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Safety Recommendation Details

Safety Recommendation H-16-022
Details
Synopsis: On Thursday, September 24, 2015, about 11:11 a.m. Pacific daylight time, the 2005 DUCK 6 amphibious passenger vehicle (APV) was traveling north on the Washington State Route 99 Aurora Bridge in Seattle, Washington. At the same time, a 2009 Motor Coach Industries motorcoach was traveling south in the center lane. The DUCK 6 driver heard a loud noise at the left front of the APV; the vehicle drifted to the right and then veered left suddenly; the driver lost control of the vehicle. The APV crossed the center line into the southbound lanes of oncoming traffic and struck the motorcoach. Three other vehicles were damaged during the crash event: a southbound 2011 Ram Trucks pickup truck and two northbound vehicles—a 2006 Toyota Highlander sport utility vehicle and a 2007 Toyota Tundra pickup truck. As a result of this crash, five motorcoach passengers died. Seventy-one motorcoach and APV occupants reported injuries ranging from minor to serious.
Recommendation: TO RIDE THE DUCKS INTERNATIONAL: Instruct your franchisees and licensees to immediately halt operation of their stretch amphibious passenger vehicles and not resume operations until they complete the axle housing repair or replacement process developed in response to Safety Recommendation H-16-20. (Urgent)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Highway
Location: Seattle, WA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: HWY15MH011
Accident Reports: Preliminary Report - Highway - HWY15MH011Amphibious Passenger Vehicle DUCK 6 Lane Crossover Collision With Motorcoach on State Route 99, Aurora Bridge
Report #: HAR-16-02
Accident Date: 9/24/2015
Issue Date: 1/3/2017
Date Closed: 4/10/2018
Addressee(s) and Addressee Status: Ride the Ducks International, LLC (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Ride the Ducks International, LLC
Date: 4/10/2018
Response: We are disappointed that you believe an operational halt to ensure APV safety is unnecessary and that you did not instruct your franchisees and licensees to take such action until the axle repair or replacement was completed. Because we expect action on our urgent recommendations to be completed within 1 year of being issued, Safety Recommendation H-16 22 is classified CLOSED--UNACCEPTABLE ACTION.

From: Ride the Ducks International, LLC
To: NTSB
Date: 1/8/2018
Response: -From Chris Herschend, President, Ride the Ducks International, LLC: Ride the Ducks International, LLC (RTDI) is in receipt of your correspondence dated December 11, 2017, requesting information on the status of the Board’s Safety Recommendation H-16-22. RTDI provides the following response. RTDI respectfully disagrees with the Board’s recommendation in H-16-22 that all franchisees and licensees should halt operations until the axle housings on the APVs were repaired or replaced. Consistent with our understanding of the facts, implementing this recommendation was and still is unnecessary. Following the September 24, 2015 incident, RTDI conducted independent inspections of the axles on all operating “Stretch” APVs to ensure that the collar weld procedures outlined in service bulletin SB-00-14-13 were implemented and were sufficient. Due to the seasonal nature of the RTDI operations, at the time the Board published its report in November 2016, RTDI had sufficient time to conduct this analysis. RTDI is not aware of any issues or concerns that suggest that the procedures set out in SB-00-14-13 were not effective at strengthening the axles housing if the repair was implemented. Additionally, RTDI and its independent engineering consultant worked closely with the National Highway Traffic Safety Administration (NHTSA) to further confirm the quality and strength of the 2013 repair. In addition to independently confirming its sufficiency as-designed, the analysis suggested a magna particle testing procedure and the inclusion of a permanently welded coupler. NHTSA was engaged during RTDI’s implementation of these changes in 2017. At this time, many of the APVs, including those in the Seattle fleet, have already received the updated axle remedy and those that have not yet been remedied will receive the axle replacement before the start of the 2018 operating season. Finally, RTDI would like to take this opportunity to reiterate that it does not agree with the Board’s conclusion that the probable cause of the September 24, 2015 incident was a mechanical failure due to “improper manufacturing" of the APVs. As you are aware, RTDI’s independent consultant previously identified a significant error in the data that NTSB investigators relied on when predicting the stresses applied to the axles. The stresses predicted by the Board’s finite element analysis were significantly above the approximate fatigue endurance limit for the axles. If the NTSB’s assumptions were the case, the APVs would likely have experienced multiple axle failures since their original manufacture in the 1950s – they would never have survived the Korean War, much less millions of over-the-road miles since. This is not consistent with the APVs field experience and demonstrates a significant and fundamental math error in the Board’s underlying analysis. RTDI verbally advised Pete Kotowski, Investigator-In-Charge, and Dr. Robert Molloy, Director, Office of Highway Safety, of this inaccuracy in January 2017 - before the final version of the NTSB’s report was published. At that time, RTDI requested the Board consider this information in preparing its final report. In RTDI’s view, the Board’s Highway Accident Report does not accurately reflect this critical information and RTDI requests that the Board amend its report to provide a full and complete record.

From: NTSB
To: Ride the Ducks International, LLC
Date: 12/11/2017
Response: We have not received any information from you regarding your actions to halt stretch APV operations since we issued this recommendation. Safety Recommendation H-16-22 was issued as an urgent recommendation, indicating that the recommended action required immediate attention to avoid an imminent loss from a similar crash. We typically expect urgent recommendations to be implemented within 1 year. Because you have not provided us any information at this point, it is impossible for us to tell if the action has been completed. We continue to believe that operations must be halted until the axle housing is repaired or replaced on all your franchisee’s and licensee’s APVs. We would appreciate receiving a response within 90 days indicating any actions you have taken or plan to take to satisfy this recommendation; until then, Safety Recommendation H 16-22 will retain its current classification of OPEN--AWAIT RESPONSE. For additional background information about Safety Recommendation H-16-22, please refer to page 44 of our report on the crash in Seattle, Washington, which can be found at https://www.ntsb.gov/investigations/AccidentReports/Reports/HAR1602.pdf. Please update us regarding your progress in addressing this recommendation, and do not submit both an electronic and a hard copy of the same response.

From: NTSB
To: Ride the Ducks International, LLC
Date: 1/3/2017
Response: On November 15, 2016, the NTSB adopted its report concerning the September 24, 2015, crash in which an amphibious passenger vehicle collided with a motorcoach in Seattle, Washington.1 Additional information about this crash and the resulting recommendations may be found in the report of the investigation, which can be accessed at our website, http://www.ntsb.gov, under report number NTSB/HAR-16/02. As a result of this investigation, we issued 10 new recommendations, including 3 to the National Highway Traffic Safety Administration, 2 to the United States Coast Guard, 1 to Ride the Ducks of Seattle, 1 to the Passenger Vessel Association, and the following 3 recommendations to Ride the Ducks International.