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Where There's Smoke There's Fire, A Tale of Three Investigations, Commercial Vehicle Safety Alliance Annual Conference, Portland, Maine
Deborah A. P. Hersman
Where There's Smoke There's Fire, A Tale of Three Investigations, Commercial Vehicle Safety Alliance Annual Conference, Portland, Maine

It's great to be here with CVSA - thank you, for the crucial leadership you provide in the commercial vehicle safety community.

Those aren't just platitudes. While I am not a roadside inspector, I truly appreciate the important work that you do.

As David (Palmer) mentioned, I learned a lot about the motor carrier world from my work on Capitol Hill. I have also accompanied your inspectors in California, Maryland, Texas and Virginia as they performed Level I inspections of trucks and buses in all weather conditions.

And, in the last eight years the NTSB has completed investigations of more than 30 truck and bus crashes and issued dozens (168) of safety recommendations aimed at improving safety.

Like Steve (Keppler) and many others here today, I've had the opportunity to work with every administrator since the Federal Motor Carrier Safety Administration was created. I can tell you that Administrator Anne Ferro has not just initiated efforts she has delivered on her initiatives. There are new rules, including a ban of texting and handheld cell-phone use for truck and bus drivers, as well as efforts to better address fatigue through electronic onboard recorders and crackdowns on marginal operators.

Yes, FMCSA still has a lot of work to do, but there have been many successes. I know everyone is looking forward to Administrator Ferro's remarks later this morning.

Today, I want to talk about motor carrier safety, of course, but I also want to share some lessons that the NTSB has learned in investigations across all modes of transportation.

These lessons reaffirm the truth of that time-honored saying, "Where there's smoke there's fire."

Let me introduce the NTSB's "firefighters," our investigators and staff who work so closely with many of you. Yes, they are from the government, and they really are here to help - Gary VanEtten, Pete Kotowski, Jennifer Morrison, Steve Prouty, Mike Fox and Julie Perrot.

My first tale has to do with you and your work: commercial vehicle safety. This audience, more than most, knows well the death toll each year on our nation's roadways from commercial vehicle crashes.

Many of you in law enforcement have had to do the hardest job there is: death notifications. You have my deep appreciation and great respect for the job you do - around the country, on average, about 11 CDL traffic accident-related notifications every day. In two months, the equivalent of all of the people at this conference - gone.

Yes, commercial vehicle safety is a huge issue - you know this, because the vehicles are large, they operate at high speeds and that can be a lethal combination.

Let me share what we learned in our investigation of the May 2011 bus crash in Doswell, Virginia.

The precipitating factor was nothing new - the driver fell asleep at the wheel. The bus went off the road, struck a cable barrier, rotated counterclockwise, overturned, and rolled onto its roof - killing four people and injuring 49 more.

No surprise to you - a bus traveling through the night at 4:55 a.m. - that wasn't the first fatigued driver behind the wheel. Nor was this crash the first safety issue for this operator. There were a number of early warning signs - smoke alarms, so to speak, in the weeks, months and years before that predawn morning when the driver fell asleep and ran off the road.

The bus operator, Sky Express, showed signs as a troubled carrier from the time it went into business. In its six years of operation, Sky Express had been visited five times - once for a safety audit (scheduled beyond the 18-month window) and four times for subsequent compliance reviews, which repeatedly identified deficiencies in the carrier's operations.

Yet, Sky Express did little or nothing to fix these problems.

Yes, where there's smoke, there's fire. As inspectors and investigators, you know full well that little things can turn into big safety issues ... if they aren't addressed.

The Doswell crash investigation brought to 25 the number of bus crashes investigated by the NTSB the last 10 years. Again and again, we have seen the same failings: a fatigued driver, poor occupant protection and marginal operators that are only put out of service after a fatal accident.

The more than 100 recommendations we have made over the years to improve bus safety fall into three main categories: better Federal government oversight, improved occupant protection and implementing advanced vehicle technologies that can assist drivers, such as lane-departure warning and electronic stability control.

The FMCSA under Administrator Ferro's leadership has sharpened its focus on high-risk bus and truck companies. With your help, on the first anniversary of the Doswell crash, the FMCSA shut down 26 bus operations.

Did that make our roadways safer?


Does commercial vehicle safety require constant vigilance?

This audience, more than any other, knows the answer to that question.


At the NTSB, we have the opportunity to look across modes. In doing this, we are able to see patterns and common themes. For one, America is a nation on the move. Last year, 730 million passengers flew on U.S. scheduled airlines. More people than that - some 750 million - traveled on motorcoaches. That number continues to grow each year.

And, as you well know, that number is dwarfed by the number of trips made by trucks. Freight operations are extremely diverse and keep our economy moving. Every item we buy has been on the interstate highway system at some point.

Yet, there are some commodities where it makes sense for another form of transportation. How many of you think of pipelines when it comes to transportation?

Yes, pipelines are a form of transportation. There are some 2.5 million miles of pipelines in this country - enough to circle the earth 100 times. Each year, those millions of miles carry gas for your homes as well as liquid petroleum products that may then be transferred to highway tankers to get to their final destinations.

This past July, the NTSB concluded our investigation into the Marshall, Michigan, spill that released 840,000 gallons of crude oil into Michigan wetlands. At $800 million - and counting - this is the most expensive onshore cleanup in U.S. history and five times the next most-costly onshore oil spill.

And, a year ago, we concluded our investigation into the 2010 pipeline explosion in San Bruno, California, that killed eight people, injured dozens, destroyed 38 homes and damaged 70 more.

In both cases, we found problems with risk management, emergency response and safety oversight. And, in both cases there had been problems before. Yes, there were repeated "smoke alarms."

Five years before the Marshall, Michigan, release, the operator - Enbridge - detected the very defect that led to 2010 failure. And, the defect was located within a corrosion area that Enbridge had already identified - the year before. Yet, for years Enbridge did nothing to address the corrosion or cracking at the rupture site.

As for PG&E, the company whose pipeline ruptured in San Bruno, it had a litany of failures. For example, in 1981, following a pipeline rupture in San Francisco, it took PG&E more than nine hours to shut down the gas flow. The NTSB found inadequate recordkeeping as a contributing cause.

And, in our investigation of a 2008 house explosion caused by a PG&E gas distribution pipeline in Rancho Cordova, California, we identified lack of quality control during pipe installation as well as inadequate emergency response procedures.

Yes, where there's smoke, there's fire.

In addition, we've repeatedly seen that federal and state officials are stretched thin. This is why we've issued recommendations to ensure that both federal and state pipeline regulators have regulations and practices with teeth and the resources to enable them to take corrective action before a rupture and not just after.

My third tale concerns commercial aviation.

On February 12, 2009, a Colgan Air airplane, en route from Newark to Buffalo, crashed five nautical miles short of the runway at Buffalo's airport, killing all 49 people on board and one person on the ground.

The Colgan Air crash brought into the harsh spotlight issues that had plagued the airline industry for decades. Our investigation determined the crash was due to poor pilot performance, but it also highlighted safety concerns with pilot commuting, fatigue, training and more. These safety concerns had factored into other NTSB investigations and they were not the first instances of problems for this carrier. For example, although they were both based in Newark, neither crew member had accommodations in the Newark area.

The captain spent the night before the accident in the crew room. And, to get to Newark, the first officer had flown the previous night in the jumpseat of a cargo flight from Seattle to Memphis. And then took another jumpseat flight from Memphis to Newark. Further, the captain had a history of poor performance on practical flight tests during his career, including two while employed by the airline.

Yes, for this airline there were a number of alarms that should have prompted action. And, yes, tragically, in this case, where there was smoke, there was fire.

What do these stories mean for you?

They serve as a reminder that past performance is a strong indicator of future performance. If you keep seeing issues within a company, what does that tell you about its enforcement posture? What does it tell the company's individual employees? And, what does it tell the regulator?

Bad things can, and do, happen to good organizations, but the continued presence of smoke can be highly informative.

In healthy companies, companies with strong safety cultures, people are assigned to look for leading indicators - for the smoke - and not to hide it. Employees are empowered to speak up if they see a problem.

And, in safety-conscious companies, there is a clearly defined organizational structure with safety responsibilities as well as ongoing evaluation and commitment to continuous improvement.

Yes, when a company has a strong safety culture it manages and values safety just as it manages and values other vital business functions.

In an unhealthy company, there may be no safety policy and no documented standard operating procedures. There may be insufficient training and little data collection and analysis to identify risks and mitigation measures.

In short, safety is not a priority.

What do you - CVSA members - have to do with "where there's smoke there's fire?"


You are the ones on the front lines. You often see the first signs of smoke. When it comes to highway safety, you are the "firefighters," but you also have a unique opportunity to prevent fires.

Through your work, you make a difference.

I know that you don't get very many "thank you's" as you are putting an operator out of service or failing a vehicle during an inspection, so listen up...

Thank you. And to our friends working across the border: Merci and gracias. You are the backbone of the enforcement program. Thank you - all - for your dedication, your professionalism and for what you do each and every day to improve highway safety and, ultimately, to save lives. It doesn't get any more important than that.