aviation’s operations manual, the Learjet 60 AFM, the Learjet Pilot Manual, the Learjet Training Manual, and the FSI Learjet 60 Pilot Training Manual all contained guidance for pilots to determine if an RTO was necessary. All of the guidance was based on engine failure scenarios. The Global Exec Aviation training program manual and the FSI Learjet 60 Pilot Training Manual contained illustrations depicting the procedures for rejecting a takeoff due to engine failure below V1 and for continuing a takeoff due to engine failure at or above V1. The Bombardier Learjet 60 Pilot Training Guide stated that the pilot flying should reject the takeoff “for any abnormality observed” before the airplane reaches 90 kts and that, between 90 kts and V1, the takeoff should be rejected for “engine failure, engine fire, loss of directional control, thrust reverser deployment, [or] catastrophic failures.” The guide further stated that, if an engine fails above V1 speed, “the takeoff will normally be continued.” The Global Exec Aviation Part 135 Training Program Manual (Appendix Learjet 60) indicates that the pilot flying is to remove his/her hand from the thrust levers at the time of the V1 callout by the pilot not flying. Interviews with Global Exec Aviation pilots, other Learjet 60 pilots, and instructors indicated that all used nearly identical criteria to determine whether to reject a takeoff. Generally, they stated that, during the low-speed regime up to 80 kts, takeoff would be rejected for any abnormal or emergency event and that, during the high-speed regime up to V1, takeoff would be rejected for only an engine fire, engine failure, thrust reverser deployment, or loss of directional control (which, according to some, included abnormal acceleration or deceleration). The consensus was that, at speeds above V1, the takeoff would be continued. Global Exec Aviation’s director of operations stated that the company used a Boeing video that discussed statistical safety on high-speed RTOs. He stated that the message communicated by the video was “do not do high-speed aborts.” Boeing’s video, Takeoff Safety, states that an RTO beyond V1 should only be attempted if the ability of the airplane to fly is in serious doubt. The video notes that taking the airplane into the air to deal with the problem offers pilots several advantages over an RTO, including reduction of airplane gross weight, ability to use landing flaps, more time to analyze the situation, ability to prepare for vibration and 32

NTSB Aircraft Accident Report 33 directional control problems on landing, and the availability of more runway on landing to allow the airplane to stop, increasing the margin of safety. The video further indicated that, if an RTO is initiated 2 seconds after V1, an airplane will exit the end of the runway (based on a balanced field length)51 at 50 to 70 kts.52 At the time of the accident, the abnormal procedures section of the QRH contained the checklist for use in the event of an RTO. The “Aborted Takeoff” procedure checklist included the following: “1. Brakes – APPLY, 2. Thrust Levers – IDLE, 3. Spoilers – EXT [extend], 4. Thrust Reversers – AS REQ’D [as required].” At the time of the accident, the Bombardier Learjet 60 Crew Checklist and the QRH contained the emergency procedure, “Inadvertent Stow of Thrust Reverser After a Crew-Commanded Deployment,” to be used in the event of an uncommanded stowage 53 of the engine thrust reversers. The first two steps of the procedure’s checklist were enclosed in a box to indicate that the procedures “should be memorized for crew accomplishment without reference to the procedure.” These two steps were the following: “1. Maintain control with rudder, aileron, nosewheel steering, and brakes, [and] 2. Both Thrust Reverser Levers – STOW.” The checklist also included the note that “failure to move the thrust reverser levers to stow will result in forward thrust ranging from idle to near takeoff power, depending on the position of the thrust reverser levers.” 1.17.2.2 Pretakeoff Passenger Briefing According to 14 CFR 135.117, before takeoff, passengers must be provided with an oral briefing that includes the following: prohibition of smoking, use of safety belts, seatback position for takeoff and landing, location and means for opening the passenger entry door and emergency exits, location of survival equipment, use of overwater equipment and supplemental oxygen, and the location and use of fire extinguishers. According to Global Exec Aviation’s operations manual, the PIC is responsible for ensuring that all passengers receive the briefing as soon as possible after passenger loading. Neither 14 CFR 135.117 nor Global Exec Aviation’s operations manual require any particular verbatim briefing content. The initial portion of the CVR recording was of insufficient quality to determine the content of any briefing that may have been provided. At 2336:32, the CVR captured a sound consistent with the cabin door closing, followed by a voice captured by the captain’s side CAM that stated, “I briefed ’em all.” At 2340:39.6, the CVR captured a sound similar to a seatbelt

51 AC 120-62, Takeoff Safety Training Aid, defines balanced field length as the runway length (including the RSA, if applicable) at which, for the airplane’s takeoff weight, the engine-out accelerate-go distance equals the accelerate-stop distance. Critical field length is defined as the minimum runway length (including the RSA) required for a specific takeoff weight, which may be the longer of the balanced field length, 115 percent of the all-engine takeoff distance, or the length established by other limitations, such as ensuring that V1 is less than or equal to Vr. 52 See Boeing Takeoff Safety Video Appendix 3-E. 53 “Uncommanded stowage,” which is synonymous with the QRH term “inadvertent stow,” occurs when the logic requirements to maintain thrust reverser deployment are lost, resulting in the stowage of the thrust reversers after a crew-commanded deployment.

NTSB Aircraft Accident Report 34 chime, and, at 2345:14, the first officer called for the checklist item, “seatbelt, no smoking,” to which the captain replied, “is, ah, on.” 1.17.2.3 Airplane Weight and Balance Calculations According to its operations specifications, Global Exec Aviation was authorized to use only the actual passenger weights (or the solicited passenger weights plus 10 pounds for each passenger) and the actual weight of all carry-on, checked, planeside-loaded, and heavy bags when determining aircraft weight and balance. The company used Ultra-Nav software and an American Aeronautics Plotter to calculate airplane loading and center of gravity. According to 14 CFR 135.63(d), the PIC of each flight must carry the weight and balance manifest on board the airplane. (The manifest for the accident flight was not located.) One of the passengers stated that neither pilot weighed any of the passengers or asked them their weight. The weight and balance manifest for the accident flight was not identified in the wreckage, and postcrash fire damage to the baggage precluded obtaining actual baggage weight. Fueling records showed that the airplane received 835 gallons of fuel minutes before departing on the accident flight; given the flight plan filed by the crew, about 7,800 pounds of fuel was on board. This information, combined with an estimated weight for the baggage and catering supplies and standard estimated adult weights for the two flight crewmembers and four passengers, indicates that the airplane’s weight at takeoff may have ranged from about 23,590 to about 23,800 pounds.54 1.17.3 Federal Aviation Administration Oversight The FAA flight standards district office in Long Beach, California, was responsible for the oversight of Global Exec Aviation. The FAA POI assigned to the company had been its POI since November 2007 and was previously the assistant POI. A review of the FAA’s National Program Tracking and Reporting Subsystem records revealed that, in the 60 months before the accident, the FAA performed numerous inspections of Global Exec Aviation, including the following: 17 aviation education and safety promotion inspections, 44 organizational certification inspections, 2 aircraft and equipment inspections, 153 airmen certification oversight inspections, 38 surveillance inspections, and 5 investigation inspections. Sixteen records for the accident captain and one for the first officer pertained to routine oversight inspections and contained no remarkable comments. In 2007, the FAA performed a special emphasis operational control inspection55 of Global Exec Aviation with

54 This estimate includes a pretakeoff fuel burn of 150 pounds, as indicated in the airplane operating manual. As referenced previously, the airplane’s maximum allowable ramp weight and takeoff weight were 23,750 and 23,500 pounds, respectively. 55 FAA Notice 8900.16, Special Emphasis Inspection: Operational Control (issued on August 17, 2007), directed POIs to inspect all Part 135 certificate holders to ensure compliance with operational control policies, procedures, and prohibitions. The inspections resulted from Safety Recommendation A-06-67, which stemmed from the NTSB’s investigation of a February 2, 2005, accident in Teterboro, New Jersey, involving a Bombardier Challenger CL-600-1A11 that was operated under a suspect charter arrangement. For more information, see

NTSB Aircraft Accident Report 35 satisfactory results. A review of FAA safety performance analysis system records showed one entry for Global Exec Aviation, which recorded that its operations specifications were amended on August 15, 2007, to reflect the addition of a minimum equipment list for the Learjet 60. 1.18 Additional Information 1.18.1 Takeoff Safety Training Aid In 1994, the FAA published AC 120-62, Takeoff Safety Training Aid, to provide guidance to “minimize, to the greatest extent practical, the probability of RTO-related accidents and incidents.” The AC, which applies to Part 121 operators, states that “many of the principles, concepts, and procedures described apply to operations under [14 CFR] Parts 91, 129, and 135 for certain aircraft, and are recommended for use by those operators when applicable.” The AC provides recommended elements for air carrier ground training programs that state, in part, that the training should, ensure thorough crew awareness in at least the following topics: (1) Proper RTO and takeoff continuation procedures in the event of failures; (2) Potential effects of improper procedures during an RTO, (3) Guidelines on rejecting or not rejecting a takeoff in the low and high speed regimes; (4) Assigned crewmember duties, use of comprehensive briefings, and proper crew coordination. The AC also provides recommended elements for air carrier flight training programs and pilot evaluations that state, in part, that simulator scenarios should include the following conditions and procedures: “demonstration of the proper and appropriate crew responses for engine failure, tire failure, nuisance alerts, and critical failures that affect the ability to safely continue the takeoff in both the high and low speed regimes.” Section 2 of AC 120-62, “Pilot Guide to Takeoff Safety,” addresses various aspects of the go/no-go decision-making process in response to various anomalies and provides the following cautions: The infrequency of RTO events may lead to complacency about maintaining sharp decision making skills and procedural effectiveness. In spite of the equipment reliability, every pilot must be prepared to make the correct Go/No Go decision on every takeoff--just in case.

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).

NTSB Aircraft Accident Report Do not attempt an RTO once the airplane has passed V1 unless the pilot has reason to conclude the airplane is unsafe or unable to fly. This recommendation should prevail no matter what runway length appears to remain after V1. With respect to tire failures, section 2 includes the following guidance: Tire failures may be difficult to identify from the flight deck and the related Go/No Go decision is therefore not a simple task. A tire burst may … cause the airplane to pull to one side, or can cause the entire airplane to shake and shudder…. A pilot must be cautious not to inappropriately conclude, under such circumstances, that another problem exists.… Degradation of control can occur, however, as a result of heavy pieces of tire material being thrown at very high velocities and causing damage to the exposed structure of the airplane and/or the loss of hydraulic systems. Section 2 also notes that rejecting a takeoff from high speeds with a failed tire is risky, especially if the airplane is near maximum gross weight: The chances of an overrun are increased simply due to the loss of braking force from one wheel. If additional tires should fail during the stop attempt, the available braking force is even further reduced. In this case, it is generally better to continue the takeoff. 1.18.2 Postaccident Safety Action 1.18.2.1 Learjet Tire Servicing Advisory Wire On October 13, 2008, Bombardier Learjet issued advisory wire (AW) 32-045, Tire Servicing, applicable to all Learjet airplanes. The AW advised maintenance and operations personnel that proper tire inflation cannot be determined visually and that underinflation can result in overload of the adjacent tire, as indicated in chapter 12 of the AMM. The AW noted that proper tire servicing should be accomplished in accordance with the AMM and recommended that cold tire pressure should be checked before the first flight of every day or every 10 days on tires installed on airplanes that are not operated daily. 1.18.2.2 Federal Aviation Administration Safety Alert for Operators On February 24, 2009, the FAA issued safety alert for operators (SAFO) 09005, “Dangers of Improperly Inflated Tires,” to emphasize to all aircraft operators, especially those operating Learjet 60s, the importance of proper tire inflation. The SAFO referenced the accident, stated that the operators’ personnel must understand the dangers of improper tire inflation, and 36

NTSB Aircraft Accident Report 37 recommended that tire pressures be checked using the manufacturer’s recommended intervals and procedures.56 1.18.2.3 Learjet Revisions to Flight and Maintenance Manuals 1.18.2.3.1 Temporary Flight Manual Change, Revised Procedures On March 9, 2009, Bombardier Learjet issued an FAA-approved temporary flight manual (TFM) change applicable for Learjet 60 and 60XR airplanes. TFM 2009-03 provided amendments to the AFM that established the limitation that “nose and main tire pressures must be checked within 96 hours (not flight hours) prior to takeoff” using the procedures listed in chapter 12 the AMM. The revision included a note to check tire pressures on airplanes parked more than 10 consecutive days and provided a table of allowable tire pressure ranges based on maximum takeoff weight. The TFM change added tire pressure checks to the AFM’s normal preflight procedures and provided expanded information for the abnormal procedures section to help flight crews recognize that a malfunction of the thrust reverser system can result in forward thrust. Specifically, the TFM revised the “Aborted Takeoff” procedure, amending step 4 to read “Thrust Reversers – Deploy if necessary. Check for DEP [deploy] indications on the EIS [engine indication system] page” and adding the following step: “If none of the [thrust reverser] lights are illuminated, both Thrust Reverser Levers – Stow.” The TFM also added a note and a warning to the “Aborted Takeoff” procedure and changed a note to a warning in the “Inadvertent Stow of Thrust Reverser After a Crew-Commanded Deployment” procedure. The notes provided information on the normal sequence of the thrust reverser annunciators, and both warnings stated that “a damaged squat switch (or other failures) may cause the thrust reverser auto stow system to activate … resulting in forward thrust, ranging from idle to takeoff power.… If this occurs, thrust reverser levers must be stowed immediately.” The warnings detailed the effect of squat switch failure on the thrust reverser annunciators and emphasized in bold text that “the absence of any [thrust reverser annunciator] lights indicates forward thrust.” 1.18.2.3.2 Temporary Revision to Maintenance Manual On March 18, 2009, Learjet issued temporary revision (TR) 12-16 to the Learjet 60 AMM. TR 12-16 moved the preflight tire pressure check recommendation to the front of the chapter and indicated that tire pressure checks must be taken per the revised AFM limitation (within 96 hours before flight). TR 12-16 included the procedure to use when checking for proper tire inflation and indicated that the checks must be documented. On May 29, 2009, the FAA issued a notice of proposed rulemaking (NPRM) to adopt a new airworthiness directive to require that the Learjet 60 AMM and AFM be revised as referenced in Learjet’s TFM change and TR 12-16.57 On July 30, 2009, the NTSB provided comments in support of the proposed rule but indicated that the rule should be expanded to cover other airplanes.

56 On June 12, 2009, the FAA issued a revised version, SAFO 09012, which contained editorial revisions. 57 74 Federal Register (FR) 25682-25684 (May 29, 2009).

NTSB Aircraft Accident Report 38 1.18.2.4 Federal Aviation Administration Legal Interpretation That Learjet 60 Tire Pressure Checks Are Preventive Maintenance In correspondence dated January 8, 2009, Learjet requested that the FAA provide a legal interpretation of “applicable rules in 14 CFR Parts 43, 91, and 135 pertaining to whether a pilot of a transport-category aircraft may check tire pressure during a normal preflight inspection.” On February 26, 2009, the FAA’s assistant chief counsel for regulations responded that checking the tire pressure on a Learjet 6058 airplane is preventive maintenance and not a simple preflight task. The FAA stated that such checks involve high air pressure and require a calibrated gauge that must be used properly to ensure correct readings. Title 14 CFR 43.3(g) allows pilots to perform preventive maintenance on an aircraft operating under Part 91 but not aircraft operated under Parts 121, 129, or 135. The FAA noted that, “accordingly, a pilot operating [a Learjet 60] under … Part 91 may, in accordance with the provisions of 14 CFR 43.3(g), perform daily landing gear tire pressure checks. Under the same regulation, however, a pilot of that aircraft operating under Part 135 may not perform that task.” The FAA stated that any Part 135 Learjet 60 operator that may be adversely affected by the maintenance requirement may petition the FAA for relief from the regulation. 1.18.3 Previously Issued Safety Recommendations 1.18.3.1 Learjet 60 Thrust Reverser System Recommendations Resulting From This Accident Investigation As a result of this accident investigation, on July 17, 2009, the NTSB issued five safety recommendations to the FAA related to the Learjet 60 thrust reverser system. (A sixth recommendation addressed the Raytheon Hawker 1000 airplane, which has some thrust reverser system failure modes similar to those of the Learjet 60.59) The NTSB’s letter to the FAA described the NTSB’s concerns about safety issues involving inadvertent stowage of thrust reversers, including the potential mismatch between the cockpit reverser lever positions and the actual configuration of the thrust reversers, the lack of adequate aural or visual cues for pilots to quickly recognize inadvertent thrust reverser stowage, and the need for improved pilot training on various inadvertent thrust reverser stowage scenarios. Safety Recommendation A-09-55 asked the FAA to do the following: Require Learjet to change the design of the Learjet 60 thrust reverser system in future-manufactured airplanes so that the reverse lever positions in the cockpit

58 In its reply, the FAA addressed only the Learjet 60, noting that Learjet’s question, although “framed in the context of transport-category aircraft,” was specific to that airplane. 59 Safety Recommendation A-09-60 asked that the FAA do the following: “Evaluate the design of the thrust reverser controls and indications in Raytheon Hawker 1000 business jets for potential thrust reverser failure modes that are similar to those identified in Learjet 60 airplanes and implement necessary changes.”

NTSB Aircraft Accident Report match the positions of the thrust reverser mechanisms at the engines when the thrust reversers stow. Safety Recommendation A-09-56 asked the FAA to do the following: Once design changes are developed per Safety Recommendation A-09-55, require Learjet 60 operators to retrofit existing airplanes so that the reverse lever positions in the cockpit match the positions of the thrust reverser mechanisms at the engines when the thrust reversers stow. During technical reviews conducted for this accident investigation (after the NTSB’s safety recommendations were issued), FAA representatives indicated that there is no basic certification requirement that the thrust reverser control lever position match that of the reverser mechanisms; this implies that the FAA will need to pursue a lengthy rulemaking project to amend the applicable certification regulations. However, an October 30, 2009, e-mail correspondence from NTSB staff to FAA representatives indicated that the thrust reverser design of the Learjet 60 does not appear to be in compliance with existing certification requirements, including 14 CFR 25.777 and 25.779, which relate to cockpit controls, and 14 CFR 25.1309. The NTSB’s safety recommendation letter also referenced Learjet’s March 2009 TFM and stated that the NTSB is concerned that Learjet 60 airplanes do not provide sufficient cues for pilots to be able to quickly recognize inadvertent reverser stowage. Safety Recommendation A-09-57 asked the FAA to do the following: Require Learjet to develop and install improved aural or visual cues on future-manufactured Learjet 60 airplanes that would allow pilots to recognize an inadvertent thrust reverser stowage in a timely manner. Safety Recommendation A-09-58 asked the FAA to do the following: Once improved aural or visual cues are developed per Safety Recommendation A-09-57, require Learjet 60 operators to install those cues on existing Learjet 60 airplanes. On September 23, 2009, the FAA responded that it had assembled a team of specialists from various technical disciplines to review the recommendations and assess their underlying safety issues. The FAA stated that it intends to develop a plan to address each recommendation and will examine the adequacy of the regulatory standards associated with the recommendations. Safety Recommendations A-09-55 through -58 (and Safety Recommendation A-09-60, which applies to the Raytheon Hawker 1000 airplane) are classified “Open—Response Received.” During interviews with several Learjet 60 pilots and instructors, the NTSB learned that, although the “Inadvertent Stow of Thrust Reverser” procedure was included during initial training, the inadvertent stowage scenario was usually taught during landing and not takeoff situations. Safety Recommendation A-09-59 asked the FAA to do the following: 39

NTSB Aircraft Accident Report 40 Require that all Learjet 60 pilots receive training, for takeoff as well as landing phases of flight, on recognizing an inadvertent thrust reverser stowage, including the possibility that the stowage can occur when the requirements for deploying thrust reversers are not fully met, such as when the air/ground sensor squat switch circuits are damaged. On November 5, 2009, the FAA issued a SAFO that referenced the circumstances of the accident and recommended that directors of safety, directors of operations, training center program managers, and individuals responsible for training programs review their programs to ensure emphasis on recognizing inadvertent stowage of thrust reversers during takeoff and landing. Safety Recommendation A-09-59 is classified “Open—Response Received.” 1.18.3.2 Ongoing Assessment of Safety-Critical Systems The safety assessment process required by 14 CFR 25.1309 and described in FAA AC 25.1309-1A, System Design and Analysis, is used during aircraft certification to identify and analyze safety-critical functions performed by the systems. Safety assessments are the primary means by which the certification process identifies failure conditions,60 evaluates the potential severity of those failures, and determines their likelihood of occurrence. In the NTSB’s 2006 safety report on the aircraft certification process,61 the NTSB noted that, once hazards62 to safety of flight have been identified, assessed, and eliminated or controlled during certification, a program must be in place to ensure continued airworthiness and the ongoing assessment of risks to safety-critical systems.63 The safety report stated that such a program can recognize that the certification process can change throughout the life of an airplane and can help ensure that ongoing decisions about design, operations, maintenance, and continued airworthiness consider operational data, service history, lessons learned, and new knowledge. In the safety report, the NTSB identified a need for the FAA to formalize a process for monitoring and assessing safety-critical systems throughout the life cycle of an airplane and stated that an ongoing safety assessment process could improve the FAA’s ability to evaluate derivative designs that were certificated many years before changes in the certification process occurred. The NTSB noted that the SAE International’s (formerly known as the Society of Automotive Engineers) aerospace recommended practice (ARP) document, SAE ARP5150,

60 AC 25.1309-1A defines a failure condition as the “effects on the airplane and its occupants, both direct and consequential, caused or contributed to by one or more failures, considering relevant adverse operational or environment conditions.… [A failure is a] loss of function, or a malfunction, of a system or a part thereof.” 61 Safety Report on the Treatment of Safety-Critical Systems in Transport Airplanes, Safety Report NTSB/SR-06/02 (Washington, DC: NTSB, 2006). 62 FAA Order 8040.4, Safety Risk Management, Appendix 1, defines “hazard” as a condition, event, or circumstance that could lead to or contribute to an unplanned or undesired event. 63 The safety report defines a safety-critical system as a system in which a failure condition would prevent the safe flight of the airplane or would reduce the capability of the airplane or the ability of the flight crew to cope with adverse operating conditions.

NTSB Aircraft Accident Report 41 Safety Assessment of Transport Airplanes in Commercial Service,64 provides an industry-accepted process for the ongoing assessment of safety-critical systems65 and describes the guidelines, methods, and tools for conducting such assessments. As a result of its findings, the NTSB issued Safety Recommendation A-06-38, which asked the FAA to do the following: Adopt [SAE International’s] SAE ARP5150 into 14 [CFR] Parts 21, 25, 33, and 121 to require a program for the monitoring and ongoing assessment of safety-critical systems throughout the life cycle of the airplane. Safety-critical systems will be identified as a result of A-06-36.[66] Once in place, use this program to validate that the underlying assumptions made during design and type certification about safety-critical systems are consistent with operational experience, lessons learned, and new knowledge. In response, the FAA indicated that it intended to formalize a process for monitoring and assessing safety-critical systems. On September 12, 2007, the NTSB classified Safety Recommendation A-06-38 “Open—Acceptable Response” pending the FAA’s related actions. However, due to the FAA’s lack of progress in addressing this recommendation, the NTSB reiterated the recommendation and reclassified it “Open—Unacceptable Response” in its October 14, 2009, report on the accident involving a Cessna Citation 550 that crashed in Milwaukee, Wisconsin.67 1.18.3.3 Crew Resource Management Between 1980 and 2003, the NTSB issued numerous recommendations for the FAA to revise 14 CFR Part 135 requirements to include FAA-approved CRM training programs for Part 135 on-demand flight crews. Most recently, on December 2, 2003, the NTSB issued Safety Recommendation A-03-52, which superseded Safety Recommendation A-02-1268 and asked the FAA to do the following:

64 Safety Assessment of Transport Airplanes in Commercial Service, SAE ARP5150 (Warrendale, Pennsylvania: Society of Automotive Engineers, 2003). 65 SAE ARP4761, Guidelines and Methods for Conducting the Safety Assessment Process on Civil Airborne Systems and Equipment, describes industry practice for assessing the criticality of hazards to safety of flight. 66 Safety Recommendation A-06-36 asked the FAA to do the following: “compile a list of safety-critical systems derived from the safety assessment process for each type certification project, and place in the official type certification project file the documentation for the rationale, analysis methods, failure scenarios, supporting evidence, and associated issue papers used to identify and assess safety-critical systems.” In response, the FAA has indicated its plans to develop and implement a safety management system as part of each type certification project. On September 12, 2007, the NTSB classified Safety Recommendation A-06-36 “Open—Acceptable Response.” 67 National Transportation Safety Board, Loss of Control and Crash, Marlin Air, Cessna Citation 550, N550BP, Milwaukee, Wisconsin, June 4, 2007, Aircraft Accident Report NTSB/AAR-09/06 (Washington, DC: NTSB, 2009). 68 On June 13, 2002, the NTSB issued Safety Recommendation A-02-12, which asked the FAA to do the following: “revise 14 [CFR] Part 135 to require on-demand charter operators that conduct operations with aircraft requiring two or more pilots to establish [an FAA]-approved crew resource management training program for their flight crews in accordance with 14 CFR Part 121, sub parts N and O.”

NTSB Aircraft Accident Report 42 Require that 14 CFR Part 135 on-demand charter operators that conduct dual-pilot operations establish and implement [an FAA]-approved crew resource management training program for their flight crews in accordance with 14 CFR Part 121, subparts N and O. Safety Recommendation A-03-52 was added to the NTSB’s list of Most Wanted Transportation Safety Improvements in November 2006. On May 1, 2009, the FAA published an NPRM titled, “Crew Resource Management Training for Crewmembers in Part 135 Operations,”69 which responded to Safety Recommendation A-03-52 by proposing to require Part 135 certificate holders to include CRM training for pilots and flight attendants. On July 15, 2009, the NTSB provided comments in general support of the proposed rule; however, the NTSB expressed concern about some aspects of the NPRM and urged the FAA to withdraw a proposed provision to allow certificate holders to give credit for initial CRM training received from another Part 135 operator. Pending issuance of the final rule, the NTSB classified Safety Recommendation A-03-52 “Open—Acceptable Response” on December 29, 2009. 1.18.3.4 Onboard Flight Recorder Systems The NTSB has issued previous safety recommendations addressing the need to record information on all turbine-powered, nonexperimental airplanes that are not required to be equipped with an FDR and are operating under Part 135 (such as the accident airplane).The NTSB noted these issues in its January 28, 2009, report on the midair collision involving electronic news gathering helicopters in Phoenix, Arizona,70 and expressed concern about the FAA’s lack of progress. In its report, the NTSB classified some of the previous safety recommendations71 as “Closed—Unacceptable Action/Superseded,” superseding them with updated recommendations, including Safety Recommendation A-09-11, which asked the FAA to do the following: Require all existing turbine-powered, nonexperimental, nonrestricted-category aircraft that are not equipped with [an FDR] and are operating under 14 [CFR] Parts 91, 121, or 135 to be retrofitted with a crash-resistant flight recorder system. The crash-resistant flight recorder system should record cockpit audio (if a cockpit voice recorder is not installed), a view of the cockpit environment to include as much of the outside view as possible, and parametric data per aircraft and system installation, all to be specified in European Organization for Civil

69 74 FR 20263-20279, May 1, 2009. 70 National Transportation Safety Board, Midair Collision of Electronic News Gathering Helicopters, KTVK-TV Eurocopter AS350B2, N613TV, and U.S. Helicopters, Inc., Eurocopter AS350B2, N215TV, Phoenix, Arizona, July 27, 2007, Aircraft Accident Report NTSB/AAR-09/02 (Washington, DC; NTSB, 2009). 71 Among these previous recommendations was Safety Recommendation A-03-65, which asked the FAA to do the following: “require all turbine-powered, nonexperimental, nonrestricted-category aircraft that are manufactured prior to January 1, 2007, that are not equipped with [an FDR] and that are operating under … 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.”

NTSB Aircraft Accident Report Aviation Equipment document ED-155, “Minimum Operational Performance Specification for Lightweight Flight Recorder Systems,” when the document is finalized and issued. On April 17, 2009, the FAA described its participation in two proof-of-concept studies that evaluated the installation of image recorders on (1) an FAA airplane that was compliant with European Organization for Civil Aviation Equipment (EUROCAE) document ED-112 and (2) a transport-category Boeing 737 flight simulator. The findings that resulted from these studies provided valuable information about the potential uses of cockpit image recording systems on airplanes that are currently not required to carry any type of data-recording equipment. The working group incorporated this information into EUROCAE document ED-155, “Minimum Operational Performance Specification for Lightweight Flight Recorder Systems,” which was published in August 2009. Safety Recommendation A-09-11 is classified “Open—Acceptable Response” pending the FAA’s issuance of a TSO that includes the specifications of ED-155. 1.18.4 Current Airworthiness Requirements and Guidance for the Certification of Changed Aeronautical Products The revision to 14 CFR 21.101 that became effective on June 7, 2002, states that an application for a changed aeronautical product to be added to a TC “must show that the changed product complies with the airworthiness requirements applicable to the category of the product in effect on the date of the application.” The current regulation is more specific than previous revisions regarding what can be used from the original certification basis in an application for a derivative model involving a major change. Also, on April 25, 2003, the FAA issued FAA Order 8110.48, How to Establish the Certification Basis for Changed Aeronautical Products, which provides the general procedures for determining the certification basis for changes to aircraft on the same TC. The handbook refers to AC 21.101-1, Establishing the Certification Basis of Changed Aeronautical Products, which contains additional guidance. 1.18.5 Tire Pressure Monitoring Systems in Aircraft Applications Tire pressure monitoring systems (TPMS) and related systems are available for aircraft use. At least one such system may be installed on newly manufactured aircraft or as a retrofit. According to product literature, the system consists of a wireless pressure and temperature sensor built into the tire’s inflation stem to facilitate the ease, accuracy, and automatic documentation of the aircraft daily tire pressure check. The system requires no batteries, power sources, or wires and obtains its operating power from an external reader or interrogator. Another manufacturer’s TPMS system takes local readings and sends data to the flight deck for display. Abnormal readings trigger visual or aural warnings in the cockpit. At the end of 2007, this TPMS was in use on nearly 2,000 commercial airliners. The second generation of this manufacturer’s TPMS technology is a wireless model that transmits data via radio frequency from the wheel to the landing gear before being sent to the cockpit. The new design is lighter, 43

NTSB Aircraft Accident Report 44 smaller, more reliable, and able to be installed on smaller wheels than the previous-generation technology; further, the new design costs about 40 percent less than the earlier design. At least one model of business jet is equipped with this system. During the accident investigation, both Learjet and Global Exec Aviation personnel stated that they were reviewing TPMS. Learjet personnel reported that one initial concern is the possibility that, because the Learjet 60’s MLG wheel well is so confined, an external tire valve stem system may strike components in the wheel well. 1.18.6 Tire Load Certification Requirements The Goodyear Flight Eagle tire used on the Learjet 60 was originally approved on April 3, 1982, by the FAA Chicago Aircraft Certification Office based on Goodyear QTR 461B-3044-TL, dated January 27, 1982. Goodyear personnel noted that some airframe manufacturers, including Boeing and Airbus, specify additional design requirements (beyond the requirements in 14 CFR 25.733 and TSO-C62e) for the tires installed on their airplanes. An airplane tire’s rated load is the maximum load that the tire is allowed to carry at a rated inflation pressure; according to the QTR, the Goodyear Flight Eagle tire has a load rating of 6,050 pounds. For airplanes with MLG axles fitted with dual wheel and tire assemblies (including the Learjet 60), 14 CFR 25.733 requires that the maximum service load for each tire (the actual load carried by each tire with the airplane at its maximum weight), when multiplied by a factor of 1.07, may not be greater than the rated load of the tire. Thus, according to the regulation, the maximum service load allowed for each Goodyear Flight Eagle tire used in a dual-wheel installation is 5,654 pounds.72 The airplane’s load is distributed primarily among the four MLG tires; the load supported by the nosewheel tire is relatively small. All FAA tire certification requirements and performance verification tests are based on static loading and dynamometer73 tests. For these tests, a properly inflated tire is mounted perpendicular to a dynamometer during load, speed, endurance, and deceleration testing.74 TSO-C62c also included an overload takeoff cycle testing requirement, which specified that the tire must be able to withstand a takeoff cycle while overloaded to at least 1.5 times the load required in the takeoff cycle tests and retain at least 90 percent of its initial test air pressure after 24 hours. The QTR for the Goodyear Flight Eagle tire indicated that, during the overload takeoff test, a single tire inflated at 220 psi withstood a 34-second test with an initial load of 9,075 pounds (1.5 times the load rating for a single wheel/tire assembly) that reduced to 8,700 pounds as the speed increased to 210 mph. The tire also exhibited no sidewall wrinkles after two 7-mile taxi tests at 40 mph with a 20-percent overload.

72 A service load of 5,654 pounds, multiplied by a factor of 1.07, equals the rated load of 6,050 pounds. 73 A dynamometer is a tire test system in which the tire is pressed against a large, motor-driven steel wheel under various controlled conditions. The dynamometer test, a tool for applying loads and speeds for specific time periods, includes extreme criteria and does not replicate other variables to which in-service tires are subjected. 74 The FAA requirements include other non-dynamic tests, such as allowable rates of air leakage.

NTSB Aircraft Accident Report 45 1.18.6.1 Learjet 60 Tire Selection At the time of the Goodyear Flight Eagle tire’s testing and approval, the tire had been developed for the Learjet 55. When the Learjet 60 was subsequently developed, the airplane required use of the tire’s load and speed capabilities at the limits of the tire’s certification criteria; that is, at the airplane’s maximum weight, the MLG tires are loaded at the maximum service load permissible based on the tire’s rated load A review of static tire load calculations indicated that, with the Learjet 60’s dual-axle installation, four properly inflated MLG tires would each support 100 percent of their share of the airplane’s load (about 1/4 of the airplane’s maximum gross weight). The calculations showed that complete pressure loss on one tire can increase the load of the adjacent, properly inflated tire on the axle to more than 120 percent. Further, changes in airplane angle also affect the load on the remaining tires. 1.18.6.2 Effect of Tire Camber Angle on Tire Sidewall Loads The investigation collected data and photographs from a Learjet 25D (which has MLG dimensions similar to the Learjet 60) that sustained damage during an RTO incident on August 19, 2009. In that incident, both of the left MLG tires were destroyed, and the right MLG tires were flat. With the left side of the incident airplane resting on the wheel rims and the right side resting on flat tires, the airplane’s roll angle was measured at 1.8° to 1.9°. Learjet ground testing data showed that, if the MLG struts remained extended, an airplane with one side resting on inflated tires and the other side resting on the outboard wheel rim would have a roll angle of 2.61°. Tire loads are spread throughout cords in the footprint and sidewalls. When an airplane has one wing lower than the opposite wing while on the ground, each tire on that airplane has a resulting camber angle,75 making one sidewall taller than the other. Goodyear load testing data conducted for the investigation showed that, as tire camber increases, the load on one sidewall increases, which is consistent with a Learjet ground test finding that a tire’s footprint and lateral loading changes with respect to camber angle. For the investigation, Goodyear personnel also performed load testing with various cambers on tires at reduced pressures; the data showed that, with camber, as tire pressure decreases, the load on one sidewall increases (and the load in the center of the tread decreases).

75 Camber is the angle between the vertical axis of the wheel and the vertical axis of the weight being applied to the tire when viewed from the front or rear.

NTSB Aircraft Accident Report 46 1.18.7 Takeoff Accident and Incident Data 1.18.7.1 High-Speed Rejected Takeoffs In 1990, the NTSB issued a special investigation report (SIR), Runway Overruns Following High Speed Rejected Takeoffs,76 that examined high-speed RTOs involving commercial jet airplanes. The SIR reviewed three studies, which included data from the NTSB, the National Aeronautics and Space Administration, and Boeing, related to the causes and outcomes of RTOs. The SIR found that tire failures led to more high-speed RTOs than engine-related anomalies. The Boeing study reviewed in the SIR analyzed data on RTO-related incidents and accidents from 1959 to 1988 and found that that many of the RTOs were initiated after V1 and that more than half of the RTOs were unwarranted. The study found that the airplanes should have been able to continue the takeoff without incident. Since the time that the SIR was published, Boeing updated its review to include a total of 94 RTO-related accidents or incidents from 1959 to 1999.77 The updated review found that just as many events were attributed to tire or wheel failures and malfunctions as propulsion anomalies (21 percent each) and that more than half of the RTOs were performed after V1. 1.18.7.2 Airplane Types Involved in Tire-Related Events A review of NTSB data for accidents and incidents involving tire problems during takeoff identified 37 events involving corporate jets since 1982. These accidents and incidents involved 10 business jet models, including four Learjet models (25B, 35, 35A, and 36), two Beechjet/Hawker Siddeley models, and one model each for the Dassault Falcon, Raytheon Hawker, Israeli Aircraft Industries (Model 1124), and Rockwell Sabreliner airplanes. Each of the events included long taxi distances, RTOs, hot day conditions, suspected low tire pressures, or a combination of these issues. 1.18.7.3 Pilot Accounts of Real and Simulated Tire Failure Events During the accident investigation, an FAA flight test manager (who had been part of the certification process for the Learjet product line) recalled having once been involved in a high-speed RTO in a Learjet 55. He stated that, at the time, he was in the first officer’s seat, and a Learjet company pilot was in the captain’s seat. They were performing a takeoff at gross weight in Orlando, Florida, and all four MLG tires came apart after the airplane was beyond V1. He stated that both he and the other pilot heard the tires coming apart and that he saw through the window that tire fragments were passing forward of the cockpit; he indicated that the takeoff was

76 National Transportation Safety Board, Runway Overruns Following High Speed Rejected Takeoffs. Special Investigation Report SIR-90-02 (Washington, DC: NTSB, 1990). 77 This information was obtained from Boeing’s website http://www.boeing.com/commercial/aeromagazine/aero_11/takeoff_reasons.html (accessed February 15, 2010).

NTSB Aircraft Accident Report rejected due to concern that the tire fragments could be ingested by an engine. The thrust reversers were available, and he recalled that it took about 9,300 feet to stop the airplane on the 12,000-foot runway. In addition, a pilot for the FAA’s Learjet 60 aircraft evaluation group stated that he attempted to recreate the accident’s inadvertent stowage scenario in a simulator. He stated that his first two attempted RTOs resulted in the simulated airplane going off the end of the runway but that his third RTO attempt was successful. Another person, who had 8 years of experience working with various Learjet-model simulators, stated that he had never performed the procedure for uncommanded thrust reverser stowage. The FAA flight test manager stated that he had trained extensively in simulators and believed that they are usually realistic but that he did not think that they could accurately portray a tire failure event. 47

NTSB Aircraft Accident Report

1. Analysis
2. 1 General

The captain and the first officer were certificated and qualified in accordance with Federal regulations and the operator’s requirements for the Part 135 on-demand flight. Neither pilot had any previous aviation accidents, incidents, or enforcement actions. FAA records showed that the captain received a total of four notices of disapproval. Although such disapprovals can be an indication of pilot competency problems, they must be assessed in the context of the pilot’s career as a whole. In the case of the accident captain, three of these disapproval notices were issued about 11 years before the accident (when the captain had only about 200 to 250 total flight hours), and only one disapproval (for which the captain successfully retested the same day) occurred during her Part 135 flying career. Interviews with other pilots, a Learjet 60 proficiency check evaluator, and flight and ground training instructors who were familiar with the captain’s flying and training in recent years revealed that none expressed any concerns about the captain’s competence. The accident airplane was properly certificated and equipped in accordance with the regulations that applied to it as a changed aeronautical product.

The presence of organic debris within the engine’s gas path is consistent with the engines running at the time of ground impact. There was no evidence of any preimpact anomalies or distress that would have prevented the engines from producing power. In addition, there was no evidence of any flight control anomalies. The relatively new set of tires on the accident airplane showed no evidence of failures in design, manufacturing flaws, or exterior damage, such as punctures or other damage from striking foreign objects. Therefore, the NTSB concludes that the following were not factors in this accident: tire design, tire manufacture, or damage to the exterior of any tire. The flight crew failed to perform airplane weight and balance calculations in accordance with the operator’s procedures. Although postaccident estimates indicated that the airplane’s maximum gross takeoff weight may have been exceeded by up to 300 pounds, there is no evidence that weight and balance issues contributed to the accident. The following analysis describes the accident sequence, including the captain’s initiation of an RTO after V1 and the uncommanded forward thrust emergency that followed; airplane tire failures and maintenance; Learjet 60 design deficiencies and certification issues; flight crew performance; passenger survivability; and certification and testing considerations for aircraft tires. 48

NTSB Aircraft Accident Report 2.2 Accident Sequence As reported by witnesses, the beginning of the accident airplane’s takeoff roll appeared normal. According to the studies discussed in sections 1.16.1 and 1.16.2, the airplane accelerated from about 12 kts at 2354:51 to about 131 kts at 2355:10.5, when the first officer stated, “V1.” During this timeframe, the airplane’s acceleration and engine operation were consistent with the airplane’s expected performance during a normal takeoff. Less than 2 seconds later, however, when the airplane was more than 2,500 feet down the runway (with about 6,100 feet remaining), the CVR captured the beginning of a loud rumbling noise. The airplane’s location on the runway at the onset of the noise correlated with the location where the first pieces of right outboard MLG tire were found. Thus, the onset of the loud rumbling noise likely resulted from pieces of the right outboard tire separating from the wheel and striking the underside of the airplane and was likely accompanied by shaking and vibration of the airframe. From this point forward, the accident sequence can be divided into two distinct segments. The first segment involves the captain’s initiation of the high-speed RTO, which was a high-risk event. The second segment of the accident sequence involves the uncommanded forward thrust emergency related to the uncommanded stowage of the airplane’s thrust reversers. 2.2.1 Captain’s Initiation of Rejected Takeoff After V1 The captain and the first officer were trained that rejecting a takeoff is acceptable for any anomaly occurring before the airplane reaches 80 kts and that, for speeds between 80 kts and V1, the takeoff could be rejected for major anomalies, such as catastrophic failure, engine fire, engine failure, thrust reverser deployment, or loss of directional control. Their training and standard operating procedures indicated that, because of the high risk of runway overrun and other dangers, rejecting a takeoff at speeds greater than V1 should be performed only when airplane control is seriously in doubt. During the captain’s pretakeoff briefing, she incorrectly stated that the takeoff could be rejected for major anomalies occurring between V1 and V2. None of the captain’s training provided by FSI and Global Exec Aviation referenced any RTO criteria beyond V1, and no evidence indicated that the captain was unfamiliar with the concept of V1 as it related to go/no-go decision-making. An instructor who provided the captain with recurrent ground and simulator training, which included V1 cuts and RTOs, described her as meticulous with good organizational skills. As noted previously, V1 for the accident flight conditions was about 136 KIAS. Given that V2 (which is a takeoff safety speed that would provide a minimum climb gradient after a loss of engine power [about 153 KIAS]) occurs after Vr (which is the airplane’s rotation speed [about 145 KIAS]), it is unlikely that the captain would have considered V2 to be part of the RTO criteria. A pretakeoff briefing is fairly standard in that the RTO criteria rarely change from one takeoff to the next. Thus, one explanation for the captain’s incorrect briefing may be the use of automaticity in processing information, which is when a person uses low levels of attention to recite routine or habitual information. Such an error was consistent with a number of other information processing errors that the captain made during the taxi (including reading back wind 49

NTSB Aircraft Accident Report information incorrectly) that showed a lack of focus. Therefore, the NTSB concludes that there was no indication that the captain’s understanding of the rejected takeoff criteria was deficient; thus, the captain likely misspoke when she incorrectly stated the criteria in her pretakeoff briefing. During the takeoff, when the first tire failed and the rumbling noise began, the first officer stated, “go,” then “go, go, go.” The airplane’s ground speed at the time was about 137 kts, and, as shown by runway gouging and tire skid marks, the airplane veered to the right and across the runway centerline. Only debris from the right outboard tire was found at the runway location that coincided with the timing of this event; thus, the runway marks were likely created by the right outboard wheel rim contacting the runway surface and the skidding of the still-intact right inboard tire. (The airplane was initially left of the runway centerline before it veered.) Hydraulic fluid, consistent with that found in at least one severed brake hose, was present on some tire fragments. In the next second (2 seconds after the onset of the rumbling sound), the captain asked, “go?” At this point in the takeoff roll, the airplane neared its peak ground speed of about 144 kts (extrapolated data show that it may have reached about 150 kts within the next second) and began shedding fragments of a landing light and other pieces (which likely separated after having been impacted by fragments of the right outboard tire). The timing of the captain’s question to the first officer coincided with the captain reducing engine power for about 1 second, then increasing it for about 1 second before decreasing it again, about which time the first officer stated, “no? ar-right … what the [expletive] was that?” The entire RTO procedure, up to this point, spanned about 5 seconds since the onset of the rumbling noise from tire fragments, first from the right outboard tire and then from the right inboard tire. Although there is no indication that either the captain or the first officer knew what type of problem occurred, each reacted to it differently. The first officer’s statements to “go” suggest that, despite being unaware of the type of failure that occurred, he relied on his training and recognized that, once the airplane’s speed passes V1, the appropriate response is to continue the takeoff for nearly all anomalies except when airplane controllability is in serious doubt. Both the captain and the first officer were trained that continuing the takeoff under such circumstances offers several safety advantages over an RTO, such as more time to analyze the situation, the ability to reduce the airplane’s gross weight and to use landing flaps, the ability to prepare for vibration and directional control problems on landing, and the availability of more runway on which to stop the airplane. The NTSB acknowledges that the first officer, as the pilot not flying, would not have received the same airplane controllability cues that the captain received, particularly when the airplane veered to the right after the first tire failure. Thus, the NTSB considered the possibility that the captain rejected the takeoff because of a perceived loss of airplane control. However, runway markings show that, after the airplane veered, it was realigned with the runway heading, indicating that the captain was able to regain and maintain directional control. Further, although the captain initially reduced engine power, she did not make an RTO callout, and her subsequent increase in engine power, concurrent with her question “go?,” indicates that she briefly considered continuing the takeoff before finally committing to the RTO. Therefore, the NTSB concludes that the captain’s uncertainty as to whether to continue the takeoff suggests that her 50

NTSB Aircraft Accident Report 51 initial action to reject it did not result from a perception that the airplane was uncontrollable and could not fly. During about 4 seconds after the captain made the second engine power reduction, the airplane’s engine N1 decreased to about 7,300 rpm, the captain made the comment “full out” (likely referring to full deployment of the thrust reversers), and wheel brakes were applied (as indicated by CVR sound evidence). Extrapolated ground speed information estimated that the airplane decelerated to about 128 kts. Debris evidence showed that, at this point, all of the MLG tires had failed (within about 9 seconds of the first tire’s failure). The captain’s action to reject the takeoff after the airplane had passed V1 placed the flight crew and passengers in a high-risk situation; accident and incident data show that high-speed RTOs can result in runway overruns. During pilot training, V1 is generally considered to be the speed at which the pilot must be committed to transition the airplane to flight; to reinforce this concept, pilot training programs and standard operating procedures (including those provided to the captain) emphasize that the pilot flying should remove his/her hand from the throttles at the time that the V1 callout is made. The purpose of such training and reinforcement is to ensure that the pilot responds immediately and correctly to any anomalies because the situation allows no time for assessment after the problem occurs, and any delays or mistakes increase the chance of an overrun (or the speed at which an overrun occurs). The NTSB concludes that, in the absence of evidence that the airplane was uncontrollable, the captain’s execution of a rejected takeoff for an unknown anomaly after the airplane’s speed had passed V1 was inconsistent with her training and standard operating procedures. 2.2.2 Uncommanded Forward Thrust Emergency As supported by the airplane performance study discussed in section 1.16.2, after the captain had committed to performing the high-speed RTO, the accident airplane’s thrust reverser system initially performed as commanded. On the basis of the captain’s comment “full out,” which coincided with a noticeable deceleration of the airplane, the study found that the thrust reversers had fully deployed, and the system provided reverse engine thrust. However, about 7 seconds after the captain committed (about 10 seconds after the rumbling noise began), the CAM captured the nosewheel steering disconnect warning tone. Because nosewheel steering is typically engaged while the airplane is on the ground, the timing of this tone provides an indication of when the system status changed to “air mode.” For this to occur, the circuit associated with the MLG electrical components and wiring, which include the wheel speed sensor and squat switch, must have sustained damage that affected the air-ground signal. Debris found on the runway and other physical evidence show that the MLG area where system components were mounted sustained damage from the shedding tire fragments.78 As a result, because the system logic requirements for maintaining thrust reverser deployment were no longer being met, the thrust reversers stowed. Meanwhile, as indicated by engineering and ground tests, the thrust reverser levers in the cockpit remained in the raised

78 The right landing light was mounted immediately above the squat switch, and the wiring was routed together. Glass from the light was found on the runway near the fragments from the right outboard and inboard tires.

NTSB Aircraft Accident Report full-reverse-thrust position, the TR DEPLOY annunciators extinguished, and the TR UNLOCK annunciators momentarily illuminated (while the reverser doors were in transit toward stow); then, the TR ARM annunciators flashed briefly before all TR annunciators extinguished completely. During this sequence, the EECs shifted logic and signaled the FADEC components to change to the forward thrust power schedule. Because the flight crew had commanded full reverse thrust, the EECs (because of the shifted logic) interpreted the TLA and RDVT positions and signaled the FADEC components to provide forward thrust at near takeoff power. As a result, the flight crew was faced with an emergency in which the wheel braking system was compromised due to tire and hydraulic system damage, and the airplane was accelerating with high engine power toward obstacles beyond the end of the runway. There was no warning annunciator in the cockpit to indicate any system anomaly; thus, initially, the captain was expecting to have continued reverse thrust as commanded with the reverse thrust levers. Under these abnormal circumstances, reducing the airplane’s uncommanded forward thrust would require moving the thrust reverser levers to the stowed position. However, moving the reverser levers to the stowed position (when maximum reverse thrust was needed and commanded) during an RTO was likely counterintuitive to the captain. (The NTSB’s safety recommendations to address this problem are discussed in sections 1.18.3.1 and 2.3.2.) As depicted in the airplane performance map overlay in section 1.16.2, the airplane was about 2,500 feet from the end of the runway at a ground speed of about 123 kts when the uncommanded forward thrust began, and the airplane accelerated for several seconds until the first officer assessed the problem and reacted. By the time that the first officer stated, “shut ’em off,” the engines’ N1 had increased to about 9,165 rpm. Although the sound spectrum evidence indicates that engine power subsequently began to decrease, the ground speed information, ground witness marks, obstacle collision evidence, and the condition and location of the main wreckage indicated that the airplane was traveling in excess of about 100 kts when it overran the end of the RSA. As mentioned previously, most of an airplane’s stopping power is provided by the wheel braking system, and the flight crew applied the wheel brakes within 1 second of the captain’s “full out” comment. However, there are no data that can be used to reliably estimate the braking performance for an airplane that has a compromised hydraulic system and no intact MLG tires. Thus, it is not possible to determine whether or not the flight crew could have safely stopped the airplane on the runway (or within the RSA) had the airplane not developed the uncommanded forward thrust. Although the captain lost seconds when delaying her commitment to the RTO, had the airplane developed reverse thrust as the captain commanded or transitioned to idle thrust with the uncommanded stowage of the thrust reversers, the airplane’s ground speed for the overrun would have been slower. Therefore, the NTSB concludes that the accident airplane’s uncommanded forward thrust, which accelerated the airplane at a time when the flight crew commanded full reverse thrust to decelerate the airplane, increased the severity of the accident because the uncommanded forward thrust substantially increased the airplane’s runway excursion speed. 52

NTSB Aircraft Accident Report 53 2.3 Airplane Issues Although the captain’s action to initiate a high-speed RTO and her delays in performing the procedure placed the flight at risk for a runway overrun, issues related to the airplane played a role in both setting up the chain of events that led to the accident and exacerbating the final outcome. Of particular concern are the operator’s tire maintenance practices, Learjet’s design of the airplane’s thrust reverser system, the inadequacy of both Learjet’s and the FAA’s review of the Learjet 60 after the 2001 accident, and the safety of the FAA’s certification process for changed aeronautical products. All of these issues combined to create a situation that was unacceptably intolerant to the captain’s deviation from a standard operating procedure. 2.3.1 Tire Failures Damage observed on fragments from all four MLG tires, such as abrasion marks on the inner liner and heat damage to the rubber and nylon materials, was consistent with overdeflection of the tires. Two tire operating conditions can result in such sidewall overdeflection: overloading and underinflation. Under either condition, excessive flexing of the sidewall generates high internal temperatures and weakening of the sidewall plies, leading directly to failure. The location of the sidewall damage on each of the accident airplane’s tires was helpful in determining which condition resulted in or contributed to the tire failures. Static test data show that, if proper inflation of all four MLG tires is assumed, to achieve the amount of overdeflection evident from the damage, each tire would need to be overloaded with about 12,200 pounds (about twice as much weight as the accident airplane could have imposed on each tire). Such overloading of four properly inflated tires is implausible (it would require an airplane gross weight in excess of 48,800 pounds), and other evidence strongly supports that the tires were not properly inflated. As indicated by Global Exec Aviation’s director of maintenance, the airplane’s tire pressures had not likely been checked in the 3 weeks before the accident. The QTR for the Goodyear Flight Eagle tire indicated a 2.2-percent average daily pressure loss (the TSO for the tire allows a loss of up to 5 percent per day). With the assumption that the accident airplane’s tires were properly inflated at the beginning of the 3-week period and that the daily loss rate was about 2 percent, the tires were likely operating while about 36-percent underinflated on the day of the accident.79 The Learjet AMM indicates that tires should be replaced after operating at 15-percent underinflation. (This replacement specification is due to the overdeflection and damage that the tire sidewalls sustain from operation at such an underinflated pressure.) As indicated in section 1.16.3.2, testing performed to determine what level of underinflation would produce the type of damage observed on the accident airplane’s tires found that the damage was consistent with tires operating while about 36-percent underinflated. Thus, the underinflation value derived from the loss-rate calculation (based on the tire service history)

79 The calculation applies the loss rate to each day’s (decreasing) initial inflation value for the tire.

NTSB Aircraft Accident Report corresponds with the value that testing showed would be needed to produce damage such as that found on all four of the accident airplane’s tires. Therefore, the NTSB concludes that all four MLG tires on the airplane were operating while severely underinflated during the takeoff roll, which resulted in the tire failures. 2.3.1.1 Operator’s Tire Maintenance Practices Global Exec Aviation’s director of maintenance indicated that he did not know how often the Learjet 60’s tire pressures should be checked but that he referred to the respective AMM for each type of airplane operated by the company to know when to perform scheduled maintenance items. Chapter 12 of the Learjet AMM suggested daily tire pressure checks, which is consistent with the AMMs for other airplanes (Cessna CE-650 and Dassault Falcon 50) operated by Global Exec Aviation. Learjet maintenance and product support publications, FAA AC 20-97B, and several Goodyear publications also specified daily or regular tire pressure checks. Although the daily tire pressure check interval referenced in the AMM was not specified as a requirement, the director of maintenance is responsible for ensuring proper airplane tire maintenance, including adequate tire pressures. Allowing the airplane to operate for weeks without a tire pressure check is inconsistent with all available guidance. Further, the NTSB’s informal survey to collect information about in-service tires found that most of the tires sampled were inflated to within 10 percent of their rated pressure (typically within AMM limits), which suggests that most, but not all, operators are ensuring adequate tire inflation. Given the average expected daily pressure loss for the accident airplane’s tires, any operations involving the accident airplane within the 2 weeks preceding the accident would have been conducted while the tires were likely at inflation pressures below the replacement criteria listed in the AMM. As indicated in the AMM, such underinflation of MLG tires cannot be determined by a visual inspection; thus, the flight crewmembers (who typically do not perform tire pressure checks) would have been unable to detect the underinflated condition of the tires. Therefore, the NTSB concludes that the accident airplane’s insufficient tire air pressure was due to Global Exec Aviation’s inadequate maintenance. 2.3.1.2 Maintenance Manual References to Tire Pressure Check Intervals As referenced, most of the tires reviewed in the NTSB’s informal survey were adequately inflated; however, some were not. Although nearly all of the maintenance providers interviewed indicated that use of the AMM is required by an operator’s operations specifications, one FBO operator interviewed noted that some AMMs do not call for mandatory tire pressure checks and that he believed that weekly pressure checks were generally good practice. Contrary to what this FBO operator believed, a weekly check would not be sufficient for some tires (such as those installed on the Learjet 60). Therefore, the NTSB concludes that some operators are not sufficiently aware of the appropriate tire pressure check intervals for the airplanes in their fleets and are operating their airplanes with tires inflated below the AMM replacement specifications. Therefore, the NTSB recommends that the FAA provide pilots and maintenance personnel with information that (1) transport-category aircraft tires can lose up to 5-percent pressure per day, 54

NTSB Aircraft Accident Report (2) it may take only a few days for such tires to reach an underinflation level below what the AMM specifies for tire replacement, and (3) the underinflation level that would require tire replacement is not visually detectable. The NTSB further recommends that the FAA require that all 14 CFR Part 121, 135, and 91 subpart K operators perform tire pressure checks at a frequency that will ensure that the tires remain inflated to within AMM-specified inflation pressures. Although the Learjet 60 AMM contained information about tire pressure checks, the information was not prominent in the manual. The only reference to tire pressure checks that appeared in the section of the Learjet 60 AMM dedicated to inspection intervals (chapter 5) was under a 300-hour interval phase inspection and indicated that the user should refer to chapter 12 for the information. Chapter 12 is a section of the AMM dedicated to descriptions of how to perform maintenance tasks but not when they should be performed. Further, the daily tire pressure check intervals listed in chapter 12 of the Learjet 60 AMM appeared under the heading “Practices and Tips,” indicating that the information was discretionary rather than mandatory. Although Learjet issued AMM TR 12-16 on March 18, 2009, to better define when and how to check tire pressures (and to state that such checks “must” be performed), this clarifying information remains in chapter 12. Other airplane manufacturers also list tire pressure check interval information in chapter 12 of their respective AMMs; however, this format is not consistent among all manufacturers’ FAA-approved manuals. The NTSB concludes that AMM formats that refer to tire pressure checks as guidance information rather than required maintenance intervals and the lack of standardization of AMM formats with respect to the location of tire pressure check interval information do not provide sufficient emphasis on the criticality of checking and maintaining tire pressure. Therefore, the NTSB recommends that the FAA require that AMMs specify, in a readily identifiable and standardized location, required maintenance intervals for tire pressure checks (as applicable to each aircraft). Other inconsistencies related to tire pressure checks were found in the FAA’s February 26, 2009, response to Learjet regarding the Learjet 60. In the letter, the FAA stated that checking the tires on a Learjet 60 is preventive maintenance, which pilots would not be permitted to do as part of a preflight check. However, the FAA further explained that a pilot flying a Learjet 60 under 14 CFR Part 91 may perform tire pressure checks but that a pilot flying a Learjet 60 under 14 CFR Part 135 may not. The NTSB notes that, according to the FAA’s interpretation, a pilot working for a Part 135 on-demand operator would be allowed to check tire pressures on a Learjet 60 for Part 91 ferry or maintenance flights but that the same pilot would be prohibited from performing the same checks on the same airplane for a Part 135 flight for revenue passengers or cargo. Because of the nature of Part 135 on-demand operations (and as evidenced by this accident flight crew’s trip pairings), it is not unusual for a flight crew to remain with an airplane away from the operator’s base for several days while flying both revenue and positioning flights. The NTSB acknowledges that the different rules that apply to Part 135 flights generally represent a higher level of safety than those contained in Part 91. In this case, however, the NTSB is concerned that the FAA’s interpretation may have an unintended negative effect on safety because the interpretation arbitrarily prohibits personnel from performing a safety task. Although the interpretation pertains only to the Learjet 60 (in direct response to questions from 55

NTSB Aircraft Accident Report Bombardier Learjet) and allows operators to petition for exemption, pilots and operators of other transport-category airplanes may be unsure if the interpretation applies to their operations. Therefore, NTSB concludes that the FAA’s legal interpretation that checking tire pressures on a Learjet 60 is preventive maintenance has an unintended negative effect on the safety of Part 135 operations because, according to the provisions of 14 CFR 43.3, a Learjet 60 pilot who is allowed to perform preventive maintenance, such as tire pressure checks, on the airplane for a flight operated under Part 91 is prohibited from performing the checks on the same airplane for a Part 135 flight. Therefore, the NTSB recommends that the FAA allow pilots to perform tire pressure checks on aircraft, regardless of whether the aircraft is operating under 14 CFR Part 91, Part 91 subpart K, or Part 135. 2.3.1.3 Lack of Tire Pressure Information for Flight Crews Tires require proper inflation to perform as designed. TPMS, which is installed in some new airplanes and can be retrofitted on others, provides flight crews with tire pressure information at the tire inflation valve (or, with some systems, visual or aural alerts in the cockpit to indicate abnormal conditions). Because the allowable daily pressure loss for aircraft tires can result in tire pressures that are below acceptable operational values within only a few days, providing tire pressure information to a flight crew helps ensure proper inflation and safe operations, particularly when the airplane is away from the operator’s maintenance base for multiday trips. As previously mentioned, the accident pilots (who were not tasked with checking the tire pressures) had no means by which to detect the accident airplane’s underinflated tires. Had the pilots been aware of the airplane’s tire condition, they could have had the airplane’s tires serviced by a maintenance facility. (The NTSB notes that the airplane was in a facility for other maintenance before the airplane was repositioned for the accident flight.) Therefore, the NTSB concludes that TPMS, which enable flight crews to easily verify tire pressures, provides safety benefits because the pressure-loss rate of aircraft tires can result in tire pressures below acceptable operational values within only a few days, and such underinflation cannot be visually detected by flight crews. Therefore, the NTSB recommends that the FAA require TPMS for all transport-category airplanes. 2.3.2 Thrust Reverser System Deficiencies The thrust reversers on the Learjet 60, as with those on other airplanes, are intended to assist with ground braking. The Learjet 60 was the first Learjet model to be equipped with a fully electronic thrust reverser control, and no other Learjet model has a similar system. To protect against thrust reverser deployment in flight, the thrust reverser logic criteria are such that, in the event of any system failures or anomalies, the thrust reversers will stow. This safety feature ensures that a system anomaly cannot result in a thrust reverser deployment in flight, which could affect the airplane’s controllability. Although the protection against in-flight deployment provided by the stowage feature is necessary, the circumstances of this accident (and the other events discussed in section 1.16.4.2) highlight a system vulnerability in which the damage from a 56

NTSB Aircraft Accident Report single tire can result in an erroneous air/ground mode signal, inadvertently activating the protection logic and leading to the acceleration of the airplane in response to a pilot’s control commands for deceleration. As previously discussed, the accident airplane’s thrust reverser system initially performed as commanded until debris damage resulted in the loss of the “ground mode” signal and the logic changed to “air mode.” As demonstrated by ground testing performed in a Learjet 60 equipped to duplicate the accident airplane’s scenario (in which the logic requirements for maintaining thrust reverser deployment were not longer being met), the sequence that followed was that the thrust reverser doors stowed while the cockpit thrust reverser levers remained lifted in the reverse thrust position (as had been selected by the captain) and the engines instead produced forward thrust at near takeoff power. The only cockpit indication available to the captain and the first officer about the nature of the emergency was the absence of thrust reverser annunciators. In a July 17, 2009, safety recommendation letter to the FAA, the NTSB concluded that, during an RTO, which requires quick and concentrated pilot actions, a pilot may have difficulties recognizing the significance of the absence of reverse thrust indicator lights. As described in section 1.18.3.1, the NTSB issued Safety Recommendation A-09-59 that asked the FAA to require that Learjet 60 pilots receive training on recognizing inadvertent thrust reverser stowage. On November 5, 2009, the FAA issued a SAFO that referenced the circumstances of the accident and recommended that directors of safety, directors of operations, training center program managers, and individuals responsible for training programs review their programs to ensure emphasis on recognizing inadvertent stowage of thrust reversers during takeoff and landing. The NTSB notes that, if the FAA can demonstrate that the issuance of the SAFO has achieved the same effect as a requirement that all Learjet 60 operators and training centers include the recommended training, the NTSB will consider the FAA’s action to be an acceptable alternative. To complete the action recommended, the FAA needs to supply information documenting that all Learjet 60 operators and training centers have incorporated the recommended training. Pending receipt of that information, the NTSB classifies Safety Recommendation A-09-59, “Open— Acceptable Alternate Response.” Because the NTSB views this pilot training as an interim measure to help mitigate the hazards associated with the identified thrust reverser design deficiencies until these deficiencies are corrected, the NTSB also issued several safety recommendations (A-09-55 through -58 and -60, referenced in section 1.18.3.1) addressing the need for changes to the Learjet 60’s (and the Raytheon Hawker 1000’s) thrust reverser system design. The recommended design changes include modifications to ensure that the thrust reverser lever positions in the cockpit match the positions of the thrust reverser mechanisms at the engines and to provide improved aural or visual cues to allow pilots to recognize an inadvertent thrust reverser stowage in a timely manner. The NTSB is pleased that the FAA has assembled a team of technical specialists to develop a plan for addressing each recommendation (as indicated in the FAA’s September 23, 2009, response). Although FAA representatives assisting with this accident investigation have indicated that there is no basic certification requirement that the thrust reverser control lever position match that of the reverser mechanisms, the NTSB notes that the thrust reverser design of the Learjet 60 does not appear to be in compliance with existing certification requirements, 57

NTSB Aircraft Accident Report including 14 CFR 25.777, 25.779, and 25.1309. Also, 14 CFR 25.933, which relates to thrust reverser systems, requires a means to prevent the engine from producing more than idle forward thrust in the event of a thrust reverser system malfunction. Because of these existing regulations, the NTSB believes that the FAA should be able to take the recommended actions without any lengthy rulemaking project to revise the certification standards. Pending the FAA’s completion of the recommended actions, the NTSB classifies Safety Recommendations A-09-55 through -58 and -60, “Open—Acceptable Response.” Although the NTSB is pleased that the FAA has initiated responsive action to address these safety recommendations, the NTSB is concerned that many of these issues were not more thoroughly addressed by Learjet and the FAA after the January 14, 2001, landing accident in Troy, Alabama, in which a Learjet 60 accelerated off the end of the runway after an uncommanded stowage of the thrust reversers. Although the 2001 accident occurred during landing, it also involved an uncommanded forward thrust event after squat switch system damage. After the 2001 accident, the FAA did not require any modifications to the airplane’s design. Although Learjet initiated a safety review of the circumstances of the accident, the solutions it implemented (and that the FAA approved) did not adequately address the design deficiencies. For example, Learjet’s AFM revision in 2003 (to include the “Inadvertent Stow of Thrust Reverser After a Crew-Commanded Deployment” procedure as an emergency procedure) inappropriately relied on a flight crew procedure to mitigate a hazard as serious as uncommanded forward thrust. Use of a procedure, instead of a design change, is not an adequate corrective action for such an emergency, especially when the airplane’s design makes performing the procedure counterintuitive. Although Learjet subsequently introduced a design change to supplement the procedure, the modification also failed to adequately address the problem. According to SB 60-78-7, which specified the modification, the design change was intended “to reduce the possibility of inadvertent stowing during thrust reverser operation.” The modification incorporated the airplane’s existing wheel speed sensors into the thrust reverser logic, but the redundant signal was designed to provide input only after the airplane’s squat switches signaled air mode for at least 2 minutes, beginning within 50 seconds of the ground-to-air transition. Although this restriction is consistent with the system’s original fail-safe concept to protect against thrust reverser deployment in flight, the restriction prevents the wheel speed sensor redundancy during RTO scenarios because the airplane never enters air mode before thrust reverser deployment. Thus, the design change did not reduce the possibility of uncommanded stowage of the thrust reversers during an RTO. An effective safety assessment process should result in the creation of system-level design requirements to ensure safe operation during abnormal or emergency conditions (such as an RTO), including situations in which there are disagreements between commanded and actual system states (as exhibited by the thrust reverser system in this accident). Guidance for demonstrating compliance with the safety requirements contained in 14 CFR 25.1309 is described in AC 25.1309-1A. This guidance directs the use of a structured process for performing safety assessments on systems that have high levels of complexity, integration, and 58

NTSB Aircraft Accident Report 59 safety-critical functionality (such as the Learjet 60 thrust reverser system). SAE ARP4761,80 which is intended to be used with the regulatory guidance contained in AC 25.1309-1A, also describes industry best practices for performing safety assessments for the certification of civil aircraft. The NTSB is concerned that neither Learjet’s safety analyses for the modification nor the FAA’s review resulted in adequate design protection against uncommanded stowage of the thrust reversers—and, more importantly, the associated uncommanded forward thrust—during RTO scenarios. The NTSB finds these shortcomings particularly alarming because the type of analyses used by Learjet and reviewed by the FAA represents a safety risk management technique that the FAA has promoted as one of the four pillars of an effective safety management system (SMS),81 which the FAA has described as the most effective way to improve safety and accomplish oversight.82 Although the NTSB endorses SMS implementation as a means to improve safety,83 it is critical that the FAA use this accident as an opportunity to examine why the processes that are essential to an effective SMS, hazard identification, and risk analysis and assessment were not effective in preventing this accident despite the presence of precursor in-service data. Therefore, the NTSB concludes that Learjet’s system safety analysis for and the FAA’s review of the Learjet 60’s thrust reverser system modification and revised crew procedure were inadequate because they failed to effectively address an unsafe condition for all phases of flight, specifically, uncommanded forward thrust during an RTO. Therefore, the NTSB recommends that the FAA identify the deficiencies in Learjet’s system safety analyses, both for the original Learjet 60 design and for the modifications after the 2001 accident, that failed to properly address the thrust reverser system design flaws related to this accident, and require Learjet to perform a system safety assessment in accordance with 14 CFR 25.1309 for all other systems that also rely on air-ground signal integrity and ensure that hazards resulting from a loss of signal integrity are appropriately mitigated to fully comply with this regulation. The NTSB further recommends that the FAA revise available safety assessment guidance (such as AC 25.1309-1A) for manufacturers to adequately address the deficiencies identified in Safety Recommendation A-10-51, require that DERs and their FAA mentors are trained on this methodology, and modify FAA design oversight procedures to ensure that manufacturers are performing system safety analyses for all new or modified designs that effectively identify and properly mitigate hazards for all phases of flight, including foreseeable events during those phases (such as an RTO).

80 Guidelines and Methods for Conducting the Safety Assessment Process on Civil Airborne Systems and Equipment, SAE ARP4761 (Warrendale, Pennsylvania: Society of Automotive Engineers, 1996). 81 AC 120-92, Introduction to Safety Management Systems for Air Operators. 82 As noted in a statement by Nicholas A. Sabatini, FAA Associate Administrator for Aviation Safety, before the House Committee on Transportation and Infrastructure, Subcommittee on Aviation, on September 20, 2006: “SMS formalizes risk management, which is imperative as we move from a forensic, or after-the-fact accident investigation approach, to a diagnostic and more prognostic, or predictive, approach. With the accident rate as low as it is, we must get in front of information, analyze trends, and anticipate problems if we are to continue to improve on an already remarkable record of achievement. Operating under [an SMS] will allow airlines, manufacturers, and the FAA to do this better than before.” 83 Reference NTSB Safety Recommendations A-07-10, A-09-89, and A-09-99.

NTSB Aircraft Accident Report 60 In the NTSB’s 2006 safety report on the aircraft certification process, the NTSB noted that a program must be in place to ensure continued airworthiness and the ongoing assessment of risks to safety-critical systems. The safety report stated that such a program can recognize that the certification process can change throughout the life of an airplane and can help ensure that ongoing decisions about design, operations, maintenance, and continued airworthiness consider operational data, service history, lessons learned, and new knowledge. The NTSB noted that SAE ARP5150 provides a process that is accepted by industry for the ongoing assessment of safety-critical systems. As a result of its findings, the NTSB issued Safety Recommendation A-06-38, which asked the FAA to do the following: Adopt [SAE International’s] ARP5150 into 14 [CFR] Parts 21, 25, 33, and 121 to require a program for the monitoring and ongoing assessment of safety-critical systems throughout the life cycle of the airplane. Safety-critical systems will be identified as a result of A-06-36.[84] Once in place, use this program to validate that the underlying assumptions made during design and type certification about safety-critical systems are consistent with operational experience, lessons learned, and new knowledge. Because of the FAA’s lack of progress in response to the recommendation, on October 14, 2009, the NTSB reiterated Safety Recommendation A-06-38 and reclassified it “Open—Unacceptable Response.” The circumstances of this accident demonstrate the importance of an FAA program to monitor and conduct ongoing assessments of safety-critical systems throughout the life cycle of an airplane to detect indications of a problem and correct the problem before an accident results. Therefore, the NTSB concludes that, had the FAA adopted the procedures described in SAE International’s SAE ARP5150, Safety Assessment of Transport Airplanes in Commercial Service, to require a program for the monitoring and ongoing assessment of safety-critical systems, the FAA may have recognized, based on problems reported after previous incidents and an accident, that the Learjet 60’s thrust reverser system design was deficient and thus may have required appropriate modifications before this accident occurred. 2.3.3 Safety of Changed Aeronautical Products The certification basis for changed aeronautical products allows an aircraft manufacturer to use the results of some of the analyses and testing from the original type certification to demonstrate compliance for derivative models, and some regulations that were in effect on the date of the original TC apply (with exceptions specified in the TCDS). The Learjet 60 was certificated in 1993 but was added to Learjet TC A10CE, which was originally issued for the Learjet 24 in 1966. From a certification basis, the Learjet 24 and the Learjet 60 are the same type of airplane; however, they share few similarities or structural components.

84 Safety Recommendation A-06-36 is discussed in section 1.18.3.2.

NTSB Aircraft Accident Report Since the certification of the Learjet 60, the FAA has made improvements in the certification process for changed aeronautical products. The current version of 14 CFR 21.101 (which was issued in 2000) is more specific than the version of the regulation that applied to the Learjet 60 with regard to the circumstances under which current airworthiness regulations must be used and when earlier amendments of a regulation are acceptable. Also, FAA Order 8110.48, issued in 2003, provides the general procedures for determining the certification basis for changes to aircraft on the same TC and specifies that the FAA may require a manufacturer to apply for a new TC for extensive changes. Although these more specific requirements and improved guidelines have removed some of the subjectivity to the certification basis for derivative model aircraft, the procedures still allow for inconsistencies and interpretation. For example, the FAA has approved airplane designs for some manufacturers that are sold as new products over production lives that span decades but are on one TC, whereas the airplane designs from another manufacturer (or certain designs from the same manufacturer, such as the Learjet 45) may have each been certificated on a new TC. As a result, airplane models that may appear comparable based on criteria such as date of release and/or payload and range specifications may actually be certificated to different safety standards. For example, although the Learjet 45 and the Learjet 60 were both introduced in the 1990s, the Learjet 45 was subject to the most updated, more stringent certification regulations at the time, whereas many of the certification requirements that applied to the Learjet 60 were based on older, less stringent requirements. (Manufacturers may electively exceed the certification requirements, and many, including Learjet, have done so.) The Learjet 60’s compliance with 14 CFR 25.1309, which relates to failures of equipment, systems, and installations, was required to be based on a modification to the original version of the regulation, even though an extensively revised version of the regulation, including amendment 25-41 (applicable to the Learjet 45), had been in effect since 1977. In 1981, during a certification review of a different Learjet derivative model, the FAA noted that the revised requirements of 14 CFR 25.1309 provided a higher level of safety than previous versions of the regulation and that “it is necessary that flight critical systems meet these more stringent requirements to ensure safety.” A comparison of the protection for equipment in the wheel wells of the Learjet 60 with that in the Learjet 45 illustrates the safety impact that the revised regulations can have on aircraft designs. Although both airplanes were subject to the same criteria specified in 14 CFR 25.729 for protecting equipment from the damage that could be caused by fragments from a disintegrating tire, the Learjet 45 was also subject to the revised version of 14 CFR 25.1309. As a result, the Learjet 45 has protective shielding and other design improvements that protect hydraulic system components, wiring, and other equipment installed in the wheel well, whereas some of the same system components in the Learjet 60 are considerably more exposed. Another improved safety feature on the Learjet 45 relates to the thrust reverser system. In the event that an abnormal condition results in the stowage of reverser doors while the cockpit levers are raised, the Learjet 45’s thrust reverser control electronically triggers the cockpit thrust reverser levers to move to the stowed position and the engine thrust to idle power. The NTSB notes that either of these Learjet 45 design features (the added wheel well protection or the improved electronic thrust reverser control) would likely prevent the Learjet 45 from producing uncommanded forward thrust after a chain of events stemming from a tire failure, which occurred in this accident. 61

NTSB Aircraft Accident Report 62 The NTSB concludes that the FAA’s 1993 certification of the Learjet 60 as a changed aeronautical product, which allowed the airplane’s equipment, systems, and installations to conform to some regulations applicable to the original 1966 certification, did not ensure the highest level of safety and allowed for deficiencies that would not likely have been present if the current regulations had applied. Therefore, the NTSB recommends that the FAA revise FAA Order 8110.48 to require that the most current airworthiness regulations related to equipment, systems, and installations (14 CFR 25.1309) are applied to all derivative design aircraft certificated as changed aeronautical products. The NTSB further recommends that the FAA review the designs of existing derivative design aircraft that were certificated as changed aeronautical products against the requirements of the current revision of 14 CFR 25.1309 and require modification of the equipment, systems, and installations to fully comply with this regulation. 2.4 Flight Crew Performance Section 2 of AC 120-62 acknowledges that tire failures may be difficult to identify from the flight deck and stresses that flight crews must be cautious not to inappropriately conclude that another problem exists. The accident airplane’s swerve, the onset of continuous noise from tire fragments striking the fuselage, and the related airframe vibration could have startled the captain. Further, the hydraulic fluid found on some tire fragments indicates that hydraulic integrity was compromised early in the sequence. As a result, the hydraulic pressure annunciators in the cockpit would have illuminated, providing the captain with additional cues about problems that she might not have fully comprehended. However, all of these cues occurred after the airplane had passed V1, and there was no strong evidence that the airplane was uncontrollable. The captain’s action to reject the takeoff and her lack of a callout, contrary to her training, may have been the result of the “startle factor,” which is often lacking in training scenarios. In most V1 training scenarios, pilots are in a simulator, are aware that they will be receiving an anomaly (usually an engine failure) on takeoff, and are prepared to respond. In the real world, the situation is more dynamic, the consequences are greater, and the pilot is not aware that a failure will occur or what type of failure it is. This “startle factor” can increase the stress level of the pilot, resulting in an incorrect decision being made. The following analysis examines factors that may have influenced the captain’s actions. 2.4.1 Lack of Training for Tire-Related Events As indicated in the NTSB’s 1990 SIR related to runway overruns associated with high-speed RTOs85 and an updated review by Boeing that includes data up to 1999, accidents and incidents related to RTOs initiated because of wheel or tire malfunctions are as common as those related to RTOs performed in response to engine failures. The accidents and incidents

85 NTSB SIR-90-02.

NTSB Aircraft Accident Report show that, like the accident captain, many other pilots have misinterpreted tire anomalies and responded by initiating an unnecessary RTO after V1. According to an FSI instructor, the training curriculum provided to the captain and the first officer did not include any scenarios in which a tire failure occurred. Training materials provided to flight crews about RTOs focus primarily on engine failures at or around V1. There was no indication that wheel and tire failure scenarios are readily trained or that training scenarios are conducted to assess a flight crew’s reactions to failures or malfunctions occurring after V1. The NTSB realizes that there are limits to the time operators can allocate to training to prepare pilots to respond to all possible emergency and abnormal situations. However, the data from past accidents show that numerous flight crews were not prepared to respond appropriately, as trained, to tire anomalies, which resulted in runway overrun accidents that might have been avoided had the takeoff been continued. Although AC 120-62 is a useful training aid in that it provides thorough guidance related to takeoff safety and cautions pilots about misinterpreting tire events, as a textual training tool, its effectiveness is limited in preparing flight crews for the startling cues, including loud noises and airframe shaking and vibration, associated with tire failures when they occur. However, flight simulators are often used effectively to train flight crews to recognize and respond properly to startling cues associated with various abnormal and emergency flight situations. The NTSB concludes that the accident pilots would have been better prepared to recognize the tire failure and to continue the takeoff if they had received realistic training in a flight simulator on the recognition of and proper response to tire failures occurring during takeoff. The NTSB recommends that the FAA define and codify minimum simulator model fidelity requirements for tire failure scenarios. These requirements should include tire failure scenarios during takeoff that present the need for rapid evaluation and execution of procedures and provide realistic sound and motion cueing. The NTSB further recommends that, once the simulator model fidelity requirements requested in Safety Recommendation A-10-55 are implemented, the FAA require that simulator training for pilots who conduct turbojet operations include opportunities to practice responding to events other than engine failures occurring both near V1 and after V1, including, but not limited to, tire failures. 2.4.2 Captain’s Experience in the Learjet 60 and as Pilot-in-Command A PIC who is not yet confident in commanding a new type of airplane may not respond quickly enough or appropriately in an abnormal situation. The captain in this accident demonstrated some uncertainty about her response to the anomalies during takeoff. Although the RTO criteria and procedures for the Learjet 60 do not fundamentally differ from those of the other airplane types flown by the captain, both her question to the more experienced first officer (“go?”) and her wavering back and forth on engine power input indicate a lack of confidence in commanding the airplane. The captain was trained and qualified to fly both the Learjet 60 and the Cessna CE-650 in Part 135 on-demand operations. The captain received a type rating for the Learjet 60 about 11 63

NTSB Aircraft Accident Report 64 months before the accident and logged about 35 hours in the airplane, about 8 of which were accumulated while acting as PIC. While accruing time in the Learjet 60, she also became type rated in the Cessna CE-650 (about 9 months before the accident) and flew about 118 hours in that airplane for Global Exec Aviation. Before the captain was assigned to the trip pairing on the accident airplane (which includes the day before the accident), the captain had not flown as PIC in the Learjet 60 for about 1 month. She had performed most of her flying duties (as PIC or SIC) in the Cessna CE-650, with fewer hours in the Learjet 60, and had not accrued much PIC experience in either airplane. The NTSB is concerned that when a pilot switches between two types of airplanes before the pilot has accrued much experience on either airplane, the pilot may lose proficiency in the newly acquired knowledge and skills. Unlike Part 135 on-demand operations, Part 121 commercial operations require that a PIC who has completed initial or upgrade training on one airplane must gain a minimum level of pilot operating experience under the supervision of a check pilot and demonstrate that he or she is qualified to perform PIC duties in that type of airplane. Also, according to 14 CFR 121.434(g), a pilot must gain 100 hours of experience in an airplane type within 120 days of obtaining the type rating or proficiency check before that pilot can act as PIC in that type of airplane without limitations.86 According to 14 CFR 121.434(h)(3), if the pilot performs flying duties for the air carrier in a different type of airplane before completing 100 hours of flight time on the new airplane, the pilot must also complete approved refresher training before he or she may serve as PIC on the newly qualified airplane. Part 135 on-demand operations have no such minimum operating flight time requirements. Minimum levels of operating experience help ensure that, when a pilot transitions to a new type of airplane, the pilot obtains the experience needed in that airplane to gain knowledge of the airplane’s particular systems and handling characteristics and to develop skills in flying it. The consolidation of knowledge and skills through operating experience helps the pilot build confidence in flying the new airplane, which is particularly important for the PIC. The NTSB notes that the cockpit environments and the duties of the dual-pilot flight crews of Part 135 on-demand operations are similar to those of Part 121 operations and often use comparably sophisticated aircraft. The NTSB concludes that, because Part 135 does not require that pilots in on-demand turbojet operations have a minimum level of experience in airplane type, the pilots may lack adequate knowledge and skills in that airplane. Therefore, the NTSB recommends that the FAA require that pilots who fly in Part 135 operations in aircraft that require a type rating gain a minimum level of initial operating experience, similar to that specified in 14 CFR 121.434, taking into consideration the unique characteristics of Part 135 operations. The NTSB further recommends that the FAA require that pilots who fly in Part 135 operations in an aircraft that requires a type rating gain a minimum level of flight time in that aircraft type, similar to that described in 14 CFR 121.434, taking into consideration the unique characteristics of Part 135 operations, to obtain consolidation of knowledge and skills.

86 For PICs who have not yet accumulated 100 hours in the airplane type, Part 121 specifies certain limitations, such as increased landing weather minimums, that must be applied to those specified in the air carrier’s operations specifications.

NTSB Aircraft Accident Report 2.4.3 Crew Resource Management CRM includes skills and techniques for effective crew coordination, resource allocation, and error management. When used effectively, CRM augments technical training and enhances crew performance in the cockpit. One aspect of CRM includes the effective use of briefings, which allow flight crews to think ahead and be prepared for abnormal or emergency situations that may arise. AC 120-62 notes that the pretakeoff briefing “should not be a meaningless repetition of known facts, but rather a tool for improving team performance that addresses the specific factors appropriate to that takeoff.” After the captain provided the incorrect RTO criteria in her briefing, the first officer initially replied, “correct” but then questioned her briefing by stating the correct criteria. The captain agreed with the first officer, but it is unclear from the exchange whether the captain recognized that she had previously misspoken. From the beginning, when the flight crew received the taxi clearance, there were instances in which the captain and the first officer had disparate thoughts about the clearance yet did not make effective use of available resources to verify the information. In one instance, the captain indicated that she believed that they were instructed to hold short of the active runway (of which she misspoke and stated was runway 22 instead of 23), but the first officer indicated, “I think he said … that we could cross it.” In this instance, the first officer was correct, and the captain went along with what the first officer stated. During a subsequent discussion (in which the captain and the first officer had different ideas about which direction to taxi), the captain again went along with what the first officer thought to be accurate; however, in this case, the first officer was incorrect, which resulted in the captain making a wrong turn onto the taxiway. In either case, because the crewmembers were not in agreement about the controller’s instructions, they should have verified the correct clearance with the controller. In addition, there were several instances during the taxi in which the captain or the first officer read back incorrect information, and the mistake went uncorrected by the other crewmember. Just before initiating the takeoff roll, the captain asked the first officer to request a wind check. However, the captain repeated the winds back to the first officer incorrectly, and the first officer agreed; thus, neither the captain nor the first officer was effectively listening to each other or the controller. The captain’s next statement that the winds were “pretty much straight down” the runway was also incorrect, and the first officer did not correct that error. Although none of the incorrect information during the taxi related directly to the circumstances of the accident, the exchanges are of concern in that, collectively, they provide evidence that neither crewmember was particularly focused. The CRM skills exhibited by the flight crew were inconsistent with the skills needed for effective communication and the coordination of a professional flight crew. During the taxi, the captain’s casual tone and lack of leadership and the flight crew’s inattention to details foreshadowed elements of the crew’s subsequent performance in responding to the anomaly. The captain’s lack of accuracy in her pretakeoff briefing and the first officer’s indirect questioning of it were missed opportunities for the crew to make use of the briefing for its intended purpose as a CRM tool for improving team performance. The NTSB concludes that the captain’s indecision in responding to the anomaly and her failure to follow standard operating procedures was the result 65

NTSB Aircraft Accident Report 66 of a combination of poor CRM skills, limited experience as a pilot-in-command in the Learjet 60, and, during the accident sequence in particular, her less than confident and assertive leadership in the cockpit. The NTSB has had longstanding concerns about the consequences of ineffective CRM among Part 135 on-demand flight crews; such issues are included on the NTSB’s Most Wanted List. On December 2, 2003, the NTSB issued Safety Recommendation A-03-52, which superseded Safety Recommendation A-02-12 and asked the FAA to do the following: Require that 14 CFR Part 135 on-demand charter operators that conduct dual-pilot operations establish and implement [an FAA]-approved crew resource management training program for their flight crews in accordance with 14 CFR Part 121, subparts N and O. On May 1, 2009, the FAA published an NPRM titled, “Crew Resource Management Training for Crewmembers in Part 135 Operations,”87 which responded to Safety Recommendation A-03-52 in that it proposed to require Part 135 certificate holders to include CRM training for pilots and flight attendants. On July 15, 2009, the NTSB provided comments in general support of the proposed rule; however, the NTSB expressed concern about some aspects of the NPRM and urged the FAA to withdraw a proposed provision to allow certificate holders to give credit for initial CRM training received from another Part 135 operator. Pending issuance of the final rule, the NTSB classified Safety Recommendation A-03-52 “Open—Acceptable Response” on December 29, 2009.. The NTSB is encouraged by the FAA’s progress and looks forward to the timely issuance of the final rule. In addition, the NTSB plans to hold a public forum in 2010 to address high standards for both flight crews and air traffic controllers. The planned forum has resulted from the NTSB’s investigation of a number of accidents and incidents in recent years involving air transportation professionals who have deviated from expected levels of performance. 2.4.4 Medication Use and Rest Opportunities Diphenhydramine, a medication that can result in drowsiness and performance deficits,88 was detected in specimens from both the captain and the first officer. Diphenhydramine is commonly used to treat allergy symptoms or as a sleep aid. However, the relevance of the reported diphenhydramine levels is difficult to determine because it is not known when the pilots last took the medication, why they took it, or in what dose.89 In addition, the reliability of the

87 74 FR 20263-20279. 88 Diphenhydramine has been shown to have a measurable effect on performance of complex cognitive and motor tasks during at least the first 4 hours after the use of a maximum over-the-counter dose. See R.C. Baselt, Drug Effects on Psychomotor Performance (Foster City, California: Biomedical Publications, 2001). 89 Medical analysis suggests that the drug levels detected in each pilot’s blood samples could be consistent with the ingestion of either the maximum over-the-counter dose about 6 to 12 hours before the accident or a lower dose more recently (Baselt, 2001). Other research suggests a significant mental impairment and increased reaction time (compared with those who took a placebo) within 2 hours of taking 50 mg of diphenhydramine, after which time no significant differences were found. Subjective reporting of drowsiness effects was significantly different for up to 6

NTSB Aircraft Accident Report 67 detected drug levels can be affected by the anatomical source and condition of the specimens tested, neither of which were reported. Based on cellular telephone records, the captain’s telephone activity on the day of the accident left the potential for three 1-hour uninterrupted periods to take a nap. Cellular telephone activity for the first officer afforded one 1-hour and one 2-hour time periods for rest.90 However, each pilot’s actual sleep, supplemental sleep (naps), and awake times in the 72 hours before the accident could not be determined. Although both the captain and the first officer made errors before and during the takeoff, these errors are consistent with the training, experience, and CRM deficiencies that are discussed in sections 2.4.1 through 2.4.3 and are addressed by separate safety recommendations. Further, both flight crewmembers were off duty for about 30 hours before reporting for work on the night of the accident, which provided enough time for adequate rest. The NTSB concludes that, although flight crew impairment related to diphenhydramine use or fatigue is possible, there is insufficient evidence to determine to what extent, if any, diphenhydramine use or fatigue may have affected the captain’s and the first officer’s performance. 2.5 Occupant Survivability In this accident, two factors were critical for occupant survival: protection from traumatic injury and the ability to quickly escape the fire. During the accident sequence, the captain and first officer sustained immobilizing blunt force injuries and died of smoke inhalation, and two of the passengers sustained fatal blunt force injuries. The fastened seatbelt buckles recovered from the cockpit suggest that the captain and first officer were likely restrained; however, the available wreckage showed evidence of cockpit crush intrusion and deformation, which may have contributed to their impact injuries. The reported cause of death for two of the passengers indicated that they succumbed to their traumatic injuries and not the postcrash fire. Although none of the cabin seatbelt buckles were found buckled, not all of the cabin buckles were located. In addition, seatbelt webbing and seat structures in the cabin were destroyed by fire. Therefore, the restraint usage for the passenger fatalities could not be determined. Both survivors, however, reported that they were wearing their seatbelts, and neither sustained any immobilizing impact injuries.

hours after administration of the drug. The observed concentrations of diphenhydramine at the “off set” of impairment ranged from 0.0582 to 0.0744 μg/mL and for drowsiness from 0.0304 to 0.0415 μg/mL. See F. Gengo, C. Gabos, and J. K. Miller, “The Pharmacodynamics of Diphenhydramine-Induced Drowsiness and Changes in Mental Performance.” Clinical Pharmacology & Therapeutics, vol. 45, 15-2, January 1989. 90 If the captain and first officer were not able to nap during the day, their time awake at the time of the accident would have been at least 12.75 hours and 14 hours, respectively. The NTSB’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 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 procedural and tactical errors. The NTSB notes that careful adherence to standard operating procedures and CRM can help flight crews mitigate the degrading effects of fatigue. See National Transportation Safety Board, A Review of Flightcrew-Involved, Major Accidents of U.S. Air Carriers, 1978 through 1990, Safety Study NTSB/SS-94/01 (Washington, DC: NTSB, 1994).

NTSB Aircraft Accident Report Global Exec Aviation’s operations manual states that the PIC is responsible for ensuring that all passengers receive an oral briefing containing required safety information. One passenger stated the captain’s briefing was not the “usual” safety briefing, and the other passenger did not recall receiving a briefing. It is likely that the passenger’s perception was based on 14 CFR Part 121 airline briefings, which are typically delivered by flight attendants or video systems and use standardized phraseology. However, neither the regulations nor Global Exec Aviation policy requires particular verbatim briefing language; thus, some variation in execution might be expected based on a pilot’s individual style and preferences of delivery. The CVR did not capture the content of the captain’s briefing; however, one passenger recalled that the captain mentioned the seatbelts, fire extinguisher, and exits. Such topics are among those required by 14 CFR 135.117. Although one passenger stated that he did not think that the safety briefing sounded very professional, evidence suggests that his actions after the crash were influenced by the captain’s briefing. This passenger had opened the aft escape hatch exit, and he stated that he remembered being told about it by a crewmember. The location of the aft escape hatch exit, because it was on the right side of the airplane in the lavatory area, was partially obscured by the lavatory partition and was not conspicuously visible from the cabin. Thus, it is unlikely that the passenger would have known about the escape hatch location had he not learned about it during the briefing. This knowledge was critical for survival because of the rapid onset of the postcrash fire and the crush-damage impingement on the other exit (the passenger boarding door), which would have made it unusable for egress. In addition, although one passenger did not recall receiving a briefing and did not know that there was an exit behind him, he benefited from the other passenger’s knowledge of the briefing because the other passenger located and opened the exit, enabling them both to escape. Therefore, the NTSB concludes that the captain’s passenger safety briefing contributed to the survival of two passengers. 2.6 Other Safety Issues 2.6.1 Tire Certification and Testing Considerations In this accident, after the first MLG tire failed, the remaining three tires failed in sequence from right to left. The investigation found that the accident airplane’s tires were subjected to internal heating damage from operating while severely underinflated, which made each tire particularly susceptible to failure. However, the investigation also examined the possibility that the effects of adjacent tire loading after the loss of one tire can overload and potentially contribute to the failure of properly inflated tires. The investigation found that, after the loss of one tire, the other tires could become subject to loads not specifically accounted for in the tire’s certification. All tire testing criteria are based on the performance of a new, optimally inflated tire. This investigation’s review of a sampling of tires in service found that most airplanes were operated with tire inflations within 10 percent of their rated pressure. However, although such inflation values are acceptable per the AMMs, FAA tire testing criteria do not necessarily account for tire pressure and wear that are at acceptable, but less than optimal, conditions. Tires 68

NTSB Aircraft Accident Report operated at acceptable but lower-than-rated pressure will experience more sidewall flexing and heating than tires in the test condition. Aircraft tire manufacturers have provided historical evidence to show that heating, such as that which accumulates in the tire sidewalls during long taxi operations, can result in potentially harmful reductions in tire capability. The FAA’s lack of testing criteria for tire operations with less-than-optimal inflation and wear is not consistent with the conservative criteria that the FAA applies to other components that require testing with more realistic operating scenarios. For example, 14 CFR 25.109 and 25.735, which are the regulations pertaining to braking performance, specify that braking performance must be demonstrated with the brakes at the maximum wear limit. That rational approach to braking performance was implemented after a series of airplane accidents. According to 14 CFR 25.733, for airplanes with dual-wheel and tire assemblies, the service load carried by each MLG tire, when multiplied by 1.07, may not be greater than the rated load of the tire. Although requirements specify this minimum margin between service load and rated load, the NTSB’s investigation found that this margin may easily be exceeded in the normal operating environment, particularly for airplanes (such as the Learjet 60) that operate with tires at the rated load. In a static situation, the Learjet 60’s load is distributed primarily among the four MLG tires. However, on this dual-axle installation, the loss of one tire can increase the load on the remaining properly inflated tire on that axle to a factor of about 1.2. The FAA’s basic static load certification criteria also do not take into consideration the additional dynamic loads, such as camber changes that could unevenly load the remaining tire’s sidewalls. None of the tire testing criteria considers the dynamic forces imposed on the MLG tires after the loss of one tire. These forces include compression of the adjacent tire when one tire in an axle pair fails; sudden, unequal sidewall loading that is not uniform when camber is created; and the side loading and other dynamics imposed up to the point of tire slippage when friction is lost in a swerve that could follow the loss of the first tire. Other conditions are also not represented, such as even greater camber attributed to uneven pressure in MLG struts. The NTSB concludes that the tire design and testing requirements of 14 CFR 25.733 may not adequately ensure tire integrity because they do not reflect the actual static and dynamic loads that may be imposed on tires both during normal operating conditions and after the loss of one tire, especially if the tires are operated at their load rating, and the requirements may not adequately account for tires that are operated at less-than-optimal conditions. Therefore, the NTSB recommends that the FAA require that tire testing criteria reflect the actual static and dynamic loads that may be imposed on tires both during normal operating conditions and after the loss of one tire and consider less-than-optimal allowable tire conditions, including, but not limited to, the full range of allowable operating pressures and acceptable tread wear. 2.6.2 Flight Recorders The accident airplane was not required by FAA regulation to have an FDR installed. In the NTSB’s January 28, 2009, report on the midair collision involving electronic news gathering 69

NTSB Aircraft Accident Report 70 helicopters in Phoenix, Arizona,91 the NTSB issued Safety Recommendation A-09-11, which asked the FAA to do the following: Require all existing turbine-powered, nonexperimental, nonrestricted-category aircraft that are not equipped with [an FDR] and are operating under 14 [CFR] Parts 91, 121, or 135 to be retrofitted with a crash-resistant flight recorder system. The crash-resistant flight recorder system should record cockpit audio (if a cockpit voice recorder is not installed), a view of the cockpit environment to include as much of the outside view as possible, and parametric data per aircraft and system installation, all to be specified in [EUROCAE] document ED-155, “Minimum Operational Performance Specification for Lightweight Flight Recorder Systems,” when the document is finalized and issued. Although the FAA is making progress in this area and Safety Recommendation A-09-11 is classified “Open—Acceptable Response,” the NTSB notes that, had the FAA implemented previous NTSB recommendations (including A-03-65, now superseded by A-09-11), the accident airplane would have been subject to the requirements for a cockpit image recording system by January 1, 2010. The NTSB concludes that a cockpit image recorder would have helped determine the precise speeds at which the accident airplane traveled and the flight crew’s responses to the anomaly, including flight and engine control inputs.

91 NTSB/AAR-09/02.

NTSB Aircraft Accident Report

1. Conclusions
2. 1 Findings
3. The captain and the first officer were certificated and qualified in accordance with Federal

regulations and the operator’s requirements for the 14 Code of Federal Regulations Part 135 on-demand flight. Neither pilot had any previous aviation accidents, incidents, or enforcement actions.

1. The accident airplane was certificated and equipped in accordance with the regulations that

applied to it as a changed aeronautical product.

1. There was no evidence of any preimpact anomalies or distress that would have prevented the

engines from producing power.

1. There was no evidence of any flight control anomalies.
2. The following were not factors in this accident: tire design, tire manufacture, or damage to

the exterior of any tire.

1. Although postaccident estimates indicated that the airplane’s maximum gross weight may

have been exceeded by up to 300 pounds, there is no evidence that weight and balance issues contributed to the accident.

1. There was no indication that the captain’s understanding of the rejected takeoff criteria was

deficient; thus, the captain likely misspoke when she incorrectly stated the criteria in her pretakeoff briefing.

1. The captain’s uncertainty as to whether to continue the takeoff suggests that her initial action

to reject it did not result from a perception that the airplane was uncontrollable and could not fly.

1. In the absence of evidence that the airplane was uncontrollable, the captain’s execution of a

rejected takeoff for an unknown anomaly after the airplane’s speed had passed V1 was inconsistent with her training and standard operating procedures.

1. The accident airplane’s uncommanded forward thrust, which accelerated the airplane at a

time when the flight crew commanded full reverse thrust to decelerate the airplane, increased the severity of the accident because the uncommanded forward thrust substantially increased the airplane’s runway excursion speed. 71

NTSB Aircraft Accident Report

1. All four main landing gear tires on the airplane were operating while severely underinflated

during the takeoff roll, which resulted in the tire failures.

1. The accident airplane’s insufficient tire air pressure was due to Global Exec Aviation’s

inadequate maintenance.

1. Some operators are not sufficiently aware of the appropriate tire pressure check intervals for

the airplanes in their fleets and are operating their airplanes with tires inflated below the aircraft maintenance manual replacement specifications.

1. Aircraft maintenance manual (AMM) formats that refer to tire pressure checks as guidance

information rather than required maintenance intervals and the lack of standardization of AMM formats with respect to the location of tire pressure check interval information do not provide sufficient emphasis on the criticality of checking and maintaining tire pressure.

1. The Federal Aviation Administration’s legal interpretation that checking tire pressures on a

Learjet 60 is preventive maintenance has an unintended negative effect on the safety of 14 Code of Federal Regulations (CFR) Part 135 operations because, according to the provisions of 14 CFR 43.3, a Learjet 60 pilot who is allowed to perform preventive maintenance, such as tire pressure checks, on the airplane for a flight operated under 14 CFR Part 91 is prohibited from performing the checks on the same airplane for a Part 135 flight.

1. Tire pressure monitoring systems, which enable flight crews to easily verify tire pressures,

provide safety benefits because the pressure-loss rate of aircraft tires can result in tire pressures below acceptable operational values within only a few days, and such underinflation cannot be visually detected by flight crews.

1. Learjet’s system safety analysis for and the Federal Aviation Administration’s review of the

Learjet 60’s thrust reverser system modification and revised crew procedure were inadequate because they failed to effectively address an unsafe condition for all phases of flight, specifically, uncommanded forward thrust during a rejected takeoff.

1. Had the Federal Aviation Administration adopted the procedures described in SAE

International’s SAE ARP5150, Safety Assessment of Transport Airplanes in Commercial Service, to require a program for the monitoring and ongoing assessment of safety-critical systems, the FAA may have recognized, based on problems reported after previous incidents and an accident, that the Learjet 60’s thrust reverser system design was deficient and thus may have required appropriate modifications before this accident occurred.

1. The Federal Aviation Administration’s 1993 certification of the Learjet 60 as a changed

aeronautical product, which allowed the airplane’s equipment, systems, and installations to conform to some regulations applicable to the original 1966 certification, did not ensure the highest level of safety and allowed for deficiencies that would not likely have been present if the current regulations had applied. 72

NTSB Aircraft Accident Report

1. The accident pilots would have been better prepared to recognize the tire failure and to

continue the takeoff if they had received realistic training in a flight simulator on the recognition of and proper response to tire failures occurring during takeoff.

1. Because 14 Code of Federal Regulations Part 135 does not require that pilots in on-demand

turbojet operations have a minimum level of experience in airplane type, the pilots may lack adequate knowledge and skills in that airplane.

1. The captain’s indecision in responding to the anomaly and her failure to follow standard

operating procedures was the result of a combination of poor crew resource management skills, limited experience as a pilot-in-command in the Learjet 60, and, during the accident sequence in particular, her less than confident and assertive leadership in the cockpit.

1. Although flight crew impairment related to diphenhydramine use or fatigue is possible, there

is insufficient evidence to determine to what extent, if any, diphenhydramine use or fatigue may have affected the captain’s and the first officer’s performance.

1. The captain’s passenger safety briefing contributed to the survival of two passengers.
2. The tire design and testing requirements of 14 Code of Federal Regulations 25.733 may not

adequately ensure tire integrity because they do not reflect the actual static and dynamic loads that may be imposed on tires both during normal operating conditions and after the loss of one tire, especially if the tires are operated at their load rating, and the requirements may not adequately account for tires that are operated at less-than-optimal conditions.

1. A cockpit image recorder would have helped determine the precise speeds at which the

accident airplane traveled and the flight crew’s responses to the anomaly, including flight and engine control inputs. 3.2 Probable Cause The National Transportation Safety Board determines that the probable cause of this accident was the operator’s inadequate maintenance of the airplane’s tires, which resulted in multiple tire failures during takeoff roll due to severe underinflation, and the captain’s execution of a rejected takeoff after V1, which was inconsistent with her training and standard operating procedures. Contributing to the accident were (1) deficiencies in Learjet’s design of and the Federal Aviation Administration’s (FAA) certification of the Learjet Model 60’s thrust reverser system, which permitted the failure of critical systems in the wheel well area to result in uncommanded forward thrust that increased the severity of the accident; (2) the inadequacy of Learjet’s safety analysis and the FAA’s review of it, which failed to detect and correct the thrust reverser and wheel well design deficiencies after a 2001 uncommanded forward thrust accident; (3) inadequate industry training standards for flight crews in tire failure scenarios; and (4) the flight crew’s poor crew resource management. 73

NTSB Aircraft Accident Report

1. Recommendations
2. 1 New Recommendations

The National Transportation Safety Board makes the following recommendations to the Federal Aviation Administration: Provide pilots and maintenance personnel with information that (1) transport-category aircraft tires can lose up to 5-percent pressure per day, (2) it may take only a few days for such tires to reach an underinflation level below what the aircraft maintenance manual specifies for tire replacement, and (3) the underinflation level that would require tire replacement is not visually detectable. (A-10-46) Require that all 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators perform tire pressure checks at a frequency that will ensure that the tires remain inflated to within aircraft maintenance manual-specified inflation pressures. (A-10-47) Require that aircraft maintenance manuals specify, in a readily identifiable and standardized location, required maintenance intervals for tire pressure checks (as applicable to each aircraft). (A-10-48) Allow pilots to perform tire pressure checks on aircraft, regardless of whether the aircraft is operating under 14 Code of Federal Regulations Part 91, Part 91 subpart K, or Part 135. (A-10-49) Require tire pressure monitoring systems for all transport-category airplanes. (A-10-50) Identify the deficiencies in Learjet’s system safety analyses, both for the original Learjet 60 design and for the modifications after the 2001 accident, that failed to properly address the thrust reverser system design flaws related to this accident, and require Learjet to perform a system safety assessment in accordance with 14 Code of Federal Regulations 25.1309 for all other systems that also rely on air-ground signal integrity and ensure that hazards resulting from a loss of signal integrity are appropriately mitigated to fully comply with this regulation. (A-10-51) Revise available safety assessment guidance (such as Advisory Circular 25.1309-1A) for manufacturers to adequately address the deficiencies identified in Safety Recommendation A-10-51, require that designated engineering representatives and their Federal Aviation Administration (FAA) 74

NTSB Aircraft Accident Report mentors are trained on this methodology, and modify FAA design oversight procedures to ensure that manufacturers are performing system safety analyses for all new or modified designs that effectively identify and properly mitigate hazards for all phases of flight, including foreseeable events during those phases (such as a rejected takeoff). (A-10-52) Revise Federal Aviation Administration Order 8110.48 to require that the most current airworthiness regulations related to equipment, systems, and installations (14 Code of Federal Regulations 25.1309) are applied to all derivative design aircraft certificated as changed aeronautical products. (A-10-53) Review the designs of existing derivative design aircraft that were certificated as changed aeronautical products against the requirements of the current revision of 14 Code of Federal Regulations 25.1309 and require modification of the equipment, systems, and installations to fully comply with this regulation. (A-10-54) Define and codify minimum simulator model fidelity requirements for tire failure scenarios. These requirements should include tire failure scenarios during takeoff that present the need for rapid evaluation and execution of procedures and provide realistic sound and motion cueing. (A-10-55) Once the simulator model fidelity requirements requested in Safety Recommendation A-10-55 are implemented, require that simulator training for pilots who conduct turbojet operations include opportunities to practice responding to events other than engine failures occurring both near V1 and after V1, including, but not limited to, tire failures. (A-10-56) Require that pilots who fly in 14 Code of Federal Regulations (CFR) Part 135 operations in aircraft that require a type rating gain a minimum level of initial operating experience, similar to that specified in 14 CFR 121.434, taking into consideration the unique characteristics of Part 135 operations. (A-10-57) Require that pilots who fly in 14 Code of Federal Regulations (CFR) Part 135 operations in an aircraft that requires a type rating gain a minimum level of flight time in that aircraft type, similar to that described in 14 CFR 121.434, taking into consideration the unique characteristics of Part 135 operations, to obtain consolidation of knowledge and skills. (A-10-58) Require that tire testing criteria reflect the actual static and dynamic loads that may be imposed on tires both during normal operating conditions and after the loss of one tire and consider less-than-optimal allowable tire conditions, including, but not limited to, the full range of allowable operating pressures and acceptable tread wear. (A-10-59) 75

NTSB Aircraft Accident Report 4.2 Previously Issued Recommendations Resulting From This Accident Investigation and Classified in This Report As a result of this investigation, the NTSB issued the following safety recommendations to the Federal Aviation Administration on July 17, 2009: Require Learjet to change the design of the Learjet 60 thrust reverser system in future-manufactured airplanes so that the reverse lever positions in the cockpit match the positions of the thrust reverser mechanisms at the engines when the thrust reversers stow. (A-09-55) Once design changes are developed per Safety Recommendation A-09-55, require Learjet 60 operators to retrofit existing airplanes so that the reverse lever positions in the cockpit match the positions of the thrust reverser mechanisms at the engines when the thrust reversers stow. (A-09-56) Require Learjet to develop and install improved aural or visual cues on future-manufactured Learjet 60 airplanes that would allow pilots to recognize an inadvertent thrust reverser stowage in a timely manner. (A-09-57) Once improved aural or visual cues are developed per Safety Recommendation A-09-57, require Learjet 60 operators to install those cues on existing Learjet 60 airplanes. (A-09-58) Require that all Learjet 60 pilots receive training, for takeoff as well as landing phases of flight, on recognizing an inadvertent thrust reverser stowage, including the possibility that the stowage can occur when the requirements for deploying thrust reversers are not fully met, such as when the air/ground sensor squat switch circuits are damaged. (A-09-59) Evaluate the design of the thrust reverser controls and indications in Raytheon Hawker 1000 business jets for potential thrust reverser failure modes that are similar to those identified in Learjet 60 airplanes and implement necessary changes. (A-09-60) Safety Recommendations A-09-55 through -58 and -60 (previously classified “Open— Response Received”) are classified “Open—Acceptable Response” in this report. Safety Recommendation A-09-59 (previously classified “Open—Response Received”) is classified “Open—Acceptable Alternate Response” in this report. These classifications are discussed in section 2.3.2 of this report.

76

NTSB Aircraft Accident Report

BY THE NATIONAL TRANSPORTATION SAFETY BOARD DEBORAH A.P. HERSMAN ROBERT L. SUMWALT Chairman Member

CHRISTOPHER A. HART

Vice Chairman

Adopted: April 6, 2010

77

NTSB Aircraft Accident Report 78

1. Appendixes

Appendix A Investigation and Hearing Investigation The National Transportation Safety Board (NTSB) was notified of this accident early on the morning of September 20, 2008. Staff from the NTSB arrived on scene on September 20, remaining there until September 25, to conduct the field portion of the investigation. Board Member Deborah A.P. Hersman accompanied the team.92 Parties to the investigation were the Federal Aviation Administration, Learjet, Global Exec Aviation, Columbia Metropolitan Airport, and The Goodyear Tire & Rubber Company. In accordance with the provisions of Annex 13 to the Convention on International Civil Aviation, the Transportation Safety Board of Canada (TSB) participated in the investigation as the representative of the State of Design and Manufacture (Powerplants). Pratt & Whitney Canada participated in the investigation as a technical advisor to the TSB. Public Hearing No public hearing was held for this accident.

92 Board Member Hersman is now Chairman of the NTSB.

NTSB Aircraft Accident Report 79 Appendix B Cockpit Voice Recorder Transcript Following is the transcript of a Universal 1603-02-12 solid-state cockpit voice recorder, serial number 1629, installed on an Inter Travel & Services LearJet 60 (N999LJ), which crashed while attempting to abort a takeoff at Columbia Airport in Columbia, South Carolina. LEGEND

CAM Cockpit area microphone voice or sound source

HOT Flight crew audio panel voice or sound source

RDO Radio transmissions from N999LJ

GND Radio transmission from the Columbia Airport ground controller

-1 Voice identified as the captain

-2 Voice identified as the first officer

-? 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: A nonpertinent word, where noted, refers to a word not directly related to the operation, control or condition of the aircraft.

NTSB Aircraft Accident Report INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME and SOURCE CONTENT TIME and SOURCE CONTENT 23:23:40.1 [start of recording]

23:36:31.9 [start of transcript]

23:36:31.9 CAM

[sound consistent with cabin door closing].

23:36:50.3 CAM-1

I briefed 'em all.

23:36:51.8 CAM-2

did you tell them about the temperature?

23:36:54.0 CAM-1

ah no I didn't.

23:36:54.8 CAM-?

let let let us know .

23:37:00.4 CAM-?

[unintelligible vocalizations].

23:37:13.3 HOT-1

hey we're startin' engines.

23:37:17.0 HOT-1

okay I'll call you when we get in.

23:37:20.0 HOT-1

I'm gonna wake you up.

23:37:27.1 HOT-1

yeah I talked to @ I think we may just check into the Airtel for a little while.

80

NTSB Aircraft Accident Report 81 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME and SOURCE CONTENT TIME and SOURCE CONTENT 23:37:32.1 HOT-1

alright?

23:37:35.6 HOT-1

okay. thanks talk to you in a bit.

23:37:40.6 HOT-1

okay perfect appreciate it. okay should only be a little over five hours so.

23:37:48.5 HOT-1

I appreciate that. talk to you later. bye.

23:38:10.4 CAM-1

• *?

23:38:11.4 CAM-2

yeah .

23:38:18.4 CAM-?

[unintelligible vocalizations].

23:38:45.7 CAM-2

so I think. (that's the wrong).

23:38:53.0 CAM-1

there's beer in there there's beer the bottom drawer and then there's a bunch in there (that we're) putting on ice.

23:39:07.5 HOT-2

'kay.

23:39:10.6 HOT-2

alright and do you have the ah checklist?

23:39:15.0 CAM-1

do you want do you want me to get something?

NTSB Aircraft Accident Report 82 INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION TIME and SOURCE CONTENT TIME and SOURCE CONTENT 23:39:17.5 CAM-1

it's no it's no problem its easier to do it now, are you sure? okay.

23:39:24.3 CAM-1

I wonder if they should, want those lights on?

23:39:26.8 HOT-2

no they didn't they- I asked 'em they said no but I don't know why they're on.

23:39:30.6 HOT-2

unless they turn on on the ground.

23:39:32.5 CAM-1

• (armed) in an emergency ?

23:39:33.8 HOT-2

yeah.

23:39:35.5 HOT-2

I don't know the answer to that.